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   Table of Contents - Current issue
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September-December 2019
Volume 3 | Issue 3
Page Nos. 573-797

Online since Monday, February 10, 2020

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ORIGINAL ARTICLES  

Serum level of cluster of differentiation 166 as novel biomarker in hepatocellular carcinoma Highly accessed article p. 573
Iman M.S El-Bagory, Amal A El-Aleem, Nessren M.B El-Deen Mohamed, Salwa A El-Latif Shendy
DOI:10.4103/sjamf.sjamf_30_19  
Background The detection of serum biomarkers associated with hepatocellular carcinoma (HCC) is the most promising approach to improve diagnostic accuracy and to overcome the disadvantages of current diagnostic strategies. The aim of this study was to evaluate the diagnostic value of serum level of cluster of differentiation 166 (CD166) in early detection of patients with HCC. Patients and methods This study was conducted on 90 patients, divided into three groups: group 1 included 30 patients with unstaged HCC; group 2 included 30 patients with HCV-related liver cirrhosis (LC) without HCC, who were subdivided into 2a subgroup (15 patients with compensated liver cirrhosis) and 2b (15 patients with decompensated liver cirrhosis); and group 3 included 30 sex-matched and age-matched apparently healthy individuals as a control group. All patients and control were subjected to detailed history taking and clinical examination, abdominal ultrasonography, and/or computed tomography. Laboratory investigations included complete blood picture, liver function tests, serum viral hepatitis markers, serum urea and creatinine, α-fetoprotein (AFP), antinuclear antibody, and assay of CD166 using enzyme-linked immunosorbent assay. Results CD166 was significantly higher in HCC group, compensated LC patients group, and decompensated LC patient group, when compared with control group (P<0.001), and in decompensated LC (P=0.003) and HCC group (P=0.01) when compared with compensated LC patient group. Receiver operating characteristic curve analysis was applied to assess the diagnostic performance of AFP, CD166, and combined AFP and CD166 in discrimination between LC and healthy control participants. Area under the curve (AUC) of AFP, CD166, and AFP+CD166 showed significant discrimination between LC and control (AUC=0.786, 0.999, and 1, respectively). CD166 and combined AFP+CD166 showed significantly higher AUC when compared with AFP AUC. For discrimination between CLD (compensated and decompensated) and healthy control participants, at the optimum cutoff level of 5.5 ng/ml for AFP, the diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 73.3, 76.7, 75, and 71.9, respectively, and at the optimum cutoff level of 167.5 ng/ml for CD166, the diagnostic sensitivity, specificity, PPV, and NPV were 96.7, 100, 100, and 96.8, respectively. However, at the optimum cutoff level of combined AFP and CD166, the diagnostic sensitivity, specificity, PPV, and NPV were 100, 100, 100, and 100, respectively. Conclusion The combination of CD166 and AFP is a better biomarker for diagnosis of HCC, where the combination showed higher diagnostic sensitivity and specificity than AFP alone.
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Role of percutaneous transluminal angioplasty for radiocephalic fistulae with junctional stenosis p. 583
Alhussein M Khedr, Sameh E Elimam, Mohamed Hamza
DOI:10.4103/sjamf.sjamf_40_19  
Background Morbidity from end-stage renal disease is primarily from vascular access. Access thrombosis is the main cause of arterio venous (AV) access failure. Decreased fistula blood flow leads to access thrombosis in arteriovenous fistulae, which occurs secondary to venous stenosis. Junctional stenosis is a complication of arteriovenous fistulas. Surgical correction and percutaneous transluminal angioplasty may correct it. Our study aimed to clarify factors for primary success of percutaneous transluminal angioplasty of radiocephalic fistulae with stenosis at the arteriovenous junction with long-term patency on follow-up. Radiocephalic junctional stenosis of fistulae involves both the radial artery and cephalic vein and site of bifurcation. Usually, radiocephalic fistula stenosis is located in the venous limb near the arteriovenous junction. Patients and methods This prospective study included 50 percutaneous transluminal angioplasty cases with stenosis at the arteriovenous junction of radiocephalic fistulae. Demographic data including age, sex, site of fistula (right or left arm), and approach (radial artery or cephalic vein) were recorded. Analysis included primary percutaneous transluminal angioplasty success and long-term patency rates. Results The total primary success rate was 88%. The existence of total occlusion was recognized as the only factor significantly associated with a high procedural failure rate (83.3 vs. 16.6%, P=0.03). For long-term patency rate, the only significant factor was the involvement of proximal radial artery dilatation (P=0.023). The 6, 12, and 18-month patency rates were 66.4, 46.8, and 23.1%, respectively, for all procedures. Conclusion Percutaneous transluminal angioplasty for junctional stenosis at radiocephalic fistula involving both the radial artery and cephalic vein at the site of anastomosis without dilating the radial artery side of the arteriovenous junction reduces the long-term patency rate; however, the initial success rate will not be affected. Initial procedural failure depends on presence of occlusive lesion mainly.
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Evaluation of serum matrix metalloproteinase-9 as a potential biomarker for diagnosis of epilepsy in children p. 587
Naglaa Abd El Moneam Abdallah, Wafaa A Kandeel, Heba A Elmalt, Maha S Zein Elabdeen
DOI:10.4103/sjamf.sjamf_57_19  
Introduction Epilepsy is a common serious neurological disorder. Medical histories and electroencephalogram are not always sufficient for epilepsy diagnosis; therefore, exploring the novel methods for the accurate diagnosis of epilepsy is of great importance. Matrix metalloproteinase (MMP) are vital drivers of synaptic remodeling in health and disease. It plays a well described role in neuroinflammation; it is suggested that at early stages of epileptogenesis, inhibition of MMP may help ameliorate cell death, aberrant network rewiring, and neuroinflammation and prevent development of epilepsy. Aim MMPs especially MMP-9 and MMP-2 are sensitive to seizures; thus, MMP-9 may be a potential biomarker for epilepsy diagnosis, we assessed MMP-9 levels in the context of its possible use as a biomarker of the activity and diagnosis of epilepsy and evaluation of the nutritional state by anthropometric measurement. Patients and methods Thirty epileptic patients aged from 4 to 17 years, selected randomly from the inpatient and outpatient neurological unit of pediatric department in Alzhraa University Hospital between 2018 and 2019 were subjected to: etailed medical history, general and neurological examination, routine laboratory studies, electroencephalogram, anthropometric measurement, and serum MMP-9 level measurement. Thirty age-matched and sex-matched healthy controls were selected and their serum MMP-9 and anthropometric measurements were obtained. Results Serum MMP-9 levels were statistically significantly high in patients with idiopathic epilepsy compared with the control group. Sensitivity of MMP-9 as biomarkers was 62.07% with 96.67% specificity. The cutoff point of MMP-9 more than 4. Conclusion MMP-9 levels increased in patients with epilepsy. This tool may be a helpful diagnostic biomarker for epilepsy with good sensitivity and specificity.
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Role of regulatory T-cells in chronic obstructive pulmonary disease p. 596
Heba H Eltrawy, Salwa Elshennawy, Sarah Y Abozaid, Sadek Mostafa
DOI:10.4103/sjamf.sjamf_58_19  
Background Chronic obstructive pulmonary disease (COPD) is a gradually progressive disease, it might have a subordinate autoimmune pathogenesis. The CD4+CD25+FOXP3+T-regulatory cells (Treg) have an important role in controlling immune and allergic reactions. Objective To determine if Treg is involved in COPD and its value in the predilection of COPD development. Patients and methods This case–control study was conducted on 30 COPD patients and 20 age-matched and sex-matched healthy controls. Spirometry and flow cytometry were done. Results The Treg% was significantly lower in COPD than controls (P<0.05). CD4+ nonsignificantly differed between COPD patients and controls. Forced expiratory volume in the first second/forced vital capacity ratio, forced expiratory volume in the first second %, and forced vital capacity % were significantly decreased, while COPD duration and occupational and/or biomass exposure were significantly increased in the COPD subgroup with lower Treg frequencies. All of them are predictive factors for lower Treg frequencies. Patients with lower Treg frequencies have a 2.8-fold increased risk of COPD development (odds ratio=2.8, confidence interval 0.86–9.0). Conclusion Lower frequencies of Treg (autoimmunity) might be a risk factor for COPD development.
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Role of assessment of the diaphragm by ultrasound during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease p. 605
Waheed G.I Yousif, Ibrahim H.E Ibrahim, Hussien A Abo-Alyzeid
DOI:10.4103/sjamf.sjamf_61_19  
Background Diaphragmatic rapid shallow breathing index (D-RSBI) is a new promising tool to predict weaning outcome. The D-RSBI is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement (DD). Its accuracy in predicting weaning failure, in ready-to-wean mechanically ventilated (MV) patients with chronic obstructive pulmonary disease (COPD), needs to be evaluated. Aim To assess diaphragm using ultrasound during weaning from MV in patients with COPD and to compare the new D-RSBI with traditional RSBI. Patients and methods A prospective observational study was carried out on MV patients with COPD who were ready to wean. During spontaneous breathing trial, evaluation of the right hemi-DD and diaphragmatic thickness by using M-mode ultrasonography was done. Then calculation of D-RSBI (RR/DD), and RSBI (RR/tidal volume) was carried out simultaneously. Outcomes of the weaning trials were recorded. Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results A total of 104 patients with acute exacerbation COPD who were ready to perform an spontaneous breathing trial from MV were included. Overall, 86 (82.7%) were successfully liberated from MV, and 18 (17.3%) patients had failure of weaning. The sensitivity and specificity of DD were 72.2 and 93.0%, respectively. The sensitivity and specificity of RSBI were 77.8 and 70.9%, respectively. However, the sensitivity and specificity of D-RSBI were 83.3 and 90.7%, respectively. Conclusion D-RSBI (RR/DD) is superior than the traditional RSBI (RR/tidal volume) in predicting weaning outcome in patients with acute exacerbation COPD.
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Cervical vestibular evoked myogenic potential and video head impulse test findings in benign paroxysmal positional vertigo p. 612
Mohammed Elgohary, Iman Eladawy, Shaimaa Elshahat
DOI:10.4103/sjamf.sjamf_67_19  
Background Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Approximately 20% of all dizziness is due to BPPV. Objective To assess the peripheral vestibular function in a group of patients with BPPV versus group of normal population by using the cervical vestibular evoked myogenic potential (cVEMP) and video head impulse test (vHIT). Materials and methods This is a comparative cross-sectional study. A total of 60 individuals [20 apparently healthy controls (40 ears) and 40 patients with BPPV, who initially were diagnosed by Dix–Hallpike test/supine roll test], were included in the study. All participants gave their written consent before participation in the study. The control as well as the study group was subjected to basic audiological evaluation and vestibular evaluation. Results Regarding the vHIT, there was a statistically significant difference between control and study groups regarding the left vertical canal gain and the asymmetry (P<0.005). There was a highly statistical significant difference in cVEMP latencies, amplitude, and asymmetry between patients with BPPV and controls (P<0.001). There was a significant difference in latencies as well as amplitude of both P13 and N23 between the affected ear and the nonaffected ear in patients with unilateral primary BPPV. Conclusion Significant abnormal cVEMP in BPPV may indicate saccular involvement in the BPPV pathophysiology, which needs more research to prove or disprove it. Abnormal vHIT gain and asymmetry of the left vertical canal only needs more research in a large sample size.
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Auditory function in children with vitiligo p. 618
Mohammed Elgohary, Hanan Darweish, Iman Eladawy, Al-Shaimaa Seibaei
DOI:10.4103/sjamf.sjamf_68_19  
Background Vitiligo is an acquired disorder of pigmentation affecting ∼0.1–2% of the world population and characterized by the development of well-defined white macules on the skin. Vitiligo is classified into two broad categories, segmental and nonsegmental (most common). Recent studies have suggested a direct relation between cochlear dysfunction and decreased amounts of melanin. Loss of melanocytes resulting in decreased melanin production (as occurring in vitiligo) could decrease cochlear health. Owing to the high importance of having normal hearing during the infancy and the childhood period, this study is designed to assess the cochlear function in pediatric patients with vitiligo. Materials and methods This study involved 30 children with vitiligo and 30 apparently healthy controls; both groups were matched in age and sex. All patients included were subjected to full history taking, otological examination, and audiological evaluation. Audiologic evaluation including pure tone audiometry, extended high-frequency audiometry, immittancemetry, and transient evoked otoacoustic emission was evaluated to detect signal to noise ratio (average) for the frequency bands 1000, 1500, 2000, 3000, and 4000 Hz. Results Children with vitiligo had high pure tone thresholds at all frequencies with a statistically significant difference on both sides in conventional and extended high-frequency audiometry. Transient evoked otoacoustic emission (TEOAEs) average signal to noise (S/N) ratio showed decreased emission in the patient group in both ears and the difference was statistically significant in comparison with the control group. The pure tone threshold in generalized and localized vitiligo is elevated, and the difference is statistically significant almost at all frequencies, but the hearing is affected more in generalized type especially at high frequencies. Moreover, there is elevation in the pure tone threshold in either positive or negative family history in vitiligo subgroups. Patients with skin type IV are more affected than other types. There is no variation in the prevalence of hearing affection regarding sex. Conclusion Vitiligo is associated with cochlear dysfunction. Hearing loss is more common in generalized type of vitiligo. Recommendation Hearing screening of pediatric patients with vitiligo should be done for early detection of hearing abnormalities to ensure maximum scholastic and academic performance to help them to achieve their best potentials.
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Epidemiological and clinical profile of acute coronary syndrome of Egyptian patients admitted to the Coronary Care Unit, Al-Azhar University Hospital, New Damietta p. 625
Mohamed S Bashandy, Heba M Abd Elgalil, Hanaa A.E Abou Elhassan
DOI:10.4103/sjamf.sjamf_74_19  
Background Acute coronary syndrome (ACS) is a multifactorial disease that represents a serious life-threatening health issue and health-care cost globally. Therefore, identifying the risk factors is of value in its prevention. We aimed to report on the epidemiological and clinical profile of ACS patients admitted to the Coronary Care Unit in Al-Azhar University Hospital, New Damietta. Patients and methods A hospital-based analytical cross-sectional study was performed for over 6 months on ACS patients recruited from the Coronary Care Unit of Al-Azhar University Hospital, New Damietta, Egypt. Assessment of patients was carried out by history, clinical cardiac examination, resting ECG, echocardiography, and laboratory investigation. Coronary angiography was done according to the clinical scenario and the patients were followed up during the time of hospitalization to assess their outcomes. Results Overall there were 184 ACS patients, 66.3% of them were either in the young (16.3%) or middle (50%) age groups with a mean age of 55.6±11.6 years; 52.2% diagnosed as ST segment elevation myocardial infarction which was more common significantly among young and middle aged patients. Male sex was predominant. Overweight/obesity was the most prevalent risk factor in all age groups, followed by current smoking in young and middle age groups. Hypertension and diabetes mellitus were more common in the older age groups. Conclusion Overweight/obesity and male sex were the major significant risk factors, followed by smoking, hypertension, and diabetes mellitus. There is an appreciable burden of major cardiovascular risk factors as all patients had at least one of them.
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Effects of prophylactic dose of ondansetron on hemodynamics during spinal anesthesia in cesarean section p. 635
Al Zahraa A Abbas, Amira M Nassar, Sawsan G Mohamed
DOI:10.4103/sjamf.sjamf_75_19  
Objective This study evaluated the efficacy of ondansetron during spinal anesthesia for cesarean section in overcoming the associated bradycardia and hypotension as the primary outcome and nausea, vomiting, intraoperative blood loss, and vasopressor requirements as the secondary outcomes. Patients and methods A total of 60 parturient women aged 20–40 years, with American Society of Anesthesiologists status I and II, scheduled for elective cesarean section under spinal anesthesia were divided into two equal groups in a randomized-controlled fashion. Before induction of spinal anesthesia, group I (n=30) received intravenous ondansetron 4 mg and group II (n=30) received normal saline. Hemodynamic variables, such as heart rate (beat/min), systolic blood pressure, diastolic blood pressure, mean arterial blood pressure (mmHg), nausea, vomiting, intraoperative blood loss (ml), and vasopressor requirements (mg), were recorded for each parturient woman. Results Blood pressure and heart rate were significantly decreased in group II in comparison with group I. Parturient in group I had significantly less requirement for vasopressor and had significantly lower incidences of nausea and vomiting. Conclusion In parturient women undergoing elective cesarean section, intravenous 4-mg ondansetron significantly decreased the hypotension, bradycardia, and vasopressor doses used.
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Intralesional methotrexate vs intralesional 5-fluorouracil in the treatment of localized plaque psoriasis: a comparative clinical and dermoscopic study p. 643
Hagar O.I Attia, Faten A.W.A Kawy, Hala S.A Hafiz
DOI:10.4103/sjamf.sjamf_76_19  
Background Multiple treatment options are introduced in the treatment of localized plaque psoriasis. However, long-term remission and total clearance can only be achieved in few patients. Aim The aim was to compare the efficacy and safety of intralesional methotrexate (MTX) and 5-fluorouracil (5-FU) in the treatment of localized plaque psoriasis both clinically and dermoscopically. Patients and methods Twenty patients with localized plaque psoriasis were enrolled in this study. Each patient was treated by split-body therapy where one psoriatic plaque was treated with intralesional MTX (25 mg/ml) and another plaque with intralesional 5-FU (50 mg/ml). A total of four injections were given at weekly intervals. The target lesions were clinically and dermoscopically evaluated at baseline, 1 week, 1 month, and 2 months after treatment. Results At the end of the study, the response rate was 85% on the MTX side and 95% on the 5-FU side. There was no significant difference between both sides regarding clinical response or side effects. Overall, there was a significant correlation between clinical response and the percentage of dermoscopic red dots. The recurrence rate was 15% on both sides. Notably, all recurring lesions on both sides were characterized by lack of clinicodermoscopic correlation. Conclusion Intralesional MTX and 5-FU are found to be an effective therapeutic modality in the treatment of localized plaque psoriasis with no significant side effects. Dermoscopy might be a useful tool for evaluating the response of psoriatic lesions to treatment and for early detection of recurrence of psoriasis.
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Pharmacodynamic evaluation of dexmedetomidine as an additive drug to bupivacaine in ultrasound-guided interscalene brachial plexus block p. 650
Ain E.A.A Hassan, Mervat S Mahmoud, Horia A Farran, Gehan A Eldesoky, Reham H Mahmoud
DOI:10.4103/sjamf.sjamf_77_19  
Introduction Dexmedetomidine, a novel α2 agonist, is widely used as an adjuvant to local anesthetic in peripheral nerve blocks to decrease the time of onset and increase the duration of the block. Aim We have conducted this study to compare three different doses of dexmedetomidine as an additive to 0.5% bupivacaine in interscalene brachial plexus block guided by ultrasound for upper limb surgery. Patient and Methods Sixty patients aged (21–60 years, ASA I, II) were divided into three groups. Group I received 15 ml 0.5% bupivacaine+50 µg dexmedetomidine (BD50). Group II received 15 ml 0.5% bupivacaine+100 µg dexmedetomidine (BD100). Group III received 15 ml 0.5% bupivacaine+150 µg dexmedetomidine (BD150). Onset of sensory and motor block, visual analog scale, total analgesic need, sedation level, side effects and complications, hemodynamic variables (systolic and diastolic blood pressure and heart rate), and stress response [cortisol, blood glucose, C-reactive protein (ultrasensitive)] were recorded for each patient. Results The onset time for sensory and motor blocks in intergroups comparisons showed nonsignificant difference between groups II and III. The results showed a highly significant difference in visual analog scale score after 12 and 24 h postoperatively in group I than in groups II and III (P<0.001). Six patients in group I required rescue analgesia whereas in groups II and III no patients required rescue analgesia in the first 24 h postoperatively. The sedation score was higher in groups II and III than in group I. No serious side effects were observed in all groups except bradycardia in one (5%) patient in group II and two (10%) patients in group III and it was clinically insignificant. Conclusion By comparing the outcomes of using different doses of dexmedetomidine, we may conclude that the use of 100 µg dexmedetomidine carries the best benefits of dexmedetomidine with little hazards and side effects.
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Vaginal or sublingual misoprostol before insertion of an intrauterine device in women who have previously had a cesarean section p. 661
Nahed H Mohammed, Hanan A.E.M Mohammed, Yassmin M.S.A El-Rahman
DOI:10.4103/sjamf.sjamf_79_19  
Background A cesarean section is an operation to deliver a baby. It involves making a cut in the front wall of a woman’s tummy (abdomen) and womb. It makes the procedure of labor easier and safer. Objective the aim was to investigate whether vaginal or sublingual misoprostol facilitates insertion of an intrauterine device (IUD) in women who have previously had a cesarean section. Patients and methods This was a randomized clinical study. The study was conducted at Mit Ghammer Maternity Hospital from March 2015 to January 2017. Regarding population of the study, 200 women candidates for TCu-380A IUD insertion were enrolled in the study. Half of them received 400 µg of misoprostol tablets vaginally and the others received sublingually 400 µg of misoprostol tablets. Results In the present study, 200 women with previous caesarean section and no prior vaginal delivery were included. They were divided into two groups: 100 women received 400 µg of misoprostol vaginally 4 h before IUD insertion, and 100 women received 400 µg of misoprostol sublingually 4 h before IUD insertion. There was no statistically significant difference between both groups regarding age, parity, and number of previous cesarean section deliveries. There was no statistically significant difference between both groups regarding menstrual changes after IUD insertion (first menstruation). Conclusion Vaginal or sublingual 400 µg of misoprostol administrated 4 h before IUD insertion facilitates IUD insertion and reduces the incidence of pain during the procedure. Vaginal misoprostol is preferred than sublingual route as cervical ripening occurs more likely with vaginal administration.
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Evaluation of laparoscopic sleeve gastrectomy with and without staple line reinforcement p. 668
Mohammed H Elshafey
DOI:10.4103/sjamf.sjamf_80_19  
Background Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Aim of the study The objective of this study was to evaluate laparoscopic sleeve gastrectomy with and without staple line reinforcement. Methods Between July 2017 and December 2018. 60 cases were prospectively and randomly enrolled in the two different techniques of handling the staple line during LSG. Group A I(30 patients) with no reinforcement. Group B(30 patients) with reinforcement by over sewing prolyn suture. Operative and postoperative complications were recorded. The study was controlled prospectively. Results Two patients develop leakage one in each group (3.3%). Two patients developed postoperative hemorrhage in Group A (6.6%), One case developed port site bleeding in Group B (3.3%). One patient developed sub phrenic abscess in group A (3.3%). Three patients readmitted for blood transfusion. Two patients re-operated for diagnostic laparoscopy, port site bleeding in group B (3.3%) and staple line bleeding in group A (3.3%). The differences between the two groups did not reach statistical significance. Conclusion In this prospective study the final results of leaving the staple line untouched appears to be safe, although the logic of reinforcement is understandable. However, improved results for reinforcement have not been supported by the statistics.
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Gastric ultrasound assessment of non-laboring third trimester pregnant women and non-pregnant women p. 675
Mofeed A Abdelmaboud, Mostafa M Sabra, Wafik E Aly
DOI:10.4103/sjamf.sjamf_81_19  
Background Qualitative and quantitative gastric ultrasound (US) assessment is a non-invasive method used successfully in both surgical patients and healthy volunteers. Aim The primary outcome was to evaluate gastric content by US after fasting in both pregnant and non-pregnant women and to determine if there was difference in the aspiration risk between them. The secondary outcome is to determine whether US can be used for rapid assessment of gastric volume and risk of aspiration. Patients and methods Fasted 135 non-laboring third trimester pregnant women (group P) and 135 non-pregnant women (group NP) fulfilling inclusion criteria were recruited in this study. Qualitative gastric US assessment was done for each patients in both groups after following fasting guideline. Patients showing grade 0 in both groups were further subdivided into three subgroups to drink either 100, 200, or 400 ml of water, then a second quantitative US assessment of antral cross-sectional area (CSA) (cm2) was done 2 min after drinking the water. Results Regarding qualitative Arzola’s antral grading, grade 0 was significantly predominant in group NP (64.4 vs 51.1%), whereas grade 2 and solid content were predominant in group P (16.6 vs 3.7% and 8.1 vs 1.5%, respectively), but grade 1 was comparable between the two groups. With respect to CSA (cm2), it was significantly larger in group P than group NP with all volumes of water taken. There was a linear relationship between CSA and volumes of water taken in both groups. Conclusion First, fasted pregnant patients were at more risk of aspiration as it showed more significant number of patients with grade 2 and solid contents but with less significant number of patients with grade 0 as compared with non-pregnant patients. Second, there was a linear relationship between CSA (cm2) and gastric fluid volume, so US can be used to assess preoperative gastric volume and risk of aspiration.
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Long-term effects of repetitive transcranial magnetic stimulation on a sample of children with autism spectrum disorder p. 681
Amgad A Moshref Gabr
DOI:10.4103/sjamf.sjamf_83_19  
Introduction Autism spectrum disorder (ASD) is one of the most common child psychiatric disorders, with a prevalence estimated at 1.1% of the population. Children diagnosed with ASD differ from typically developing children on many cognitive and behavioral dimensions, and therefore the term ‘spectrum’ is used to emphasize its full scope. Transcranial magnetic stimulation (TMS) is a promising, emerging tool for the study and potential treatment of ASD. Aim To study long-term effects of repetitive transcranial magnetic stimulation (rTMS) on a sample of children with ASD. Patients and methods The included sample consisted of 30 children with ASD, and their ages ranged from 4 to 10 years old. They were diagnosed clinically according to Diagnostic and statistical manual of mental disorders, fifth edition through a designed semistructured interview and through application of Childhood Autistic Rating Scale (CARS). There were five female children, representing a percentage of 16.7%, whereas 25 children were males, representing a percentage of 83.3%. All patients in the sample did not stop their medical or behavioral therapy for ASD. After 3-month follow-up, 24 children were reassessed again by CARS after stoppage of rTMS sessions. Results The results of the study after the completion of 12 sessions of the rTMS showed that there is a significant difference and improvement in the severity of the clinical symptoms for ASD, except for the level of activity, listening response, and use of the body, by comparing the severity of symptoms before and after rTMS. On conducting statistical tests, the average measures of problems with respect to relationship with people, sensory responses, and verbal communication after sessions were relatively reduced. This relative decrease was found to be highly significant. The average measurements of problems such as imitation, emotional response and object use and visual response, fear or nervousness, nonverbal communication, level of consistency of intellectual response, general impression, as well as the total CARS score after conducting rTMS have relatively decreased, and it was found to be statistically significant. The average score in the CARS scale changed from 40.2 to 31.4 after 3 months of follow-up, and there was a change in the aforementioned results. Conclusion This study concluded that rTMS over left dorsolateral prefrontal cortex may be a safe and effective way of providing temporarily relief of ASD symptoms, so maintenance therapy is recommended.
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Metabolic changes after laparoscopic sleeve gastrectomy p. 687
Samar R Elsayed Abo Elenin, Hoda A El-Azim Youssef, Amer H El-Barawey
DOI:10.4103/sjamf.sjamf_84_19  
Introduction Obesity is a major cause of premature death, and its prevalence is increasing worldwide. Obesity is a major risk factor for the development of insulin-resistance type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia. Aim The aim of this study was to evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on metabolic diseases such as diabetes mellitus, hypertension, and dyslipidemia. Patients and methods This is a prospective and retrospective study that included 30 patients. All patients underwent LSG as a primary one-stage bariatric procedure in Al Zahraa University Hospital during the period from 2018 till 2019. Preoperative evaluation followed the same standard protocol and included a thorough history, complete endocrinal workup, and counseling by a dietician. All patients underwent upper abdominal ultrasonography, to especially exclude gallstones. All comorbidities that increase perioperative risk were controlled before surgery as far as possible. Results One of the main purposes of this study was to investigate further the effect of LSG on T2DM, hypertension, and hyperlipidemia. Our study shows that LSG resolved or improved lipid profile in most patients. After 12 months from surgery, significant changes in lipid profile included increased level of high-density lipoprotein and decreased level of cholesterol, triglycerides, and low-density lipoprotein level, and also improvement of T2DM and hypertension. Conclusion According to our results, we have shown that at 12 months after surgery, SG is effective in inducing remission of obesity-associated metabolic comorbidities, such as T2DM, hypertension, and hyperlipidemia.
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Role of thoracic ultrasound in children with chronic kidney disease p. 693
Saneya Abd El-Halim Fahmy, Naglaa Abd El-Moneam Abd Allah, Amira I Al-Masry, Eman Sobh
DOI:10.4103/sjamf.sjamf_85_19  
Background Chronic kidney disease (CKD) and dialysis may affect different body systems such as the cardiovascular, respiratory, and musculoskeletal system dysfunction. Pulmonary complications reported in patients with CKD include pulmonary edema, pleural effusion, pulmonary hypertension, respiratory infections, pulmonary fibrosis, and hypoxemia. Ultrasound (US) is a simple noninvasive method that is available at the bedside. It can be used to guide diagnostic and therapeutic decisions and monitor efficacy of treatment; in addition, sonographic signs are simple to learn. Aim The aim of the work was to evaluate thoracic ultrasound (TUS) findings in children of CKD and those on regular hemodialysis. Patients and methods This was a cross-sectional comparative study that was carried out on 90 children; their age ranged from 4 to 17 years. We included two groups: the first group comprised 60 patients with CKD: 30 of them on regular hemodialysis and the other 30 children with CKD not on hemodialysis. The second group was the control group (30 children). Medical history, clinical examination, anthropometric measurement, and routine laboratory studies were done. Chest radiograph and TUS were done for all patients. Computed tomography (CT) chest was done when indicated, whereas TUS in dialysis cases was done before and after dialysis. All groups were age and sex matched. Results Among the dialysis group patients, there was no significant difference between CT, US, and radiograph regarding lung congestion, consolidation, pericardial effusion, and pleural effusion. On the contrary, air trapping, cavity, granuloma, and calcified nodules were detected only with CT. US was sensitive to detect fluid overload even when body weight was below the estimated dry weight by 300 g, and B-lines more than 14 is a cutoff point with high sensitivity. In patients with CKD not on dialysis, there was no significant difference between radiograph, CT, and US chest findings regarding lung congestion, consolidation, pleural effusion, and atelectasis. Conclusion Chest US is a useful tool for the detection of pulmonary complications in pediatrics on regular hemodialysis. The technique is sensitive for detecting fluid overload and can be used for follow-up.
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Chronic obstructive pulmonary disease and ultrasonographic assessment of quadriceps muscle p. 701
Hanaa S Abdellateef, Entesar S Ahmed, Zeinab R Adawy, Hemmat Elabd, Eman Sobh
DOI:10.4103/sjamf.sjamf_86_19  
Introduction Quadriceps muscle (QM) dysfunction has been recognized as a major cause of impaired physical activity in patients with chronic obstructive pulmonary disease (COPD). Clinical assessment of muscle power is not fully accurate in differentiating the degree of impairment. The use of muscle ultrasound has been introduced to study extrapulmonary complications in COPD such as diaphragm and limb muscle impairment. Aim To assess the relationship between severity of COPD and ultrasonographic assessment of QM and its strength by dynamometer. Patients and methods This prospective observational case–control study was conducted on 100 patients with stable COPD attending Chest Diseases Outpatient Clinic and 100 healthy controls with normal lung functions from December 2017 to June 2019. Spirometry, arterial blood gases, and 6-min walking distance were done for all cases. A hand-held dynamometer was used to measure QM strength. Ultrasonography was used to evaluate QM subcutaneous fat, quadriceps muscle thickness (QMT), and rectus femoris cross-sectional area (RFCSA). Results Patients with COPD had significantly lower QM clinical power and strength by dynamometer and decreased QMT and RFCSA in comparison with controls. Overall, 89% of patients with COPD had decreased QM strength by dynamometer, 68% had decreased QMT, and 67% had decreased RFCSA. Most of the patients with COPD who experienced QM weakness were older, had low body mass, had more severe airway obstruction, had more advanced COPD stage, and had lower quality-of-life scores. Life space activity (LSA) score, thigh circumference, and maximum voluntary volume were the factors that had significant effect on RFCSA. However, disease duration, dyspnea score, COPD Assessment Test score, LSA score, and thigh circumference had significant effect on QMT. Meanwhile, LSA and maximum voluntary volume had significant effect on QM strength. Conclusion Most patients with COPD had QM weakness and are associated with more advanced disease and worse quality of life. These findings are important and indicate that peripheral muscle assessment should be incorporated into the clinical assessment of COPD.
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The interoperator agreement and reliability of measurement of diaphragmatic movement by ultrasonography in patients with chronic obstructive pulmonary disease p. 709
Yasmeen M Elkabany, Amani Ezz-Elarab, Zeinab Adawy, Eman Sobh
DOI:10.4103/sjamf.sjamf_87_19  
Introduction Diaphragmatic motion (excursion) measurement by ultrasonography (US) has been used to evaluate diaphragmatic functions in several conditions including chronic obstructive pulmonary disease (COPD). The main limitation of US is that it is operator dependent. Aim The aim of this study was to assess the intraoperator and interoperator agreement and reliability of US measurement of diaphragmatic movement in COPD by pulmonologists. Patients and methods This study included 50 patients with COPD between May 2017 and August 2017 in a tertiary hospital. Readings of diaphragmatic excursion were recorded separately during inspiration and expiration using B-mode US. All measurements were recorded by two operators: one experienced and one MD student who received training to perform diaphragm US. Mean and SD of variation and intraclass correlation coefficient (ICC) in the measurement were calculated for assessment of variability and reliability, respectively. Results Fifty patients with COPD were included in the study. The mean difference between the readings of both operators was 0.014±0.094 for quiet breathing, −0.0102±0.058 for deep breathing, and −0.0598±0.430 for sniffing, and this difference was statistically nonsignificant. There was good to excellent agreement between both operators for all readings (intraclass coefficient values were 0.998, 0.999, and 0.901 for quiet breathing, deep breathing, and sniffing, respectively). Three readings were taken by the same operator during different phases of breathing (tidal, deep, and sniffing), and Cronbach’s α for readings of operator A were 0.968, 0.935, and 0.983 for quiet breathing, deep breathing, and sniffing, respectively, and 0.995, 0.948, and 0.980 for quiet breathing, deep breathing, and sniffing, respectively, by operator B, which indicate excellent reliability. Conclusion The measurement of diaphragmatic excursion using US in patients with COPD was reproducible and reliable test in all breathing phases when performed by pulmonologists.
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Ultrasound-guided transversus abdominis plane block versus local anesthetic wound infiltration for postoperative analgesia after lower abdominal surgery p. 715
Manal F Abd-Almoniem, Wafaa G Ahmed, Marwa F Negm
DOI:10.4103/sjamf.sjamf_88_19  
Background Transversus abdominis plane (TAP) block is an effective technique to reduce postoperative pain and narcotic consumption. However, local anesthetic infiltration is commonly used as a traditional method. Objective The aim was to compare the pain relief and frequency of analgesic requirement after lower abdominal surgeries using ultrasound-guided TAP block with that of wound infiltration with local anesthetic agent. Patients and methods This was a randomized, prospective, comparative, and double-blinded trial. A total of 60 patients with American Society of Anesthesiologists status I/II scheduled for elective lower abdominal surgeries were included. They were classified after informed consent. The patients in group T received TAP block with 20 ml of 0.25% bupivacaine at the end of surgery using ultrasound device with a linear transducer (5–10 MHz), whereas those in group I had wound infiltration at the end of surgery with 20 ml of 0.25% bupivacaine. In postanesthesia care unit, visual analog scale was used to assess the pain postoperatively. Conclusion Comparable short-term postoperative pain relief was provided by both ultrasound-guided TAP block and local wound infiltration, but TAP block provided better and long-lasting effects.
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Ventricular ejection time: a noninvasive echocardiographic parameter for assessment of severity of congestive heart failure in cardiomyopathic patients p. 722
Asmaa A Ali
DOI:10.4103/sjamf.sjamf_89_19  
Background Due to the burden of heart failure (HF) disease, a simple utilized noninvasive tool for identifying its severity in patients is indicated. Timing of mechanical cardiac events, especially left ventricle (LV) ejection, studied since 40 years using a phonocardiogram, an ECG, and echocardiography. This approach is useful, helpful, and valuable for many clinical uses and applications. Aim The aim was to clarify the validity of right ventricle ejection time (RVET) and left ventricle ejection time (LVET) to assess the severity of HF in dilated cardiomyopathic patients by their correlation with New York Heart Association (NYHA) functional class as a clinical assessment of severity of HF. Patients and methods The enrolled 85 cases included 55 myopathic patients and 30 age-matched and sex-matched healthy persons who served as the control group. All cases underwent complete transthoracic echocardiography study to measure LV and right ventricle (RV) dimensions, volumes, and functions. LV and RVET are calculated and correlated with NYHA functional class. Results Patients with dilated cardiomyopathy had significantly increased RV volumes (P<0.001) and significantly lower RV and LV systolic functions. In addition, there was significant decreased LVET and RVET in the cardiomyopathic patients group versus the normal group. Moreover, RVET and LVET had a significant correlation with NYHA functional class (RVET (r=−0.013, P<0.00001), LVET (r=−0.06, P<0.00001). Conclusion Right ventricular dysfunction is common in dilated cardiomyopathy. LVET and RVET is considered a reliable indicator and simple noninvasive means for clinical assessment of severe HF by using the NYHA functional class.
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Incidence of tracheostomy in prolonged mechanically ventilated patient in the respiratory intensive care unit p. 730
Ahmed H Wahba, Farid S Basiony, Ahmed N Elsamanody, Mohamed O Nour
DOI:10.4103/sjamf.sjamf_92_19  
Background Tracheostomy is considered for ill patients with respiratory failure with expected prolonged mechanical ventilation not only to facilitate pulmonary toilet, ventilator weaning but also decrease the direct laryngeal injury of endotracheal intubation. Aim The aim was to assess the incidence, indications, complications, and outcome of tracheostomy for patients with prolonged mechanical ventilation. Patients and methods A retrospective study was carried out over 10 years from January 2009 to December 2018 at the Respiratory Intensive Care Unit, El-Hussein University Hospital. This study included 120 patients who underwent open tracheostomy in the operation theater carried out by otorhinolaryngology surgeons. Complications of tracheostomy were documented. Results The age of the study group ranged from 45 to 82 years. The complications were two cases of bleeding, one case of cardiac arrest, two cases of Pneumothorax, three cases of stomal sepsis, and four cases of surgical emphysema. Laryngotracheal stenosis was observed in five patients and tubal obstruction in three patients. Conclusion Prolonged endotracheal intubation is the first main indication of tracheostomy in the respiratory ICU, although there were minimal complications from this procedure. Recommendation Early tracheostomy is recommended for patients who are expected to have prolonged tracheal intubation.
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The role of dermoscopy in the recognition of dermatofibroma p. 735
Laila H Elshahed, Hoda K El-Sebaei, Zeinab M Faik
DOI:10.4103/sjamf.sjamf_93_19  
Introduction A central white scar-like patch and a delicate pigment network at the periphery are the typical signs of dermatofibromas (DFs) on dermoscopy. Aim The aim was to analyze the different dermoscopic appearances of DF. Patients and methods This study was carried out between June 2018 and June 2019 from the Dermatology Outpatient Clinic at Al Zahraa University Hospital, Al Sayed Galal University Hospital, and El-Hood El-Marsood Hospital, and included 50 cases of DF with 63 lesions of DF. Each lesion was examined by dermoscopy and histopathological examination was performed for suspicious lesions. Results A typical pattern (central white scar-like patch and peripheral pigmented network) was observed in 49 of 63 (77.7%) lesions and variants from this typical pattern included peripheral homogeneous pigmentation and central white network in two (3%) lesions, multiple white patches with peripheral pigmented network in two (3%) lesions, central homogenous pigmentation and peripheral pigmented network in one (1%) lesion, and total pigmented network in one (1%) lesion, whereas an atypical pattern, which was named the ‘nonDF-like’ pattern (1%), was seen in 14 of 63 lesions (22.2%). Atypical DFs showed features resembling different conditions such as melanoma in two (3%) lesions, psoriasis-like pattern in one (1%) lesion, basal cell carcinoma in one (1%) lesion, squamous cell carcinoma in one (1%) lesion, and aneurysmal in one (1%) lesion. Vascular patterns in our study were found in three (5%) lesions, which had a linear and dotted pattern. Conclusion DFs may display different morphological faces. The typical dermoscopic patterns allow a confident diagnosis, whereas a full surgical excision is always recommended in all doubtful cases.
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The role of optical coherence tomography angiography in early detection of primary open-angle glaucoma p. 744
Israa M Bazeed, Doaa A Mahmoud, Zeinab S Hasan
DOI:10.4103/sjamf.sjamf_94_19  
Introduction Glaucoma is a slowly progressive disease with characteristic optic nerve abnormalities caused by accelerated ganglion cell complex (GCC) loss and concomitant retinal nerve fiber layer (RNFL) thinning. Glaucoma suspects are the key group to identify and treat with intraocular pressure lowering therapy in an effort to prevent blindness. Aim Determination and correlation of the role of the whole image, peripapillary, and inside disk vascular density (%) (wiVD%, ppVD%, and idVD%) in the RNFL of optic nerve head by optical coherence tomography angiography (OCT-A) and their correlation to GCC and RNFL thickness by OCT in early detection of preperimetric primary open-angle glaucoma. Patients and methods This prospective, nonrandomized, noninvasive, and observational case–control study was performed at the Ophthalmology Department and clinics of Al-Zahraa University Hospital, Al-Azhar University. It included 46 eyes of 23 participants who were divided into two groups: group I (control) consisted of 20 eyes of 10 healthy eyes. Group II (glaucoma suspects) consisted of 26 eyes of 13 preperimetric glaucoma suspects of the same age group. The peripapillary and inside disk optic nerve head vessel density were measured. Clinical data, visual field (VF) parameters, and spectral-domain OCT evaluation (RNFL thickness, GCC thickness, and rim area) were recorded. Results Significant decreases were found in whole image, peripapillary, and inside disk vascular density (%) and RNFL thickness especially in the temporal side, GCC, VF mean deviation, and VF index in suspected eyes than the normal eyes indicating the presence of early vascular changes in glaucoma. Conclusion OCT-A is a novel, noninvasive imaging technology that detects vascular changes as early signs in glaucoma disease progression; reduced vessel density also was associated with thinning of RNFL, and decrease in GCC count in a majority of cases. So, the diagnostic ability of OCT-A is a promising tool for early diagnosis of glaucoma.
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Unilateral paravertebral block guided by nerve stimulator with a single-level injection for ipsilateral hernioplasty using 0.5% levobupivacaine Hcl versus 2% hyperbaric prilocaine Hcl p. 752
Ahmed M Abd-El Galeel, Mohammed A Frahat
DOI:10.4103/sjamf.sjamf_95_19  
Background Thoraco-lumbar paravertebral blockade (PVB) provides the best alternative for anesthesia in lower abdominal surgeries owing to minimization of postoperative pain, reduction of nausea and vomiting, shortened hospital stay, patient satisfaction, and rapid return to normal activities. Aim This study was designed to compare two local anesthetics drugs, levobupivacaine Hcl 0.5% versus hyperbaric prilocaine Hcl 2%, used in PVB-guided nerve stimulator. Patients and methods A total of 60 American Society of Anesthesiologists I and II patients scheduled for elective unilateral open technique hernioplasty under regional anesthesia using ipsilateral thoraco-lumber PVB technique were divided into two groups. Patients were randomly assigned to receive a single injection of thoraco-lumbar PVB-guided nerve stimulator with local anesthetic 20 ml in total volume, levobupivacaine Hcl 0.5% (group L) (n=30) and hyperbaric prilocaine Hcl 2% (group HP) (n=30), at 12 thoracic vertebra (T12), with a catheter inserted in PV space. Parameters measured were onset and offset time of anesthesia and motor block, hemodynamics evaluation, numeric rating scale for pain assessment, blood glucose level, cortisol level, interleukin 6 level, time of first voiding, patient satisfaction, postoperative complications, and first 24-h postoperative morphine consumption. Results There was statistically significant longer time of onset of sensory block and motor regression in group L than group HP. Patient stress response was highly significantly lower in each group when compared between values at T0 and T1, whereas the response was significantly lower in HP group only at T1 but insignificantly at T2. Postoperative morphine consumption was significantly higher in group L than group HP only at T0, whereas was insignificant in T1, T2, T3, T4, T5, and T6 postoperatively. Conclusion PVB is a highly efficient anesthetic technique with lesser complications than general or regional anesthesia.
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Effects of intrathecal dexmedetomidine vs intrathecal magnesium sulfate as adjuvants in spinal anesthesia p. 760
Rawdaa M Eloraby, Amira A ElNasr Awad, Ragia H.A Hashim
DOI:10.4103/sjamf.sjamf_96_19  
Aim Intrathecal adjuvants are used for prolongation of duration of subarachnoid block and provide adequate analgesia. This study was designed to evaluate the onset, duration, and regression of sensory and motor block of intrathecal dexmedetomidine vs magnesium sulfate as an adjuvant to 0.5% hyperbaric bupivacaine for spinal anesthesia. Materials and methods Sixty patients aged 21–50 years, with American Society of Anesthesiologists status I, II scheduled for elective lower abdominal and lower limb surgeries, were divided into three equal groups in a randomized-controlled manner: the control group (S: n=20) received 15 mg hyperbaric bupivacaine (3 ml) and 1 ml saline, the dexmedetomidine group (DXM: n=20) received15 mg hyperbaric bupivacaine (3 ml) and 10 µg of dexmedetomidine, and the magnesium sulfate group (Mg: n=20) received 15 mg hyperbaric bupivacaine (3 ml) and 50 mg of magnesium sulfate. Hemodynamic variables such as heart rate, systolic and diastolic blood pressure, onset of sensory and motor block, regression time, time to first analgesic request, and adverse effects were recorded for each patient. Results The onset time of sensory and motor block was rapid in the DXM group in comparison with the Mg and control groups. The onset time of sensory and motor blockade were delayed in the Mg group in comparison with the S group. The regression time of sensory and motor blockade was prolonged in the DXM group and in the Mg group compared with the S group. Demand for analgesia was significantly late in the DXM group compared with the Mg and control groups, but early in the control group. Conclusion Dexmedetomidine had faster onset of sensory and motor blocks, and provided prolonged postoperative analgesia compared with the magnesium sulfate and control groups
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Noninvasive assessment of arterial CO2 from end-tidal CO2 in pediatric intensive care unit of Al-Zahraa Hospital p. 768
Ragaa Abdel-Salam, Soheir I Mohamed, Sally A.-E.M Ezz-Elarab
DOI:10.4103/sjamf.sjamf_101_19  
Background Arterial carbon dioxide tension (PaCO2) is considered to be the gold standard for accurate monitoring in pediatric ICU; however, it is invasive, costly, and intermittently gives snapshots about the patient status. Objective The aim was to use end-tidal carbon dioxide (ETCO2) as an effective, persistent, and non-invasive monitor of arterial CO2. Patients and methods This observational study was conducted on 50 mechanically ventilated children aged from 1 to 5 years in pediatric ICU of Al-Zahraa University Hospital. PaCO2 and ETCO2 were recorded at the same time, and the results were analyzed for correlation and agreement. Lung disease severity was measured by ventilation index (VI) and PaO2/FiO2 (P/F) ratio. Results This study showed that the mean PaCO2 was higher than ETCO2 value (31.32±14.49 and 29.79±13.81 mmHg, respectively). The mean difference between PaCO2 and ETCO2 was 1.8±3.23 mmHg. A positive correlation was present between both PaCO2 and ETCO2 (correlation coefficient r=0.969, P<0.001, and 95% confidence interval=0.946–0.982). A positive correlation was found between PaCO2 and ETCO2 in mild and moderate lung disease, where P/F ratio is greater than 200 (n=39, r=0.961, P<0.001) and VI is less than 20 (n=38, r=0.885, P<0.001), and also in severe lung disease, where P/F ratio is less than 200 (n=12, r=0.991, P<0.001) and VI is greater than 20 (n=12, r=0.988, P<0.001). Conclusion This study suggests a significant correlation between PaCO2 and ETCO2. ETCO2 monitoring exhibited a good validity to predict PaCO2 in critically ill children
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Parathyroidectomy with and without autografting in management of secondary hyperparathyroidism in hemodialysis patients p. 773
Fatma M Kotb
DOI:10.4103/sjamf.sjamf_102_19  
Background Secondary hyperparathyroidism (sHPT) develops in most, if not all, patients with end-stage renal disease. It is known as long-term parathyroid hyperplasia, which results in the formation of functionally independent parathyroid adenoma. sHPT can lead to high-turnover bone disease, interstitial and vascular calcifications, as well as cardiovascular mortality and morbidity. Objective To study the value of parathyroid autografting following parathyroidectomy in cases of sHPT with chronic renal failure. Patients and methods A total of 30 patients with end-stage renal disease on dialysis with sHPT were enrolled in this study. All patients are subjected to parathyroidectomy (15 patients with autografting vs. 15 patients without autografting). Clinical evaluation and laboratory investigations (including serum intact parathormone, total and ionized calcium, phosphorus, and alkaline phosphatase) were done preoperatively and postoperatively. Results There was a significant difference between preoperative and postoperative clinical and laboratory parameters in both groups. Moreover, there was a significant decrease in hospital and intravenous calcium in the group subjected to autografting. Otherwise, there was a nonsignificant difference between the two groups regarding calcium, phosphorus, intact parathormone, and alkaline phosphatase. Conclusion Parathyroid autografting following parathyroidectomy in patients with sHPT has a significant effect in decreasing postparathyroidectomy hospital stay and intravenous calcium.
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Intracervical local anesthesia versus NSAID analgesics for pain relief during office hysteroscopy p. 780
Olfat Nouh, Hala A Wahab, Mazen A El Zahry, Hossam El Ktatny
DOI:10.4103/sjamf.sjamf_103_19  
Introduction Office hysteroscopy provides great predictive value for multiple patients categorized as having infertility, abnormal uterine bleeding (AUB), or missed intra uterine contraceptive device (IUCD); however, pain during procedure is still a hindering problem. Multiple studies were done, but still no clear evidence-based data have been settled. Aim To compare intracervical injection of mepivacaine hydrochloride versus intramuscular injection of NSAIDs before hysteroscopy procedure in office hysteroscopy. Patients and methods This was a single-blind randomized comparative study. Both sample size and randomization were done by a computer program. Patients were classified into two groups: group 1 was subjected to intracervical injection of 5 ml of mepivacaine hydrochloride at position 4 and 8 o’ clock of the vaginal portion of the cervix, at least 15 min before procedure was done, and group 2 received NSAID intramuscular injection 15 min before the procedure. Hysteroscopy was done, and if any abnormality was detected, an intervention was done. A descriptive scale of pain was used, classified as mild, moderate, or severe (assigned by interruption of the procedures). Results There was a statistically significant difference between both groups in the three pain grades. However, there was no statistically significant difference between both groups for vomiting. In spite of number of operative cases being low in both groups, the number in study group was double that of control. However, pain during cervical handling and bleeding were two remarkable annoying factors owing to lengthy procedures and occasional considerable bleeding. Conclusion Intracervical injection of a local anesthetic is an effective method in reducing pain during hysteroscopy but time of procedure should be taken into consideration.
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Correlation of neuron-specific enolase with radiological findings and degree of disability in acute ischemic stroke p. 785
Nabil H Ibrahim, Mohamed A Abboud, Wael R Hablas, Khaled M Sobh, Mohamed A Zaki, Mohamed Safwat K Youssif
DOI:10.4103/sjamf.sjamf_104_19  
Introduction Neuron-specific enolase (NSE) is a blood marker released in acute neuronal injury and can be estimated in serum of patients with acute ischemic stroke (AIS) to assess neurological outcome. Aim To demonstrate the relationship between serum NSE levels in patients with AIS and National Institute of Health Stroke Scale (NIHSS) score and apparent diffusion coefficient (ADC) changes to predict the prognosis and outcome. Patients and methods This clinical observational study was performed on 50 patients with AIS who attended the emergency and inpatient unit of Al-Azhar University Hospitals, Nabarouh Central hospital, and Mansoura University Hospitals, during a period of 2 years from January 2017 to 2019. Serum NSE was checked within 72 h from admission. NIHSS score was calculated within the same period and then after 1 and 6 months. MRI of brain with diffusion-weighted imaging was done. ADC was calculated up to 1 week from admission. Results There was a statistically significant strong negative correlation between NSE and ADC, and a statistically significant strong positive correlation between NSE and NIHSS on admission and after 1 and 6 months (P=0.000). Conclusion Serum NSE can reflect the severity of AIS and predict the short-term and long-term outcomes.
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CASE REPORT Top

Rhinocerebral mucormycosis: a case report and literature review p. 792
Reda A Elhawary, Mohammed S Abdelwahed, Ali S Odadi, Ahmed A Etwadi
DOI:10.4103/sjamf.sjamf_90_19  
Mucormycosis is a rare rapidly progressing and lethal invasive fungal infection that involves the nose, paranasal sinuses, and orbit of the head and neck regions. Mucormycosis commonly affects patients with uncontrolled diabetes, especially those with ketoacidosis. The authors report a case of rhinocerebral mucormycosis in a 45-year-old diabetic patient who presented at Khamis Mushayt General Hospital, Aseer region, south of Saudi Arabia, with ketoacidosis, right nasal sinusitis, right orbital cellulitis, and loss of vision. Rhinocerebral mucormycosis is suspected clinically, so surgeon immediately did tissue biopsy. Mucormycosis fungal organisms were detected pathologically as well as in fungal culture. The patient responded well after aggressive surgical debridement with antifungal medication. The authors conclude that the diagnosis of rhinocerebral mucormycosis as early as possible is essential for a good therapy effect as well as better survival and limited morbidity of patients.
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LETTER TO THE EDITOR Top

Study of the association between obesity, plasminogen activator inhibitor-1, and asthma in preschool children p. 797

DOI:10.4103/sjamf.sjamf_54_19  
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