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   Table of Contents - Current issue
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October-December 2019
Volume 32 | Issue 4
Page Nos. 1163-1530

Online since Tuesday, December 31, 2019

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ANESTHESIA AND INTENSIVE CARE - REVIEW ARTICLES  

Earlier start versus standard start dialysis in patients with acute kidney injury: systematic review and meta-analysis Highly accessed article p. 1163
Osama A El-Sharqawy, Khaled M Gaballah, Mohamed SM Elshahat
DOI:10.4103/mmj.mmj_184_18  
Objectives The aim of the present review is to synthesize evidence from the published literature about the effect of early versus late initiation of renal replacement therapy (RRT) on the outcomes of patients with acute kidney injury (AKI). Backgrounds AKI is a serious clinical disorder with significant increase in risk of mortality and morbidity, especially among hospitalized patients. Data sources A computer literature search of Medline via PubMed, Cochrane CENTRAL Register of Controlled Trials, SCOPUS, and Web of science was conducted. Study selection Records were screened for eligible studies according to the predetermined inclusion and exclusion criteria. Data extraction Data were extracted and synthesized using standardized tables. Data synthesis Dichotomous data were pooled as relative risk (RR) in a random-effect model using Mantel–Haenszel method. Continuous data were pooled as standardized mean difference (SMD) in generic-variance model. We used Review Manager 5.3 for Windows. Findings The present review included nine studies. Our pooled effect estimates did not favor early initiation of RRT versus late intuition in terms of all-causes mortality (RR = 0.88; 95% confidence interval (CI), 0.68, 1.14; P = 0.33), RRT dependence (RR = 0.81; 95% CI, 0.46, 1.42; P = 0.46), length of stay in ICU (SMD, −0.28; 95% CI, −0.58, 0.03; P = 0.08), and length of stay in hospital (SMD, −0.40; 95% CI, −0.83, 0.03; P = 0.07). Conclusion The present systematic review and meta-analysis shows that early initiation of RRT does not improve survival outcomes and hospital stay among patients with AKI, in comparison with late initiation of RRT.
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Predictors of outcomes in bariatric surgery and anesthesia p. 1169
Ashraf M Moustafa, Ayman A Rady, Hala M Koptan, Mansour Gamal Shaban Alhanouny
DOI:10.4103/mmj.mmj_239_18  
Objective The aim of this study was to assess the perioperative and postoperative complications and predictors of outcomes in bariatric surgery and anesthesia. Materials and methods We reviewed papers on the predictors of outcomes in bariatric surgery and anesthesia from Medline databases, which are PubMed, Medscape, Science Direct, and EMF-Portal, and all materials available in the internet up to 2017. The initial search presented articles that studied the predictors of outcomes in bariatric surgery and anesthesia. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls mentioned, and adequate information provided and assessment measures defined. Significant data were collected. Thus, a structured review was performed. Findings Results showed that bariatric surgery is considered high risk, but careful planning, preoperative risk assessment, adequate anesthetic management, strict venothrombotic event prevention, and effective postoperative pain control will all help to reduce the risk. Conclusion Careful planning, preoperative risk assessment, adequate anesthetic management, strict venothrombotic event prevention, and effective postoperative pain control will all help to improve outcomes and reduce the risk of perioperative mortality.
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The role of root cause analysis in the prevention of venous thromboembolism in intensive care patients p. 1173
Osama A EL Sharkawy, Ayman A Rayan, Mohamed H Younis
DOI:10.4103/mmj.mmj_356_18  
Objective To review the role of root cause analysis (RCA) in the prevention of venous thromboembolism (VTE) in intensive care patients. Data sources A systematic search of MEDLINE (PubMed, Medscape, Science Direct, and EMF-Portal) and internet was conducted on all articles published from 2003 to 2017. Study selection English-language reports of the indications of revision sinus surge were included. Data extraction Articles not reporting on the role of RCA in the prevention of VTE in intensive care patients were not included. Three independent investigators extracted data on methods, health outcome, and prevention protocols. Data synthesis Comparisons were made by structured review, with the results tabulated. Four authors studied the role of RCA in the prevention of VTE. There were 11 studies on VTE risk assessment protocols and eight studies emphasized different methods of VTE prophylaxis. Findings Analysis of the avoidable events showed that lack of the VTE risk assessment in the first place was the main factor for their occurrence. Conclusion Organizations are required to investigate all inpatient venous thromboembolic events using RCA methodology, where specific questions can be asked in relation to VTE risk assessment and prophylaxis; this eventually allows them to learn from VTE incidents and improve patient safety.
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Assessment of the central venous-to-arterial carbon dioxide tension difference (pCO2 delta) in adult patients with sepsis: a systematic review p. 1177
Abd El Rahman A Ahmed, Yasser I Mohamed, Khaled M Gaballah, Ahmed A. M Abd El Aziz
DOI:10.4103/mmj.mmj_406_18  
Objective The aim was to review studies that assessed the central venous-to-arterial carbon dioxide tension difference (pCO2 delta) in septic adult patients, published between 1990 and 2016 in the MEDLINE (PubMed, Medscape, and Science Direct) and EMF-Portal, and methodological quality was evaluated. Materials and methods A systematic search of MEDLINE (PubMed, Medscape, and Science Direct), EMF-portal, and Internet was conducted on all articles published from 1990 to 2016. English-language reports of pCO2 delta in patients with sepsis were reviewed. The initial search presented 135 articles, where 30 fulfilled the inclusion criteria. Articles not reporting on pCO2 in patients with sepsis 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. Ten studies emphasized old and new definitions of sepsis, pCO2 delta, and mortality; seven about pCO2 delta and tissue perfusion variables; seven about pCO2 delta and cardiac output; and nine about pCO2 delta and therapeutic interventions. Findings High pCO2 delta values were seen to be associated with poorer clinical outcomes, including worsened hemodynamic parameters, poorer tissue perfusion, and greater in-hospital mortality and mortality after 28 days. Higher serum lactate levels and lower SvcO2 values were seen when the patients presented with pCO2 delta greater than 6 mmHg, compared with those showing pCO2 delta less than 6 mmHg. The usefulness of pCO2 delta alone or other tissue perfusion variables for assessing tissue perfusion in sepsis and septic shock is limited. Conclusion Delta pCO2 is a valuable complementary tool to guide tissue perfusion in sepsis and septic shock with previous tissue perfusion variables, but this pCO2 delta parameter is not enough alone to detect tissue perfusion and or to be used alone as a marker of prognosis in severe sepsis and septic shock.
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ANESTHESIA AND INTENSIVE CARE - ORIGINAL ARTICLES Top

Hyperinsulinemic–normoglycemic technique in patients with cirrhosis undergoing hepatic resection: a randomized controlled trial p. 1185
Magdy K Khalil, Mohammed H Afifi, Maha L El-Sheikh, Mohammed Z Khalil
DOI:10.4103/mmj.mmj_18_18  
Objective To evaluate the efficacy of hyperinsulinemic–normoglycemic clamp technique (HNCT) versus the insulin sliding scale for glycemic control in patients with cirrhosis undergoing hepatic resection. Backgrounds There is a consensus in the published literature about the increased risk of hyperglycemia among patients undergoing hepatic resection. Previous reports have established the significant association between hyperglycemia and the extent of hepatic injury in hepatectomized patients. Patients and methods A randomized controlled trial was conducted on 60 patients with cirrhosis who underwent hepatic resection. Patients were randomly assigned to either HNCT group control (n = 30) or insulin sliding scale group (n = 30). The postoperative liver function was assessed by the score proposed, and patients were followed for 1 week postoperatively. Results The mean operative durations of HNCT study and control groups were 4.4 and 4.3 h, respectively. Moreover, 60% of the study group had a focal resection, whereas 60% of the control group had multiple resection operation. Postoperatively, HNCT group showed a statistically significant marked reduction in Schindl score compared with the control group (P < 0.001). In addition, HNCT group showed a marked improvement in postoperative liver parameters compared with the control group (P < 0.001). Conclusion HNCT significantly attenuates hepatic dysfunction and improves clinical outcomes postoperatively.
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Comparative study between thoracic epidural and ultrasound-guided thoracic paravertebral block in perioperative pain management for mastectomy p. 1191
Safaa M Helal, Ahmed A Abdel Aziz, Khaled A Gab-Allah, Eman G Ramadan
DOI:10.4103/mmj.mmj_154_18  
Objectives To compare between ultrasound-guided thoracic paravertebral block (PVB) and thoracic epidural block in patients undergoing mastectomy for pain control, intraoperative hemodynamics, and postoperative patient satisfaction. Background Thoracic PVB and thoracic epidural appears promising when combined with general anesthesia in reduction of postoperative pain. Patients and methods Between mid-2016 and December 2017, this prospective clinical study included 60 female patients scheduled for a unilateral mastectomy in Menoufia University Hospitals and divided into two groups, 30 each. Patients in group A were given single shot ultrasound-guided PVB at T4 level using 0.3 ml/kg of 0.5% bupivacaine. Patients in group B were given single shot epidural block at T4 level using 2 ml/segment of 0.5% bupivacaine. Results A total of 60 patients were included, of them, 30 patients received PVB and 30 received thoracic epidural. Heart rate was significantly higher in paravertebral group than in thoracic epidural group (P < 0.001). Mean arterial blood pressure was significantly higher in paravertebral group than in thoracic epidural (P < 0.001). The mean score measured using a seven-point Likert-like verbal rating scale for patient satisfaction in paravertebral group was 6.2 ± 0.85, compared with 4.9 ± 1.03 in epidural group; there was a highly significant statistical difference (P < 0.001). There was no significant statistical difference among the studied groups with respect to fentanyl requirements and postoperative visual analogue scale. Conclusion Ultrasound-guided PVB is an effective technique showing greater hemodynamics stability and pain control compared with epidural analgesia for mastectomy.
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INTERNAL MEDICINE - REVIEW ARTICLES Top

Human leukocyte antigen in medicine p. 1197
Sabry Shoeib, Emad El-Shebiny, Alaa Efat, Khairy A El-Hady
DOI:10.4103/mmj.mmj_211_16  
Objective The aim was to evaluate human leukocyte antigen (HLA) biology and its importance in medicine. Materials and methods Medline databases (PubMed, Medscape, ScienceDirect, and MMJ) were searched. The initial search presented 500 articles, papers, and journals about immunity, major histocompatibility complex, HLA, minor histocompatibility complex, autoimmune diseases, infectious diseases, transplantation, and HLA application in medicine. Short reviews were made on HLA biology and different associated diseases. Conclusion Most of the genes in the major histocompatibility complex region express high polymorphism, which is fundamental to their function. The most important function of HLA molecule is in the induction and regulation of immune responses. Many human diseases, such as autoimmune, infectious, inflammatory, and malignant, are significantly more common among individuals carrying particular HLA alleles. HLA-disease association is the name of this phenomenon, and the mechanism underlying is still a hot debate topic.
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Biologics: a target therapy of lupus nephritis: a systematic review p. 1208
Sabry A Shoeib, Emad M Elshebini, Alaa N AbdAlla
DOI:10.4103/mmj.mmj_42_19  
Objective To review the use of biological management of lupus nephritis (LN). Data sources A systematic review of Medline (PubMed, Medscape, Science Direct, and EMF-Portal) and Internet was conducted on all articles published from 2006 to 2017. Study selection English-language reports on biological management of LN were searched. The initial search presented 150 articles, where 30 satisfied the inclusion criteria. Data extraction Articles not reporting on biological management of LN in the title or abstract were not included. A total of five independent investigators extracted data on methods. Data synthesis Comparisons were made by structured review, with the results tabulated. Overall, seven studies were about traditional therapy, 14 about biological therapy, and seven about evidence-based treatment for LN. Findings The various biological agents consisted of anti-B-cell therapies targeting either B-cell surface antigens or B-cell survival factors, anticytokines antibodies, and novel drugs intervening in B-T cell costimulation. Use of leflunomide in LN was found to be equally efficacious and safe at least in short term and in refractory LN. Immunosuppressive treatment should be guided by renal biopsy, and treatment aimed at complete renal response. Conclusion Biologicals, especially rituximab, although still off the shelf as an induction agent, can be used for resistant LN. Overall, treatment has to be individualized, multidisciplinary, and holistic to prevent loss-of-organ function.
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INTERNAL MEDICINE - ORIGINAL ARTICLES Top

Plantar pressure changes in diabetic peripheral neuropathy p. 1214
Hak-Chol Ri, Sin-Hyok Hwang, Chol-Jun Ho, Ri-Hyang Paek
DOI:10.4103/mmj.mmj_256_18  
Objective To assess the plantar pressure changes in diabetic peripheral neuropathy compared to healthy condition. Patients and methods The study was performed with 150 participants containing 42 nondiabetic, 66 diabetic without peripheral neuropathy and 42 patients with diabetes mellitus with peripheral neuropathy. Using the plantar pressure platform, dynamic pressure variables such as peak plantar pressures and pressure–time integral (PTI) were measured in each foot. Results We have divided the participants into three groups: group A, healthy individuals (n = 42); group B, those with diabetes mellitus without peripheral neuropathy and plantar foot ulceration (n = 66); and group C, diabetic peripheral neuropathy with plantar foot ulceration (n = 42). There is no significant difference in peak plantar pressures between groups A and B, and between groups A and C (P < 0.05). No pressure on the medial midfoot region was recorded in both groups A and B, but a little in group C. There is also no significant difference in plantar PTIs between groups A and B, but there is significant difference of plantar PTI between groups A and C (P < 0.05). No significant difference was found on the medial midfoot region in both groups A and B, but a little in group C. Conclusion There were significant correlations between plantar pressures in diabetic peripheral neuropathy. Furthermore, plantar pressure can be helpful in detecting the possible sites for plantar foot ulcerations.
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The role of endothelin-1 in intradialytic hypertension p. 1217
Mahmoud A Kora, Yassein S Mohammed, Khaled M Elzorkany, Gehan A Tawfeek, Amal M Abdelraouf Baghdadi
DOI:10.4103/mmj.mmj_7_19  
Objectives To evaluate the role of endothelin-1 (ET-1) in intradialytic hypertension (IDH). Background The etiology and pathogenesis of hemodialysis (HD)-induced hypertension remains complex and speculative. There is mounting evidence that ET-1 may play a vital role in IDH. Patients and methods This is a case–control study on 84 individuals including 56 end-stage renal disease patients on regular HD and 28 normal individuals. The patients were divided into three groups. Group I (cases group): 28 patients with IDH, group II (HD control group): 28 patients with well-controlled blood pressure and no history of IDH throughout HD, and group III (healthy control group): 28 healthy volunteers. Results The mean age in this study was 50.1 years in group I, 57.1 years in group II, and 34.7 years in group III. Mean arterial pressure (MAP) significantly increased during dialysis in group I and significantly decreased in group II. Delta MAP started to increase more than or equal to 15 mmHg, that is IDH, 2 h after the start of HD session. Mean ET-1 level in group I was 281.8 pg/dl and in group II it was 250.5 pg/dl. There was significant positive correlation between ET-1 level after 2 h of starting of HD session and MAP and delta MAP. Conclusion ET-1 is a significant risk factor for having IDH.
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PEDIATRIC SURGERY - ORIGINAL ARTICLE Top

A simple procedure for management of urethrocutaneous fistula after hypospadias repair p. 1223
Aditya P Singh, Arvind K Shukla, Pramila Sharma, Dinesh K Barolia
DOI:10.4103/mmj.mmj_213_18  
Objective The treatment of urethral fistula is quite challenging. We tried to evaluate the results of a simple procedure in urethral fistula repair. Background A urethrocutaneous fistula is a common complication of urethroplasty. These fistulae may be caused by a variety of factors and occur in different sizes at various sites of the previous repair. Materials and methods A variety of methods have been described in the literature for the repair of urethrocutaneous fistulae with variable results. In this study of 25 cases, we have successfully repaired urethrocutaneous fistulae using perifistula non-hair-bearing penile skin flaps for their closure in the period spanning from January 2005 to December 2015. The operation consists of the creation of perifistula non-hair-bearing penile skin-based flap after marking the site. It was created with one side being kept large as compared with the other side in any direction. We mobilized the flap and the larger sized flap was folded over the tube just like a hat of a box and sutured it with the other side of the flap. We did it in only midpenile and proximal fistulas, irrespective of the size of the fistulas, whether they were small, medium or large sized. We included recurrent as well as fistula after primary repair. Results The mean age of patients was 6 years. We have successfully repaired all urethrocutaneous fistulae using our protocol with a success rate of 100%. Conclusion Flap technique is an appropriate procedure for repair of midshaft and proximal urethral fistulae of any size.
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PEDIATRIC SURGERY - CASE REPORT Top

Complex gastroschisis with gangrene gut: a rare case p. 1227
Dileep Garg, Aditya P Singh, Arun K Gupta, Dinesh K Barolia
DOI:10.4103/mmj.mmj_166_18  
Gastroschisis is a congenital abdominal wall defect. Proposed classification of this malformation is simple if isolated or complex in the presence of coexisting intestinal anomalies at birth such as intestinal atresia, stenosis, perforation, necrosis, or volvulus. We report a case of gastroschisis with gangrene of intestine. At the time of surgery, we found a small abdomen wall defect through which intestine was herniating. In our view, it was the small defect that caused gangrene in the gut. Gangrene gut was resected and end-to-end anastomosis was done. The patient died owing to septicemia.
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GENERAL SURGERY - ORIGINAL ARTICLES Top

Necessity of stent placement after successful common bile duct stone clearance by endoscopic retrograde cholangiopancreatography p. 1229
Hatem M Sultan, Tarek M Rageh, Ashraf MA Alsoaood
DOI:10.4103/mmj.mmj_215_18  
Objective The aim was to evaluate the role of stent insertion in the common bile duct after complete stone clearance by endoscopic retrograde cholangiopancreatography (ERCP). Background Biliary stents are usually inserted when complete stone clearance cannot be achieved. However, stent insertion after clearance may lower the pressure in the bile ducts and provide better bile drainage, thus preventing recurrent biliary events. Patients and methods This is a prospective study that was done on a consecutive sample of 40 patients who were admitted to Menoufia University Hospital during the period between May 2016 and May 2018 with choledochocystolithiasis, who underwent complete stone clearance by ERCP. The patients were divided into two groups: group I with bile duct stent insertion and group II without bile duct stent insertion. The patients were followed up for 1 month. The complications and the outcome of the operation were recorded. Results Three cases were omitted due to failed ERCP: 10.5% of group II developed recurrent obstructive jaundice, 5.3% needed repeat emergency ERCP compared with 5.6 who developed obstructive jaundice and needed emergency ERCP in group II and 5.6% of group I developed pancreatitis. Conversion to open cholecystectomy was done only in 5.6% of group I; 11.1% of group I had downward stent migration; 5.6% had upward migration; and 5.6% had their stent occluded. Conclusion Biliary stent insertion after choledocholithiasis clearance has the disadvantage of prolonging ERCP time, increasing its cost and the stent-related complications with no advantage for this group over the group without stent insertion.
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Evaluation of foam sclerotherapy in treatment of lower limbs – primary varicose veins p. 1234
Ahmed T Gafar, Walid M Omran, Yahia M Alkhateep, Ayman A Albatanony
DOI:10.4103/mmj.mmj_149_18  
Objective The aim was to evaluate the efficacy of foam sclerotherapy for treating primary varicose veins. Background Foam sclerotherapy is a standard method of treatment of primary varicose veins. It is a less invasive method, simple, effective, and can be done in outpatient. Materials and methods This is a prospective study on 50 consecutive patients who were diagnosed to have clinical and radiological evidence of primary varicose veins in the Department of Vascular Surgery Unit in Menoufia University hospitals from February 2017 to February 2018. Local ethics committee's approval and a written consent were obtained. The foam was generated by Tessari method. Results Fifty lower limbs of 50 patients were presented with primary varicose veins and competent saphenofemoral junction. There were 35 (70%) females and 15 (30%) males with mean age of 35.4 ± 10.125 years (range: 22–55 years). Fifty limbs included 20 (40%) right limbs and 30 (60%) left limbs. Twenty-five (50%) patients complained of disfigurement, 30 (60%) patients of pain, 30 (60%) patients of heaviness, and 35 (70%) patients of swelling. The complications were pain at injection sites in 32 (64%) patients, itching in four (8%) patients, ecchymosis in 18 (36%) patients, and superficial thrombophelibitis in eight (16%) patients. Conclusion Foam sclerotherapy is safe, effective, and less complicated in treating primary varicose veins.
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Assessment of metabolic bariatric surgery for the remisson of obesity and type 2 diabetes p. 1239
Adel M Khalf, Abd Al-Kareem Elias, Farag Khalil
DOI:10.4103/mmj.mmj_296_18  
Objectives The aim of this study was to assess the short-term remission of both obesity and type 2 diabetes (T2D) after metabolic bariatric surgery (MBS). Background The prevalence of obesity is increasing at a rapid rate internationally, paralleled with an increase in the number of people with T2D. Bariatric surgery may induce a lot of anatomical, physiologic, and hormonal changes that improve diabetes with obesity, with durable effects. Patients and methods This study includes 20 obese diabetic patients who underwent MBS treatment of obesity and T2D. Surgical outcome, weight loss, glycated hemoglobin level, comorbidities, and complications were recorded. Patients were followed up every week for 1 month, and then on every month of the first year. All patients were followed up for at least 1 year. Results In the studies, the mean age was 40.08 ± 2 years, male/female ratio was 8/12, and mean BMI was 35.3. The mean operative time and estimated blood loss of sleeve gastrectomy are significantly less than Roux-en-Y gastric bypass. After surgery, mean BMI and mean glycated hemoglobin was reduced, with significant weight reduction (P < 0.001). Conclusion MBS is an effective procedure for treating morbid obesity and T2D which results in sustained weight loss and a high resolution of comorbidities.
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Evaluation of Prince of Wales Hospital score in predicting massive blood transfusion in trauma p. 1246
Moharam A Mohamed, Mahmoud S El-Desoky, Mohamed AE. Elhamzawy
DOI:10.4103/mmj.mmj_302_18  
Objective To evaluate the performance of Prince of Wales Hospital score (PWH score) in predicting the need for massive transfusion (MT) and comparing its performance with Assessment of Blood Consumption (ABC) score and the Trauma-associated Severe Hemorrhage (TASH) score. Background Because of the great risk of massive bleeding that may be life-threatening especially if uncontrolled, early prediction of ongoing bleeding and the need for MT reduce mortality of polytraumatized patients. PWH score was developed for the purpose of early prediction of need of MT. Patients and methods This is a prospective comparative study done on 61 polytraumatized patients, with Injury Severity Score more than or equal to 16, who presented to the Emergency Department of Menoufia University Hospital during the period from September 2017 to September 2018. PWH score was applied to assess its performance and comparing it with ABC and TASH scores. Results PWH, TASH, and ABC scores were applied on 61 patients with trauma meeting inclusion criteria to predict the need for MT. The area under the receiver operating characteristics curve was 0.92 for PWH score, 0.96 for TASH score, and 0.72 for ABC score. PWH was better in performance than ABC score, and TASH score was the most accurate and specific. Conclusion The results of this study support that TASH score has greater area under the (receiver operating characteristics) curve than PWH and ABC scores and is more accurate than both of them at cutoff point of more than or equal to 13.5. PWH performs better than ABC score at cutoff point of more than or equal to 4.5 for PWH and cutoff point of more than or equal to 1.5 for ABC score.
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Accuracy of change in leukocytic count in relation to clinical pictures and histopathology in diagnosis of acute appendicitis p. 1252
Mohamed I Hamza, Awatef E Farghaly, Abd ElMieniem F. Mohamed
DOI:10.4103/mmj.mmj_329_18  
Objective To evaluate the accuracy of change in leukocytes count in comparison with clinical pictures and histopathology in diagnosis of acute appendicitis. Background The diagnosis of acute appendicitis is primarily clinical and should be made on clinical symptoms and signs. However, some patients have equivocal physical findings and may be admitted for a period of observation. We suggest that these patients could also have serial total white cell counts taken as an aid for diagnosis. Patients and methods The study is a prospective randomized clinical trial. This study was conducted on patients presenting to the General Surgery Department in Menoufia University Hospitals and Al Minshawy General Hospital in Tanta during the period from March 2017 to March 2018. This study included 68 patients with acute lower abdominal pain suspecting acute appendicitis divided into two groups: A (34 patients) and B (34 patients). Patients in group A had normal leukocytes count and patients in group B had a high leukocyte count. All specimens of appendectomies were sent for histopathological examination. Results The leukocytes count has a sensitivity of 58%, specificity of 85%, accuracy of 63%, and negative appendectomy rate of 19%. Conclusion It was found that if the total leukocytes count and neutrophils were highly elevated and correlated with the clinical picture, the diagnostic accuracy of acute appendicitis was more increased.
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Evaluation of dorsal metacarpal artery perforator flaps in the reconstruction of hand soft-tissue defects p. 1256
Tamer H Al-Baz, Shawky S Gad, Tarek F Keshk, Medhat S Aly
DOI:10.4103/mmj.mmj_365_18  
Objective Evaluation of the dorsal metacarpal artery perforator (DMAP) flaps in the reconstruction of hand soft-tissue defects. Background The DMAP flap is a nonconventional solution for treating hand and finger defects. We present our experience in resurfacing a variety of soft-tissue defects of hand and fingers with this single-stage flap, reducing the need for other conventional flaps which may need more than one stage for reconstruction. Patients and methods This study was done on 20 patients (18–65 years) with soft-tissue defects of the hand and fingers, following trauma in 15 patients, postburn deformity reconstruction in four patients, and in one patient for post-tumor excision, presented at the Menoufia University Hospital and Kafr Al-Shaikh General Hospital over a 1-year period. Results The average flap size was 6 × 2.5 cm; raised from the dorsum of the hand as an island elliptical flap. Twelve flaps were used to resurface defects between metacarpophalangeal and proximal interphalangeal joints; three flaps were used to resurface defects between proximal and distal interphalangeal joints; one flap was used to resurface defect beyond the distal interphalangeal joint; and four flaps were used to resurface web space defects. The donor site closed primarily in all cases. Complications were distal necrosis in two flaps and congestion in two flaps. Wound dehiscence of the donor site occurred in two cases. Conclusion DMAP flap is a reliable alternative for treating defects on the hand and fingers. The flap offers the surgeon simple, single-stage, and fast procedure with minimal donor site morbidity and with preservation of functional and esthetic outcomes.
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Diagnostic markers in acute appendicitis p. 1262
Ahmed S Elgamal, Waled Omran, Abdelrahman H Meselhy
DOI:10.4103/mmj.mmj_375_18  
Objective The objective of the study was to determine the value of white cell count (WBC), C-reactive protein (CRP), and bilirubin as diagnostic markers in acute appendicitis. Background Appendicitis is a frequent reason for hospital admissions. Elevated CRP, white blood cell count, and serum bilirubin have been suggested as individual markers for appendicitis and appendicular perforation. Patients and methods This prospective observational study was conducted on patients admitted with clinical suspicion of acute appendicitis at Menoufia University and Bolak El-Dakror Hospitals in the 6 months period starting from June 2017 involving 150 patients. Results A total of 150 patients were operated under suspicion of appendicitis. From these, 65.3% of patients had simple appendicitis, 18.7% had normal appendix, and 16% of patients had complicated appendicitis. Complicated appendicitis was accompanied with higher WBC level with significant correlation (P = 0.03); complicated and simple ones were accompanied with a higher level of total bilirubin than normal appendix with significant differences (P < 0.001). Complicated appendicitis and simple appendicitis were accompanied with higher CRP positivity than in normal appendix with significant differences (P < 0.001). Conclusion Combining blood markers was useful in predicting appendicitis and perforated appendicitis, in addition to CRP and WBC, and blood levels of bilirubin.
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Is it safe to do laparoscopic cholecystectomy for acute cholecystitis up to 7 days? p. 1267
Mohamed M Abdalgaleil, Ahmed M Shaat, Osama S Elbalky, Mamdouh M Ibrahim, Mohamed S Elnagaar
DOI:10.4103/mmj.mmj_206_19  
Objective The aim was to compare the safety of early (≤72 h) vs late (>72 h to 7 days) laparoscopic cholecystectomy (LC) from symptom onset for acute cholecystitis (AC). Background As LC within 72 h of symptom onset was considered the optimum time, sometimes there was a delay in diagnosis and management. So, we raised the question of safety and feasibility of performing LC for patients with AC who failed to have LC within 72 h of acute attack. Patients and methods This was a prospective randomized comparative study carried out on 120 patients presented with AC at Damanhour Teaching Hospital, El Beheira, Egypt, between September 2017 and April 2019. Patients were randomly allocated into two equal groups assigned to LC: group E: within 72 h of symptom onset, and group L: after 72 h up to 7 days from symptom onset. Results There were no statistically significant differences between both groups regarding demographic data, American Society of Anesthesiologist physical status, history of previous upper abdominal operations, conversion to open cholecystectomy, postoperative complications, and hospital stay. Operative duration and intraoperative blood loss were significantly higher in group L than group E. Conclusion Extending the golden time for LC up to 7 days of acute attack was safe and feasible. It was associated with the same open cholecystectomy conversion rate, postoperative complications rate, and length of hospital stay; however, the operative duration and intraoperative blood loss were significantly increased. We highly recommend a well-trained laparoscopic surgeon to perform the procedure for patients' safety.
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Evaluation of the effect of ozone therapy in diabetic foot ulcers p. 1272
Ayman A Albatanony, Yahia M El-Khateep, Sadek Abdel Maseeh Sadek, Ahmed S Sadaawy Baghid
DOI:10.4103/mmj.mmj_20_19  
Objectives The objective of this study was to evaluate the effect of local ozone as an adjuvant therapy in patients with diabetic foot ulcers. Background Diabetes mellitus is a major problem that results in complications such as infections, gangrene, amputation, coma, and death. Diabetic foot ulcer can be treated by many methods; recently, ozone has been used in their treatment. Patients and methods A prospective cross-sectional study was conducted at Menoufia University Hospital and Moustafa Kamel Military Hospital for the treatment of foot ulcer. Sixty patients were selected on clinical, laboratory, and radiological bases. They were divided into 39 patients who had complete healing, 13 patients who had partial healing, and eight patients had no healing. All patients received two sets of local ozone therapy weekly for 10 weeks. They were evaluated for degree of healing and followed-up for 8 weeks after the end of therapy for healing. Results There were no significant differences between the studied groups with regard to age, sex, and type of diabetes. There was a significant reduction in the length of treatment and size of the ulcer in the healing group. Most of our patients showed complete healing (65%) and 21.6% showed partial healing, while only 13.4% showed nonhealing. Only 11.4% of cases of complete healing recurred. Conclusion The use of local ozone therapy markedly improves healing of diabetic foot ulcers with low incidence of recurrence.
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PLASTIC SURGERY - ORIGINAL ARTICLES Top

Comparative study between harvesting extended sural flap with and without punch of gastrocnemius muscle p. 1277
Tarek F Kishk, Yasser M Elsheikh, Ashraf M Alrahawi, Yasser E M Elsehity
DOI:10.4103/mmj.mmj_244_18  
Objective To evaluate the safety of harvesting reverse-flow sural flap from the proximal one-third of the leg with the inclusion of a part of the gastrocnemius muscle with its mesentery and with the inclusion of the mesentery only. Background The reversed sural artery flap in standard technique is usually not harvested from the proximal third of the leg. Conversely, this study is conducted to evaluate the efficiency, safety, and success of reversed sural flap harvested from the proximal third of the leg even without the inclusion of the gastrocnemius muscle. Patients and methods This study included 32 patients presented with soft tissue loss of the leg or foot, from January 2015 to January 2018 with a follow-up period of 6 months. The cases were divided into two groups: group A included 17 patients, where a part of the gastrocnemius muscle and its mesentery was involved in the flap, and group B included 15 patients, where the flap was devoid of the muscle completely. Results Postoperative splinting by plaster of Paris with a bridge over the pedicle and the full length of the flap to avoid pressure over the flap was done. In group A, two patients had full-thickness tip necrosis, where one of them required debridement and skin grafting; two patient had superficial epidermolysis of the flap, which passed unnoticed; three patients had venous congestion; and six patients had donor site scarring. In group B, one patient had marginal tip necrosis, which required skin grafting later on; two patients had venous congestion; one patient had suture rupture; and two patients had donor site scarring. Conclusion The reversed sural flap can be harvested safely from proximal one-third of the leg without harvesting a part of gastrocnemius with the flap.
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Outcomes of paramedian forehead flap for reconstruction of large nasal defects: Menoufia experience p. 1282
TarekFouad Keshk, Ahmed Farag El-kased, Dalia Mofreh El-Sakka, Sherif Mohamed El-kashty, Hanan Ali Ali Dawoud
DOI:10.4103/mmj.mmj_18_16  
Objective The aim of this case series study was to evaluate outcomes of paramedian forehead flap in reconstruction of large nasal defects. Background Nasal reconstruction is a challenging pursuit owing to its complex three-dimensional structure; the different components of skin, bone, cartilage, and mucosal lining; and the variations in skin thickness and color of the nose. This study describes forehead flap technique for reconstruction of large nasal defects more than 2 cm after excision of a neoplasm. Patients and methods From January 2012 to December 2015, 14 patients who had large nasal defects received surgical treatment in the form of either expanded paramedian forehead flap (group A, n = 5 patients) or nonexpanded paramedian forehead flap (group B, n = 9 patients). Demographic data, nasal defect characteristics, postoperative complications (infection, wound dehiscence, and flap necrosis), comparison between two groups of patients, and doctor and patient satisfaction were recorded. Results The overall results were satisfactory regarding function and appearance without major complications according to patient and doctor satisfaction. Wound dehiscence occurred in one (7.14%) case and healed with conservative treatment. Another patient (7.14%) was complicated with infection at the site of expander port and was treated with antibiotics. Conclusion The forehead flap continues to be one of the best options for closure of surgical defects of the nose larger than 3 cm. Adequate knowledge and careful application of the technique and its modifications allows excellent results to be obtained with few complications.
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Pedicled perforator flaps for leg reconstruction p. 1289
Tarek F Keshk, Tarek M Rageh, Ahmed A Talaab, Hashem M R Elragaby
DOI:10.4103/mmj.mmj_249_18  
Objective The objective of this study was to assess the efficacy of perforator flaps for the reconstruction of an injured leg. Background Defects of the lower limb remain a health problem. Application of perforator flaps for reconstruction of these defects represents a very good option giving good coverage. Patients and methods This was a prospective study. It was performed at Menofia University Hospital and Shebin El-Kom Teaching Hospital during a period of 14 months from February 2017 to March 2018. The study was carried out on 20 patients with leg defects; six types of perforator flaps were used; seven patients were treated by posterior tibial artery perforator flap, seven patients by reversed sural perforator flap, two by peroneal artery perforator flap, two by lateral supramalleolar flap, one by anterior tibial artery perforator flap and one by medial sural artery perforator flap. Results The mean ± SD age of the patients was 36.85 ± 16.60 years. Of 20 patients, 15 (75%) were male individuals and five (25%) were female individuals. The mean ± SD area size of the defect was 43.90 ± 33.47 cm. Of 20 flaps, 14 (70%) flaps had no complications, four (20%) flaps were complicated by distal-end congestion, 18 (90%) flaps passed successfully, and two (10%) flaps were complicated by necrosis and failed to survive. Conclusion Perforator flaps represent an effective method for reconstruction of leg defects, giving good satisfactory, functional and aesthetic results, as leg defects were successfully covered and healed by using perforator flaps, giving normal function and shape of the leg.
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Assessment of autologous fat transfer to the breast: clinically and radiologically p. 1297
Fouad M Ghareeb, Mohammed G Ellabban, Dalia M Elsakka, Souzan F Omar, Ahmed A Atia
DOI:10.4103/mmj.mmj_330_18  
Objective The aim was to assess the results of autologous fat graft to the breast through the rate of fat necrosis, cyst formation, and calcification patterns to avoid unnecessary breast biopsies. Background Autologous fat transfer is widely used in plastic surgery for both reconstructive and esthetic purposes. Patients and methods This study included 30 patients, from September 2015 to February 2018. Baseline mammography was done for patients 40 years or older and ultrasound scans for those younger than 40 years and then repeated at 6 and 12 months postoperatively. Results The age of the patients ranged 19–51 years. The mean amount of the fat transferred to each breast was 252.17 cm3 with range of 100–410 cm3. No major complications were recorded. Six months after breast lipofilling, six (25%) patients of 24 patients younger than 40 years showed multiple small anechoic and hypoechoic lesions (solid nodules) with disruption of surrounding normal breast tissue. Three patients showed cystic lesions of variable size. Microcalcifications were detected in four mammograms (66.6%) of the six patients older than 40 years. One year after breast lipofilling, cystic lesions increased to five. Microcalcifications were detected in three patients. The microcalcifications in the fourth patient had an increased amount of calcifications and progressed to macrocalcification. Conclusion Fat grafting to the breast can be associated with complications such as fat necrosis, liponecrotic cysts, and calcifications. The high incidence of these complications is associated with improper technique of fat grafting.
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Different modalities for correction of breast asymmetry p. 1303
Mohamed A Megahed, Yasser M Elsheikh, Ahmed A Talab, Mohammed S AboShaban
DOI:10.4103/mmj.mmj_344_18  
Objective The aim of this study was to evaluate the different types of breast asymmetry and choice of the suitable approaches for each type of deformity. Background Naturally, there is asymmetry in female normal breast. When the difference in the site, size, shape, or volume of the breast, nipple–areola complex, and inframammary crease position is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Patients and methods The study included 29 female patients presented by breast asymmetry aged 14–43 years in the period from September 2016 till September 2018 at the Department of Plastic and Reconstructive Surgery of Menoufia University Hospitals. All patients were evaluated by history, physical examination, investigations, and photography. Surgical methods used for correction of breast asymmetries include: reduction mammoplasty, mastopexy, breast lipofilling, silicone gel implant and reconstruction of the missing breast, nipple–areola complex, and inframammary fold using different methods including pedicled latissimus dorsi, free transverse rectus abdominis myocutaneous, deep inferior epigastric artery perforator as well as a combination of the mentioned techniques. Results Most of the breast asymmetries were corrected by a combination of surgical procedures. Having combined different surgical procedures achieve satisfactory results. Conclusion The key to successful treatment is to define the nature of the breast asymmetry, respecting the patient's esthetic goals. It is critical to grasp the concept that the more similar the procedures performed on each breast, the more likely there will be symmetry over time.
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The aesthetic outcome of short scar periareolar inferior pedicle reduction mammoplasty technique p. 1308
Fouad M Ghareeb, Sherif M El-Kashty, Tarek M Rageh, Basma N Omran
DOI:10.4103/mmj.mmj_370_18  
Objective The aim was to determine the esthetic outcome of short scar periareolar inferior pedicle breast reduction (SPAIR) technique. Background SPAIR mammoplasty is an effective method of breast reduction created to reduce the amount of cutaneous scar by half and improves breast shape that is stable overtime. This method is applicable to a wide variety of breast problems ranging from simple ptosis to extremes of macromastia. Patients and methods Twenty female patients aged 30–50 years were enrolled in this prospective clinical study presented at Menoufia University Hospitals and were scheduled for breast reduction surgery after approval of the local ethics committee and after taking an informed written consent. They were all done by the same technique. Results The results obtained using the SPAIR mammoplasty had been satisfying and more esthetic as regards other techniques of breast reduction. The resultant shapes were more rounded in appearance, with excellent projection. The pleasing shape that was created immediately, improved and maintained overtime as the breast settled and resolution of postoperative edema occurs, which is usually completed by 6 months postoperatively. Conclusion The SPAIR mammoplasty is an easily applied and technically straightforward technique for breast reduction and that affords the advantages of esthetic shape, reduced scar burden, and stability.
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Second-generation self-inflating tissue expanders: a new dimension in tissue expansion p. 1313
Ibrahim A Soliman, Tarek F Kishk, Dalia M El Sakka, Ashraf M Al Rahawy
DOI:10.4103/mmj.mmj_180_19  
Objective To study the different uses of second-generation self-inflating tissue expanders regarding the advantages, disadvantages, and the rate of complications. Background Tissue expansion is a valuable technique in soft-tissue reconstruction. Osmotic expanders are self-inflating and obviate the need for repeated injections. They eliminate port-site problems and reduce the potential to introduce infection. The use of such expanders has become more common in recent years. Patients and methods The study included two parts: retrospective part from January to June 2017 and prospective part from August 2017 till January 2019. The study included 40 patients, admitted to the Plastic Surgery at El-Menoufyia University Hospital and Prince Mohammad Bin Abdulaziz National Guard Hospital – Madinah in Saudi Arabia. The patients had post-burn scars, alopecia, and large nevi. A total of 69 second-generation self-inflating tissue expanders were implanted from January 2017 till January 2019, with a follow-up period of 12 months. Results Of the patients, 30 patients were females and 10 were males. The indication was large scar in 30 cases, alopecia in five cases, and giant nevus in five cases. Extrusion occurred in 10 (14.4%) expanders, which occurred in six (15%) patients. The highest percentage of extrusion occurred in the scalp, in which six of 10 expanders extruded. Conclusion The study indicates that self-inflating expanders can be safely and effectively used for various plastic and reconstructive procedures especially in children. The fact that numerous painful and distressing filling sessions are obviated with these expanders is particularly beneficial for those children too young to understand and cooperate. Moreover, this approach minimizes the risk of infection and lowers costs.
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CARDIOTHORACIC SURGERY - ORIGINAL ARTICLES Top

Short-term results of coronary artery bypass grafting for vessels with previous percutaneous coronary intervention p. 1318
Ahmed L Dokhan, Bassem A Hafez, Mohammed A El-Hag-Aly, Michael Adel Soliman Yousef
DOI:10.4103/mmj.mmj_201_18  
Objectives To determine whether previous percutaneous coronary intervention (PCI) has a prognostic impact on the outcome of subsequent coronary artery bypass grafting (CABG). Background Interventional cardiologists have a growing role in the treatment of coronary artery diseases due to improvement of technology. Its 'less invasiveness' is more attractive to patients. Around one-third of patients with multivessel disease treated with bare metal stents will require reintervention within few years. CABG and PCI have a long history as invasive options for treating patients with coronary artery disease. The interventional efficacy and relative benefits have been compared in several randomized and observational studies. However, the patients who have undergone successful myocardial revascularization may subsequently require repeat invasive cardiological or surgical intervention. Patients and methods This was a prospective analytical study conducted on 50 consecutive patients with previous PCI indicated for CABG from Police Authority Hospitals and Nasser Institute Hospital and who have undergone CABG in the period between May 2016 and May 2018. These patients collected and were investigated by laboratory tests and radiologically to determine whether previous PCI has a prognostic impact on surgical outcome. Results The mean age was 51.36 ± 8.056 years. The mean number of grafts was 2.84 ± 0.47. Inotropes was used in 13 patients. ICU stay was 72.56 ± 54.44 h, hospital stay was 10.72 ± 3.99 days, and total postoperative complication occurred in 18 (36%) patients, which was perceived as a high morbidity rate. Conclusion Previous PCI has a negative impact on the outcome of subsequent CABG regarding morbidity. However, there was no impact on the postoperative mortality.
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Short-term outcomes of emergency coronary artery bypass grafting p. 1323
Abouelmakarem M Abdelmoaty, Ahmed L Dokhan, Aly H Taher, Medhat R Nashy
DOI:10.4103/mmj.mmj_252_18  
Objectives This study aims to evaluate short-term outcomes of emergency coronary artery bypass grafting (CABG) surgery, about inotropic support, complications, and early postoperative morbidity and mortality. Background Outcomes of emergency CABG surgery for critical left main coronary artery disease. Patients and methods Forty patients were examined from October 2013 to May 2018. Those included were those who underwent emergency CABG; patients with left main coronary artery disease more than 90% or left main equivalent more than 90%,; and all patients undergoing coronary artery bypass surgery. Results Most of our patients had severe chest pain before surgery. Sixteen (40%) patients showed severe chest pain in one or two steps. Fourteen (35%) patients show severe pain during rest, Hemo-dynamic (HD) instability (32.5%), need for inotropes (32.5%), need for intra-aortic balloon pump counterpulsation (67.5%), postoperative bleeding (7.5%), arrhythmia (10%), myocardial infarction (2.5%), renal impairment (2.5%), stroke (2.5%), and in hospital postoperative mortality (2.5%). The study shows a statistically significant difference in the improvement of ejection fraction% in the study group through the whole period of study with a P value of 0.047. Conclusion Our study demonstrated that the patients undergoing emergency CABG have a significant higher preoperative risk especially with myocardial impairment. A reasonable and favorable clinical outcome can be achieved when those patients tolerate the surgery and survive. Also, we assume that establishing hemodynamic stability in conjunction with the cardiologist prior to surgery significantly influences the surgical outcome.
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GENERAL AND VASCULAR SURGERY - ORIGINAL ARTICLE Top

Recent trends in the management of deep vein thrombosis in cancer patients p. 1328
Nehad A Zaid, Mahmoud S Abd El-Haleem, Ali M. S El-Sayed Shaat
DOI:10.4103/mmj.mmj_407_18  
Objective To focus on the recent trends in the management of deep vein thrombosis (DVT) in malignancy as well as its fatal complications. Background DVT is usually silent in nature in most of the hospitalized patients and is usually presented by nonspecific symptoms and signs. Patients and methods A prospective study was carried out on 60 patients at Ahmed Maher Teaching Hospital between 2017 and 2018. The patients were divided into two groups: the first group composed of 30 cancer patients on whom prophylactic measures against venous thromboembolism was applied for 8 months and the second group composed of 30 cancer patients with a history of DVT and who had undergone management and follow-up for 3–6 months. Full history, routine, physical examination, routine investigations, and coagulation profile were done. Results The mean age of the prevention group was 54.87 ± 11.34 and 59.10 ± 12.50 in the management group. The incidence of DVT was 16.7%. In the management group, the rate of resolution of DVT without complications after being treated with low molecular weight heparin (LMWH) for 6 months was 66. The rate of cases developed pulmonary embolism from the management group was 10%. The rate of deaths due to DVT and its complications was 3.3%. Conclusion LMWH prophylaxis in patients undergoing cancer-related surgery has proved to be effective and safe in reducing the risk of an acute event. Thromboprophylaxis with LMWH, unfractionated heparin, and mechanical methods should be considered for all patients with a malignancy who undergo surgery.
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OBSTETRICS AND GYNECOLOGY - ORIGINAL ARTICLES Top

Comparison of the effect of carbetocin versus oxytocin during cesarean section in women with high risk of postpartum hemorrhage p. 1333
Ahmad N Abdelhamid, Tarek M Sayyed, Haitham A Hamza, Abeer A A Emara
DOI:10.4103/mmj.mmj_160_18  
Objectives To compare the hemodynamic effects of oxytocin and carbetocin and to assess the efficacy of these two drugs in terms of blood loss and the additional uterotonic needed in cesarean section in women with high risk of primary postpartum hemorrhage (PPH). Background Prevention of PPH is a major issue owing to its effect on maternal morbidity and mortality. Although oxytocin is the most widely accepted uterotonic agent, carbetocin can be given as an intravenous bolus instead of continuous oxytocin infusion. Patients and methods This is a prospective, randomized controlled study conducted from March 2016 and October 2017 within the Department of Obstetrics and Gynecology in Menoufia University Hospitals. The study included 100 pregnant women with high risk of PPH; women were divided randomly into group A, which received oxytocin infusion of 20 international units, and group B, which received 100 μg carbetocin as an intravenous bolus. Results Regarding the hemodynamic effects, there was a significant lower reduction in blood pressure within the oxytocin group. Significantly more women needed additional uterotonic agents in the oxytocin group. Uterine fundal level was significantly below 2 cm from the umbilical point in carbetocin group. The mean cost in oxytocin group is lower with a highly significant difference. Conclusion Single injection of carbetocin has more safe hemodynamic profile and less need of uterotonics, but the introduction of oxytocin appears to provide improved clinical outcomes along with cost savings.
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Visceral adiposity and insulin resistance in the prediction of gestational diabetes mellitus in early pregnancy: a prospective observational study p. 1338
Osama A Elkelani, Alaa E Elahalaby, Ibrahim Saif Elnasr, Abeer E Abo El-Fetouh
DOI:10.4103/mmj.mmj_207_18  
Objective The aim was to study the relationship between abdominal adiposity and insulin resistance in the prediction of gestational diabetes mellitus (GDM) in early pregnancy. Background There is a positive association between high prepregnancy BMI and risk of GDM. Patients and methods This prospective cohort study included 83 women at 11–14 weeks for abdominal adiposity measurement and at 16–22 weeks for oral glucose tolerance test measurement. The patients were divided into two groups: group 1included patients who did not develop GDM and group 2included patients who developed GDM. This study was conducted at the Obstetrics and Gynecology Department, Menoufia University Hospital between March 2015 and March 2017. Results There was a significant statistical difference between both groups as regards visceral adipose tissue (VAT) depth (P = 0.001) with a mean ± SD of VAT depth (5.85 ± 0.47) increase in group 2. There was a positive relationship between visceral adiposity and the homestatic model assessment of insulin resistance and a negative relationship between visceral adiposity and insulin sensitivity. The γ2 values examining the association between VAT depth and measured homestatic model assessment of insulin resistance or insulin sensitivity were higher than the γ2 examining the association between BMI and measured homestatic model assessment of insulin resistance or insulin sensitivity index. Conclusion Measurement of visceral adiposity during the 11–14 weeks' gestation by ultrasound might improve the performance of screening for GDM better than BMI.
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Effect of transdermal nitroglycerin compared with sildenafil citrate on Doppler indices in intrauterine growth restriction p. 1343
Zakaria F Sanad, Hamed E El-lakwa, Hesham S E Mahmoud, Ahmed Z Nofal, Mustafa Abd El-Hakeem Muhammad
DOI:10.4103/mmj.mmj_211_18  
Objective This study aimed to compare the effect of sildenafil citrate on pulsatility index of uterine, umbilical and middle cerebral arteries to that of nitroglycerine in cases of intrauterine growth restriction (IUGR). Background IUGR is one of the most common and serious complications of pregnancy. Sildenafil citrate and nitroglycerine are emerging as potential candidates for the treatment of IUGR through improving uteroplacental blood flow. Participants and methods Ninety singleton pregnancies, with IUGR and abnormal uterine and umbilical arteries Doppler, were included in the study and randomized into three groups to receive either oral sildenafil citrate (50 mg), a transdermal nitroglycerine patch (10 mg), or placebo. Maternal mean arterial blood pressure and the pulsatility index (PI) of uterine (Ut.A), umbilical (UA) and fetal middle cerebral (MCA) arteries were measured before and two hours after application of drugs. Results A significant reduction of Ut.A-PI occurred after application of both sildenafil citrate (16.7%, P = 0.001) and nitroglycerine (18.7%, P = 0.001). UA-PI also showed a significant decrease with both sildenafil citrate (17.8%, P = 0.001) and nitroglycerine (17.03%, P = 0.001), with no significant difference between the two drugs. No changes were observed in Doppler velocimetry in the placebo group, and no significant change in MCA-PI was observed in any group. Maternal arterial blood pressure decreased significantly with administration of both sildenafil citrate and nitroglycerine. Conclusion Sildenafil citrate has an effect similar to nitroglycerine in improving Doppler indices and blood flow of uterine and umbilical arteries in growth-restricted fetuses.
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Three-dimensional sonographic assessment of placental volume and vascularization in pregnancies complicated by hypertensive disorders p. 1350
Emad A Soliman, Mohammed A Emarah, Abd Elhamid E. Shaheen, Hamed H E. Yassin
DOI:10.4103/mmj.mmj_233_18  
Objective The aim was to compare placental volumes (PVs) and vascularization between normotensive pregnant women and women with hypertensive disorders using three-dimensional sonography. Background Hypertensive disorders in pregnancy are responsible for substantial maternal and fetal morbidity and mortality. Materials and methods This study was conducted at the Outpatient Clinic and Obstetric Departments of Shebin El Kom Teaching Hospital from February 2017 to January 2018. This study included 60 pregnant women, among which 20 were with normal blood pressure which served as the control group (group 1) and 20 were having chronic hypertension (group 2), and 20 with mild preeclampsia (group 3). Full history taking, physical examination, and laboratory investigation were done. Each patient from each group underwent three-dimensional ultrasound examination of the placenta for PV and placental vascular indices. Results There was significant statistical difference between three groups as regards PV to fetal weight ratio, with significant statistical differences between normotensive and chronic hypertensive groups (P = 0.016) and with significant statistical differences between normotensive and mild preeclamptic groups (P = 0.002). As regards placental vascular indices, there was high significant statistical differences between the three study groups (P = 0.001) as regards placental vascularization index with significant statistical differences between the three studies groups as regards placental vascular flow index (P = 0.03), But, there was no significant statistical difference between the tree groups as regards placental flow index (P = 143). Conclusion Pregnancies complicated by hypertensive disorders are associated with reduced placental vascularity but not with reduced PVs.
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Role of transvaginal Doppler sonography in cases of irregular uterine bleeding with depot medroxyprogesterone acetate p. 1355
Medhat Essam, Alaa Alhalabi, Haitham Hamza, Mohammed Wahid Al-Sarag
DOI:10.4103/mmj.mmj_237_18  
Objectives To evaluate role of transvaginal Doppler sonography in cases of irregular uterine bleeding with depot medroxyprogesterone acetate (DMPA). Background Abnormal uterine bleeding is the leading cause of cessation of DMPA use. The definite mechanism of abnormal uterine bleeding has remained vague. Transvaginal Doppler is a noninvasive technique for studying Doppler changes of uterine and spiral artery in cases of abnormal uterine bleeding with DMPA. Patients and methods A case–control study was done on two groups of users of DMPA, one group included 21 cases with abnormal uterine bleeding, and the second group included 21 cases with amenorrhea. Transvaginal sonography was done, and endometrial thickness was measured in greatest sagittal section of the uterus. Uterine and spiral artery pulsatility index (PI) and resistance index (RI) were measured. Data were collected and tabulated. Results Significant changes in PI and RI of uterine and spiral arteries were detected. Uterine artery RI and PI were lower in bleeding group (P = 0.003 and 0.021, respectively), and spiral artery RI and PI were lower in bleeding group (P = 0.0007 and 0.0003, respectively). Conclusion Abnormal uterine bleeding with DMPA is associated with hemodynamic changes in transvaginal Doppler in form of increased blood flow in uterine and spiral arteries as indicated by significant decrease in RI and PI of both arteries.
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Evaluation of placenta accreta index to predict placental invasion in patients with placenta previa p. 1359
Hamed ElLakwa, Zakaria Sanad, Haitham A Hamza, Nareman Elhamamy, Mohamed El-Sheikh, Amr Samak
DOI:10.4103/mmj.mmj_197_19  
Objective To evaluate the role of placenta accreta index in predicting placental invasion in patients with placenta previa. Background Placenta accreta placenta is a condition in which placenta is adherent to the uterine wall because of myometrial invasion. Patients and methods In this prospective study, 60 pregnant women with placenta previa were enrolled at the Obstetrics Clinics of Menoufia University Hospitals in the period from January 2016 to December 2017. The placenta was scanned using gray-scale ultrasound and color Doppler. Placenta accreta index was formulated for each patient. Definitive diagnosis was made at delivery when the myometrium invasion by the placenta was seen. The hysterectomy specimens were sent for pathological confirmation of placental invasion. Data were collected and entered using Statistical Packages for the Social Science program for statistical analysis. Results Nineteen patients were found to have placenta accreta. All the parameters of placenta accreta index were statistically significant. The total score was significantly higher in accreta patients (P < 0.001). Receiver operating characteristic curve showed that score 4 was the best cut-off point to diagnose placenta accreta. The number of patients that had index above 4 was 18 patients. Seventeen patients of them were proved to have placenta accreta (P < 0.001). Conclusion Placenta accreta index score 4 can be used as a cut-off value for prediction of placental invasion in patients with placenta previa.
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Infertility and related risk factors among women attending rural family health facilities in Menoufia Governorate p. 1365
Zakaria F Sanad, Nora Abd El-Hady Kalil, Eman S. Abd El-Rahman Beddah
DOI:10.4103/mmj.mmj_269_18  
Background Infertility is perceived as a problem across virtually all cultures and societies and affects 10–15% of couples in their reproductive age. Objective The current study aimed to assess the prevalence of infertility among women attending the studied health facilities and explore the different factors related to infertility among the studied group. Patients and methods The cross-sectional descriptive study was conducted on 320 married women in the child-bearing period. The calculated sample was collected from four primary health-care facilities which were randomly selected. Women were interviewed by a predesigned questionnaire. Results The prevalence of infertility among the studied group was 25%. The prevalence of primary and secondary infertility was 9 and 16%, respectively. Infertility was significantly associated with overweight and obesity (P < 0.05), sedentary lifestyle (P < 0.001), irregular menstruation (P < 0.001), history of pelvic inflammatory disease (P < 0.001), and passive smoking (P < 0.05). Conclusion There are numerous risk factors affecting infertility in the Egyptian women, and many of them are preventable.
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Effect of metformin treatment on ovarian stromal blood flow in women with polycystic ovary syndrome p. 1371
Mehany M Abd EL-Sattar, Osama A EL-Kelany, Alaa EL-Din F EL-Halaby, Hussein M A Esmaeel
DOI:10.4103/mmj.mmj_294_18  
Objective The aim was to study the effect of metformin treatment on ovarian stromal blood flow in women with polycystic ovary syndrome (PCOS). Background PCOS is an endocrine disorder that affects mostly women of reproductive age. Metformin has positive biochemical effects in PCOS patients' therapy. Patients and methods A case–control study was conducted on 98 women who were divided into: group I which included 49 infertile women with PCOS and group II which included 49 fertile women without PCOS. All patients attended the Obstetrics and Gynecology Outpatient Clinic at Menoufia University Hospitals and Tala General Hospital, Egypt, from April to November 2017. Detailed history, clinical examination, routine baseline investigations, and Doppler flow were done. Results There was a statistically significant difference between the studied groups regarding weight, BMI, follicle-stimulating hormone, and Doppler post-treatment resistance and pulsatility indices (left, right). There was a statistically highly significant difference (P ≤ 0.001) regarding Doppler posttreatment resistance and pulsatility indices (left, right) before and after metformin treatment. Also, a nonsignificant correlation was recorded between Doppler resistance and pulsatility indices (left, right) and age, weight, BMI, follicle-stimulating hormone (mIU/ml), and luteinizing hormone (mIU/ml) in the patients group after metformin treatment. Conclusion Metformin has a beneficial effect in women with PCOS via correcting the ovarian stromal blood flow and hormonal profile. Ovarian stromal Doppler markers such as the resistance index and pulsatility index can help us to follow up the therapy of PCOS patients.
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Comparison the efficacy and safety between Insulin and Metformin in gestational diabetes mellitus management p. 1376
Ahmed N Abdel Hamid, Alaa M Abd El-Gayed, Ibarhim A Saif-Elnasr, Mohamed H Soliman
DOI:10.4103/mmj.mmj_303_18  
Objective The objective of this study was to evaluate the efficacy and safety between insulin and metformin in the management of gestational diabetes mellitus (GDM). Background GDM is a common complication of pregnancy. Blood glucose control improves perinatal outcomes. Medical nutrition therapy is the milestone management. Patients and methods In a prospective randomized comparative study, 240 antenatal women whose pregnancies had been complicated by GDM and did not respond to diet alone were recruited from antenatal clinics at the Obstetrics Department in Menofia University Hospitals and Shebin El-Kom Teaching Hospital from November 2016 to March 2018. They were divided randomly into two groups; 120 patients in each group were subjected to either insulin or metformin medications. Outcomes were comparing the effects of medications on maternal glycemic control, maternal complications and neonatal outcome. Results There was no significant difference in controlling high blood sugar in GDM with the use of insulin or metformin. Maternal complications in both groups had no significant difference, and fetal outcomes were as well similar. Conclusion Glycemic control in GDM can be achieved by using metformin orally without increasing the risk for maternal complications with a satisfying neonatal outcome.
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Comparing the efficacy of cefixime versus amoxicillin/clavulanate in the treatment of asymptomatic bacteriuria in pregnant women p. 1382
Emad Eldeen Soliman, Mohamed A Emara, Abdelhamid E Shahin, Mahmoud A M Nafie
DOI:10.4103/mmj.mmj_304_18  
Objective To evaluate efficacy of cefixime and amoxicillin/clavulanate in the treatment of asymptomatic bacteriuria (ASB) in pregnant women. Background ASB can cause progressive and severe infections and endanger maternal as well as fetal health. Bacteriuria is usually associated with low birth weight, high blood pressure during pregnancy, maternal anemia, and fetal death. Patients and methods A prospective randomized study was conducted on 100 pregnant women having ASB in the first and early second trimester attending the pregnancy follow-up clinic in Galaa Teaching Hospital. Detailed history, laboratory investigations, obstetric, and ultrasound follow-up study were done. Results Maternal age (year) of patients ranged from 20 to 35 years, with a mean of 26.06 ± 4.91 years. The presence of pus and serial assessments of fetal growth were significant differences among the studied patients. Overall, 25% of patients had Intrauterine growth retardation (IUGR), 13% had premature rupture of membranes, and 13% had preterm labor. Adverse effects of drug such as presence of Gastrointestinal (GIT) upset, diarrhea, and vaginal candida infection were significantly increased in group 1 (18, 22, and 22%, respectively) than group 2 (4, 6, and 6%, respectively). Conclusion The use of amoxicillin/clavulanate is significantly more often accompanied by the development of adverse reactions compared with cefixime. Amoxicillin/clavulanate shows higher incidence of GIT manifestation, diarrhea, and vaginal candida infection. So, further larger studies could provide cost-benefit data necessary to inform a national screening program.
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Uterine artery Doppler indices may predict significant causes of perimenopausal bleeding p. 1388
Ayman Shabana, Mohamed Rezk, Dalia Ibrahim, Shaimaa Abd-Elhamid, Mohammed Salah
DOI:10.4103/mmj.mmj_335_18  
Objective The aim was to assess whether uterine artery Doppler indices can predict significant causes of uterine bleeding in patients with perimenopausal bleeding or not. Background Treatment of abnormal uterine bleeding needs easy diagnostic procedure, for determining the etiological factor of disease. The abnormal uterine bleeding is more common in the perimenopausal than in the postmenopausal women, and it is a sign of endometrial proliferative or hyperplastic changes. Patients and methods This prospective observational study was conducted on 106 women with perimenopausal bleeding [who were subdivided into two groups, one with nonsignificant causes (52 patients) and the other with significant causes (54 patients)] and 50 healthy controls, with transvaginal ultrasonic color Doppler study performed before endometrial sampling with pipelle in those with perimenopausal bleeding. Test characteristics of uterine artery pulsatility index and resistance index for prediction of significant causes of bleeding were the main outcome measures. Results Uterine artery pulsatility index at cutoff value of 1.82 with area under the curve of 0.834, sensitivity of 70.8%, specificity of 92%, positive predictive value of 94.9%, negative predictive value of 69.9%, and accuracy of 78%, whereas uterine artery resistance index at cutoff value of 0.575 with area under the curve of. 998, sensitivity of 96.2%, specificity of 100%, positive predictive value of 100%, negative predictive value of 92.6%, and accuracy of 97% were predictive of significant causes of perimenopausal bleeding. Conclusion Uterine artery Doppler is a simple, readily available and noninvasive tool that could be beneficial in conjunction with endometrial sampling to detect significant causes of perimenopausal bleeding.
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Comparison between intracervical Foley catheter plus misoprostol and misoprostol alone for labor induction p. 1393
Osama A El-Kelani, Alaa El-Deen F El-Halaby, El-Sayed A El-Shamy, Taher N Abd El-Fattah
DOI:10.4103/mmj.mmj_342_18  
Background and objective Potential advantages of mechanical methods, compared with pharmacological methods, may include simplicity of preservation, lower cost, and reduction of the adverse effects. The objective of this study was to compare the efficacy of combined intracervical Foley catheter and vaginal misoprostol with vaginal misoprostol alone for labor induction. Participants and methods This study was a prospective randomization clinical trial carried out from July 2016 to May 2018 in Benha Health Insurance Hospital. Two hundred pregnant women underwent induction of labor with singleton pregnancies at full-term gestation with (Bishop Score ≤6) by Foley catheter plus vaginal misoprostol (group A, n = 90) or vaginal misoprostol alone (group B, n = 110). Women with fetal malpresentation, multiple pregnancies, spontaneous labor, contraindication to prostaglandins, intrauterine growth restriction, anomalous fetus, and in active phase of labor, or previous cesarean delivery were excluded. The outcome measures were induction-to-delivery time, mode of delivery, oxytocin use, tachysystole with fetal decelerations, complications, neonatal Apgar scores, and neonatal ICU admission. Data were expressed as mean ± SD. Student's t-test was used to compare the mean difference between the two groups, and P value is used to determine the significance of the result. Results The mean induction-to-delivery time was shorter in group A when compared with group B (14.5 ± 4.1 h compared with 18.9 ± 5.2 h, difference 4.4 ± 1.1 h). There were no differences in labor complications or adverse neonatal and maternal outcomes. Conclusion A combined method resulted in a shorter induction-to-delivery time without increasing labor complications.
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Prevalence of aerobic bacterial vaginosis among chronic copper T380 intrauterine device users p. 1397
Said Abd El AttiSaleh, Ibrahim A SaifAlnasr, Ahmed A K Nasef
DOI:10.4103/mmj.mmj_368_18  
Objective To determine the prevalence of bacterial vaginosis (BV) among chronic copper T380 intrauterine device (IUD) users. Background There are two gold standards used to diagnose BV: Amsel clinical criteria and laboratory-based Nugent gram-staining evaluation. IUD may affect the normal vaginal microbiota system causing BV. Materials and methods The present study was conducted at Al Amiriyah General Hospital, Family Planning Clinic, Gynecology Department, after informed consent was taken from them. It was approved by the research ethics committee at Faculty of Medicine, Menoufia University. One hundred female patients came for routine checkup on their intrauterine contraceptive device and fulfilled the inclusion criteria. Samples of the vaginal discharge were obtained with two dry cotton-wool-tipped swabs from the lower third of the vaginal wall. For the first swab, wet mount preparation for examination of clue cells, measurement of vaginal pH, and Whiff test were performed to fulfill Amsel criteria. The second swab was gram stained by a microbiologist and assessed using Nugent's criteria. The outcome measures positive culture of aerobic BV and positive Amsel criteria. Results It was found that age group above 30 years old had the highest prevalence of BV and there was no statistically significant relation between use of douche and Amsel criteria. Conclusion There was a statistically significant association between diagnosis of BV and age group above 30 years using copper IUD for more than 1 year.
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Role of hysteroscopy and laparoscopy in evaluation of unexplained infertility p. 1401
Mohamed S Gad, Ragab M Dawood, Mohamed S Antar, Shaimaa E M Ali
DOI:10.4103/mmj.mmj_387_18  
Objective To evaluate the diagnostic and therapeutic role of combined hysterolaparoscopy in female infertility. Background Infertility affects approximately 10–15% of reproductive age couples. Causes of infertility in the female partner include ovulatory, tubal, uterine, cervical, and endometriosis. Owing to its noninvasive nature and low cost, hysterosalpingography (HSG) is widely used as a first-line approach to assess the patency of the fallopian tubes and uterine anomalies. We assessed hysterolaparoscopy as a one-step procedure and compared it with HSG, in the ovulatory infertile women with normal pelvic sonography, seminogram, hormonal assays, and HSG. Even in women thought to be at low risk for significant pelvic pathology affecting reproduction, the yield was high. Laparoscopy was helpful in making a decision to go to assisted reproductive technology. Patients and methods An observational cross-sectional study conducted on 200 women aged 20–40 years old with unexplained infertility. Methylene blue test, inspection for abnormal pelvic and intrauterine pathology, and therapeutic interventions when needed were done. Results Of 200 patients, 116 had primary and 84 had secondary infertility. The patients in the secondary infertility group were older compared with the primary group. The most common intrauterine pathology was uterine septum. Adnexal adhesions and endometriosis were the most common abnormalities detected in laparoscopy. The prevalence of endometriosis and unilateral tubal block was higher in the primary group. The operative interventions, both hysteroscopic and laparoscopic, were also recorded. Conclusion Hysterolaparoscopy is a reliable method in comprehensive evaluation of infertility.
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Correlation between second and third trimester placental thickness with ultrasonographic gestational age p. 1406
Ahmed N Abdelhamid, Tarek M Sayyed, Abdel Hamid E Shahin, Mohammed A Zerban
DOI:10.4103/mmj.mmj_389_18  
Objectives The objective of this study was to evaluate the correlation between placental thickness in the second and third trimesters with gestational age, weight, and fetal outcome. Background Ultrasonography enables the evaluation of the placenta and the detection of placental abnormalities using different parameters such as placental thickness and volume or special techniques like three-dimensional power Doppler. Materials and methods This cohort study was conducted at the Departments of Obstetrics and Gynecology of Menoufia University Hospitals and Shebien Elkom Teaching Hospital from June 2017 to May 2018. This cohort study comprised 100 pregnant women who were attending the antenatal clinic at 24 weeks and were followed-up at 32 and 36 weeks. Detailed history was taken to rule out medical and surgical illnesses that could affect the study. Thorough general, physical, and obstetrical examinations were carried out. US examinations were performed at three visits: first between 24 and 28 weeks, second between 28 and 32 weeks, and third between 32 and 36 weeks. Results There was a significant positive correlation between placental thickness and birth weight in the second and third trimesters. The mean age of cases was 28 ± 5 years. Mean birth weight was 3243 ± 402 g, and mean placental weight was 511 ± 64 g. US measures of placental thickness in the first, second and third visit were 24.91 ± 1.27, 29.50 ± 1.23, and 34.60 ± 1.6 mm, respectively. Conclusion Measurement of placental thickness by ultrasonography is a good predictor tool for estimating the fetal weight.
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Screening for bacterial vaginosis before and after intrauterine device insertion p. 1411
Ahmed N Abd El-Hamid, Tarek M Sayyed, Eman H Salem, Asmaa N Hasan
DOI:10.4103/mmj.mmj_414_18  
Objective To screen for bacterial vaginosis (BV) before and after insertion of intrauterine device (IUD), screen for complications of IUD, and evaluate the relation between BV and complication of IUD. Background IUD is one of the most prevalent and effective reversible methods of contraception worldwide. Users of the IUD may be at increased risk for BV, pelvic inflammatory diseases, and other complications. Patients and methods An observational cohort study was done for 147 women who came for IUD insertion. Complete history was taken, questionnaire was filled out, and vaginal swabs were taken from the posterior vaginal fornix before insertion of IUD and at 1 and 2 months after insertion of IUD. Complications of IUD were recorded. BV was diagnosed using Amsel's criteria and Nugent scoring methods. Results The prevalence of BV was 27.2% before IUD insertion and 9.5% after insertion (fresh diagnosis) at 1 month. The commonest complications of IUD were pelvic pain, vaginal bleeding, followed by abnormal vaginal discharge and dyspareunia. These complications were significantly higher in Gram stain-positive group than Gram stain-negative group. Conclusion The prevalence of BV is within the range of BV found among women of reproductive age group worldwide. The current standard of care does not require screening for BV before IUD insertion. The complication rate appeared significantly higher in patients with BV than those without.
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OTORHINOLARYNGOLOGY - ORIGINAL ARTICLES Top

Outcome of supracricoid laryngectomy in moderately advanced cancer larynx p. 1417
Abd El-Latif I El-Rasheedy, Yaser A Khlail, Ibrahim A Abd El-Shafy, Hossam A Husien, Anwar Abd El-Atty Ibrahim
DOI:10.4103/mmj.mmj_210_18  
Objective To assess the oncological outcomes of supracricoid laryngectomy in moderately advanced laryngeal cancer. Background Recently supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) and other surgical laryngeal preservation protocols have undergone major advancement to treat early and moderately advanced laryngeal tumors. SCPL with CHEP and CHP preserves the airway and laryngeal sphincter function with considerable decrease in the amount of risk of aspiration. Patients and methods A total of 10 patients with moderately advanced laryngeal squamous cell carcinoma (T2b toT4a) who were fit for surgery were recruited from two different specialized care centers in Egypt and India from January 2017 to January 2018. Patients with interarytenoid area involvement, cricoarytenoid joint involvement, pre-epiglottic space invasion, or subglottic extension were excluded. Results Patients were mainly T3 (four patients). They underwent SCPL with CHP in four cases and with CHEP in six cases. Preservation of one arytenoid was done in nine patients. The local control rate was 100%. Aspiration occurred in two cases. Both pexy rupture and salivary fistula occurred in one case. Removing of nasogastric tube and decannulation of tracheostomy were done in seven and six cases, respectively, before 1 month. Conclusion SCPL with CHEP and CHP was an effective treatment option with excellent oncological outcomes for T2b–T4a laryngeal cancer. Specific efficacy was revealed in cases with anterior commissure or paraglottic space involvement. Low rate of complications was reported in our study.
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Evaluation of nasal and paranasal findings in cases of migraine p. 1423
Essam A Behairy, Tarek A Abd El-Hafez, Khaled H Afifi, Marwa K Moustafa
DOI:10.4103/mmj.mmj_283_18  
Objective The objective of this study was to evaluate nasal and paranasal findings in cases of migraine. Background Migraine triggers are abundant, and anatomical nasal variations like septal spur, concha bullosa, and hypertrophied inferior turbinate may be considered as important trigger factors for migrainous headache by mucosal contact according to the trigeminovascular theory as a proposed mechanism for migraine. Patients and methods This was an observational cross-sectional study comparing 60 patients with migraine versus 40 normal participants with neither migraine nor nasal presentations. History was taken to define the type of migraine and its severity according to Migraine Disability Assessment Score. Computed nasal and paranasal tomography scan, diagnostic nasal endoscopy, and nasal decongestant test were done for all of them to diagnose nasal and paranasal findings in both groups and to confirm mucosal contact points in migraineurs. Results There was a significant increase in overall septal, turbinate, and mucosal findings in case group compared with control group. There was a statistically significant difference between the two groups regarding septal spur, concha bullosa, and abnormal nasal mucosa, being more prevalent in the case group. The most common contact point was between the septum and middle turbinate, with a nonsignificant correlation between the type of contact point and severity of migraine. Conclusion The presence of nasal findings in migraineurs was significantly associated with triggering of migraine through contact point mechanism. The significant findings were septal spur, concha bullosa, and abnormal nasal mucosa, with the most common contact point being between the septum and middle turbinate.
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OPHTHALMOLOGY - ORIGINAL ARTICLES Top

Incidence and pattern of ocular trauma among ophthalmic patients in Menoufia University Hospitals p. 1430
Hoda M. K. El-Sobky, Amin F. A. Ellakwa, Moataz F. A. El-Sawy, Ahmad Al-Kamel Hamed
DOI:10.4103/mmj.mmj_254_18  
Objectives The aim of this study was to determine the incidence and pattern of ocular trauma among ophthalmic patients who presented to Menoufia University Hospitals. Background Ocular trauma is a major preventable cause for monocular morbidity and blindness worldwide. Patients and methods This was a prospective study estimating patients who sustained ocular trauma within a 1-year period (January 2016–December 2016); the association between variables was checked by the χ2 test. Results A total of 1138 eyes of 1129 patients had sustained ocular trauma in a 1-year period (2016). The incidence of ocular trauma was 6.1%, and hospitalized patients accounted for 11.2%. The mean age of the patients was 22.4 ± 19.2 years; 69.1% were male patients and 30.9% were female patients, with a male to female ratio of 2.2: 1. The majority of injuries were adnexal injuries (42.1%) followed by globe injuries (30.6%), ocular surface foreign body (25.2%), ocular wall foreign body (0.4%), chemical injuries (0.4%) and radiation injuries, that is, 'photokeratitis' (1.2%). In globe injuries, 67 (19.3%) were open globe (52 eyes with rupture globe, 13 eyes with penetrating injury, two eyes with intraocular foreign body) and 281 (80.7%) were closed globe [32 (11.4%) were contusion, whereas 249 (88.6%) were lamellar laceration]. The most common eye injury was periocular ecchymosis and edema (40%). Conclusion Ocular trauma is a major problem for monocular morbidity and blindness. Students and workers who were involved in street activities and workplaces were the most affected.
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Intraocular pressure changes after repeated ranibizumab injection p. 1436
Hasham M El-Mazar, Ahmed A Al Hagaa, Ahmed S Elesawy
DOI:10.4103/mmj.mmj_270_18  
Objective The aim was to evaluate early changes of intraocular pressure (IOP) after repeated ranibizumab (Lucentis) injection. Background Ranibizumab is widely used in the treatment of macular edema and choroidal neovascularization. Screening should be frequently done to avoid its adverse effect. Materials and methods A prospective noncomparative case series study was conducted at Menoufia and Kalawoon hospitals, where patients were subjected to intravitreal injection of ranibizumab (Lucentis) for early IOP changes. IOP was measured with a Goldman tonometer before injection, after 30 min, after 1 day, and after 1 week of injection. Results At every time of injection, there was a highly significant difference in IOP measured at 30 min after injection (P < 0.001). However, there was no significant difference measured after 1 day (P = 0.91) and after 1 week of injection (P = 0.56). In repeated intravitreal ranibizumab injection comparison of preoperative, 30 min, 1 day, and 1 week after injection correspondingly, we found no significant difference in IOP measured between first and second injection in preoperative, 30 min, 1 day, and 1 week after injection (P = 0.11, 0.36, 0.17, and 0.26, respectively). However, there was a significant difference in IOP measured between first and third injections regarding preoperative, 30 min, 1 day, and 1 week after injection (P = 0.3, 0.2, 0.1, and 0.3, respectively). Conclusion Ranibizumab injected intravitreally causes a significant transient rise of IOP. The rise is transient for 24 h and normalizes after that.
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Outcome of keratoprosthesis implantation in end-stage corneal diseases p. 1441
Ehab S Othman, Hany A Khairy, Sameh S Mandour, Mahmoud Y Mahmoud
DOI:10.4103/mmj.mmj_394_18  
Objective The objective of this study was to evaluate the indications, outcomes, and complications of keratoprosthesis (type I Boston keratoprosthesis) in end-stage corneal disease. Background Corneal diseases are the leading cause of blindness worldwide, second after cataract. Eyes with deep corneal vascularization, limbal stem cell deficiency, autoimmune diseases, and chemical injury are prone to graft rejection. Keratoprosthesis offers visual rehabilitation in such situations. Patients and methods In this prospective clinical study, 10 eyes of 10 patients with an end-stage corneal disease underwent implantation of type I Boston keratoprosthesis, with a mean follow-up of 6.9 ± 1.4 months. The indications included multiple failed grafts (n = 6), ocular cicatricial pemphigoid (n = 3), and vascularized corneal opacity (n = 1). Antibiotic prophylaxis was administered postoperatively, and patients were followed up at 1 week, 1, 3, and 6 months. The main outcome measures were best-corrected visual acuity, retention of prosthesis, and complications. Results The most common indication for keratoprosthesis implantation was graft failure (6/10, 60%). Mean best-corrected visual acuity improved significantly after the surgery (P = 0.018). Nine (90%) patients had final visual acuity of 20/200 or better. Ten (100%) of 10 patients had retained keratoprosthesis. Complications occurred in only two (20%) patients, where one (10%) patient had keratitis and one (10%) patient had peripheral corneal melting. Conclusion Boston keratoprosthesis provides improved vision for patients having corneal blindness owing to end-stage corneal diseases; however, long-term studies are needed to monitor the late-onset complications in the postoperative period.
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Evaluation of intravitreal injection of ranibizumab in diabetic macular edema p. 1447
Abdel-Rahman E Sarhan, Sameh S Mandour, Ahmed Z Zayed
DOI:10.4103/mmj.mmj_410_18  
Objectives The aim of this study was to evaluate the intravitreal injection of antivascular endothelial growth factor of ranibizumab in patients with diabetic macular edema (DME). Background The study evaluated short-term and long-term effects of ranibizumab on the morphology and function of the retina. Patients and methods Fifty eyes of 44 patients with DME were enrolled in this prospective study. After intravitreal ranibizumab injection, central macular thickness (CMT) and best-corrected visual acuity (BCVA) were measured before, 1, 2, 3, and 6 months later. Results The mean CMT and logarithm of minimum angle of resolution BCVA improved significantly (P < 0.001) after the first, second, and third injections. Three eyes did not show improvement in CMT while seven eyes did not show improvement in BCVA. The most significant (P < 0.0001) correlation in mean CMT and logarithm of minimum angle of resolution BCVA is seen after the first month. In addition, significant change is seen in CMT (P = 0.001, 0.002) and BCVA (P = 0.0001, 0.001) between the first and second month and second and third month, respectively. Three months after the last injection, mean CMT insignificantly (P = 0.24) increased, and mean BCVA insignificantly (P = 0.51) decreased, but they were still significant with baseline. There was a significant correlation (P < 0.001) between the mean change in CMT and BCVA at all stages of the study. Conclusion In DME, intravitreal ranibizumab effectively decreased CMT as a structural aspect and hence improved BCVA as a functional aspect. Evaluation of the short-term effects of ranibizumab can predict the therapeutic outcome 1 month after injection.
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TROPICAL MEDICINE - ORIGINAL ARTICLE Top

Diagnostic value of platelet indices, carbohydrate antigen 19-9 and carcinoembryonic antigen in differentiating malignant from benign gastric ulcers p. 1452
Ayman M El Lehleh, Naglaa S El-Abd, Suzy F Gohar, Mohammad O Zarad
DOI:10.4103/mmj.mmj_186_19  
Objective To elucidate the value of platelet indices, carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) in differentiating malignant from benign gastric ulcers. Background Gastric cancer is one of the most common malignant diseases and benign gastric ulcer is a worldwide disease, responsible for substantial premature mortality. Clinical symptoms of early gastric cancer could not be used to distinguish gastric cancer from ulcers. Platelet indices: mean platelet volume (MPV) and platelet distribution width (PDW) are a group of platelet parameters investigated as platelet activation indicators. Patients and methods This prospective study included 150 patients: 30 patients with malignant gastric ulcer, 60 patients with benign gastric ulcer, and 60 healthy control participants. Upper endoscope with tissue biopsy and pathological evaluation, Helicobacter pylori stool antigen, platelet count, PDW, MPV, CEA, CA 19-9, computed tomography scan of the chest, abdomen, and the pelvis were assessed. Results Platelet count, MPV, PDW, CEA, and CA 19-9 were significantly higher in malignant gastric ulcer patients than benign ulcer patients and controls. MPV and PDW showed sensitivity, specificity, and area under the curve (93.3, 70 and 0.934% and 96.7, 86.7 and 0.966%, respectively) in predicting malignancy in gastric ulcer patients with improved diagnostic accuracy when combined with CEA and CA 19-9. Higher platelet count and PDW were significantly associated with advanced clinicopathological parameters of gastric cancer. Conclusion Changes in platelet indices are valuable markers in predicting malignancy in gastric ulcer patients. Significant increase in platelet count and PDW correlate and could be reliable markers, together with other markers of gastric cancer (CEA and CA 19-9), for clinicopathological features of malignant gastric ulcer.
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FAMILY MEDICINE - ORIGINAL ARTICLES Top

Screening of vitamin D deficiency among preschool children in family health facilities p. 1459
Hala M Shaheen, Karima A. E. Diab, Noha I Salam, Safa H Alkalash
DOI:10.4103/mmj.mmj_188_19  
Objective To assess the prevalence and risk factors of vitamin D deficiency among preschool children in family health facilities in Birket El Sabaa district. Background Vitamin D deficiency in childhood may play an important function in pathophysiology not only of rickets but also of nonskeletal diseases that have an immune system-mediated pathogenesis. Patients and methods An analytical cross-sectional study was conducted on 96 preschool children who attended the selected family health facilities in Birket El Sabaa district during the period of data collection (3 months). This study started on the1st of April 2018 and lasted till March 2019. History, clinical examination, and serum vitamin D level measurement were conducted. Results The prevalence of vitamin D deficiency among preschool children was 63.5%, and 20.83% of them had mild deficiency, 31.25% moderate deficiency and, 11.46% had severe deficiency. Vitamin D deficiency was more among male children (54.10%) than female (45.90%). Fatigue, bone fracture, and delayed teething were significantly higher in vitamin D-deficient children than normal children. There was a statistically significant difference between vitamin D-deficient children and normal children regarding sex, education and work of mother, socioeconomic state, and sun exposure. Conclusion From the current study, we can conclude that vitamin D deficiency among preschool children was 63.5%. Risk factors for vitamin D deficiency were male children who had basically educated and working mothers and moderate socioeconomic status. Vitamin D deficiency was more among obese, exclusively breastfed children and who ate fish and egg and drank milk once daily and who did not have enough sun exposure. Fatigue and bone fracture were significantly higher in vitamin D-deficient children than normal children.
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Screening for learning difficulties among primary school children p. 1466
Hala M Moselhey, Samar G Mostafa, Safa H Alkalash
DOI:10.4103/mmj.mmj_255_19  
Background Learning difficulties (LDs) are associated with increased comorbidity, especially depression and anxiety; it constitutes one of the major health problems that affect the educational process. Objective The aim was to assess frequency, types, and risk factors of LDs among primary school children in Toukh city. Patients and methods A cross-sectional study was conducted on 273 students who were randomly selected from two primary schools in Toukh city. Data were collected by using a questionnaire which included questions about sociodemographic criteria of the participants, diagnosis, and risk factors of LDs. Results Prevalence of LDs among primary school children was 31.9%. The most prevalent types were dyslexia, dyspraxia, perceptual difficulties, social difficulties, and auditory difficulties, representing 31, 29, 27, 27, and 25%, respectively. Predictive factors for LDs were low socioeconomic state, [odds ratio (OR) 5.4], female sex (OR: 3.7), nonworking mothers (OR: 0.25), and finally age upto10 years (OR: 0.35); other predictive factors were failure in school achievement (OR: 21.97), noncooperation between home and school (OR: 14.26), neglect of the student (OR: 9.64), and increased course content (OR: 1.21). Conclusion Prevalence of LDs was 31.9% among the studied group. Dyslexia was the most prevalent type. Low socioeconomic state, female children who were more than 10 years old with nonworking mothers, failure in school achievement, noncooperation between home and school, neglect of student, and increased course content were other predictive factors of LDs.
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Parents' perception towards the effect of mobile and internet use on their children's health p. 1472
Nagwa N Hegazy, Ali M Elshafie, Yousra A Alghalban, Ahmed A Mashal
DOI:10.4103/mmj.mmj_203_18  
Objective The aim of this study was to identify parents' perception towards the effect of internet use on their children health. Background The consequences of using internet sources at a young age are currently being studied comprehensively across the different parts of the world, as surfing the web had been found to have its pros and cons. It gives users independence, provides opportunities for global learning, and creates a platform for initiating social change. In contrast, it increase the likelihood of engaging in high risk and socially destructive behaviors. Parents recognize the significance of adopting technology in order to function in the 21st century. Participants and methods A cross-sectional study was conducted in a rural area where nearly 3000 primary school children were distributed in four main schools. Cluster sampling was carried out, and one school was chosen for the study with 1000 participants. A questionnaire was formulated for this purpose and underwent validity and reliability assessments. The questionnaire was given to the students' parents to answer it, registering their answers in the questionnaire form. Results The mean age of the children was 9.4 ± 1.9 years. Girls comprised 50.2% and boys comprised 49.8%. Children used mobiles and the internet at a younger age, starting from 4 years. Games were the types of programs mostly used. Most of the parents (43.4%) thought that the Internet had bad effects that outweighed positive effects, and (49.1%) most parents were worried about their children's use of the Internet. Conclusion Most parents thought that the Internet had bad effects, and they were worried about their children's use of the Internet.
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RHEUMATOLOGY, PHYSICAL MEDICINE AND REHABILITATION - ORIGINAL ARTICLE Top

Assessment of osteoporosis in hemiplegic patients with stroke p. 1479
Abd E. I. El-Hewala, Samar G Soliman, Dina R Al Sharaki, Dina S Fotoh
DOI:10.4103/mmj.mmj_137_16  
Objective The aim of this work was to find out the proportion of patients with stroke who are at risk of osteoporosis (OP) and to examine the relationships between bone mineral densities (BMDs) and severity of stroke and functional assessment. Background Loss of BMDs and fractures in patients after stroke are among the most serious health complications. Neurogenic OP is explained by the neural connection between brain and bone, which is mediated centrally by classic neurotransmitters and several neuropeptides. Moreover, mechanical stress on bone is one of the determinants of bone morphology, BMD, and bone strength. So reduction of mechanical stress on bone in patients with stroke inhibits osteoblast-mediated bone formation and accelerates osteoclast-mediated bone resorption, leading to what has been called disuse OP. Patients and methods A total of 100 patients with stroke diagnosed on clinical evaluation, including the mode of onset, the neurologic examination, and brain computed tomography scans, were included in this study. All patients were subjected to laboratory investigations, including the measurement of complete blood count, total and ionized serum calcium, and parathyroid hormone, and radiological investigations, including assessment of BMD of the lumbar spine (L2–L4), total hip, and distal forearm by dual-energy radiographic absorptiometry on both paretic and nonparetic sides. Results There were significant differences between BMDs at the spine and hip on the paretic side and duration of stroke, Lawton instrumental activity of daily living, and Scandinavian stroke scale (P < 0.001). There was a statistically significant increase in BMD regarding Barthel index (P < 0.001). There was also significant decrease in BMD on the paretic side in comparison with the nonparetic side (P < 0.001). Conclusion OP was more severe on the paretic side in patients with stroke compared with the nonaffected side. There was a significant negative correlation between BMD and age and duration of stroke.
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CLINICAL PATHOLOGY - ORIGINAL ARTICLES Top

Tumor suppressor p53 gene codon 72 polymorphism and imatinib cytogenetic response in chronic myeloid leukemia p. 1485
Khaled Abd Almoamen Khalifa, Enas S Essa, Wafaa M Shehata Radwan, Enas A Elkholy, Yasmin A. H Sadek Younis
DOI:10.4103/mmj.mmj_88_16  
Objective To study p53 codon 72 polymorphism in relation to cytogenetic response to imatinib treatment in patients with chronic myeloid leukemia (CML). Background P53 polymorphism involves the substitution of an arginine for a proline at codon position 72. Many studies have investigated a genetic link between this variation and response to treatment in cancer. Patients and methods This study was conducted on 54 CML patients presented to the Clinical Oncology Department, Menoufia University during the period from June 2013 to April 2015. They were classified according to their cytogenetic response to imatinib therapy into 40 CML patients, cytogenetic responders to imatinib and 14 CML patients who are cytogenetic nonresponders to imatinib. Patients were genotyped for p53 codon 72 polymorphism using PCR. Follow up of the patients should be done after 3, 6, 9, 12, and 18 months after diagnosis, and was done by complete blood count, conventional cytogenetic, and fluorescence in-situ hybridization. Results Age, sex, hematologic, and cytogenetic response to imatinib in CML patients did not differ significantly among p53 codon 72 genotypes (arg/arg, arg/pro, and pro/pro) (P = 0.44, P = 0.45, and P = 0.11, respectively). P53 codon 72 polymorphism did not significantly alter the risk to imatinib cytogenetic unresponsiveness (P = 0.9221). Conclusion It could be concluded that p53 codon 72 polymorphism is not associated with imatinib unresponsiveness in CML.
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CD62L expression in patients with chronic lymphocytic leukemia p. 1490
Mohamed A Soliman, Wafaa M. S. Radwan, Enas A Elkhouly, Sanaa S. M. Gebril
DOI:10.4103/mmj.mmj_587_17  
Objective The objective of this study was to evaluate CD62L expression in chronic lymphocytic leukemia (CLL) and its effect on survival of malignant B cells. Background CLL is the most common adult leukemia and often presents as an early-stage disease. It could be stable for many years with no or minimal intervention. CD62L is one of the selectin family of adhesion molecules that plays an important role in the trafficking/homing of lymphocytes to the lymph node. Patients and methods This study was conducted on 35 patients with CLL and 15 age-matched and sex-matched healthy individuals as a control group. All patients were subjected to full history taking, clinical examination, and laboratory investigations. CD62L/CD19 expression on lymphocytes was measured for all the study participants using flow cytometry technique before and after cell culture. Results CD62L/CD19 expression increased minimally in controls at day 7 compared with day 0 (mean ± SD = 33.9 ± 5.3 and 18.03 ± 3.4, respectively) (P < 0.001), whereas the diseased group showed marked elevation at day 7 than day 0 (mean ± SD = 90.7 ± 6.4 and 36.9 ± 17.2, respectively) (P < 0.001). CD62L/CD19 expression in patients was higher than the controls at day 0 (mean ± SD = 36.9 ± 17.2 and 18.03 ± 3.4, respectively) and showed increase of approximately threefolds at day 7 (mean ± SD: 90.7 ± 6.4 and 33.9 ± 5.3, respectively) (P < 0.001). Conclusion There is high expression of CD62L on lymphocytic cells in patients with CLL associated with increased survival of malignant B cells.
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Applications of bone marrow-derived cells in acute liver disease p. 1496
Laila M Montaser, Dina S El-Azab, Gehan A Tawfeek, Sara A Saied
DOI:10.4103/mmj.mmj_393_15  
Objective To evaluate the effects of bone marrow mononuclear cells (BMMCs) transplantation in rats with toxic acute liver damage induced by carbon tetrachloride (CCL4). Background Acute liver failure is a severe syndrome which need rapid and effective treatment. The present study was to examine whether BMMCs might be useful in the management of acute liver failure in an animal model or not. Materials and methods BMMCs were obtained from 8 to 10 ml of human bone marrow (10 × 106 cells) injected into the portal vein of rats 24 h (n = 32) after liver damage with CCL4. Control group (n = 32) was injected with only saline in CCL4-treated animals. Transaminases and survival were measured at 24 h, 72 h, 1, 2, 3, 4 weeks. Liver histology was observed 2 and 4 weeks after injury. Results Transplanted BMMCs were found to populate the damaged liver. Animals that received BMMCs also showed a trend toward improved liver enzymes as well enhanced survival rates, relative to the control. Conclusion This study results indicate that BMMC transplantation has potential as a new therapeutic option for acute liver disease and suggest that these cells may contribute to hepatic recovery.
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PEDIATRICS - ORIGINAL ARTICLES Top

Galectin-3 in children with heart failure secondary to congenital heart diseases p. 1501
Ahmed A Khattab, Nagwan Y Saleh, Mohamed S Rizk, Shimaa T El-Taweel
DOI:10.4103/mmj.mmj_418_18  
Objective The aim was to assess serum level of galectin-3 in children with heart failure (HF) secondary to congenital heart disease (CHD) and correlate it with diagnosis and outcome. Background Galectin-3 is an emerging biomarker that has been linked to tissue fibrosis, a hallmark in cardiac remodeling and HF. Galectin-3 can reliably be measured in the circulation to detect early failure. Patients and methods This prospective cohort study was conducted at Pediatric Intensive Care Units of Menoufia University Hospital from September 2017 to July 2018. The assessed serum galectin-3 levels in 30 children with CHD with HF were compared with 30 children who had CHD without symptoms of HF and 20 apparently healthy children, used as controls, who visited the pediatric outpatient clinic and were subjected to routine clinical examinations. Results The demographic data of the studied groups showed that there was no statistically significant difference among the studied groups regarding sex, age, weight, and height, but there was a statistically significant difference among the studied groups regarding BMI, where P value was 0.03. There was a highly statistically significant difference among the studied groups regarding galectin-3 levels. There was a highly statistically significant correlation between galectin-3 levels and echo finding, i.e., ejection fraction, but there was no statistically significant correlation between galectin-3 and outcome of CHD with or without HF. Conclusion Galectin-3 has a promising diagnostic value in pediatric HF.
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Soluble suppression of tumorigenisity 2 as an indicator of severity of heart failure in children with congenital acyanotic heart diseases p. 1506
Rania S Elzayat, Ahmed A Khattab, Mohammed S Rizk, Rabab M Shaban
DOI:10.4103/mmj.mmj_154_19  
Objective We aimed to evaluate the role of soluble suppression of tumorigenisity 2 (sST2) as an indicator of severity of heart failure (HF) in children with congenital acyanotic heart diseases. Background HF in congenital heart diseases (CHD) is a serious problem encountered in early infancy or later. It is a significant cause of morbidity and mortality in children with CHD. SST2 is currently gaining interest as a biomarker in cardiac disease. Patients and methods A prospective comparative study was conducted on 60 children having CHD with left-to-right shunt from the Pediatric Department of Menoufia University Hospitals between August 2017 and August 2018 and were divided into two groups: group 1: 30 children with manifestation of HF. Group 2: 30 children without manifestation of HF. In addition, 25 age-matched and sex-matched healthy children were set as a control group. All children were subjected to a full clinical history and examination. Serum level of sST2 were determined. Results Level of sST2 was 82.2 ± 22.3 and 25.63 ± 19.33 ng/ml in patients with and without HF, respectively. SST2 was significantly higher in patients who developed HF than in those without HF (P < 0.001). SST2 was significantly elevated with increased severity of HF (P < 0.001), wherein it was 25.63 ± 19.3, 55.5 ± 2.6, 86.1 ± 7.7, and 109.9 ± 6.4 ng/ml in patients with ROSS class I, II, III, and IV, respectively. Conclusion SST2 is a promising novel cardiac biomarker that could reflect the severity of HF.
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PEDIATRICS - LETTER TO THE EDITOR Top

Prevalence of stunted growth in children under 5 years of age in Qalyubia Governorate p. 1512
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_194_18  
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RADIOLOGY - ORIGINAL ARTICLE Top

Role of multidetector computed tomography imaging in the management of patients with blunt chest trauma p. 1513
Basma Abdel-Moneim Dessouky, Shaimaa Abdel-Hamid Hassanein, Mohammed M Salaheldin Abdelrehim
DOI:10.4103/mmj.mmj_435_18  
Objectives To demonstrate the capabilities of multidetector computed tomography (MDCT), in revealing injuries and guiding management of patients with blunt chest trauma. Background MDCT has become a cornerstone tool for evaluating blunt chest trauma owing to quick scanning, identification of concealed injuries, viewing images in many planes, providing three-dimensional images, ability to clarify tracheobronchial or vascular injuries, usage of contrast media, and detection of coexisting nonthoracic injuries. Patients and methods This study included 40 patients referred from Emergency Department with blunt chest trauma presented mainly with chest pain and dyspnea. All were subjected to clinical history, general and local examination, chest radiography (CXR), and MDCT studies for diagnostic evaluation and received intravenous water-soluble contrast. Results MDCT showed superior sensitivity, detecting more injuries than CXR and detecting other injuries that were totally missed such as sternal, dorsal spinal fractures, lung lacerations, herniation, and trachea-bronchial injuries. CXR sensitivity was low regarding detection of many injuries such as chest wall, pleural, parenchymal, and mediastinal injuries. Accuracy of MDCT was superior to CXR for positive findings providing more details about them with subsequent changes in the management plans. Conclusion Our results support that MDCT is the imaging modality of choice for blunt thoracic trauma in hemodynamically stable patients, being more sensitive and accurate, being rapid, showing injuries that are well clarified with contrast media, and enabling postprocessing reformatted images with subsequent more diagnostic findings that would change patient management plan.
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DERMATOLOGY - ORIGINAL ARTICLE Top

Dermatological adverse effects of new era of direct-acting antivirals in hepatitis C virus treatment p. 1521
Mohamed A Gaber, Ahmed E Sallam, Shaza A. M. Elhamaky
DOI:10.4103/mmj.mmj_60_19  
Objective To detect dermatological adverse effects of direct-acting antiviral (DAAs) drugs in treating patients infected with hepatitis C virus (HCV). Background HCV affects more than 200 million people, with an estimated HCV prevalence of 2.2% globally; the highest prevalence (15–20%) has been reported from Egypt. Patients and methods This prospective study was conducted on 108 patients with HCV infection. Patients with any dermatological manifestations before treatment by DAAs were excluded. Patients who came during treatment of HCV or after treatment were examined for dermatological adverse effects that appeared during or after treatment by DAAs. Results The data collected were tabulated and analyzed by Statistical Package for the Social Sciences, version 22.0 on International Business Machines compatible computer. The most common dermatological adverse effects was itching in 36.1% of the cases. In most of the cases (63.9%), the symptoms appeared during the treatment. There was a significant statistical difference between different treatment regimens regarding adverse effects, as itching was more common with regimen 1, dryness was more common in regimen 2, falling of hair was more common in regimen 1, oral ulcer in regimen 4, and photosensitivity was more common with regimen 5. Itching was more common after treatment, whereas pigmentation of skin (hyperpigmentation appeared during treatment versus hypopigmentation appeared both during and after treatment) and photosensitivity appeared during treatment. Conclusion DAAs have dermatological adverse effects. The most common dermatological adverse effects were itching, rash, and photosensitivity. Most of these adverse effects appeared during treatment, in 45.4% of patients.
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RADIO DIAGNOSIS - CASE REPORT Top

Synovial haemangioma of the knee joint diagnosed on magnetic resonance imaging: a rare case report p. 1528
Ishan Kumar, Ashish Verma, Pramod K Singh
DOI:10.4103/mmj.mmj_163_18  
Synovial haemangioma is an extremely uncommon condition which presents with nonspecific clinical symptoms. The diagnosis, if delayed, can ensue early arthritis, early epiphyseal fusion, and growth abnormality. As it resembles various benign cystic lesions on MRI, utility of contrast MRI, Doppler study, and presence of high index of suspicion are crucial in the diagnosis. We report a case of synovial haemangioma in a 45-year-old female patient, in which the diagnosis was missed on initial MRI.
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