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   Table of Contents - Current issue
September-December 2018
Volume 2 | Issue 3
Page Nos. 137-290

Online since Friday, December 21, 2018

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Subarachnoid versus intravenous dexmedetomidine and fentanyl for minimizing stress response in laparoscopic cholecystectomy Highly accessed article p. 137
Mofeed Abdalla
Background The magnitude of stress response depends on several factors such as duration and intensity of surgical trauma, patient’s age, surgical method, anesthetic technique, blood loss, and postoperative pain. Aim of the work The aim of this work was to study the effect of intravenous versus intrathecal dexmedetomidine and fentanyl on stress response during laparoscopic cholecystectomy. Patients and methods Sixty patients fulfilling the inclusion criteria who were undergoing laparoscopic cholecystectomies were randomly assigned to receive either intravenous fentanyl and dexmedetomidine (group I) or intrathecal fentanyl and dexmedetomidine (group II). Mean arterial blood pressure and heart rate were recorded before induction of anesthesia (T0), 5 min after intubation (T1), 30 min after start of surgery (T2), at skin closure (T3), 6 h postoperatively (T4), and 24 h postoperatively (T5). The number of patients who required intraoperative intravenous fentanyl and total intraoperative fentanyl consumption (µg), and the number of patients who required intravenous morphine at the end of surgery were recorded. Visual analogue scale and total postoperative morphine consumption (mg) at the end of surgery (M0), and at 6, 12, 18, and 24 h (M1, M2, M3, and M4, respectively) were recorded. Blood interleukin-6, cortisol, and glucose were measured before anesthesia (F0) and after recovery (F1). Postoperative complications were recorded. Results Heart rate and mean arterial blood pressure were statistically lower in group II at T2 and T3. The number of patients requiring intraoperative intravenous fentanyl and total intraoperative fentanyl consumption (µg), and the number of patients requiring intravenous morphine at the end of surgery were statistically lower in group II. Visual analogue scale and postoperative morphine consumption (mg) were statistically lower in group II at M0 and M1. Blood cortisol and blood glucose level were statistically lower in group II at F1. There were no statistical differences as regards complications. Conclusion Apart from lowering heart rate and BP, intrathecal dexmedetomidine and fentanyl was superior to intravenous dexmedetomidine and fentanyl, wherein it lowered pain score and analgesic consumption with attenuation of stress response.
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Comparison between subtenon block and extraconal block during cataract surgery p. 144
Ahmed M Abd El-Galeel, Osama I.A Badr, Khaled G Mohamed
Background Most ophthalmic procedures are performed under local anesthesia, and cataract extraction is the most frequently performed surgery in elderly patients. The aim of this study is to compare the intraoperative hemodynamic variables, efficacy, and efficiency of extraconal block versus subtenon block with low concentration of local anesthetic during cataract surgery. Patients and methods This prospective, randomized, and single-blind study was done on 80 patients American Society of anesthesiologists status I–III undergoing cataract surgery, of which 40 patients underwent subtenon block (group S) and 40 patients underwent extraconal block (group E). Five minutes after the start of anesthetic monitoring care, 5-ml mixture of lidocaine 1% and bupivacaine 0.25% containing 100 IU hyalorunidase, in a mixture ratio of 1 : 1, was injected intraocular slowly. Patients were monitored for intraoperative hemodynamics, ocular movement during surgery, and intraoperative pain sensation as primary outcome, and onset of blockade, pain assessment within 30 min postoperatively, number of patients need rescue dose, surgeon discomfort, and postoperative complications as secondary outcomes. Results Mean arterial blood pressure and heart rate in group S were significantly lower than those in group E but within safety margin. No significant difference was found between the two groups regarding full range of eye movement, surgeon’s discomfort grade during cataract surgery, and also, intraoperative pain sensation. The onset of blockade was significantly faster in group S than group E. Although group S had better postoperative analgesic effect than group E, postoperative rescue dose was of insignificant value. Conclusion Subtenon block seems to be a better local anesthetic technique than extraconal for cataract surgery, as it is faster, has less surgeon discomfort grading, and better postoperative analgesia. However, on the contrary, both subtenon and extraconal blocks are equally effective in pain control during surgery and also have good ocular akinesia during operation.
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Endometrial hyperplasia versus carcinoma: does phosphatase and tensin homolog immunohistochemical expression differentiate between them p. 150
Marwa A El Kholy, Eman A El Kholy
Context Phosphatase and tensin homolog (PTEN) is a protein that acts as a tumor suppressor by dephosphorylating the lipid second messenger phosphatidylinositol 3,4,5-trisphosphate. Loss of PTEN function and mutation in PTEN gene have been implicated in the pathogenesis of endometrial carcinoma (EC). Objective The aim was to evaluate the immunohistochemical expression of PTEN in endometrial hyperplasia and EC and to evaluate the relationship between its expression and tumor grade in EC. Materials and methods Specimens included 16 cases of endometrial hyperplasia without atypia, six cases of atypical endometrial hyperplasia, and 18 EC specimens. Immunohistochemical staining for PTEN was performed using diaminobenzidine detection kit on formalin-fixed and paraffin-embedded tissue samples. Tumor tissue blocks and clinical data were collected from the files of the Pathology Department of Al-Zahraa University Hospital during the period 2010–2014. Results Immunohistochemistry showed that PTEN was positive for nuclei and cytoplasm of glandular endometrial cells. The PTEN expression was decreased significantly in atypical hyperplasia or EC compared with simple or complex hyperplasia (P0.041). In EC, we proved that PTEN expression is downregulated in high-grade tumors. Conclusion A positive PTEN expression correlates significantly with hyperplasia without atypia and well-differentiated tumors. The downregulation of PTEN indicates a more malignant phenotype.
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Brain natriuretic peptide for prediction of mortality in patients with sepsis p. 156
Amani K Mohamed, Nagwa Abd El-Ghaffar Mohamed, Nalgaa Abou-Elfattah Tawfik, Marwa Yahia Mohamed
Introduction Worldwide, sepsis is one of the leading causes of morbidity and mortality. Patients are at high risk for irreversible organ failure and a lethal course. About 60 000 individuals die from sepsis annually, and survivors have a reduced quality of life. In addition, sepsis places a considerable economic burden on the society. Early and comprehensive treatment improves outcome significantly. Brain natriuretic peptides (BNPs) are powerful predictors of death and major events in patients with stable coronary disease and pulmonary embolism. Several prospective studies have been carried out to investigate the potential role of BNPs in predicting mortality in septic patients in ICUs. The aim of this prospective study was to evaluate BNP for the prediction of mortality and myocardial dysfunction in severe sepsis and septic shock. Patients and methods This prospective study was carried out on 50 patients including group I, patients with sepsis, group (II), patients with severe sepsis, and group III, patients with septic shock. This study was carried out in the ICU of the Internal Medicine Department, Al-Zahraa University Hospital, in the period between January 2013 and March 2014 with written consents from our patients according to the ethical committee of the university. BNPs were determined by enzyme-linked immunosorbent assay. Results There was a highly statistical difference in the mean±SD of the BNP levels in group III (901.77±259.6) compared with group II (610.84±102.46), P value less than 0.01; also, there was a statistical difference in the BNP levels in group III (901.77±259.6) compared with group I (217.4±81.16), P value less than 0.01, whereas there was a statistically significant difference in group II (610.84±102.46) compared with group I (217.4±81.16), P value less than 0.05. In terms of the correlation between the BNP levels and other parameters of the patient groups, there was a highly positive significant correlation between BNP levels and the acute physiology and chronic health evaluation (APACHE II) score, the Sequential Organ Failure Assessment score, and white blood cells count. A significant positive correlation was found between BNP levels and prothrombin concentration (PC). There was a nonsignificant correlation between BNP and age, creatine phosphokinase, creatine kinase-MB, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, prothrombin time, international normalized ratio, and length of stay. Conclusion Our results suggested that an elevated BNP level may prove to be a powerful predictor of mortality in patients with sepsis. Future larger and more adequately powered prospective studies are warranted to clarify the prognostic value of BNPs in conjunction with other biomarkers.
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Expression of TWIST1 and CD44 as diagnostic and prognostic biomarkers in patients with gastric cancer p. 163
Marwa A El Kholy, Hala A El Sayed, Eman M Ahmed
Objective The aim of this study was to investigate the association of TWIST1 and CD44 in gastric cancer (GC) with clinical parameters and their relation to prognosis, which may be beneficial for targeted therapeutic strategies in the future. Materials and methods The material of this work consisted of 40 primary GC specimens from patients who underwent radical gastrectomy. Patients who received neoadjuvant chemotherapy or chemoradiotherapy, those who presented with other cancers at the same time, or the patients with incomplete clinical data were excluded from the study. Hematoxylin and eosin-stained sections from all cases were re-evaluated and further stained immunohistochemically using antibodies against TWIST1 and CD44. Results TWIST1 and CD44-positive expressions were significantly increased in GC cases of diffuse type (P=0.019 and 0.002, respectively). Moreover, there was a statistically significant correlation between both markers and tumor grade, stage, and lymphovascular invasion (P=0.027 and 0.010, P=0.002 and 0.012, and P=0.001 and 0.005, respectively). A statistically significant correlation was found between TWIST1 and CD44 expressions in GCs (P=0.000). Conclusion The presence of TWIST1-positive carcinoma cells and CD44-positive cancer stem-like cells in GC tissue can be used as a diagnostic tool for GC and regarded as a marker of poor prognosis in patients with GC, which may provide potential targets for GC therapy.
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Homocysteinemia in relation to anemia in hypothyroid patients p. 171
Samia Souka, Hanaa Kandil, Soheir Korraa, Aida A Abdel Hameed, Marwa Hassan
Background Anemia and hypothyroidism are both common diseases in the community. Homocysteine (HCY) levels are increased in patients with hypothyroidism and methylenetetrahydrofolate reductase (MTHFR) deficiency is the most common genetic cause of hyperhomocysteinemia. The aim of the present study was to evaluate the level of serum HCY in patients with hypothyroidism and to study the relation of associated anemia with the serum level of HCY and MTHFR gene in patients with hypothyroidism. Patients and methods The study was conducted on 60 adult women attending the Endocrinology Outpatient Clinic of Al-Zahraa Hospital between September 2014 and June 2015 for proper diagnosis and management. Individuals of the study were divided into two main groups: group I (GI) with 30 hypothyroid patients, where 13 of them were postsurgical cases, and group II (GII) with 30 euthyroid individuals as a control group. Diagnosis was based on thyroid-stimulating hormone level reference values. Patients in GI were further classified into two subgroups: mild hypothyroid (subgroup I) and overt hypothyroid (subgroup II). Patient and control groups also were classified into anemic and nonanemic subgroups according to hemoglobin levels. The selected hypothyroid patients were women under thyroid hormone replacement therapy. Blood sample was obtained for proper investigations. Complete blood count, routine blood chemistry, serum iron level, thyroid function tests, vitamin B12 level, serum homocysteine (HCY), and MTHFR were performed. We performed a pilot study on MTHFR gene polymorphism. The C677T MTHFR gene mutation was detected in three of 10 patients and in two of 10 controls. No evidence of TT MTHFR gene mutation was observed in both patient and control groups. IBM SPSS statistics (version 23.0, USA, 2015) was used for data analysis. Results revealed the presence of anemia according to hemoglobin level (<12 g/dl). In patients group (GI), 50% (15/30) as compared with 13.3% (4/30) in the control group (GII) had anemia. Serum iron level in patients group (GI) was deficient in 40% (11/30), whereas deficient in 16.7% (5/30) in control group (GII). Vitamin B12 deficiency was found to be 44% (11/25) in patients group (GI), whereas in the control group (GII) was 6.7% (2/30). Analysis by Wilcoxon’s rank sum test, homocysteine (HCY) serum level showed a highly significant increase among patients (GI) as compared with control (GII). Ranked Spearman’s correlation test for the patients (GI) and control (GII) showed a significant negative correlation between homocysteine (HCY) and MTHFR serum levels, whereas the correlation with red cell indices parameters was insignificant. Serum iron and B12 levels were significantly correlated in patient group (GI). Pearson χ2 tests were done between both patients and control groups for the presence of anemia, iron deficiency, and elevated serum homocysteine (HCY) level and all revealed statistically significant results. Conclusion There is no significant correlation between homocysteinemia and anemia. However, the strong association between anemia and hypothyroidism is attributed mainly owing to combined iron and vitamin B12 deficiencies. This might explain the decreased response to treatment among the selected hypothyroid patients.
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Impact of direct-acting antiviral therapy in Egyptian patients with chronic hepatitis C and liver cirrhosis p. 181
Mohammed H Elnadry, Sherif A Abdel-Aziz, Mohammed Ghareb, Ali A Ahamad, Nagah M Abu-Mohammed, Marwan M Tayel
Background and aims In Egypt, ∼14.7% of the population has hepatitis C infection and genotype 4 infection accounts for more than 90% of the hepatitis C virus infections. Available data with newer all-oral regimens in the treatment of genotype 4 infection suggest that sustained virological response (SVR) 12 rates in treatment-naïve cirrhotic and noncirrhotic patients are greater than 95%. The study aimed to evaluate the virological response 12 weeks after treatment (SVR12), change in the model for end-stage liver disease score, and adverse clinical events during the study period. Patients and methods This prospective study included 451 patients with chronic hepatitis C and liver cirrhosis over a 3-month period started at January 2017. And the study was ethically approved by the Medical Research Ethics Committee, Faculty of Medicine, Al-Azhar University. The enrolled patients were classified into three groups: group I included 162 patients with chronic hepatitis C and liver cirrhosis subjected to direct-acting antivirals (DAAs) therapy (100/162 compensated cirrhosis and 62/162 decompensated cirrhosis), group II included 234 patients known to have chronic hepatitis C without liver cirrhosis subjected to DAAs therapy, and group III included 55 patients with chronic hepatitis C and liver cirrhosis not subjected to DAAs therapy according to the national protocol of therapy (as a control group). Treatment was administered for 12 weeks that included variable regimens of DAAs according to the Egyptian Ministry of Health protocol. Results We included 451 patients with chronic hepatitis C infection and liver cirrhosis; 47.8% of the patients were male, 84.4% were treatment naive, and 54.9% had cirrhosis. Of the study participants, 150 patients in group I and 53 patients in group II received sofosbuvir+daclatasvir+ribavirin, 183 patients received daclatasvir+sofosbuvir (group II), seven patients in group II received sofosbuvir+ledipasvir, five patients received sofosbuvir+ledipasvir+ribavirin (in group I), and seven patients in group I and nine patients in group II received ombitasvir/paritaprevir/ritonavir+ribavirin. Twelve weeks after end of treatment (SVR12) were 91.3% and 96.5% observed in group I and group II, respectively irrespective of the regimen of therapy. Treated patients in group I had a mean negative change in model for end-stage liver disease (−0.722; SD, 2.603) representing an improvement in liver function, whereas untreated patients in group III showed a minimal mean positive change (0.00; SD, 2.92) representing a deterioration in liver function (P<0.001). Improvements were observed in the Child-score (Child–Pugh–Turcotte) in group I versus untreated patients in group III. Hepatic encephalopathy was evident in 6.1% of patients in group I after treatment versus 38.1% in untreated patients (group III), and ascites developed in 30.2% of patients after treatment (group I) versus 65.4% in untreated patients (group III). Conclusion Oral regimens of DAAs are effective in the treatment of hepatitis C virus infection even in patients with liver cirrhosis, leading to improvements in liver functions.
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Studying the changes of ocular wavefront aberrations after neodymium : yttrium aluminum garnet laser capsulotomy p. 189
Nermeen M Badawi
Aimof the study The aim of this study is to evaluate the changes of wavefront aberrations after performing neodymium : yttrium aluminum garnet (Nd : YAG) laser posterior capsulotomy for the management of posterior capsular opacifications. Patients and methods This study is a prospective study that was performed on 100 eyes of 87 patients with posterior capsule opacification following phacoemulsification, in the period from March 2017 to October 2017. A complete ophthalmic examination and optical wavefront imaging were performed to every patient. Patients underwent posterior capsulotomy using Nd : YAG laser with a follow-up period of 6 months. Results There were no significant changes in postoperative refraction at P value more than 0.05 still the best-corrected visual acuity showed a clinically significant at P value less than 0.05. The intraocular pressure was statistically significantly increased on the first postoperative day (P<0.05) but not in other postoperative visits. Regarding higher order aberrations there was a statistically significant improvement in total third-order aberrations (P<0.05), coma aberration (P<0.05), total fourth-order aberrations (P<0.05), spherical aberration (P<0.05), and total higher order aberrations (P<0.05) while quadrafoil and fifth-order aberrations showed no statistically significant changes. Conclusion Nd : YAG laser posterior capsulotomy causes a significantly decrease in wavefront aberrations in patients with posterior capsule opacification.
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Bone mineral density in relation to polycystic ovary syndrome: an insight into irisin and insulin p. 194
Olfat Fawzy, Nagwa A Elghaffar, Eman Mahmoud, Abeer Helmy
Background and aim Polycystic ovary syndrome (PCOS) is a complex metabolic and endocrine disorder. The influence of different metabolic and endocrine changes in women with PCOS and their relevance to bone status remains to be documented. Irisin is a newly identified adipo-myokine, which may play a role in the etiopathogenesis of PCOS as well as bone metabolism. The aim of the study was to assess bone mineral density (BMD) and serum irisin level in women with PCOS and to determine BMD relationship with irisin and other hormonal parameters. Patients and methods The study enrolled 80 women of reproductive age having PCOS and 15 age-matched and BMI-matched healthy women to serve as controls. A metabolic panel, reproductive hormones, and serum irisin level were measured. In addition, BMD of the spine and femur was also assessed using dual-energy X-ray absorptiometry. Results Serum irisin level, fasting insulin, and homeostatic model assessment of insulin resistance were significantly higher in the PCOS group compared with the control group. Receiver operating characteristic curve for serum irisin was done for the PCOS group and the control group and demonstrated that the cut-off value for serum irisin was 0.161 μg /dl. There was also a statistically significant difference between the PCOS group and the control group in BMD of spine and femur, being higher in the PCOS group. Logistic regression analysis has shown that serum irisin level, waist circumference, and fasting serum insulin were predictors for the z-score of spine in the PCOS group. Conclusion Serum irisin level may be considered as a novel biomarker for PCOS diagnosis. Circulating irisin in PCOS is strongly related to BMD. This suggests that irisin as an adipo-myokine may also be associated with bone metabolism.
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Occult hepatitis B virus among patients with chronic hepatitis and hepatocellular carcinoma p. 205
Khodeir A Naeima, Abd-El-Samae M Eman, Aly R Dina, El-Moatassem M Ola
Background Hepatitis B virus (HBV) infection is diagnosed when the circulating HBV surface antigen (HBsAg) is serologically detected. Occult HBV infection is defined as the infection state negative for HBsAg serology, but it has shown viral genome persistence in infected individuals. The aim of the study is to determine the prevalence of occult HBV among patients with chronic hepatitis negative to HBsAg in the presence or absence of hepatitis C virus (HCV) infection. Patients and methods This study was conducted on a total number of 55 patients with chronic hepatitis (liver cirrhosis in 44 cases, nonalcoholic fatty liver in six cases) and hepatocellular carcinoma in five cases. All studied cases were subjected to routine liver function tests, HBsAg, HBsAb, hepatitis c virus immunoglobulin G (HbcIgG), α-fetoprotein, HCV RNA, and HBV DNA detection. Result All cases were negative to HBsAg and HBsAb in the presence or absence of HCV infection. HBV DNA detection by real-time RT-PCR confirmed the positivity of HBV infection [occult hepatitis b infection (OBI)] in two (4.5%) out of 44 cases of cirrhotic liver and represented 3.6% of the total cases studied with a viral DNA of 116 and 159 copies/ml, respectively. One case of OBI had a high level of α-fetoprotein (392 Iu/ml) and the second case had high copies of HCV RNA 127 000 copies/ml, that is coinfection. HbcIgG was positive in 31.8% in cirrhotic patients (including one out of the two positive OBI). HCV RNA was negative in 100.0% of nonalcoholic fatty liver, positive in 39 (one was positive OBI) cases with cirrhosis with a median value of 45 000 copies and in four out of the five hepatocellular carcinoma cases with a median value of 1.85E+08. This is statistically significant (P=0.01). We come to the conclusion that occult HBV do exist in our community. The diagnosis of OBI should be based on high sensitivity of HBsAg and HBV DNA testing.
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Comparison study between the outcome of laparoscopic and open repair of perforated duodenal ulcer p. 212
Abdallah Abdelwahed, Anas Mashal
Background Duodenal ulcer perforation is a surgical emergency that may lead to a risk for major morbidity and even mortality. Patient selection criteria are crucial to guide the surgeon in selecting the option of laparoscopic approach for patients with perforated duodenal ulcers. The purpose of this study was to compare the resulting outcomes for laparoscopic and open approaches for the repair of perforated duodenal ulcers. Patients and methods A total of 26 patients with perforated duodenal ulcers were included in this study, operated at Alain Hospital and Ain Shams University Hospitals, from June 2013 to June 2016. A total of 13 patients were operated by the laparoscopic approach and 13 patients were operated by the open approach. Follow-up indices such as mean operative time, hospitalization expense, and postoperative pain were included. The main outcomes were immediate surgical postoperative complications, fatalities, and reoperation. Secondary outcomes included operative time, postoperative pain, postoperative hospital stay, and time to resume diet. Results There were no major differences in the selected patients between these two procedures in main outcomes including overall surgical efficacy including surgical complication rate and surgery-related deaths. Further analysis of the surgical outcome revealed that laparoscopic repair had less surgical wound complication rate (wound infections and incisional hernias) compared with the open approach. Otherwise both approaches had almost similar rates of leakage, intra-abdominal collections, and ileus and thromboembolic complications. Regarding the secondary outcomes, it was notable that postoperative pain was much less, return to the regular diet was earlier, and hospital stay was decreased in the laparoscopic approach. This remarkable improvement of the secondary outcome attributed to overall patient satisfaction in the laparoscopic approach. Conclusions Laparoscopic approach is comparable with the open approach as a modality of repair for perforated peptic ulcer in the properly selected patients. The obvious advantages of laparoscopic surgery are the lower surgical site infection rates, early return to regular diet, shorter hospital stay, early return to work, less postoperative pain, better cosmetic outcome, and improved overall patient satisfaction. However, more studies should be undertaken to further assess the safety and efficacy of laparoscopic repair for peptic ulcer disease in the high risk patients’ category.
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Assessment of right and left ventricular functions in interstitial lung diseases p. 217
Khadiga S.M Salama, Samiha M Abou Bakr, Taghreed S Farag, Hoda A Eid, Layla A Mohamed
Background Subclinical or overt cardiovascular affection in patients with interstitial lung diseases (ILD) may expect to have increased mortality and/or reduced exercise capacity. Objective Echocardiographic (echo) assessment of right ventricular (RV) and left ventricular (LV) functions in patients with ILD. Patients and methods Conventional echo, tissue Doppler imaging (TDI) and two-dimensional speckle tracking echo (2D STE), spirometry [forced vital capacity (FVC%), forced expiratory volume in 1 s% and forced expiratory volume in 1 s/FVC], and functional exercise capacity (6 min walking test) were performed on 60 patients with ILD and 60 age-matched and sex-matched controls. Pulmonary involvement was identified in high-resolution computed tomography (HRCT) and scored according to a semiquantitative Warrick score. Results Using conventional echo-Doppler, TDI, and 2D STE, there are statistically significant impairments in both RV systolic and diastolic functions, as well as LV diastolic functions in ILD patients compared with controls (P<0.05). LV systolic dysfunction was detected by TDI and STE only; however, ejection fraction was normal by standard echo. In the ILD group, the tricuspid annular plane systolic excursion was positively correlated with PaO2 and FVC%, while it was negatively correlated with the HRCT score. RV global longitudinal strain% was positively correlated with both 6 min walking distance and FVC%. Moreover, LV global longitudinal strain% was positively correlated with both 6 min walking distance and PaO2, while it was negatively correlated with HRCT score. Conclusion Both RV and LV systolic and diastolic dysfunctions were detected by echo in ILD patients. Ventricular dysfunctions were related to hypoxemia, radiological score, and vital capacity of the lungs. Ventricular dysfunction has a negative impact on function exercise capacity of patients with ILD.
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Effects of volatile versus intravenous anesthesia on oxygenation and hemodynamic response during thoracotomy with one-lung ventilation p. 224
Sherin Abd Elazim Mohamed, Ruqaya M ELsayed Goda
Background The aim of this study was to evaluate the effects of total intravenous anesthesia by propofol and ketamine (ketofol) versus that of inhalational anesthetic technique using sevoflurane on oxygenation and hemodynamics before, during, and after one-lung ventilation (OLV) in adults undergoing thoracic surgery. Patients and methods Twenty-eight patients (American Society of Anesthesiologists) II–III were undergoing thoracic surgery requiring OLV. Each patient was randomly allocated to one of two groups: ketofol group, in which induction was performed with 1% propofol 1.5–2.5 mg/kg, with ketamine 1 mg/kg and, in the second group (sevoflurane), 8% sevoflurane. Fentanyl 2 μg/kg and cisatracurium 0.1 mg/kg was administered to both groups. Anesthesia was maintained with ketamine and propofol in the ketofol group and 2% sevoflurane in the sevoflurane group. Results Arterial blood gas analysis, end-tidal carbon dioxide concentration, heart rate, mean arterial pressure, and end-tidal concentration of sevoflurane were noted in the sevoflurane group. In patients receiving ketofol, fentanyl requirements were decreased when compared with the sevoflurane group. However, the total dose of phenylephrine was greater in patients receiving sevofluran when compared with those receiving ketofol (5 µg/kg/patient vs. 1.1 µg/kg/patient). Mean arterial pressure was reduced during the course of OLV in both groups, as compared with levels found before OLV (P<0.05). Sevoflurane anesthesia induced a significant reduction in heart rate, whereas no significant difference in heart rate was found in the ketofol group. Initiation of OLV caused a significant decrease in PaO2 and SpO2 in both groups, especially in the sevoflurane group, as compared with the ketofol group. Conclusions The combination of ketamine and propofol anesthesia has a relatively mild influence on hypoxic pulmonary vasoconstriction and more hemodynamic stability compared with conventional inhalational anesthetics with sevoflurane for OLV anesthesia.
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Efficacy and efficiency of hepatitis B core antibody in the diagnosis of occult hepatitis B in hemodialysis patients p. 231
AL-Sayed M Rashed, Emad A Mohamed, Magdy A AL-Dahshan, Mohamed A Said, Mohamed S AL-Shorbagy
Background Occult hepatitis B viral infection (OHBI) is defined as hepatitis B virus (HBV) DNA detection in serum by sensitive diagnostic tests in hepatitis B surface antigen (HBsAg) negative patients with or without serological markers of previous viral infection. Aim This study aimed to evaluate hidden infection of hepatitis B among HBsAg negative chronic kidney disease patients on regular hemodialysis (HD) using hepatitis B core antibody as a marker in the sera of these patients, HBV DNA by PCR, and to evaluate the efficacy and efficiency of hepatitis B core antibodies in the diagnosis of occult hepatitis B in HD patients. Patients and methods Eighty chronic kidney disease patients on regular HD were included in this study; the mean age of studied patients was 41.8±12.72 years. They were recruited from HD Unit, Internal Medicine Department, Bab Alshearia University Hospital, Al-Azhar University, Cairo, Egypt, after exclusion of HBsAg positive, HBV antibody positive, intravenous drug users, and alcoholic patients. All patients were subjected to a full assessment of history, blood chemistry, HBsAg by ELISA, hepatitis B core immunoglobulin G (anti-HBcIgG), HB DNA by PCR, hepatitis C antibody (HCV Ab) by ELISA, and abdominal ultrasound. Results Our results showed that HCV Abs were positive in 50% of cases (40 cases); of these patients, 30% (12 cases) were positive for HBcIgG, whereas 50% of the cases (40 cases) were negative for HCV Ab. Of these, 20% (eight cases) were positive for HBcIgG, but the remaining 32 patients were negative for both HCV Abs and HBcIgG. All these results showed negative PCR in all cases (0% of cases). Conclusion OHBI among Egyptian HD patients is low, with a 0% prevalence by PCR; 6 months of repeated PCR is recommended as liver biopsy is difficult in HD patients and HBc Abs are not sufficient for the diagnosis of OHBI in HD patients.
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Intrathecal versus intravenous infusion of dexmedetomidine during subarachnoid block in lower abdominal surgeries p. 237
Fatma H Ashour, Asmaa S Abdellah, Ruqaya Mohamed El Sayed
Background Adjunct analgesic strategy is an alternative to prolong the analgesic duration and decrease the potential risk of side effects. The objective of this study was to evaluate the efficacy of dexmedetomidine as an adjuvant to subarachnoid anesthesia during lower abdominal surgeries compared with dexmedetomidine intravenous infusion. Patients and methods Forty patients, classified as American Society of Anesthesiologists I and II patients, aged 20–50 years, undergoing elective lower abdominal surgeries, were randomly allocated into two equal groups. Group I (n=20) consisted of patients who received intrathecal 0.5% hyperbaric bupivacaine 15 mg (3 ml)+dexmedetomidine (10 µg) for subarachnoid block. Group II (n=20) consisted of patients who received intravenous infusion of dexmedetomidine 0.5 μg/kg/h (without loading) after subarachnoid block. The onset and duration of sensory and motor block, the hemodynamic effects, the duration of analgesia and the incidence of side effects were recorded. Interleukin-6 level was estimated. Results Hemodynamic data were comparable between both groups. The mean time taken for the sensory block to reach T10 dermatome and motor block to reach B3 was significantly fast in group I as compared with group II. The time for two segment regressions and regression of sensory block to S2 dermatome and B0 motor block were significantly prolonged in group I compared with group II. The time to first rescue analgesic was prolonged, and the amount of analgesic/24 h was decreased significantly by the addition of dexmedetomidine to bupivacaine. Ramsay sedation scores were highly significant, being higher in group II. The level of interleukin-6 and the incidence of side effects were significantly lower in group I compared with group II. Conclusion In lower abdominal surgery, the use of intrathecal dexmedetomidine as an adjuvant to local anesthesia provides good motor and sensory blockade and is associated with mild sedation, decreased incidence of side effects, and inflammatory response compared with intravenous infusion.
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Serum mir-30e and mir-223 as novel noninvasive biomarkers for hepatocellular carcinoma p. 244
Iman M El Bagoury, Amal M Al Ramly, Abd Elaty M El Ghonimy, Enas A Farrag
Background Liver cancer is the sixth most common cancer that accounts for 7% of all cancers. Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide with ∼600,000 new cases per year, and it is the second leading cause of cancer-related deaths alone. Aim The aim of this work was to study the clinical utility of miR-30e and miR-223 as early novel biomarkers for HCC in chronic viral hepatitis patients. Patients and methods In this study, we tested two serum microRNAs (miRNAs), 223 and 30e, that can be used as potential biomarkers to diagnose HCC. A total of 55 patients were divided into three groups. Group I included 20 newly diagnosed patients with HCC on top of chronic hepatitis C virus infection. The HCC group included 11 male patients and nine female patients with ages ranging from 55 to 65 years. Liver masses discovered on surveillance by abdominal ultrasound were further investigated by triphasic abdominal computed tomographic scan. Group II included 20 patients of chronic hepatitis C virus with no HCC (10 male patients and 10 female patients), with ages ranging from 53 to 63 years. Group III included 15 apparently healthy participants as a control group (five male individuals and 10 female individuals), with ages ranging from 55 to 61 years and who were selected from relatives and friends. The samples were analyzed by quantitative real time PCR to detect both miRNAs. Result Our study revealed that both miRNAs, 30e and 223, were expressed at significantly lower levels in the sera of patients with HCC compared with healthy participants. Conclusion Expression levels of miR-30e and miR-223 were reduced in HCC sera; they have potential as noninvasive biomarkers for diagnosis of HCC, with high specificity and sensitivity for miR-30e, although with moderate sensitivity and high specificity for miR-223.
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Evaluation of plasma fibrinogen and plasminogen activator inhibitor- 1 in type 2 diabetes mellitus patients with coronary artery disease p. 252
Zeinab H El Sayed, Sahar Mohamed Ismail, Heba A ELhakeem
Introduction Coronary artery disease (CAD) remains the main cause of death in patients with type 2 diabetes mellitus (T2DM). It is more extensive and diffuse in diabetics in spite of antiplatelet therapy. Hence, the prevention and the early diagnosis of CAD among patients with T2DM are very important. There is a variety of hemostasis abnormalities in T2DM. Therefore, fibrinogen and plasminogen activator inhibitor-1 (PAI-1) may have a link between T2DM and CAD. Aim The aim was to evaluate the plasma fibrinogen and PAI-1 levels in some Egyptian patients with T2DM with and without CAD. Patients and methods A total of 30 Egyptian patients with T2DM attending the Internal Medicine Department of Al Zahraa Hospital were included in this study. Their ages ranged between 31 and 54 years. Based on ECG changes and echocardiography, the patients were divided into the following: 15 who had CAD and 15 without. Another 15 apparently healthy participants were enrolled as a control group. Blood samples were analyzed for routine blood tests, fasting lipid profile, renal function, liver function, glycosylated hemoglobin, plasma fibrinogen, and PAI-1, which was measured by enzyme-linked immunosorbent assay. Results Plasma fibrinogen and PAI-1 were significantly higher in Egyptian patients with T2DM with CAD than those who had only T2DM, and both markers were higher in Egyptian patients with T2DM than healthy controls. Fibrinogen and PAI-1 levels were positively correlated with glycosylated hemoglobin in Egyptian patients with T2DM. Conclusion Egyptian type 2 diabetic patients with T2DM are prone to develop CAD more often than not owing to increase in plasma fibrinogen and PAI-1 levels; therefore, we can give a small dose of anticoagulant for all patients with T2DM.
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Ultrasonograph versus β-human chorionic gonadotropin titer for verification of termination of missed first trimester miscarriage p. 264
Aziza H Nassef, Nahed H Mohammed, Samar M Ibrahim
Introduction Miscarriage is one of the common complications of pregnancy. Up to 20% of recognized pregnancies will end in miscarriage. However, when women were followed with serial serum human chorionic gonadotropin (hCG) measurements, the actual miscarriage rate was found to be 31%. Many pregnancies are lost spontaneously before a woman recognizes that she is pregnant, and the clinical signs of miscarriage are mistaken for a heavy or late menses. In some countries with low resources, ultrasound may be not available in all medical centers. So, confirmation of complete termination of first trimesteric miscarriage may be not possible, and these cases may present with complications of inadequate treatment. So, we need to study other method for verification of successful management such as β-hCG titter. Objective The aim was to assess the usefulness of testing serum β-hCG titer to confirm the effective medical termination of the first trimester miscarriage. Patients and methods A prospective study was conducted at the Department of Obstetrics and Gynecology at Al Zahraa university Hospital in the period between December 2017 and April 2018. A total of 34 pregnant women with first trimester miscarriage (7–13 weeks from the first day of last menstrual period) were submitted for medical termination of miscarriage, and each case was subjected to ultrasonography 7 days after termination of miscarriage (for measurements of endometrial thickness) and serum β-hCG at 3 and 7 days after termination of miscarriage. Results Endometrial thickness decreased after termination of miscarriage (with cut-off value <15 mm). Moreover, β-hCG decreased after medical termination of miscarriage. In our study, receiver operating characteristics curve was used to define the best cut-off value of β-hCG, which was greater than 34 mIU/ml, with sensitivity of 90%, specificity of 70.8%, positive predictive value of 56.4%, and negative predictive value of 94.4%, with diagnostic accuracy of 83.5%. Conclusion Measuring β-hCG level is an effective alternative to transvaginal ultrasound measurements of endometrial thickness to verify the completion of termination of early miscarriage.
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Total intravenous versus desflurane-based anesthesia for shunt procedure in pediatric congenital cyanotic heart disease p. 269
Ahmed M Abd-El Galeel, Esmail K Abd-Elraouf
Background Congenital cyanotic heart disease (CCHD), inclusive of all types of cyanotic heart disease with resulting hypoxemia and hypoxia, has diverse multisystem effects, including erythrocytosis, hyperviscosity, cholelithiasis, cerebral abscess, vascular dysfunction, and hemoptysis. Most, but not all, patients with CCHD, undergo surgical repair in childhood, resulting in either an elimination or reduction in the degree of hypoxemia and its complications. Systemic-to-pulmonary artery shunt is a necessity as a life-saving procedure that is carried out through placement of extracardiac systemic-to-pulmonary artery shunts, using many procedures such as Blalock–Taussig shunt procedure or its modification [modified Blalock–Taussig shunt (MBTS)], which is commonly used nowadays, modified Blalock–Thomas–Taussig shunt (commonly called the MBTS) is a surgical procedure used to increase pulmonary blood flow for palliation in duct-dependent cyanotic heart defects such as pulmonary atresia, which are common causes of blue baby syndrome. In this procedure, there is temporarily direction of the blood flow to the lungs and relieve cyanosis. Traditionally, these surgical procedures are accomplished by either a total intravenous anesthesia (TIVA) or inhalational-based anesthesia. The TIVA technique achieves hemodynamic stability but has many disadvantages such as increases in the period of mechanical ventilation and its associated complications, and increase in ICU stay. Although inhalational anesthetic-based technique may be associated with myocardial depression and dysarrythmias (up to ventricular arrhythmia), but, due to lower blood solubility, facilitates early awakening and endotracheal extubation; this technique decreases the duration of mechanical ventilation, ICU stay, and, therefore, total hospital stay. Patients and methods Forty ASA classes III and IV patients between 18 months and 6 years, scheduled for MBTS procedure for repairing CCHD, were to undergo systemic to pulmonary shunt using cardiopulmonary bypass (CPB) after median sternotomy. They were divided into two groups: patients in the TIVA group (n=20) were administered a combination of midazolam–fentanyl–propofol along with neuromuscular blockade, whereas the desflurane group (n=20) was administered desflurane with 0.6–1 MAC in 100% oxygen with a combination of fentanyl with neuromuscular blockade. Hemodynamic parameters [heart rate (HR), mean blood pressure], duration of elective ventilation, incidence of supraventricular tachycardia and ventricular tachycardia/ventricular fibrillation, and level of myocardial injury were detected by cardiac troponin I as a cardiac biomarker for myocardial injury recorded as primary outcome, whereas duration of inotrope use, ICU and hospital stay, and serum creatinine levels were recorded preoperatively, thereafter, at 24 h postoperatively, they were recorded as secondary outcome. Any serious adverse events, such as acute renal injury, or any other major cardiovascular/neurologic events were recorded. Results Repeated measure analysis was carried out to see the trend in HR from HR1 (at baseline) in both groups, HRs HR2 (just prior to CPB), HR3 (weaning from CPB), and HR4 (arrival at ICU) were significantly higher than HR1 (P<0.001). The mean arterial pressures recorded at time intervals where T2 (just prior to CPB) and T4 (arrival at ICU) were found to be significantly lower in patients included in the TIVA than in the desflurane group (P=0.003 and 0.002, respectively), but mean arterial pressure values at T1 (at baseline) and T3 (weaning from CPB) were insignificant in both the groups (P>0.05). Duration of mechanical ventilation, ICU stay and hospital stay were lower in the desflurane group compared with the TIVA group (P<0.005). While patients in the TIVA group recorded significantly lower inotrope use than those in the desflurane group (P<0.001). Likewise, the creatinine values measured at baseline and 24 h postoperatively were compared in both groups and also, inbetween group itself, were only significantly increased in the TIVA group (P=0.018). For cardiac troponin I levels, at T2 there were significantly higher than those at T1 in the TIVA group (P=0.001) when compared to the desflurane group (P=0.836). Conclusion TIVA has the advantage of hemodynamic stability, but it prolongs the duration of controlled ventilation and length of hospital stay. The current study demonstrated that a desflurane-based anesthetic provides comparable stability, early recovery of myocardial contractility, decreased duration of controlled ventilation, duration of ICU admissions, and total hospital stay.
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Evaluation of early complications after laparoscopic sleeve gastrectomy for the treatment of morbid obesity: a single-center experience p. 276
Mahmoud Abdella Abdel Razek, Omnia Mohamed H Rabie
Background Laparoscopic sleeve gastrectomy (LSG) nowadays is one of the most popular operations for the treatment of morbid obesity. It has good effect in weight reduction and has less complications. The most common complications include leakage, hemorrhage, splenic injury, gastric stenosis, and gastroesophageal reflux. Aim To evaluate our experience in LSG in the management of morbid obesity as regards intraoperative and early postoperative complications. Patients and methods One hundred and fifty patients with morbid obesity and/or obesity-related comorbidities were included in this study. Their BMI range from 35 to 60 kg/m2 and were managed at Al-Zahraa University Hospital from July 2015 to June 2018. Preoperative demographic data, operative procedure, intraoperative, and short-term follow-up results of LSG are analyzed. Results LSG was performed successfully on 149 cases while conversion to open was done in one case due to intraoperative bleeding. The mean operative time was 105±25 min. The mean postoperative hospital stay was 4 days (3–10 days). There was no intraoperative mortality but in two cases mortality was recorded in the postoperative period. Hemorrhage in 1.3%, leakage in 2%, and other complications such as vomiting in three cases and pulmonary embolism in one case were recorded. Conclusion LSG safe operation in the management of morbid obesity and the hazards of its complications can be avoided if diagnosed early and managed well. Leakage is the most serious complications which may end by death if not probably treated.
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Effect of nebulized ketamine versus betamethasone gel on postoperative pharyngo-laryngeal complications after proseal laryngeal mask insertion in day case surgery p. 283
Ayman S Emara
Background General anesthesia with laryngeal mask airway can lead to trauma of the airway mucosa resulting in postoperative pharyngo-laryngeal complications. We compared between the effects of betamethasone gel applied over proseal laryngeal mask and nebulized ketamine in reducing pharyngo-laryngeal complications such as sore throat, hoarseness of voice, dysphagia, and cough during the first, 12 postoperative hours after elective day case surgical procedures. Patients and methods In all, 120 patients (aged 16–45 year) American Society of Anesthesiologists physical status I and II, scheduled for elective day case surgery with proseal laryngeal mask, were enrolled into this prospective, randomized, double-blinded study. The patients were randomly allocated into four groups of 30 participants each: group C received nebulized saline and lubricant gel over laryngeal mask; group B received nebulized saline and 0.05% betamethasone gel over laryngeal mask; group K received nebulized ketamine (1 mg/kg) and lubricant gel over laryngeal mask; group KB received nebulized ketamine (1 mg/kg) and 0.05% betamethasone gel over laryngeal mask. The incidence and the severity of postoperative sore throat, hoarseness of voice, dysphagia, and cough were graded at 30 min, 2, 4, 8, and 12 h. Results The incidence and severity of postoperative sore throat, hoarseness of voice, dysphagia, and cough were significantly lower in groups KB, K, and B, compared with control group (P<0.05). The incidence and severity of postoperative sore throat, hoarseness of voice, dysphagia, and cough were lower in group KB compared with groups K and B at all times after removal of laryngeal mask up to 12 h without significant difference. Conclusion The prophylactic use of betamethasone gel or nebulized ketamine significantly reduced the incidence and severity of postoperative pharyngo-laryngeal complication. Betamethasone gel and nebulized ketamine were significantly more effective than using each of these drugs alone.
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