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   2018| July-September  | Volume 31 | Issue 3  
    Online since December 31, 2018

 
 
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ORIGINAL ARTICLES
Role of color Doppler ultrasonography in differentiating benign and malignant cervical lymphadenopathy
Mohamed S Elzawawy, Sameh M Azab, Reham M Elshiekh
July-September 2018, 31(3):1030-1035
DOI:10.4103/mmj.mmj_96_17  
Objective The aim of the present study was to identify the role of color Doppler ultrasonography in differentiating benign and malignant enlarged cervical lymph nodes. Background Cervical lymphadenopathy is a common presenting symptom and sign for a variety of diseases ranging from subtle infections to life-threatening head and neck malignancies. Ultrasound is a useful imaging tool for the initial evaluation of cervical lymph nodes because it has high sensitivity (98%) and specificity (95%), particularly when combined with fine-needle aspiration cytology. Patients and methods The present study included 40 (27 male and 13 female) patients with cervical lymphadenopathy. Cases were divided into two main groups: the inflammatory group and the neoplastic group. The inflammatory group was further divided into the nonspecific group and the tuberculous group. The neoplastic group was further divided into the primary group and the metastatic group. The lymph nodes were subjected to sonographic and Doppler studies, which were correlated with clinical and pathological diagnoses obtained either by lymph node biopsy or after surgical excision whenever possible. Results Regarding the vascular pattern of each lymph node, our study showed that there was a different pattern of vascularity for each type of lymphadenopathy. Regarding the resistivity index, this study also showed that the sensitivity and specificity of the resistivity index for detecting malignant lymph nodes were 50 and 100%, respectively. Therefore, the value of spectral Doppler ultrasonography evaluation of intranodal vascular resistance is limited in routine clinical practice. Conclusion High-resolution ultrasonography has an important role in differentiating benign and malignant lymphadenopathy based on the shape (longitudinal/transverse ratio), hila, cortical thickness, cortical echogenicity, intranodal necrosis, pattern of vascularity, and resistivity index of the nodes.
  1,821 84 -
Cutting seton in management of complex perianal fistula – is it a safe procedure?
El Mohamady M Saeed
July-September 2018, 31(3):867-870
DOI:10.4103/mmj.mmj_615_17  
Objective The aim of this study was to evaluate the effectiveness, frequency of incontinence, and recurrence after treatment of complex perianal fistula with cutting seton. Background Cutting seton commonly is prescribed for complex perianal fistula, because it is simple and cheap, but high incontinence rates suggest that cutting seton can damage continence musculature. Patients and methods A study was carried out in Damanhur Medical National Institute Colorectal Unit from October 2013 to October 2016 and included 30 patients with complex anal fistula. Patients were treated with cutting silk seton. Patients were followed-up for tightening or change of seton and for observing complications like incontinence and recurrence. Results There were 24 male and six female. Mean age was 38 years. There were 14 high intersphincteric, 12 trans-sphincteric, and four suprasphincteric fistulas. Time taken for seton to cut through the fistulous tract varied from 4 to 10 weeks. Fistulas completely healed in 90% of the patients in 12 weeks. Recurrence of fistula developed in 10% of patients during the follow-up period. A total of six patients experienced minor incontinence, with two from each type of fistula in the study. Incontinence was to flatus in two patients and to liquid stool in four patients. There were no incidents of solid stool incontinence. Conclusion Use of cutting seton in treatment of complex perianal fistula is simple and cheap. This commonly used technique can damage continence musculature. Other techniques that do not cut the sphincter, when available, should be performed for higher fistula and anterior fistula in female.
  1,447 52 -
Relationship between serum vitamin D and iron level in children with attention-deficit hyperactivity disorder
Fahima M Hassan, Mohamed A Soliman, Sameh A Abd El-Nabi, Ghada A Elgazzar
July-September 2018, 31(3):999-1004
DOI:10.4103/mmj.mmj_88_17  
Objectives The aim of this study was to determine the association between iron, ferritin, and vitamin D deficiency with attention-deficit hyperactivity disorder (ADHD) and the effect of their deficiency on the development of ADHD in children. Background ADHD is one of the most prevalent mental health disorders. It has been reported that iron, ferritin, and vitamin D deficiency may be related to the pathophysiology of ADHD. Patients and methods Our study includes 60 children with ADHD aged 3–18 years and 20 controls aged 3–18 years. Sociodemographic and clinical data were collected. The health status of the patients was assessed by symptoms and clinical presentations, family history, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V), and laboratory investigations, including serum level of iron, ferritin, and 25-hydroxyvitamin D. Result Mean age (SD in years) for ADHD and control children was (7.13 ± 1.89 vs. 7.95 ± 1.84). There were statistically significant differences between ADHD versus control children for serum iron (44.05 ± 25.28 vs. 91.15 ± 33.83 μg/dl), ferritin (15.76 ± 18.06 vs. 98.2 ± 52.37 ng/ml), and vitamin D (13.1 ± 5.66 vs. 32.9 ± 9.12 ng/ml). There were many factors that were sought to be associated with increased risk of developing ADHD. Conclusion The study indicates that low serum iron, ferritin, and vitamin D deficiency may be related to ADHD pathophysiology.
  1,089 60 -
Comparative study between Doppler ultrasound and computed tomography angiography in diabetic lower limb arterial insufficiency
Zeinab A Ali, Rehab M Habib, Mahmoud A. M Abo Hendy
July-September 2018, 31(3):1050-1057
DOI:10.4103/mmj.mmj_175_17  
Objective This work aimed to highlight the role of color Doppler ultrasound in the assessment of lower limb arterial insufficiency in patients with diabetes as well as the characteristics of lower limb arterial disease in diabetic patients. Background Diabetic lower limb arterial insufficiency is a major health problem affecting the individuals and community health. Doppler ultrasound is a widespread relatively cheap examination with no health hazards of radiation. Hence, we considered studying the role of Doppler ultrasound in determining the characteristics of lower limb arterial diabetic insufficiency and its level of accuracy. Patients and methods One hundred diabetic patients with clinically suspected lower limb arterial insufficiency were examined using Doppler ultrasound and computed tomography angiography (CTA), and the characteristics of diabetic lower limb arterial disease and accuracy of Doppler results in relation to CTA were determined. Results Diabetic lower limb arterial disease was characterized by being bilateral and multisegmental in the majority of cases with more affection of the distal (below knee) arteries. There was no significant difference between Doppler and CTA results at the above knee arteries as regards detection of significant arterial stenosis (luminal narrowing ≥ 50% of artery diameter); P values were as follows: common iliac artery segment, 0.695; external iliac artery, 0.776; common femoral artery, 0.563; and superficial femoral artery, 0.599. Further, a low significant difference at below knee arteries was found; P values were as follows: popliteal artery segment, 0.033; anterior tibial artery, 0.025; posterior tibial artery, 0.019; and peroneal artery, 0.031. The overall sensitivity of Doppler in evaluating lower limb arteries was 90.46%, the specificity was 92.05%, and the accuracy was 91.81% when CTA was taken as a standard. Conclusion Duplex ultrasound provides high-resolution, precise anatomical and physiological information of the peripheral arteries. It should be first-line investigation for lower limb arterial assessment and also be combined with other arterial imaging modalities to obtain better diagnostic accuracy.
  927 103 -
The barriers to breastfeeding among women: a single-center experience
Hala M Shaheen, Nagwa N Hegazy, Sara S.A Sakr
July-September 2018, 31(3):855-861
DOI:10.4103/mmj.mmj_869_17  
Objective To estimate the prevalence of exclusive breastfeeding (EBF) and to identify barriers to breastfeeding among the studied mothers in Berket El-Sabaa District, Menoufia Governorate, Egypt. Background Human breast milk is the ideal and unique food for infants. However, most infants today still do not receive the full benefits of breastfeeding. Low breastfeeding rates during the first 6 months imply that mothers are constantly faced with multiple barriers to continue breastfeeding. Patients and methods The study was a cross-sectional study. It was conducted on 370 mothers of infants aged 2–6 months. All participants were interviewed using a predesigned questionnaire included personal data about mothers and their youngest infants, socioeconomic status, and barriers of initiation and EBF. Results Nearly two-thirds of the mothers (60%) came from the rural area, and 55.1% were housewives. Nearly two-thirds of mothers' families (61.6%) had moderate socioeconomic status. Only 28.6% of infants were exclusively breastfed. The most prominent barriers to EBF were lack of health education about breastfeeding (84.1%) (P ≤ 0.001), hungry infant (43.2%) (P ≤ 0.001), nipple fissures and soreness (40.2%) (P = 0.002), easiness of artificial feeding (39.4%) (P ≤ 0.001), and belief of insufficient milk supply (37.9%) (P ≤ 0.001). Conclusion Prevalence of EBF is low among studied group. Many barriers obscure breastfeeding making it nonexclusive. Awareness should be raised about benefits of EBF for the first 6 months of infant's life and breastfeeding problems and how to overcome them.
  944 80 -
Early versus delayed feeding after placement of percutaneous endoscopic gastrostomy tube with safe anesthetic techniques
Mohamed M Abdalgaleil, Ahmed M Shaat, Osama S Elbalky, Mohamed S Elnagaar, Amr M Kamoun
July-September 2018, 31(3):1058-1063
DOI:10.4103/mmj.mmj_164_18  
Objective To compare the safety of early (≤4 h) versus 24 h tube feeding after percutaneous endoscopic gastrostomy (PEG) tube placement and to determine the effectiveness of i.v. sedation combined with ultrasound-guided, left side transversus abdominis plane (TAP) block versus combination with local anesthetic (LA) infiltration for PEG placement. Background Tube feeding used to be delayed up to 24 h after PEG placement, but results from many randomized controlled trials revealed that there was no need for delaying the tube feeding. The procedure was earlier done with general anesthesia or i.v. sedation with LA infiltration, but the use of i.v. sedation with TAP block may be another option. Patients and methods This was a prospective randomized study including 60 patients, requiring long-term nutritional support, who underwent the PEG procedure at GIT Endoscopy Unit, Damanhour Teaching Hospital, El Beheira, Egypt; between August 2017 and March 2018. Patients were randomly allocated into two equal groups, in group A; early tube feeding (≤4 h) was done and performed with i.v. midazolam and propofol-based sedation combined with ultrasound-guided, left side TAP block, whereas in group B; delayed tube feeding (24 h postprocedure) was done and performed with i.v. midazolam and propofol-based sedation with LA infiltration. Results There were no statistically significant differences between both groups with respect to procedure-related or anesthesia-related complications. Conclusion Early tube feeding (≤4 h) after PEG placement may be a safe option to delayed (24 h postprocedure) feeding. I.v. sedation combined with ultrasound-guided, left side TAP blockade can be used successfully as the primary anesthetic modality for PEG placement.
  904 84 -
Screening the intelligence of primary school children using ‘draw a person’ test
Ali M El Shafie, Dalia M El Lahony, Zein A Omar, Samar B.M El Sayed
July-September 2018, 31(3):994-998
DOI:10.4103/mmj.mmj_79_17  
Objectives The objective of this study was to screen the intelligence of primary school children using ‘draw a person’ (DAP) test in Berket El Sabaa district, Menoufia governorate. Background The significance of children's drawings has been explored extensively since the late 19th century, and they are thought to provide indications of visual-motor development, levels of cognitive functioning and intellectual maturity, projections of personality and self-concept, and assessments of emotional state and disturbances. Drawing is an activity that children tend to enjoy, and they willingly produce spontaneous scribbles and drawings from a young age. Patients and methods This study was carried out on 1000 apparently healthy, primary school children aged 6–12 years in Berket El Sabaa district, Menoufia governorate. All participants were subjected to adequate assessment of history and complete clinical examination. Parents were required to complete a questionnaire to collect data on telephone number, full name, date of birth, any serious medical problems in the past, as well as educational level of parents, father's occupation, family size, and family income to assess socioeconomic level, school achievement, and DAP test. Results The present study showed that 9.2% of children were highly intelligent, 71.9% had average intelligence, 10.6% of children had borderline intellectual function, and 8.3% of children had mild mental retardation. In addition, positive correlations were found between IQ levels and socioeconomic status, school achievement, residence, and sex. There was a significant negative correlation between IQ levels and children's BMI. Conclusion The DAP test can be a useful developmental screening device for pediatricians and alert them to the possibility of developmental disorders.
  817 62 -
Therapeutic effect of phenyl vinyl sulfone and nitazoxanide on experimentally infected mice with cryptosporidiosis
Omaima K El Shafei, Abdel-Gawad E Saad, Nancy M Harba, Osama F Sharaf, Rehab M Samaka, Shaimaa A Farag
July-September 2018, 31(3):786-794
DOI:10.4103/mmj.mmj_712_17  
Objective Evaluation of the therapeutic effect of phenyl vinyl sulfone (PVS) as cysteine protease inhibitors, nitazoxanide (NTZ), and combined therapy on Cryptosporidium parvum infection regarding the parasitological and histopathological parameters. Background Cryptosporidium spp. had been identified as the second most important diarrheal pathogen after rotavirus in young children. The immune status of the host plays a critical role. There is no reliable treatment for cryptosporidiosis, as the only approved drug NTZ provides no benefit for immunocompromised patients. Materials and methods A total of 180 female laboratory-bred Swiss albino mice were divided into two major divisions, immunocompetent and immunosuppressed, with the following groups for each one, respectively: negative control (I and VI), infected control (II and VII), infected treated with PVS (III and VIII), infected treated with NTZ (IV and IX), and infected treated combined (V and X). Stool examination for oocyst shedding was done at different days postinfection, and mice were killed at 18 and 30 days postinfection (groups A and B, respectively). Histopathological assessment of the ileum was done, and the endogenous developmental stages of the parasite were counted. Results Combined therapy in groups V and X resulted in the highest reduction in Cryptosporidium spp. oocysts shedding (P = 0.044 and <0.001, respectively) and mean number of endogenous developmental stages in group X (P < 0.001) than either drugs when used alone. This is followed by NTZ-treated groups and then cysteine protease inhibitors-treated groups, which gave the least reduction. Conclusion Combined therapy is more effective than either NTZ or PVS used alone. NTZ is still a better treatment option than PVS.
  747 64 -
Circulating cell-free DNA as a sensitive biomarker in patients with acute myocardial infarction
Eman S Arafat, Ibrahim Elmadbouha, Esam-Eldin I Radwan, Abd-Allah M Kamal, Eman A Badr, Naglaa M Ghanayem
July-September 2018, 31(3):772-779
DOI:10.4103/mmj.mmj_345_17  
Objective The aim of this study was to evaluate the role of circulating cell-free DNA as an early cardiac biomarker in patients with acute myocardial infarction (AMI). Background Circulating cell-free DNA mainly originates from programmed cell death or acute cellular injury and reflects the extent of cellular damage. Patients and methods This study was carried out on AMI patients (n = 50) and healthy controls (n = 30). All participants were subjected to a full assessment of history, clinical examination, ECG, and echocardiography. Blood samples were taken for cardiac biomarkers, kidney function tests, liver enzymes, lipid profiles, and real-time quantitative PCR for cell-free DNA at the first and the third day of AMI attacks. Results AMI patients had significantly higher levels of cardiac markers, total cholesterol, triglyceride, low-density lipoprotein, L1PA2-222, L1PA2-90, and L1PA2-222/L1PA2-90 ratio versus controls. There was a significantly higher peak on the first day of the attack in L1PA2-90 and L1PA2-222 cell-free DNA levels and the L1PA2-222/L1PA2-90 ratio in AMI patients and a gradual decrease on the third day, without a nonsignificant difference between ST-elevation and non-ST-elevation myocardial infarction. There were nonsignificant correlations between the concentration of cell-free DNA parameters and clinical, echocardiography, or laboratory parameters. The diagnostic validity for the L1PA2-222/L1PA2-90 cfDNA ratio on the first day of an AMI attack was significantly higher (P < 0.001) at the cutoff point of 0.61 with a sensitivity of 54% and a specificity of 87%; there was a gradual decrease on the third day of attacks. Conclusion Elevated cell-free DNA can be used as an early cardiac biomarker in AMI patients and may complement traditional cardiac troponin-I and creatine kinase-MB biomarkers in the diagnosis of AMI.
  734 68 -
Factors affecting the prognosis of hypertrophic cardiomyopathy disease
Hala Mahfouz, Ghada M Soltan, Ahmed Y Salem
July-September 2018, 31(3):871-874
DOI:10.4103/1110-2098.248754  
To assess the potential factors affecting the prognosis of hypertrophic cardiomyopathy disease. Medline databases (PubMed, Medscape, HYPERLINK “http://www.sciencedirect.com/”ScienceDirect. EMF-Portal) and all materials available in the Internet from 2000 to 2014, and Topol manual of cardiovascular medicine 4th edition. The initial search presented 30 articles of which 20 met the inclusion criteria. The articles studied the relation between several risk factors and the prognosis of hypertrophic cardiomyopathy. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Comparisons were made by structured review with the results tabulated. In total 20 potentially relevant publications were included; They indicate an association between left ventricular outflow tract obstruction, previous cardiac arrest, sustained VT, prolonged or repetitive episodes of nonsustained VT on Holter monitoring , left ventricular wall thickness more than 30mm , family history of sudden cardiac dealth , no change or decrease in the blood pressure with exercise , syncope or near syncope, LA size, occurrence of AF, late gadolinium enhancement by magnetic resonance imaging, and poor prognosis in the terms of morbidity and mortality of hypertrophic cardiomyopathy patients. We found an association between left ventricular outflow tract obstruction, previous cardiac arrest, sustained VT, prolonged or repetitive episodes of nonsustained VT on Holter monitoring, left ventricular wall thickness more than 30mm (thirty millemeters), family history of sudden cardiac death, no change or decrease in the blood pressure with exercise , syncope or near syncope, left atrial size, occurrence of AF, late gadolinium enhancement by magnetic resonance imaging, and poor prognosis in the terms of morbidity and mortality of hypertrophic cardiomyopathy patients.
  744 40 -
A comparative study of ultrasonography and computed tomography in diagnosing renal masses
El-Sayed E. E El-Mekkawy, Tarek F Abdella, Mohammad A. H. El-Batt
July-September 2018, 31(3):1036-1043
DOI:10.4103/mmj.mmj_113_17  
Objective The aim of this study was to compare the role of ultrasonography (US) with computed tomography (CT) in diagnosing renal masses. Background New technological US and CT techniques are being designed to diagnose patients with renal masses. These new techniques will help doctors define and easily diagnose neoplastic and non-neoplastic renal masses. Patients and methods A total of 50 patients were included in the present study (27 males and 23 females; age range 3–67 years; mean age 32.7 ± 21.96 years). Detailed medical history of all patients was obtained, and all of them underwent general examination, routine laboratory investigations, especially those related to the renal system, real-time pelvic-abdominal US with color Doppler, and preintravenous and postintravenous contrast-enhanced CT of the abdomen and pelvis. Results Using US, we found 26 cases with malignant renal masses and 24 cases with benign renal masses. Using CT, we found 24 cases with malignant renal masses and 26 cases with benign renal masses. After correlation with histopathology results, we found that US detected four false-positive cases and one false-negative case, whereas by using CT we found only one false-positive case (P = 0.002). Conclusion US is the first-choice imaging procedure to detect characteristic features of renal masses. It can be performed safely as it is noninvasive and painless as well as relatively inexpensive. CT is considered to be the gold standard for accurate characterization of renal masses, differentiation of malignant from benign masses according to some criteria, and staging of these malignant masses showing distant metastasis and lymph node enlargement.
  726 52 -
Role of ultrasound, Doppler, and MRI in the diagnosis of placenta accreta
Adel El Wakeel, Sameh Azab, Heba M Abdel Rahman
July-September 2018, 31(3):1023-1029
DOI:10.4103/mmj.mmj_80_17  
Objectives The objectives of this study were to compare the accuracy of ultrasonography and MRI for prenatal diagnosis of placenta accreta (PA) and to compare the sensitivity and specificity of individual ultrasonographic and MRI markers in predicting placental invasion in cases of PA. Background PA is a significant cause of maternal morbidity and mortality, and at present it is the most common reason for emergent postpartum hysterectomy. Placenta previa and previous cesarean section are the two most important known risk factors for PA. Accurate prenatal identification of affected pregnancies allows optimal obstetric management. Ultrasonography still remains the diagnostic standard. However, in recent years, there has been increased interest in MRI in evaluating PA. Patients and methods A combined prospective and retrospective study was carried out on 20 pregnant women with persistent placenta previa (after 28 weeks gestation). All patients were subjected to history taking, complete medical examination, and ultrasound, Doppler, and MRI. Results The sensitivity and specificity of ultrasonography were 63.6 and 91.6%, whereas the sensitivity and specificity of MRI were 72.70 and 100%, respectively, in their ability to diagnose PA. Conclusion MRI hand-in-hand with ultrasound is important for the accurate diagnosis of placenta previa and the serious coexisting PA. Use of both modalities may provide more diagnostic information.
  691 72 -
Evaluation of serum albumin level among preterm septicemic newborn infants
Dalia M El-Lahony, Hanan M El-Sayed, Heba M Mostafa
July-September 2018, 31(3):1018-1022
DOI:10.4103/mmj.mmj_725_17  
Objective The objective of this study was to evaluate the clinical value of serum albumin levels for the evaluation and prognosis of preterm infants with neonatal sepsis. Background Neonatal sepsis is considered a leading cause of morbidity and mortality in preterm newborn infants, as the mortality rates due to neonatal sepsis range between 3 and 50%, particularly with Gram negative pathogens. Nowadays, serum albumin has been suggested to be a valuable marker for prognosis of neonatal septicemia. Patients and methods This study was conducted on 85 preterm neonates, 46 male and 39 female, admitted within 24 h of life to neonatal intensive care unit in the period from March 2016 to January 2017. Patients were grouped according to their serum albumin level (≥3, 2.5–3, or ≤2.5 g/dl) or according to their discharge diagnosis (sepsis, neonatal infection, or no infection). Results There was a highly significant difference between discharge diagnosis groups as regards their serum albumin levels, and also there was a significant correlation between serum albumin level and both clinical and hematological sepsis scores. Conclusion Albumin was proven to be a marker in the diagnosis of neonatal septicemia.
  687 70 -
Study of acylcarnitine and amino acid profiles in hyperammonemia pediatric patients
Shimaa Abd El Sattar, Manar Obada, Yasser El ghobashy, Elsayd Abou-El Nour, Osama Zaki, Hala El-Said
July-September 2018, 31(3):742-752
DOI:10.4103/1110-2098.248715  
Objective The aim of this study was to study amino acid and acylcarnitine profiles in Egyptian pediatric patients with hyperammonemia using high-performance liquid chromatography (HPLC). Background Hyperammonemia is a life-threatening problem during childhood that requires prompt intervention. Emerging metabolomics such as amino acid and acylcarnitine assay provide a powerful platform for discovering new biomarkers to improve early diagnosis. Patients and methods A total of 110 pediatric patients were enrolled in this study: 40 patients with hyperammonemia suspected as having an inborn error of metabolism, 20 hyperammonemia patients suspected as having hepatic disorders, and 50 apparently healthy children who served as the control group. Routine laboratory investigations were carried out for all participants (blood ammonia, liver function tests, kidney function tests, and arterial blood gas analysis). Amino acid and acylcarnitine profiles were measured quantitatively for all participants using HPLC. Results Fourteen metabolites were supposed to be ‘potential metabolite markers’ for differentiation between patients with hyperammonemia due to inborn error of metabolism and those with hyperammonemia due to hepatic causes. Seven of these metabolites were amino acids (Gly : Ala, Leu-Ile, Leu : Phe, Met : Phe, methionine, tyrosine, and valine), and seven were acylcarnitines (C3, C3 : C2, C5-DC, C10 : C1, C16-OH, C18, and C14-carnitines). Conclusion Acylcarnitine and amino acid profiles detected using HPLC could be potential noninvasive diagnostic biomarkers for differentiation of hyperammonemia cases.
  699 56 -
REVIEW ARTICLES
Comparative study between cognitive adverse effects of bitemporal and bifrontal electroconvulsive therapy
Lamiaa G Elhamrawy, Amr S Shalaby, Eman G Saleh, Mustafa A.E Mohamed
July-September 2018, 31(3):735-741
DOI:10.4103/1110-2098.248756  
In the past 26 years, an increasing number of articles have been published about the effects of bitemporal and bifrontal electroconvulsive therapy (ECT) on cognitive functions. Here, we review these studies, because there have been conflicting reports about the extent and persistence of ECT cognitive adverse effects related to the electrode position. In total, eight psychological and medical databases (Medline, PubMed, Psych INFO, Science Direct, EMBASE, CINAHL, Cochrane, and Web of Knowledge) were searched during June 2016 to investigated studies from 1991 to 2016. The initial search presented 35 articles, of which 13 met the inclusion criteria. The articles studied the cognitive adverse effects of bitemporal and bifrontal ECT. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Comparisons were made by structured review with the results tabulated. In total, 13 potentially relevant publications were included, most of the included studies found that cognitive impairment is less noticed in bifrontal ECT than bitemporal ECT. Few authors did not see evidences of the advantage of bifrontal ECT regarding cognitive profile. Evidence suggests that cognitive impairment does occur because of bifrontal and bitemporal ECT. Objective measures found cognitive impairment to be relatively fewer and lasting for a short term in bifrontal ECT than bitemporal ECT.
  679 48 -
ORIGINAL ARTICLES
The effect of atorvastatin on bleomycin-induced pulmonary fibrosis in rats
Eman A Ali, El Sayed M Abd El Salam, Mohamad-Hesham Y Daba, Abd Elrahman A Yassin, Noha M El kady, Eman A.E Badr
July-September 2018, 31(3):1081-1087
DOI:10.4103/mmj.mmj_379_15  
Objective This work aims to investigate the effect of atorvastatin on bleomycin-induced pulmonary fibrosis in rats. Background Pulmonary fibrosis is a lung disease refractory to treatment with poor prognosis. It is characterized by progressive irreversible destruction of lung architecture resulting from scar formation and organ dysfunction. Atorvastatin ameliorates pulmonary fibrosis in rats via having antioxidant and antifibrotic effects. Materials and methods The study was conducted for 3 weeks using 30 male Wister albino rats divided into three groups of 10 rats each as follows. Group 1: injected with saline intratracheal single dose and received saline orally. Group 2: injected with a single intratracheal dose of bleomycin (1 mg/kg) and received saline orally. Group 3: injected with bleomycin intratracheal and received atorvastatin (10 mg/kg/day) orally. The following procedures were done: (a) baseline body weight, final body weight, lung weight, and lung coefficient. (b) Biochemical measurements: lung malondialdehyde (MDA), lung reduced glutathione (GSH), and serum transforming growth factor-β1 (TGF-β1). (c) Histopathological examination of hematoxylin and eosin and Masson's trichrome stained sections followed by α-smooth muscle actin (α-SMA) immunostaining. Results Toxic group (group 2) showed a significant decrease in body weight and lung GSH associated with increase in lung weight, lung coefficient, serum TGF-β1, lung MDA level, histopathological fibrosis score, and H-sore of α-SMA compared with the normal group (group 1). In contrast, atorvastatin-treated group (group 3) showed a significant increase in body weight and lung GSH with reduction in lung weight, lung coefficient, serum TGF-β1, lung MDA level, histopathological fibrosis score, and H-sore of α-SMA compared with (group 2), but still significant to normal group levels. Conclusion It is concluded that atorvastatin attenuated bleomycin-induced pulmonary fibrosis in rats by reduction of oxidative stress markers, suppression of TGF-β1, and improving fibrosis score and H-score of α-SMA.
  637 65 -
REVIEW ARTICLES
Tumor necrosis factor-related apoptosis-inducing ligand in patients with systemic lupus erythematosus
Wafaa A Zahran, Amal F Makled, Asmaa M Elbrolosy, Elham A Negm, Mohamed A Helwa, Emad M Elshebini, Gamalat A Elgedawy
July-September 2018, 31(3):717-722
DOI:10.4103/mmj.mmj_911_17  
The aim of this study was to study the relationship between serum level of soluble tumor necrosis factor-related apoptosis-inducing ligand (sTRAIL) and the disease activity in patients with systemic lupus erythematosus (SLE) and also to compare sTRAIL levels between patients with lupus and patients with rheumatoid arthritis as well as healthy volunteers. A search was performed in Medline databases (PubMed, Medscape, Science Direct, and EMF-Portal) and all materials available in the Internet from 2000 to 2017. The initial search presented 18 articles of which eight met the inclusion criteria. These articles studied the relation between sTRAIL and the disease activity in patients with SLE. 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 included, adequate information provided, and assessment measures defined. Comparisons were made by structured review with the results tabulated. In total, eight potentially relevant publications were included, and all were human studies. The studies had demonstrated elevated serum concentrations of sTRAIL in patients with SLE and their association with disease activity, which suggest an important role for TRAIL in the pathogenesis of SLE. Serum level of sTRAIL was significantly higher among patients with active SLE as compared with those of other groups and positively correlated with disease activity.
  619 71 -
ORIGINAL ARTICLES
Calcium and vitamin D supplementation after total thyroidectomy in thyrotoxic patients
Shawky G Shaker, Mohammed A Sabry, Abdel-Naser A Gad Allah, Salah M Fouad
July-September 2018, 31(3):1064-1068
DOI:10.4103/mmj.mmj_117_18  
Objective Evaluation of the efficacy of routine postoperative oral calcium and vitamin D supplementation in preventing symptomatic hypocalcemia after total thyroidectomy in cases of hyperthyroidism. Background Thyroidectomy is the most common surgical procedure performed in the neck by surgeons. Hypocalcemia is the most frequent complication after total thyroidectomy, and it is the main cause of prolonged hospital stay. Patients and methods Thirty patients who underwent total thyroidectomy for toxic goiters were randomly assigned to routinely receive or not receive oral calcium (3 g/day) and vitamin D (1 μg/day) for 4 weeks. Hypocalcemic symptoms and signs, and total serum calcium and parathormone levels were monitored and compared between the two groups. Results The incidence of symptomatic and laboratory hypocalcemia was lower in the treatment group receiving the supplement than in the control group not receiving the supplement: one of 15 patients (6.7%) versus five of 15 (33.3%). The hypocalcemic symptoms were minimal in the treatment group, but more severe in the control group not receiving the supplement. Serum calcium levels decreased in both groups after surgery, but were less in the treatment group. Conclusion Routine administration of oral calcium and vitamin D supplementation may be effective in reducing the incidence and severity of hypocalcemia after total thyroidectomy.
  640 46 -
Out-of-pocket health expenditure in rural population
Taghreed M Farahat, Hala M Shaheen, Nora A Khalil, Basma S Ibrahem
July-September 2018, 31(3):846-849
DOI:10.4103/mmj.mmj_223_17  
Objectives The aim of this study was to distinguish between the different determinants of out-of-pocket (OOP) health expenditure in rustic Egypt. Background OOP well-being expenditure represents 60% of total health expenditures in Egypt. Numerous families in Egypt depend on OOP to fund healthcare services. This specifically impacts their entrance to quality well-being administrations. Creating knowledge about the determinants of OOP is a need to configuration polices that shield family units from impoverishment. Patients and methods The study was a cross-sectional one that was directed in country zone, lower Egypt, from September 2015 to October, 2016. The calculated sample size was 380 participants selected by means of systematic random sampling. They were divided according to the health expenditure in last medicinal services required in the recent weeks into the OOP and the non-OOP group. A predesigned questionnaire was utilized to recognize different determinants of OOP well-being use (e.g., age, sex, and health status). Results An overall 85% of studied shared members had OOP costs over the most recent 4 weeks for healthcare. There was a statistically significant difference (P < 0.001) between displaying OOP and being a woman in childbearing age, living in high socioeconomic level, having chronic disease, absence of health insurance coverage, poor perception of health, and private care. Conclusion OOP health expenditure is more predominant in specific gatherings of population and is affected by basic determinants. Tending to such determinants ought to have a noteworthy impact on getting legitimate medicinal services and thus in the expectations for everyday comforts.
  619 66 -
Immunohistochemical expression of cytokeratin 14 and association with the extent of squamous differentiation in urothelial carcinoma
Alyaa A Moselhy, Hayam A Aiad, Hala S El Rebey, Shereen F Mahmoud
July-September 2018, 31(3):826-833
DOI:10.4103/mmj.mmj_400_17  
Objective Evaluation of the diagnostic utility of cytokeratin 14 (CK14) immunostaining for squamous differentiation in urothelial carcinoma (UC). Background UC with squamous differentiation usually presents at an advanced stage than pure UC. Moreover, increased extent of squamous differentiation in UC tends to be associated with poor survival. Sometimes, immunohistochemical marker may be needed for diagnosis of squamous differentiation in UC. Materials and methods This retrospective cross-sectional study included 58 cases of radical cystectomy and 16 cases of cystoscopic biopsy diagnosed with bladder cancer. The cases included 16 cases of squamous cell carcinoma (SCC), 26 of pure UC, 31 of UC with squamous differentiation, and one case of adenocarcinoma. They were subjected to immunohistochemical staining for CK14. CK14 expression and its association with some clinicopathologic parameters were evaluated. Results CK14 showed positive expression in 74.2% of UC with squamous differentiation, 19.2% of pure UC, and all cases of SCC. It showed sensitivity of 74% and specificity of 81% for detecting squamous differentiation in UC. Its expression has significant association with the extent of squamous differentiation in UC (P = 0.001), perineural invasion (P = 0.03), and grade of SCC (P = 0.0001). Conclusion CK14 is a specific and sensitive marker in diagnosis of SCC and squamous differentiation in UC, and its expression is associated with poor prognostic parameters in bladder cancer.
  636 47 -
REVIEW ARTICLES
Epigenetics and autoimmunity
Sabery A Shoeib, Alaa E Abd El Hamid, Salah M.S Abozied
July-September 2018, 31(3):723-729
DOI:10.4103/1110-2098.248748  
Objectives The aim of the study was to review epigenetics and its role in the evolution and treatment of autoimmune disorders. Data sources Data were obtained from Medline databases (PubMed, Medscape, and Science Direct) and from materials available on the Internet from 2003 to 2016. Study selection The initial search presented 100 articles, of which 30 met the inclusion criteria. The articles studied the role of epigenetics in the pathogenesis and treatment of autoimmune disorders. Data extraction A special search was carried out on Medline with keywords (epigenetics and autoimmune) in the papers, and extraction was made, including assessment of the quality and validity of papers that met with the prior criteria that describe the role of epigenetics in autoimmunity. Data synthesis Each study was reviewed independently; the obtained data were translated into the language of the researcher and have been presented in sections throughout the article. Findings The studies define epigenetics as changes in gene expression without changes in the DNA itself. Epigenetic regulation was achieved through DNA methylation, histone modification, and microRNA interference. Deregulations in epigenetic mechanisms present an important pathway toward the development of autoimmune disorders. DNA-demethylating and histone-deacetylating agents are the first era of drugs directed at treating epigenetic deregulations with significant success rates. Conclusion Unlike genetics, the reversible nature of epigenetics makes them highly attractive targets for cancer therapies. DNA-demethylating and histone-deacetylating agents are the first drugs directed at treating epigenetic deregulations. Understanding epigenetic mechanisms will be helpful in introducing new lines of treatment.
  603 76 -
ORIGINAL ARTICLES
Epidemiology of metabolic syndrome in Menoufia University students
Omaima A Mahrous, Hewaida M Anwar El Shazly, Safaa A Badr, Reda A Ibraheem, Zeinab A Kasemy, Ghadeer M.M El Sheikh
July-September 2018, 31(3):839-845
DOI:10.4103/mmj.mmj_791_17  
Objective The aim was to assess the prevalence of metabolic syndrome (MetS) and its associated risk factors in Menoufia University students. Background MetS is a growing public health concern worldwide. The rapid sociocultural transition associated with major changes in lifestyle and eating habits has been claimed for the rising rates of MetS among young adults and children, which is the leading cause of developing type II diabetes and cardiovascular diseases. Participants and methods A cross-sectional study was conducted during the academic year 2016/2017 at Menoufia University on 455 university students aged 18–25 years. The students were chosen from four faculties using multistage random sample. Anthropometric measurements were obtained. Blood pressure, fasting glucose level, and fasting lipid profile were also measured. MetS was diagnosed using adult treatment panel-III guidelines. Results The overall prevalence of MetS was 16.7%, which was more frequent among female students. The most prevalent MetS components were increased waist circumference (41.8%) followed by high triglyceride levels (40.2%) and reduced high-density lipoprotein-cholesterol levels (36.3%). The predisposing factors for having MetS included the following: being female, older than 20 years, obese, physically inactive, high levels of stress, and a positive family history of hypertension and diabetes. Conclusion MetS is considered as a public health problem among Menoufia University students. These findings indicate the need for health promotion and prevention programs directed toward the screening, diagnosis, and management of MetS among university students.
  620 56 -
Assessment of enthesitis in the early spondyloarthropathy by ultrasonography combined with power Doppler
Abdelsamad I Elhewala, Samar G Soliman, Dina R Alsheraki, Waleed A Mousa, Samah S Yusef
July-September 2018, 31(3):810-815
DOI:10.4103/mmj.mmj_874_17  
Objective The aims were to assess prevalence of enthesitis among different subtypes of early spondyloarthropathy (SpA) and to evaluate specificity of entheseal involvement in such patients using ultrasonography and power Doppler. Background Enthesitis is one of the characteristic etiopathogenic manifestations of spondyloarthritis; however, in clinical practice, its presence often goes unnoticed. Ultrasound (US) can visualize most of the relevant enthesitis-associated pathologies such as bone erosions, calcification, bursitis, tendon structure, and thickness. Patients and methods A total of 80 patients with SpA with early disease duration and 20 controls (10 with mechanical low back pain and 10 with rheumatoid arthritis) of matched age and sex underwent ultrasonographic evaluation of entheses and were scored according to Madrid Sonographic Enthesitis Index. Patients were distributed as 36 patients with ankylosing spondylitis, 18 patients with reactive arthritis, and 26 patients with psoriatic arthritis. Results On clinical examination of entheses, 22.5% of the examined sites were abnormal as compared with US, which achieved higher sensitivity of 62.5%. Mean US score was significantly higher in patients with SpAs (22.6 ± 6.34) as compared with controls (P < 0.001). Elemental US lesions (calcification, Doppler, bone erosion, and bursae) also achieved significant difference between both groups (P < 0.003, 0.001, 0.003, 0.001, respectively). Disease duration but not human leukocyte antigen-B27 positivity had a significant correlation with the US score. Conclusion The entheses US score may be useful for improving the diagnostic accuracy of early SpA, which is difficult to diagnose.
  615 44 -
Correlation between the serum alkaline phosphatase level and the severity of coronary artery disease
Ghada M Soltan, Ahmed M Elkersh, Walaa Farid, Islam I Hegazy
July-September 2018, 31(3):882-886
DOI:10.4103/mmj.mmj_145_17  
Objective The aim of this study was to investigate the correlation between serum alkaline phosphatase (ALP) levels and the severity of coronary artery disease (CAD) by assessing the Gensini score. Background The serum ALP level has been shown to be a prognostic factor in myocardial infarction and peripheral vascular disease by its promoting effect on vascular calcification. Patients and methods A total of 200 patients with stable angina pectoris were evaluated retrospectively. Upon admission, their ALP levels were measured with automated AU480 analyzer using kinetic rate method, and were evaluated according to Gensini score. Results The mean ALP level was 60 ± 21.858, ranging from 29 to 110 U/l, and there were 95 (47.50%) patients with low normal level (<63 IU/l), 75 (37.50%) patients with midrange level (63–78 IU/l), and 30 (15%) patients with high normal level (>78 IU/l). The mean Gensini score was 20.7 ± 21.8; 31 (15.50%) patients had a score of 0, 64 (32%) patients had mild CAD with a score ranging from 1 to 15, 75 (37.5%) patients had moderate CAD with a score ranging from 16 to 30, and 30 (15%) patients had severe CAD with a score more than 30. The advanced CAD group included more patients with diabetes mellitus and hypertension. Regression analysis showed a significant correlation between increased levels of serum ALP and advanced CAD in the multivariate model (χ2 = 372.434) (P < 0.001). Conclusion There was a significant correlation between serum ALP and severity of CAD according to Gensini score.
  607 40 -
Evaluation of hepcidin as a biomarker for neonatal sepsis
Fadi M Elgendy, Ahmed A Khatab, Hassan S Badr, Gehanabdel Fatah, Ahmed M El Fishawy
July-September 2018, 31(3):977-982
DOI:10.4103/mmj.mmj_32_17  
Objective The aim of this study was to evaluate serum hepcidin as a biomarker for neonatal sepsis. Background Neonatal sepsis is one of the most important neonatal disorders frequently associated with high rate of mortality and morbidity. Hepcidin is the key iron regulator; the clear link between hepcidin and innate immunity may be used for detection of sepsis. Patients and methods This case–control study was carried out in the NICU of Menoufia University Hospital from April 2015 to October 2016. It was conducted on 60 neonates: 40 neonates admitted in NICU as they were suspected for neonatal sepsis based on clinical and hematological scores and 20 healthy outpatient neonates served as a control group. The newborn infants were both full term and preterm, and their ages ranged from 1 to 28 days. An informed consent was taken from the parents before their enrollment in the study. We evaluate the serum hepcidin level as a biomarker for neonatal sepsis; we compared the results of serum hepcidin regarding blood culture and C-reactive protein (CRP) in case and control groups. All participants were subjected to history taking, thoroughly clinical examination, and laboratory investigations (complete blood count, CRP, blood culture, and micro-erythrocyte sedimentation rate), and we measured the serum level of hepcidin in septic and control groups. Results Serum levels of hepcidin were significantly higher in neonates with sepsis than in healthy neonates. Serum levels of hepcidin were significantly correlated with blood culture results and CRP levels. After antibiotic therapy, the serum level of hepcidin was significantly decreased as compared with its pretreatment level. Conclusion Hepcidin – the key iron regulatory hormone –is a promising acute-phase reactant that may be a useful adjunct test aiding in the evaluation of neonatal sepsis. Use of hepcidin includes in early-onset sepsis as well as late-onset sepsis, in both full-term and preterm neonates.
  594 53 -
REVIEW ARTICLES
TRAIL receptor 1 polymorphism and cancer risk: a systematic review
Amr A.F Mohamed, Samia H Kandeel, Hassan E Zaghlaa, Nahla F Osman, Mohamed A Helwa, Hanan M.I Bedier
July-September 2018, 31(3):730-734
DOI:10.4103/1110-2098.248755  
The aim of this study was to perform systematic review to summarize the association of TRAIL receptor 1 polymorphism at codon A683C and C626G with cancer risk. Medline, articles in Medscape, AAFP, and PubMed were searched. The search was performed on 1 August 2016, and included all articles with no language restrictions. The initial search presented 219 articles. A total of 16 research studies met the inclusion criteria for the two DR4 polymorphisms; the articles included TRAIL receptor 1 polymorphism and increased cancer risk. Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. There was heterogeneity in the collected data. It was not possible to perform meta-analysis. Significant data were collected. Thus, a structured review was performed. TRAIL receptor 1 polymorphism at codon A683C and C626G increases the risk of different types of malignancy such as hepatocellular carcinoma (HCC), gall bladder cancer, ovarian cancer, hematological system cancer, and bladder cancer, but without significant increase in the risk of other malignancies such as lung and breast cancers. A total of 14 articles were reviewed summarize the TRAIL receptor 1 polymorphism and cancer risk. Genotyping of this polymorphism at codon A683C and C626G can be used to assess patients' risk of developing cancer, which would allow early diagnosis with subsequent improvement in patient survival. Furthermore, TRAIL- directed therapy is likely to be beneficial in these cases.
  574 73 -
ORIGINAL ARTICLES
Metal phosphide poisoning in Menoufia University Hospitals
Samy M Badawi, Amira M Alseidy, Ahmed K Alfeki, Magda Mansour, Amira Abd El-Hamid
July-September 2018, 31(3):816-821
DOI:10.4103/mmj.mmj_1_18  
Objective To assess the pattern, severity, and outcome of metal phosphide poisoning cases admitted to Menoufia University Poison and Dependence Control Center (MPCC). Background Over the past years, the consumption of metal phosphide rodenticide has been increasing, causing severe morbidity and elevated mortality. It was the first cause of death in poisoning cases admitted to MPCC during the past 2 years. On phosphides contact with moisture or acids, liberation of phosphine gas leads to widespread organ damage. Phosphine blocks the enzyme cytochrome C oxidase, as a result of which mitochondrial oxidative phosphorylation is inhibited. It also denatures many enzymes involved in cellular respiration and metabolism. Patients and methods A prospective study was conducted on 80 patients with acute zinc and aluminum phosphide (ALP) poisoning who were admitted to MPCC, during the period from the first of September 2015 to the end of February 2016. Results A significant relation was found between zinc phosphide, time passed since exposure, and complaint on arrival (P = 0.04), and a nonsignificant relation between ALP, time passed since exposure, and complaint on arrival was detected (P = 0.1). Highly significant relation was noticed between type of phosphide and both echocardiography and poison severity score (P < 0.001). Relation between type of phosphide and outcome of cases was highly significant. Conclusion Metal phosphide compounds cause very serious manifestations to exposed humans with high mortality, which is especially pronounced in ALP poisoned cases.
  591 48 -
Diagnostic value of apolipoprotein A1 in neonatal sepsis
Fady M El-Gendy, Dalia M El-Lahony, Dina A R. Midan, Wafaa M Amin Shaban
July-September 2018, 31(3):1011-1017
DOI:10.4103/mmj.mmj_193_17  
Objective The aim of this study is to detect the value of apolipoprotein A1 (Apo A1) in the diagnosis and prognosis of neonatal sepsis in neonatal ICU of Menoufia University Hospitals. Background Neonatal sepsis is used to describe the inflammatory response to infection in neonates younger than 30 days of age. Apo A1 is the major protein component of high-density lipoprotein in plasma, which decreases during the inflammatory process. Patients and methods Our study was carried out on 60 neonates admitted to neonatal ICU of Menoufia University Hospitals from April 2015 to April 2016 and were divided into two groups: group I (cases) included 40 neonates with a positive clinical and hematological sepsis score and group II (controls) included 20 healthy neonates with no evidence of sepsis. The two groups were subjected to assessment of history, clinical examination, and laboratory investigations in the form of complete blood counts, blood cultures, C-reactive protein, and Apo A1 level. Results Apo A1 level was lower in group I (55.33 ± 1.53 mg/dl) than in group II (85.20 ± 1.69 mg/dl) and the best cut-off point to detect sepsis is 80 mg/dl with a sensitivity of 100% and a specificity of 100%. Conclusion Apo A1 was found to be a diagnostic and prognostic factor in neonates with sepsis.
  569 68 -
Efficacy of high-dose atorvastatin in preventing contrast-induced nephropathy in patients undergoing coronary angiography
Saied Shalaby, Awny Gamal, Osama R Kandeel
July-September 2018, 31(3):894-899
DOI:10.4103/mmj.mmj_195_17  
Objective The aim of this study was to examine the efficacy of high-dose atorvastatin in preventing contrast-induced nephropathy (CIN) in statin-naive patients with moderate or high risk of CIN undergoing coronary angiography. Background CIN occurs in 20–30% of patients who receive standard preventive measures. This means that current treatments are not adequate. Patients and methods The present study included 300 patients scheduled for coronary angiography. They were randomized into two groups: the atorvastatin group received 80-mg atorvastatin 12 h before the procedure, with a further 40-mg preprocedural dose, and the placebo group did not receive the loading dose of atorvastatin. The primary end point of the study was evaluation of renal function before and 48 h after contrast-medium administration. Results A total of 300 patients were included in this study. The incidence of nephropathy in the placebo group was 20% (30 patients), whereas the incidence in the atorvastatin group was 9.3% (14 patients) (P = 0.009). Conclusion High-dose atorvastatin has a significant protective role against contrast-induced nephropathy in patients with moderate and high risk for contrast nephropathy undergoing coronary angiography.
  589 48 -
Role of beclin 1 and autophagy in vitiligo
Rehab M Samaka, Mohammed A Basha, Amany M Zahran
July-September 2018, 31(3):822-825
DOI:10.4103/mmj.mmj_88_18  
Objective The objective of this study was to perform a systematic review to summarize the role of beclin 1 and autophagy in vitiligo. Background Vitiligo is an acquired autoimmune pigmentary disorder due to loss of functional melanocytes. Few studies have shown that beclin 1 and autophagy play a role in vitiligo. Materials and methods Medline databases (PubMed, Medscape, ScienceDirect) and all materials published in English language are available on the Internet from 2008 to 2017. The search was performed in December 2017. All the studies were independently assessed for inclusion. They were included if they fulfilled the following criteria: published in English language, published in peer-reviewed journals, and focused on the role of beclin 1 in vitiligo. The initial search presented 16 articles of which three met the inclusion criteria. The articles studied the effect of role of beclin 1 in vitiligo. If the studies did not fulfill the above criteria, they were excluded. Comparisons were made by a structured review with the results tabulated. Results In total, three potentially relevant publications were included; there was an association between vitiligo, autophagy, and beclin 1. This association was due to the effect of beclin 1 as an autophagy gene on melanogenesis and melanosome degradation. Conclusion Beclin1 and autophagy have a role in the pathogenesis of vitiligo.
  581 47 -
Thrombophilia testing in adults: a systematic review
Sabri A Shoeib, Mohamed A Abd El Hafez, Ghada A Elgammal
July-September 2018, 31(3):900-904
DOI:10.4103/1110-2098.248753  
Objective The aim of this study was to carry out a systematic review to summarize diagnosis and management of thrombophilia in adults. Data sources In September 2016, Medline, articles in Medscape, AAFP and PubMed were searched. Study selection The initial search presented 250 articles. Only six articles met the inclusion criteria. The selected articles covered thrombophilia clinical presentation, investigation to confirm the diagnosis, and management in adults. Data extraction Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. Data synthesis There was heterogeneity in the collected data. It was not possible to perform meta-analysis. Significant data were collected and then a structured review was carried out. Conclusion Six articles were reviewed, five articles and one systematic review, summarizing the clinical presentation investigation and testing of thrombophilia. Patients with thrombophilia presented with deep vein thrombosis and pulmonary embolism, usually occuring in the legs, characterized by pain, swelling, and heaviness due to damage in the veins. Testing of thrombophilia include protein C, protein S, factor V Leiden, antithrombin III, prothrombin G 20210 mutation, and hyperhomocystenemia. Other factors include elevated factor VIII, elevated factor XI, dysfibrinogenemia, factor XII defeciency, and plasminogen defeciency. As soon as the diagnosis is made, vitamin K antagonist (e.g., warfarin) should be added to heparin. Monitoring of anticoagulation is carried out by the prothrombin time, expressed in terms of international normalized ratio.
  578 45 -
Evaluation of serum Midkine as a novel marker in hepatocellular carcinomas
Rawhia H EI-Edel, Gehan A Tawfik, Rasha I Noreldin, Mohammed A El-Jaky, Doaa A Eisaa
July-September 2018, 31(3):1094-1098
DOI:10.4103/mmj.mmj_335_15  
Objectives To evaluate the clinical significance of serum Midkine (MDK) levels in the diagnosis of hepatocellular carcinoma (HCC) compared with alpha-fetoprotein (AFP). Background It was demonstrated that serum MDK levels are increased in cancer patients. So, it was suggested that MDK would likely be a novel marker for diagnosing tumors. In this study, we evaluated the significance of serum MDK levels in the diagnosis of HCC and early-stage HCC compared with AFP. Patients and methods The study was conducted on 90 patients who were divided into three groups: group I is the HCC group (n = 50), group II the liver cirrhosis group (n = 20), and group III is the control group (n = 20). Serum samples were obtained from all patients and were used to measure AFP and MDK levels. Receiver operating characteristic curves were drawn for both AFP and MDK in the diagnosis of HCC and early-stage HCC. Area under the curves (AUC) were calculated and were used to measure the sensitivity, specificity, and accuracy of both markers in the diagnosis of HCC and early HCC. Results AFP and MDK levels were increased in HCC over cirrhosis groups; and in HCC over control groups with a highly significant difference. MDK had the largest AUC in the diagnosis of both HCC (AUC = 1.00) and early-stage HCC (AUC = 0.829). In the diagnosis of HCC, serum MDK at a cutoff point of 0.62 ng/ml was 98.9% accurate compared with an accuracy of 73.3% for AFP at a cutoff point of 20.2 ng/ml. At a cutoff point of 0.92 ng/ml, serum MDK was 73.3% accurate in the diagnosis of early HCC compared with an accuracy of 65.6% for AFP at a cutoff point of 19.5 ng/ml. Conclusion Serum MDK could be a novel diagnostic tumor marker for the detection of HCC, particularly in patients at an early stage.
  573 49 -
Hot flushes among perimenopausal women
Safaa A Badr, Fatma A El-Esrigy, Yara M Heikal
July-September 2018, 31(3):834-838
DOI:10.4103/mmj.mmj_713_17  
Objective The aim of this study was to assess the prevalence and factors affecting hot flushes (HFs) among perimenopausal women. Background More than 80% of women report physical and psychological symptoms especially HFs that commonly accompany the perimenopausal period and so understanding the factors affecting HFs is important to decrease the severity of HFs and its effects. Participants and methods The study was carried out in two randomly selected family healthcare centers in urban and rural areas in Berket El Saba district, Menoufia Governorate during the period from 1 October to 1 December 2016. An analytic cross-sectional study was conducted on a convenient sample of 300 perimenopausal women aged from 45 to less than 60 years. The questionnaire was designed to obtain full history and analysis of HFs. Results The prevalence of HFs among the studied perimenopausal women was 86%. In binary logistic regression, the most significant factors affecting HFs were BMI greater than 25 [odds ratio (OR): 42.8, 95%CI: 6.9–264)], followed by basic education (OR: 10.6, 95%CI: 2.6–43.4) followed by sedentary life (OR: 3.5, 95%CI: 1.6–7.7), and being housewife (OR: 3.2, 95%CI: 1.4–7.2). Caffeine consumption did not significantly affect the presence of HFs, but affected their severity (P < 0.05). Conclusion Most perimenopausal women suffer from HFs with different degrees of severity. Moreover, the most significant factor was BMI greater than 25.
  581 40 -
Clinical evaluation of intra-articular platelet-rich plasma injection for the treatment of knee osteoarthritis
Taher A Eid, Osama G Ahmed, Mohamed Y Abuzeid
July-September 2018, 31(3):1088-1093
DOI:10.4103/mmj.mmj_279_17  
Objective The aim of this study was to evaluate results of intra-articular injection of plasma sample rich in platelets for the treatment of knee osteoarthritis (OA). Background OA is a progressive, chronic condition leading to pain and loss of function that reduce patients' quality of life. Materials and methods The study was performed on 30 knees of 30 patients with age 30–65 years. All of the patients presented with knee OA grade I, II, and III and were treated with two intra-articular platelet-rich plasma (PRP) injections with three weeks interval. Preparation was done by centrifugation of 50 ml blood in two separate cycles, finally resulting in 5 ml of PRP then get activated by calcium chloride (CaCl2) at concentration of 50 μl/1 ml PRP, added just before injection. Western Ontario and McMaster universities score was used for clinical evaluation. Complications and adverse events were also recorded. Results Mean age of patients was 52 years. All of them were followed up to 12 months. The clinical results were classified on subjective base and were graded as excellent in 19 (63.3%) patients, good in six (20%) patients, and poor in five (16.7%) patients. No complications were noted. There was significant significance between BMI and clinical success (P = 0.000). The study showed significant association between grade of OA and clinical success (P = 0.008). Conclusion Maximal improvement occurred in a month and continued above basal levels in 12 months follow-up, especially in the young individuals. These findings indicate that treatment with PRP injections can reduce pain and improve knee function and quality of life with short-term efficacy.
  566 44 -
Serum interleukin-17 level in patients with ankylosing spondylitis and its relation with disease activity
Abd El-Samad I Al Hewala, Samar G Soliman, Manal A Saafan, Alaa A Labeeb, Amany M Hashish
July-September 2018, 31(3):805-809
DOI:10.4103/mmj.mmj_509_17  
Objective The aim of this study is to measure the level of interleukin-17 (IL-17) in the serum of patients with ankylosing spondylitis (AS) and correlating it with disease activity. Background AS is a chronic inflammatory disease that affects axial joints, characterized by a diffuse stiffness, with the advanced stage producing a rigid spine from the occiput to the sacrum. IL-17 may play a role in the pathogenesis, activity, and clinical manifestations of AS. IL-17 is produced by T helper 17 cells. Methods Fifty patients with AS (male:female 48:2) and 20 age-matched healthy male volunteers as controls were included in this study. Patients were diagnosed as having AS according to Assessment of SpondyloArthritis International Society criteria. All were subjected to demographic data, clinical examination, and laboratory investigations including serum level of IL-17A by enzyme-linked immunosorbent assay. The results were correlated with disease activity, which was assessed by Bath Ankylosing Spondylitis Disease Activity Index and Ankylosing Spondylitis Disease Activity Score. Results In our study, the serum levels of IL-17A in patients were significantly higher than those of the healthy controls (P < 0.001). There was a positive correlation between serum IL-17A and both Bath Ankylosing Spondylitis Disease Activity Index and Ankylosing Spondylitis Disease Activity Score and negative correlation between serum IL-17A and disease duration. Conclusion Serum IL-17A levels of patients with AS were significantly higher than healthy controls, and it was positively correlated with disease activity.
  557 43 -
Serum mannose-binding lectin as a biomarker in neonatal sepsis
Fady M El-Gendy, Seham A Khodeer, Hanan M Elsayed, Sabrin A Elsayed
July-September 2018, 31(3):987-993
DOI:10.4103/mmj.mmj_61_17  
Objective The aim of thi s study was to evaluate the levels of mannose-binding lectin (MBL) in neonates to determine the relation between MBL deficiency and the development of sepsis. Background The MBL is a member of the collection family that is produced by the liver as an acute-phase protein. MBL activates macrophages, enhances phagocytosis, and contributes toward complement activation. Low serum MBL levels increase the risk of infections, especially if associated with other conditions such as immune deficiencies of various origins. Neonates are considered to be immunocompromised because their adaptive immunity has not yet been developed. Patients and methods This case–control study was carried out on 86 neonates classified into two groups: 45 neonates diagnosed with sepsis and 41 healthy neonates with no clinical signs or laboratory evidence of sepsis who were enrolled as a control group. Assessment of history, clinical examination, and investigations (complete blood count, C-reactive protein, blood culture, MBL levels) were performed for all neonates. Results The mean MBL serum level was found to be lower in the septic group (0.49 ± 0.1) than the control group (1.4 ± 0.3) with high statistical significance. Conclusion Low MBL serum levels are related to the development of sepsis.
  543 53 -
Paroxonase 1-L55M gene polymorphism in Behcet's disease
Sabry Abd Allah Shoeib, Hesham G Amer, Ashraf Abd El-Raoof Dawood, Mohamed A Abd El-Hafez, Emad M El-Shebiny, Alaa E Abd El-Hamid, Enas S Attia Zahran
July-September 2018, 31(3):940-945
DOI:10.4103/mmj.mmj_237_17  
Objective The aim of this work was to study paroxonase 1-L55M gene polymorphisms in Behcet's disease (BD) and its relation to clinical manifestations. Background BD is a type of vasculitis characterized by recurrent orogenital ulcers, relapsing uveitis, and skin, articular, vascular, neurologic, and gastrointestinal manifestations. Genetic, environmental, and immunological factors are involved in its pathogenesis. Paraoxonase is thought to play an important role in the protection of low-density lipoprotein and high-density lipoprotein particles from oxidation. Lipid peroxidation and free oxygen radicals are believed to play a role in BD pathogenesis. Patients and methods In the current study, we examined 40 BD patients (group II). The diagnosis of BD was made according to the International Study Group Criteria of Behcet's Disease. We included 40 healthy adults as controls (group I). All participants were subjected to thorough history taking, physical examination, and laboratory investigations, including serum lipid profile (total cholesterol, triglycerides, high-density lipoprotein-cholesterol, and low-density lipoprotein-cholesterol) and paroxonase 1-L55M gene study using PCR. Results BD shows male predominance with a male:female ratio of 2.1:1. Oral and genital ulcers were the most common presentation and were present in almost all patients, followed by vascular, skin, central nervous system, and articular manifestations. There were no significant statistical differences between BD patients and the control group as regards PON1 genotype and allele frequencies. Conclusion PON1 L55M gene polymorphism is not associated with an increased risk for BD or its clinical manifestations.
  534 55 -
Evaluation of serum soluble klotho protein in patients with different degrees of chronic kidney disease
Gehan K El Saeed, Seham A Khodeer, Yassen S Yassen, Marwa M Elwan Elshouny
July-September 2018, 31(3):957-962
DOI:10.4103/mmj.mmj_136_17  
Objectives The aim of this study was to investigate serum α-klotho as a new biomarker for the diagnosis of chronic kidney disease (CKD), especially in its early stages. Background α-Klotho is a novel antiaging protein that was identified as a regulator of calcium and phosphate homeostasis, which is highly expressed in the kidney. The soluble form of klotho acts as an endocrine substance that exerts multiple actions including the modulation of renal solute transport and protection of the kidney. Methods A case–control study was conducted at the Clinical Pathology Department, Menoufia University Hospitals, Faculty of Medicine, during the period from January 2015 to November 2016. Sixty-eight patients suffering from CKD who were admitted to the hospital during the period from January 2015 to November 2016 were included in this study. In addition, 10 apparently healthy subjects with matching age and gender formed the control group. Routine laboratory investigations performed were: hemoglobin, urea, creatinine, uric acid, calcium (Ca2), phosphate (PO4), and albumin and the estimated glomerular filtration rate were measured and the α-klotho protein level was measured by ELISA. Results Serum soluble α-klotho protein levels were significantly lower in CKD patients compared with normal controls. Besides, α-klotho protein levels were positively correlated with estimated glomerular filtration rate, hemoglobin and were negatively correlated with renal function tests and phosphate. Conclusion Soluble α-klotho levels are significantly decreased in CKD not only in the advanced stages but also in the early stages.
  543 44 -
Impact of human cytomegalovirus on the response of chronic hepatitis C virus-infected patients to pegylated interferone and ribavirin combination therapy
Hossam I Mohamed, Amira M Ahmed Badawy, Ahmed A Salama, Sammar A Hassan El-Said
July-September 2018, 31(3):1073-1080
DOI:10.4103/1110-2098.248746  
Objective The aim of this study was to study the impact of human cytomegalovirus infection in response rates of patients with chronic hepatitis C virus infection to pegylated interferon and ribavirin combination therapy. Background Cytomegalovirus affects the liver and overall immunological status of the host body. In chronic hepatitis C virus patients, co-infection with Cytomegalovirus could be an additional threat to the host and may contribute to the complexity of disease outcome. Patients and Methods This study was conducted on 40 patients with chronic hepatitis C virus infection candidates for pegylated interferon and ribavirin combination therapy. They were classified into two groups according to response to therapy. Group I (non-responders): included 20 chronic hepatitis C virus patients with any form of non response to therapy. They were 12 males (60%) and 8 females (40%). Group II (responders): included 20 patients with adequate response to therapy at the end of treatment (48 weeks). They were 9 males (45 %) and 11 females (55 %). Results There were significant increases in the number of patients with positive polymerase chain reaction for Human cytomegalovirus DNA in non-responders when compared with responders (14 out of 20 patients versus 5 out of 20 patients respectively). Conclusion Human cytomegalovirus is one of the independent factors that may significantly affect response of chronic hepatitis C virus patients to pegylated interferon and ribavirin combination therapy.
  538 43 -
Study of interleukin-18 during antiviral therapy for hepatitis C with sofosbuvir, ribavirin, and interferon in Menoufia hospitals
Ghada R El-Hendawy, Ahmed A Salama, Alaa E Abd El-Hamid, Asmaa T.M Esmaeel
July-September 2018, 31(3):762-771
DOI:10.4103/mmj.mmj_554_16  
Objectives The objectives of this study were to evaluate the role of interleukin-18 (IL-18) in liver cirrhosis caused by hepatitis C, and to determine the effect of the triple regimen treatment sofosbuvir, ribavirin, and interferon on its serum levels. Background IL-18 is a member of the IL-1 family. Recent studies have suggested that IL-18 plays a role in the pathogenesis of liver damage during acute and chronic hepatitis; furthermore, IL-18 may be involved in the development and progression of liver fibrosis. Patients and methods The present study was carried out on 27 hepatitis C patients and 15 age-matched and sex-matched healthy individuals. All patients were subjected to history taking, complete medical examination, and laboratory investigations for liver and kidney functions. Serum levels of IL-18 were measured by ELISA three times for each patient: the first one was measured before treatment initiation, the second after 1 week of treatment, and the third was measured after 3 months of treatment. Results The serum levels of IL-18 were highly elevated in hepatitis C patients compared with controls (P < 0.001). In addition, we found that serum IL-18 was significantly higher before initiation of treatment, decreased after 1 week of treatment, and it was markedly decreased after 3 months of treatment. Conclusion There is significant elevation in the serum levels of IL-18 in hepatitis C patients. IL-18 concentrations were reduced following a successful course of antiviral treatment.
  518 60 -
The effect of metabolic syndrome on patients with knee osteoarthritis
Abd El Samad I Al Hewala, Samar G Soliman, Dina R El Sharaqi, Wafaa A Fadel
July-September 2018, 31(3):795-799
DOI:10.4103/mmj.mmj_250_17  
Objective The aim was to study the effect of metabolic syndrome (MS) on the severity of knee osteoarthritis (OA), as well as its association with generalized OA. Background Knee OA is a major cause of disability. Studies suggested that metabolic factors may have a negative effect on cartilage and may play a role in the pathogenesis of OA. Patients and methods A total of 60 patients with primary knee OA were divided into two groups: group I included patients with knee OA and MS and group II included patients with knee OA and without MS. Both groups were matched regarding age, disease duration, and MS (BMI). All were subjected to demographic data, blood pressure measurement, waist circumference, BMI, laboratory investigations, knees and hands radiograph, disease severity assessment by Lequesne functional index, and radiological Kellgren and Lawrence score. Results Group I patients were significantly more affected with varus deformity, flexion deformity, and tenderness over knee joint line and hand OA than group II patients. Radiologic findings revealed higher grades of Kellgren and Lawrence score grading system in group I patients than group II. The patellofemoral OA showed significantly higher mean in group I than in group II. The total functional score of Lequesne for knee OA showed significantly higher mean in group I (P < 0.001). Conclusion MS in patients with knee OA is associated with more severe clinical signs, progressive radiological damage, severe grades of functional disability, and more frequent affection with generalized OA in comparison with patients with OA without MS.
  533 41 -
Serum polymorphonuclear leukocyte elastase enzyme level in neonatal sepsis
Ahmed T Mahmoud, Dalia M El-Lahouny, Khalid A Khalifa, Mohamed R Hosny
July-September 2018, 31(3):970-976
DOI:10.4103/mmj.mmj_31_17  
Objective The aim of this study is to evaluate the clinical importance of polymorphonuclear leukocyte (PMN) elastase level in neonatal sepsis. Background Neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first 4 weeks of life. When pathogenic bacteria gain access into the bloodstream, they may cause overwhelming infection without much localization (septicemia) or may be predominantly localized to the lung (pneumonia) or the meninges. Patients and methods This prospective study was performed on 60 newborns, which included 30 newborns with positive clinical sepsis score and 30 healthy neonates matched for age, sex, and weight as a control group. Blood samples for blood culture, routine biochemistry, whole blood count, immature neutrophil: total neutrophil ratio, C-reactive protein, and PMN elastase were taken. Antibiotics were commenced after the blood specimens were collected. Second blood samples for sepsis markers were obtained from the patient only on the fourth day of treatment. Results In our study, we found that respiratory distress was the most common clinical presentation (86.7%) in neonates with sepsis followed by poor activity (83.3%) and jaundice (40%). PMN elastase levels in neonates with sepsis were highly significantly increased compared with controls. Overall, 100% of patients had a positive PMN elastase test result, and PMN elastase has a sensitivity of 96% and positive predictive value of 86% in prediction of sepsis. The sensitivity of C-reactive protein in detecting sepsis was 77%, specificity was 93%, positive predictive value was 87%, and negative predictive value was 14%. Conclusion These findings indicate that PMN elastase level is a major indicator for the early diagnosis of sepsis in newborns.
  534 39 -
A Study of hypogonadism in type 2 Diabetes Mellitus male patients attending Shebin ElKoum Teaching Hospital- Egypt
Mostafa G El-Nagar, Alaa El-Din A Daood, Mohamed Z Nouh, Ahmed M Essa
July-September 2018, 31(3):922-927
DOI:10.4103/mmj.mmj_121_17  
Objective To the objective of this article is to evaluate serum-free testosterone levels as an indicator of hypogonadism in male patients with type 2 diabetes mellitus (DM). Background DM is considered to be one of the most common chronic diseases. Male hypogonadism is characterized by low levels of serum testosterone and is closely linked to the development of diabetes. Patients and methods This study included 80 individuals recruited from the Internal Medicine Department of Shebin El-Kom Teaching Hospital, Menoufia, Egypt. They were classified into: a case group which included 40 patients of type 2 DM in the age group of 30–65 years and a control group which included 40 healthy control persons matched for age and sex. After providing written informed consent, all patients were clinically evaluated, had routine laboratory investigations and assessment of glycated hemoglobin% (HbA1c%) and free testosterone and those who had low levels of free testosterone underwent assessment of the circulating levels of the follicle-stimulating hormone and luteinizing hormone. Results There was significant difference between the two groups regarding the presence of erectile dysfunction and hypogonadism as their percentages were increased in the case group. A comparison between diabetic patients with hypogonadism and diabetic patients with eugonadism regarding HbA1c has shown that diabetic patients with hypogonadism had significant elevated levels of HbA1c. Conclusion This study demonstrates the presence of a significant relationship between type 2 DM and presence of hypogonadism and erectile dysfunction in men.
  533 40 -
Study of tumor necrosis factor-α in postdialysis fatigue patients
Said S.A Khamis, Yassein S Yassein, Ahmed M Zahran, Rania M.A El-Shazly, Mohamed S.H Aboelmagd
July-September 2018, 31(3):946-951
DOI:10.4103/mmj.mmj_10_18  
Objective The aim was to study the tumor necrosis factor-α in postdialysis fatigue (PDF). Background Fatigue is one of the most frequent complaints of dialysis patients and is associated with impaired health-related quality of life. Patients and methods A cross-sectional study was conducted on 50 patients receiving hemodialysis treatment who were divided into two groups: group I included 25 patients with PDF, and group II included 25 patients without PDF. All patients attended the Dialysis Unit at Menoufia University Hospital and El Sahel Teaching Hospital in the period from January to October 2017. Demographic, clinical, and laboratory data were recorded for each patient. Results A total of 50 patients were included in the current study. The mean age of group I was 50.20 ± 13.02 years and of group II was 46.76 ± 13.40 years. There was a statistically significant difference between the studied groups regarding sex (P = 0.045), education levels (P = 0.029), weight change (P = 0.001), predialysis diastolic blood pressure (P = 0.016), postdialysis diastolic blood pressure (P = 0.004), hemoglobin (P = 0.001), calcium (P = 0.035), albumin (P = 0.040), and C-reactive protein (P = 0.007). Conclusion Our results concluded that excessive ultrafiltration, intradialytic hypotension, anemia, hypocalcemia, malnutrition, and C-reactive protein were statistically significantly increased in postdialysis fatigue (PDF) group compared with non-PDF. Moreover, there is a lack of correlation between tumor necrosis factor-α and PDF. Finally, it is crucial to design adequate studies to understand the mechanism of PDF, and more importantly, for developing effective therapeutic strategies.
  527 39 -
Study of glycated albumin to glycated hemoglobin ratio during the progression of hepatitis C virus-related liver fibrosis
Hany S Sabry, Gamal S El-Deeb, Christopher C Thompson, Ayman A Sakr
July-September 2018, 31(3):1099-1104
DOI:10.4103/mmj.mmj_355_16  
Objective The aim was to show the relation between glycated albumin (GA) to glycated hemoglobin (HBA1c) ratio alone or combined with aspartate aminotransferase to platelet ratio index (APRI) and the progression of liver fibrosis in correlation with liver biopsy. Background Hepatitis C virus induced-liver fibrosis can result in chronic liver disease, liver cell failure, and the need for liver transplantation. However, liver biopsy still remains the cornerstone for assessment of liver fibrosis; many modalities have been investigated to overcome its complications. Subjects and methods This study was prospectively conducted on 90 patients (47 men, 43 women), with chronic hepatitis C virus infection attended to a tertiary medical center in Egypt. All patients were subjected to routine investigations and percutaneous liver biopsy with histopathological interpretation and classification according to the METAVIR system into five groups F0–F4 and subgroups: F0–F1: no minimal fibrosis, F2–F3: intermediate fibrosis, F3–F4: severe fibrosis, and F4: cirrhosis. GA to HBA1c ratio and APRI were then calculated. Results The mean age of patients was 43.27 ± 11.6. GA/HBA1c and APRI are positively correlated with progression of liver fibrosis with highly statistically significant difference between the groups (P = 0.001 and 0.013, respectively). The sensitivity and specificity of APRI greater than 1.5 or GA/HbA1c ratio greater than 3.0 for the detection of significant liver fibrosis were 39/60 (65%) and 23/30 (76.7%), respectively; but, 34/60 (56.7%) and 26/30 (86.7%) when using APRI greater than 1.5 or GA/HbA1c ratio greater than 3.2. The positive and negative predictive values are highest (89.5 and 52%) when using GA/HBA1c greater than 3.2 or APRI greater than 1.5, respectively. Conclusion We can use GA/HbA1c ratio with or without APRI as a supportive index for assessing liver fibrosis.
  522 43 -
Evaluation of pentraxin-3 level in patients with diabetic retinopathy
Mohamed Zakarya Nouh, Ahmed Sonbol, Mohammed Mogahed
July-September 2018, 31(3):928-934
DOI:10.4103/mmj.mmj_140_17  
Objective The aim of this study was to evaluate serum pentraxin-3 (PTX3) levels as an indicator of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM). Background DR is responsible for 10.2% of worldwide visual loss. Pentraxin-3 is an acute phase protein secreted by different types of cells and correlates with the disease activity. Patients and methods A total of 80 individuals were included in the study. They were divided into three groups. Group 1 included 30, type 2 diabetic patients without retinopathy, group 2 included 30, type 2 diabetic patients with retinopathy, and group 3 included 20 apparently healthy individuals. Group 2 was subdivided into 20 patients with nonproliferative and 10 patients with proliferative DR. Serum glycated hemoglobin, C-reactive protein (CRP), lipid profile, liver function tests, renal function tests, serum PTX3 level, and fundus examination were measured in all the patients. Results Serum PTX3 was significantly elevated in T2DM with retinopathy than T2DM without retinopathy and control group. There is no statistical difference between proliferative and nonproliferative DR regarding PTX3. Serum PTX3 was significantly positively correlated with age and high-sensitivity CRP in the proliferative DR group and cholesterol, low-density lipoprotein and high-sensitivity CRP in the proliferative DR group. Conclusion PTX3 levels were significantly higher in T2DM with retinopathy than those without retinopathy and control group, and positively correlated with inflammatory marker. Thus, it might be used in the prognosis of DR.
  520 43 -
Intima media thickness measurement as a marker of subclinical atherosclerosis in systemic lupus erythematosus patients
Samar G Soliman, Alaa A Labeeb, Ghada M Soltan, Dalia A Nofal
July-September 2018, 31(3):800-804
DOI:10.4103/mmj.mmj_262_17  
Objective The aim of this study was to evaluate subclinical atherosclerosis in patients with systemic lupus erythematosus (SLE) and its relationship to disease activity and damage indices. Background Increased morbidity and mortality in patients with SLE is mostly due to cardiovascular events. Assessment of the intima media thickness (IMT) using B-mode ultrasonography at the carotid artery level is a noninvasive measure to assess subclinical atherosclerosis. Patients and methods The study included 60 patients with SLE (female:male 57:3) in addition to 20 healthy volunteers (female:male 16:4) as a control group. These patients were diagnosed with SLE according to the modified American College of Rheumatology criteria for classification of SLE. IMT was measured using B-mode ultrasound on both sides. The results were correlated with lipid profile, anticardiolipin antibodies, and lupus anticoagulant complement components. Clinical disease activity and damage were evaluated using Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Systemic Lupus International Collaborating Clinics (SLICC) indices. Results There was a highly significant difference between patients and controls regarding IMT; it was higher in patients (0.84) than in controls (0.61) and P value less than 0.001. There was a positive correlation between age, duration, erythrocyte sedimentation rate, low-density lipoprotein, cholesterol, SLEDAI and SLICC score, and IMT, and a negative correlation between complement 4 (C4) and IMT. Conclusion Subclinical atherosclerosis is frequent in patients with SLE. The occurrence of premature atherosclerosis increases with increased disease activity and damage index.
  521 40 -
An overview of respiratory tract infections in preschool children in primary healthcare
Nagwa N Hegazy, Omima A.E Mahrous, Mona A Salah
July-September 2018, 31(3):862-866
DOI:10.4103/mmj.mmj_537_17  
Objective The aim of this study was to explore the frequency of upper respiratory tract infections (RTIs) in children in primary healthcare and possible factors affecting their improvement. Background RTIs were considered the most common diagnoses among preschool children. Participants and methods A cohort retrospective study was conducted on 250 children aged from birth to 5 years old. By reviewing all the health records in the past 6 months, all the children diagnosed with RTIs were invited through their guardians to participate in the study. All the participants' were interviewed and their health records were revised using a checklist to gather their sociodemographic data, diagnosis, and management plan. Results The most affected age group was from 1 to 2 years (32.4%). Acute tonsillitis was the most frequent diagnosis (25.6%) followed by influenza (16.4%). Nearly 45.2% of all cases had received antibiotics. Almost 90% of the cases with RTIs were managed in primary care. Among patients who received antibiotics, 47.2% had improved in less than 7 days and 48.5% in more than 7 days, whereas 41.5% did not improve. Receiving health education and following up the patients were significant factors for improvement. Conclusion According to these findings, most of the RTIs in preschool children can be managed in primary healthcare (90%). There is a high incidence of antibiotic consumption, leading to increasing bacterial resistance to antibiotics.
  521 35 -
Evaluation of computed tomography morphologic criteria in gastrointestinal tract hepatic metastases patients treated by chemotherapy
Hala H Mohammed, Mohammad S Abdullah, Alshimaa M Alhanafy, Hanem A Metwally
July-September 2018, 31(3):1044-1049
DOI:10.4103/mmj.mmj_149_17  
Objectives The objective of this study was to evaluate morphologic and response evaluation criteria in solid tumors (RECIST) criteria in gastrointestinal tract (GIT) liver metastases patients as regards tumor marker and clinical response of patients. Background To evaluate morphological response criteria which detect tumor density changes on contrast enhanced computed tomography (CECT) in GIT liver metastases patients. These criteria will help to detect response to treatment by chemotherapy early before tumor size changes. Patients and methods We included in this study 40 patients already diagnosed with GIT liver metastases by physical examination, tumor marker assessment, and CECT. The patients received three to six cycles of chemotherapy followed by repeated physical examination, CECT, and tumor marker assessment. The lesions in the liver were then evaluated by RECIST and response criteria depending on morphology. Results There is a significant statistical relationship between morphological response and tumor marker response of patients (P = 0.002). However, the relationship between morphological response and clinical response is not statistically significant (P = 0.087). There is no significant statistical relationship between morphological response and RECIST (P = 0.281). Conclusion Morphologic criteria had significant statistical association with tumor marker response in patients with GIT liver metastases treated by different types of chemotherapy.
  518 35 -
Hemoglobin A1c level in nondiabetic children with end-stage renal disease receiving regular hemodialysis
Ghada M El-Mashad, Maha M Allam, El-Sayed I El-Gebally, Hend G Talha
July-September 2018, 31(3):983-986
DOI:10.4103/mmj.mmj_56_17  
Objective This study was designed to assess hemoglobin A1c (HbA1c) levels in nondiabetic children with end-stage renal disease (ESRD) receiving regular hemodialysis (HD). Background HbA1c level represents an established tool to monitor glycemic control in diabetic patients. Patients and methods We enrolled 30 nondiabetic ESRD children receiving HD as a HD group and 30 healthy children as a control group for this study. All children were subjected to full history taking and physical examination. HbA1c, fasting blood glucose, hemoglobin level, hematocrit value, serum calcium, potassium, phosphate, blood urea nitrogen, creatinine, and parathormone hormone were measured in all participants. HbA1c level was measured by using the turbidimetric immunoassay method. Results We found a statistically significant difference as regards HbA1c (%) between cases and controls. In addition, there was no statistically significant difference in fasting blood glucose (mg/dl) between the two studied groups. Conclusion Our limited data indicate that HbA1c levels are elevated in nondiabetic ESRD patients receiving HD.
  509 43 -
mRNA expression of interleukin-17 in viral hepatitis B and hepatocellular carcinoma patients
Hatem M El Sebaii, Ayman K Abd El-Hamid, Elsayed S Abou Elnour, Gasser I El-Azab, Nesreen G El-Helbawy, Sherin S El-Naidany
July-September 2018, 31(3):753-761
DOI:10.4103/1110-2098.248729  
Objective We aimed to study the mRNA expression of interleukin-17 (IL-17) in patients with chronic viral hepatitis B (HBV) and evaluate its role in the development of liver cirrhosis and hepatocellular carcinoma (HCC). Background IL-17 is a cytokine produced by a newly defined subset of helper T cells. The IL-17 family of cytokines has been reported to be involved in many immune processes, most notably in inducing and mediating proinflammatory responses. Recent studies have found that both natural and acquired immunity play important roles in regulating liver fibrosis, tissue repair, and recovery, which are vital for the maintenance of tissue homeostasis. Inflammation is a pathological hallmark feature of chronic liver diseases. Sustained inflammation then promotes liver fibrosis and as an end-stage liver cirrhosis or HCC. Participants and methods This study was carried out on 50 participants classified into the following groups: group I included 15 patients with chronic HBV; group II included 15 patients with HBV-related cirrhosis; group III included 10 patients with HCC with HBV infection; and group IV included 10 age-matched and sex-matched healthy individuals as controls. Liver function tests, HBV and hepatitis C virus serology, AFP alpha-fetoprotein and HBV DNA analysis by PCR were performed for all individuals. IL-17 level was estimated by enzyme-linked immunosorbent assay, and mRNA expression of IL-17 was determined by RT-PCR in peripheral blood. Results The results showed that both serum IL-17 level and mRNA expression of IL-17 increased in HCC patients compared with the cirrhosis and control groups. In patients with posthepatitis B cirrhosis, there was a significant rise in serum IL-17 and mRNA expression of IL-17 when compared with the control group. There was significant positive correlation between IL-17 and mRNA expression of IL-17 and aminotransferases and total and direct bilirubin in all groups. There was a negative correlation between serum IL-17 and mRNA expression of IL-17 and serum albumin in all groups. Conclusion Serum IL-17 and mRNA expression of IL-17 may play a role in disease progression and development of HCC in chronic HBV patients; they might be candidates for novel biological markers of HCC.
  499 33 -
Myeloma immunotherapy
Sabry A Shoieb, Mohammad A Abdelhafez, Alaa E Abdelhamid, Amira M Elmasry
July-September 2018, 31(3):905-910
DOI:10.4103/mmj.mmj_29_17  
The objective of this study was to review the role of immunotherapy in treating multiple myeloma (MM). Medline databases (PubMed, Medscape, and ScienceDirect) and all related materials available on the internet from January 1993 to December 2016 were searched. The initial search presented 90 articles of which 29 met inclusion criteria. The articles studied the role of immunotherapy in treating MM. If the studies did not fulfi ll inclusion criteria, they were excluded. Study quality assessment included whether ethics approval was gained, eligibility criteria were specifi ed, appropriate controls were used, adequate information was provided, and whether defi ned assessment measures were undertaken. Each study was reviewed independently; the data obtained were rebuilt into a new language according to the need of the researcher and arranged into different topics through the article. All articles included in this review were human studies. The studies defi ne myeloma as a disorder of differentiated plasma cells. Understanding immune dysregulation in myeloma has led to development of new therapies. Immunotherapy is a promising treatment modality in the management of MM. Many novel immunotherapies such as immunomodulatory drugs, adoptive cell therapy, and monoclonal antibodies were reviewed. Basic research efforts toward better understanding of normal and missing immune surveillance in myeloma have led to development of new strategies and therapies that require the engagement of the immune system. Many novel immunotherapy strategies such as immunomodulatory drugs, adoptive cell therapy, and monoclonal antibodies are currently under investigation in clinical trials.
  489 41 -
Evaluation of survivin gene expression as a prognostic biomarker in pediatric B-acute lymphoblastic leukemia
Samar M Kamal Elden, Ayman Azzam, Fathia Elbassal, Mahmoud A El-Hawy, Nagwan Y Saleh
July-September 2018, 31(3):952-956
DOI:10.4103/mmj.mmj_132_17  
Objective The aim of this study was to evaluate the level of survivin mRNA expression in Egyptian patients with acute pediatric lymphoblastic leukemia and to outline any significant relation between the level of survivin expression and the clinical and hematological findings in those patients. Background Survivin, a unique member of the inhibitor of apoptosis protein family, plays an important role in regulating both apoptosis and cell division and was found to be highly expressed in various kinds of tumors. Patients and methods Survivin expression was quantitatively determined by real-time (RT) PCR in 30 newly diagnosed acute lymphoblastic leukemia (B-ALL) pediatric patients before and after induction therapy and in 15 age-matched and sex-matched immune thrombocytopenic purpura individuals serving as a control group. Results A highly significant elevation (P < 0.001) was found in survivin mRNA level in B-ALL children at diagnosis compared with controls. After induction therapy, a significant decrease of survivin mRNA expression level was found in B-ALL patients compared with those at diagnosis (P < 0.001). Survivin mRNA level was significantly higher in the nonsurvived group and in patients with induction failure compared with patients with favorable response (P = 0.01). In addition, a positive correlation was found between survivin mRNA expression level and initial leukocyte count (r = 0.72; P < 0.001) and bone marrow blast cells percent (r = 0.44; P = 0.015). Conclusion Survivin is overexpressed in B-ALL at presentation and may be used as a prognostic marker for ALL in pediatric patients.
  490 36 -
Serum level of surfactant protein-D and its genetic polymorphisms in chronic obstructive pulmonary disease patients
Naglaa M Ghaniam, Iman A Badr, Ashraf A Dawood, Rania M Elshazly, Rabab A Elwahsh, Manal A Ellaithy
July-September 2018, 31(3):780-785
DOI:10.4103/mmj.mmj_406_17  
Objective The aim of this study was to study the serum level of surfactant protein-D (SP-D) and its genetic polymorphisms in chronic obstructive pulmonary disease (COPD) patients and its relation with severity. Background SP-D plays a role in COPD progression. It contributed toward the inflammatory response in the lungs. Single nucleotide polymorphisms of the surfactant protein-D gene (SFPTD) are believed to be associated with the risk of COPD. Patients and methods A case–control study was carried out on 76 individuals: group I included 50 patients with COPD and group II included 26 age-matched and sex-matched apparently healthy individuals. All participants were subjected to an assessment of history, clinical examination, BMI estimation, spirometry, serum SP-D by enzyme-linked immunosorbent assay, and genotyping of single nucleotide polymorphisms of SFPTD gene (rs721917, rs3088308) using the TaqMan allelic discrimination assay by real time PCR. Results Serum SP-D was significantly higher in patients than controls. The CT genotype of rs721719 was significantly more prevalent in patients. The T allele of both rs3088308 and rs721917 and smoking index were associated with increased SP-D levels. The T allele of rs721917 was associated with the risk of COPD. There was a significant difference between different genotypes of rs721917 in forced expiratory volume in 1 s (FEV1), forced volume capacity (FVC), FEV1/FVC, and serum SP-D. Conclusion SP-D can be used as a biomarker of the severity of COPD. The T allele of rs721917 might be a susceptible gene for COPD. The T allele of rs3088308 was associated with elevated serum SP-D, but not with COPD.
  488 35 -
Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography
Mahmoud A Soliman, Mohamed M Seleem, Awny G Shalaby, Ashraf F Abd-Allah
July-September 2018, 31(3):875-881
DOI:10.4103/mmj.mmj_95_17  
Objective The aim of the study was to evaluate the prevalence and predictors of renal artery stenosis (RAS) in hypertensive patients undergoing elective coronary angiography. Background Hypertension and ischemic nephropathy are the most important consequences of RAS. Ischemic nephropathy progresses to end-stage renal disease in 6–17% of patients. RAS is the most common potentially reversible disorder leading to renal replacement therapy; in recent years, efforts have been made to determine the prevalence of RAS and its predictors among patients with coronary artery disease. Patients and methods In a cross-sectional study, between March 2013 and October 2016, 200 hypertensive patients, candidates for diagnostic cardiac catheterization, underwent renal angiography before completion of their coronary angiography procedure. A standardized questionnaire was used to collect demographics, cardiac history, indications for cardiac catheterization, and angiographic data, and RAS result was estimated visually by a skilled cardiologist. Results Overall, 200 patients with mean age of 58 ± 7 years were included in the study. Of them, 116 (58%) were male and 84 (42%) were female. The prevalence of RAS was calculated at 22.5%. According to the present study, diabetes mellitus and serum creatinine level were predictors of RAS, whereas other factors included in our study were not. Conclusion According to the present data, we suggest considering renal artery angiography in combination with coronary artery angiography especially in hypertensive patients who are diabetic and those with high serum creatinine level.
  489 31 -
High-mobility group box 1 protein serum level in children with febrile seizures
Ahmed T Mahmoud, Sameh A Abd Alnabya, Mohamed M Debdeb
July-September 2018, 31(3):1005-1010
DOI:10.4103/mmj.mmj_156_17  
Objective The aim of the work was to assess the level of high-mobility group box 1 (HMGB1) protein in the serum of children with febrile seizures (FS) versus other groups of children suffering from afebrile seizures or febrile children without seizures in order to detect the relationship between HMGB1 and FSs. Background FS is considered as one of the most common seizure types during childhood. Fever is induced by increased HMGB1 level during infection and this may induce the development of FSs. HMGB1 is a highly conserved protein found in the nuclei and cytoplasm of nearly all cell types. HMGB1 is considered to be a key mediator of inflammatory diseases. Patients and methods This case–control study was held at Menoufia University Hospital on 80 children from January 2016 to July 2016. Our population was classified into four groups: the FS group (n = 20), febrile children without seizures (n = 20), afebrile seizure patients (n = 20), and healthy controls (n = 20). All groups were subjected to history taking, complete neurological examination, and laboratory investigations [serum blood (sodium, potassium, calcium, blood urea nitrogen, and creatinine), C-reactive protein, complete blood count, and serum HMGB1]. Results Serum HMGB1 was significantly higher in the FS group of children than in other groups. Conclusion From this study we conclude that serum HMGB1 was significantly higher in patients with FSs. Our data suggest that HMGB1 may contribute to the generation of FSs.
  484 26 -
Primary percutaneous coronary intervention versus fibrinolytic therapy combined with early coronary catheterization using the left radial approach
Walaa F Abdel Aziz, Mahmoud K Gaber, Mohamed M Mandour, Assem M Hassan
July-September 2018, 31(3):887-893
DOI:10.4103/mmj.mmj_181_17  
Objectives The objectives of this study were to compare primary percutaneous coronary intervention (PCI) with the strategy of fibrinolysis combined with coronary angiography within 6–24 h in ST-segment elevation myocardial infarction (STEMI) patients who presented within 3 h of symptom onset. Background Guidelines for acute STEMI patients recommend primary PCI as the favorable reperfusion strategy. This approach is contingent on performing PCI in a timely manner. Most patients do not attend PCI-capable hospitals; this factor has led to major challenge in many regions. Patients and methods This was a prospective, single-center study that included 100 consecutive STEMI patients admitted to the ER Unit at the National Heart Institute between June 2013 and December 2015. Cases were divided into the following groups: group A included 50 STEMI patients with onset of symptoms within 3 h and received fibrinolysis with streptokinase followed by timely coronary artery with or without PCI using the left redial approach, and group B included 50 patients who underwent primary PCI. In-hospital outcomes were reviewed and reported after 30 days. Results No statistically significant differences among groups were found with respect to mean age, sex, pulse, blood pressure, prevalence of previous stroke, peripheral arterial disease, previous myocardial infarction, previous PCI or previous coronary artery bypass graft, the duration from onset of symptoms to emergency department (ED) arrival, number of vessels treated, maximum inflation pressure, use of drug eluting stents, number of stents at target lesion, stent length, total stent length, mean nominal stent diameter, and incidence of cardiac deaths. In contrast, highly significant differences were observed in both groups regarding the prevalence of visible thrombus (P = 0.00), initial diameter stenosis (P = 0.031), total occlusion (P = 0.00), and baseline TIMI flow grade (P = 0.00) as the incidence was significantly higher in group B compared with group A. Highly significant differences were observed among group A and group B regarding severe bleeding, heart failure, and overall complications (P = 0.00 for all). Conclusion Left radial strategy for primary/delayed PCI in acute elevation of ST patients with previous myocardial infarction is feasible, safe, and successful with low incidence of complications. Early fibrinolytic therapy combined with early percutaneous intervention is a favorable choice for management of acute STEMI patients.
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Endovascular management of small intracranial aneurysms: a retrospective study of 98 consecutive patients
Mostafa S Melake
July-September 2018, 31(3):1069-1072
DOI:10.4103/mmj.mmj_138_17  
Objectives The aim of the study was to assess the feasibility and safety of endovascular treatment of small intracranial aneurysms. Background Endovascular coiling of small intracranial aneurysms is still controversial mainly owing to possible technical difficulties in such groups of aneurysms. Patients and methods We retrospectively analyzed the angiographic and clinical effects of endovascular therapy of 98 small intracranial aneurysms (≤5 mm), both ruptured and unruptured, between March 2002 and August 2013. The angiographic and clinical outcomes of those patients were studied retrospectively using chart reviews, operative, and angiographic reports. Glasgow Outcome Scale was used as a clinical follow-up tool. The overall outcome and the pretreatment variables predicting outcomes were analyzed thoroughly. Results Aneurysm occlusion was complete in 64.3%, a neck remnant in 19.4%, and aneurysm body filling in 16.3% of the small aneurysms embolized. According to Glasgow Outcome Scale, clinical outcome showed good recovery in 76.5%, moderate disability in 6.1%, severe disability in 8.2%, vegetative state in 5.1%, and death in 4.1%. The complication rate was 9.2% (9/98). Five of nine complications occurred in patients with ruptured aneurysms. Four patients died, three were harboring ruptured aneurysms, and one had an unruptured aneurysm. Conclusion Endovascular embolization may be an effective and feasible treatment for small intracranial aneurysms.
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Study of hyperglycemia in critically ill patients and its impact on the outcome
Mostafa G El-Nagar, Mohamed A El-Raouf, Walied S El-Dien, Mohamed Z Nooh, Aliaa S Tawfiek
July-September 2018, 31(3):935-939
DOI:10.4103/mmj.mmj_157_17  
Objective The aim of this study was to evaluate the control of hyperglycemia in diabetic patients by evaluating glycosylated hemoglobin A1c (HbA1c), to differentiate between already diabetic patients and stress-induced hyperglycemia in patients who presented with first-time hyperglycemia, and to study the effect of hyperglycemia on mortality. Background Hyperglycemia is common in critically ill patients and has poor impact on the outcome. Therefore, it should be discovered early and controlled by evaluating glycosylated HbA1c. Patients and methods This cross-sectional study included 281 patients attending the ICU of Mit Ghamr General Hospital, Dakahlia, Egypt, for a period of 1 year from May 2015 to May 2016. These patients were classified as diabetic patients, patients with first-time hyperglycemia, and nondiabetic patients. After obtaining written informed consent from patients or from relatives of comatose patients, all patients were evaluated clinically and by means of routine laboratory investigations including the following: random blood sugar, fasting blood sugar, HbA1c, complete blood count, prothrombin time, international normalized ratio, serum creatinine, blood urea, and serum albumin for all patients and computed tomography of the brain, arterial blood gases, and cardiac enzyme for selected cases. Results Hyperglycemic patients with higher HbA1c showed worst outcomes with increased mortality. Stroke, renal impairment, and higher HbA1c were independent risk factors for mortality in ICU patients. There was a significant positive relationship between HbA1c and white blood cells, blood urea, and creatinine. Moreover, there was a negative relationship between HbA1c and red blood cells, hemoglobin, and albumin. Conclusion Hyperglycemia is a common phenomenon in critically ill patients regardless of whether or not the patients were diabetic; the higher the HbA1c, the higher the incidence of mortality and complications.
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Knowledge of evidence-based medicine among primary care physicians in Gharbia Governorate
Mohamed M Al-Kot, Aml Salama, Mohamed R Abdel Fattah
July-September 2018, 31(3):850-854
DOI:10.4103/mmj.mmj_90_17  
Objective The aim of this study was to assess knowledge of primary care physicians regarding evidence-based medicine (EBM). Background EBM is very important in the process of decision making, diagnosis, and treatment of patients. For years, medical schools have developed instructions for EBM to determine the knowledge of physicians towards EBM, to improve the practice of family physician with regard to EBM. Participants and methods This is a cross-sectional study. A total of 93 family physicians were selected randomly during their monthly meeting, which all attended. Physicians were included from rural and urban primary care centers using stratified random sampling in Gharbia Governorate. Study was conducted through a predesigned questionnaire for testing physician's knowledge regarding EBM. The main outcome measure was knowledge of physicians regarding EBM. Results The response rate was 95.1%. Regarding the demographic characteristics of the studied group, the present study showed that female primary care and family physicians constituted a higher percentage (73.5%) than male physicians (26.5%). Of the 93 participants, there was a higher percentage of primary care and family physicians in the age group 20–29 years (59.2%) than in the age group 30–39 years (28.6%). Regarding the knowledge of family physicians for evidence-based, a higher percentage were somewhat knowledgeable (62.4%). Regarding the good total knowledge grading according to demographic characteristics, 71.1% of female physicians and 84.2% of physician working in family medicine unit had good knowledge grading. Conclusion This study was conducted to assess the knowledge of physicians and show improvement of knowledge regarding EBM.
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Glycemic control in type 2 diabetes mellitus and new hepatitis C virus genotype 4 therapy
Nabil A El Kafrawy, Alaa A Dawood, Mohamed Z Nouh, Raghda S El Meligy Matared
July-September 2018, 31(3):916-921
DOI:10.4103/mmj.mmj_104_17  
Objective The aim of this study was to evaluate the effect of glycemic control on the response to new therapy for hepatitis C virus infection (HCV) and the impact of the new HCV therapy on glycemic control in type 2 diabetes mellitus (T2DM) patients. Background HCV genotype 4 is prevalent in the Middle East, in Egypt, and in Central Africa. It is associated with an increased risk for T2DM as it causes insulin resistance. Direct pancreatic β-cell destruction, autoimmune injury, and other mechanisms associated with HCV are not entirely clear. HCV genotype 4 patients can be treated with interferon-free direct antiviral agents such as sofosbuvir (400 mg) and daclatasvir (60 mg) given daily for 12 weeks with or without ribavirin. Patients and methods Our study included 359 HCV patients who were divided into nondiabetic patients, controlled diabetic patients, and uncontrolled diabetic patients. These patients received anti-HCV treatment in Shebin El-Kom Teaching Hospital. They underwent tests for evaluation of glycated hemoglobin, HCV PCR, random blood sugar, liver function, creatinine levels, complete blood count, α-fetoprotein levels, and thyroid-stimulating hormone levels and an abdominal ultrasound. Results There was a highly significant response to HCV treatment in the nondiabetic group and a highly significant relapse in the uncontrolled diabetic group. There was also a highly significant decline in glycated hemoglobin levels at the end of treatment in both controlled and uncontrolled diabetic patients. Conclusion The successful treatment of HCV using new interferon-free direct antiviral agents has a significant beneficial effect on glycemic control in T2DM patients and also on thyroid-stimulating hormone levels.
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Dipeptidy l peptidase 4 enzyme in chronic hepatitis C
Mohamed A Shaaban, Alaa El Din A Dawood, Mohamed A Helwa, Basem M El Sayed El Khyary
July-September 2018, 31(3):911-915
DOI:10.4103/mmj.mmj_66_17  
Objective The objective of this study was to assess the role of serum dipeptidyl peptidase 4 (DPP-4) in patients with diabetes mellitus (DM) and in chronic hepatitis C infection patients. Methods Our data sources were Medline databases (PubMed, Medscape, and Science Direct; EMF Portal). Articles with values of serum DPP-4 in patients with DM and in chronic hepatitis C patients from Medline databases were selected. We used the following search terms: DPP4/DM/HCV/GLP1/insulin resistance/fatty liver/antiviral drugs. The initial search presented nine articles, of which five met inclusion criteria. The articles studied the value of serum DPP-4 in patients with DM and in chronic hepatitis C patients. If the studies did not fulfill inclusion criteria, they were excluded. Study quality assessment included whether ethics approval was gained, eligibility criteria were specified, appropriate controls were used, and whether adequate information and defined assessment measures were provided. Comparisons were made by a structured review with the results tabulated. Results In total, nine potentially relevant publications were included. Some studies indicated that the serum DPP-4 activity was not increased in type 2 diabetes, provided that patients with liver disease were intentionally excluded, whereas similar to our findings several studies support increased DPP-4 activity in type 2 diabetes patients. However, the cause for the increase in DPP-4 activity in diabetic patients remains unclear. Conclusion Serum DPP-4 activity in patients with chronic hepatitis C virus strongly suggests that serum DPP-4 is a novel biomarker of chronic hepatitis C virus, irrespective of the presence of DM.
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Seroprevalence of Helicobacter pylori infection among school children in Al Qulubia governorate
Mohsen M Deeb, Wael A Bahbah, Dalia H Abou-Elela, Marwa M Hessen
July-September 2018, 31(3):963-969
DOI:10.4103/mmj.mmj_548_16  
Objective The aim of this study was to determine the seroprevalence of Helicobacter pylori infection among apparently healthy Egyptian school children. Background H. pylori infection has a widespread distribution, but the prevalence varies between developed and developing countries. Patients and methods A series of 400 apparently healthy children attending basic schools were included in our study. Serum samples were withdrawn and assayed for the presence of anti-H. pylori antibody (immunoglobulin G) measured by the enzyme-linked immunosorbent assay test, and studied for the effect of age, sex, and socioeconomic background. The children's ages ranged from 6 to 13 years. All infected patients were treated successfully. Results The overall H. pylori seroprevalence in the study was 44% (176/400), and the frequency of seropositive cases increased highly significantly with advance in age. In a trial to study the risk factors for acquisition of H. pylori infection in our cases, we found a highly significant difference between seropositive and seronegative cases regarding socioeconomic status, family income, educational status of the parents, and occupational status of the parents (P = 0.001). On the other hand, we found no significant differences between seropositive and seronegative cases regarding sex and water supply (P = 0.304). Conclusion H. pylori is acquired in early childhood and the prevalence increases with age. The prevalence of H. pylori infection in Qulubia, Egypt, was substantially higher compared with developed countries and more or less within the range detected in developing countries, especially in African countries.
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