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   Table of Contents - Current issue
January-April 2018
Volume 2 | Issue 1
Page Nos. 1-40

Online since Thursday, July 12, 2018

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The role of ultrasound in the diagnosis and evaluation of diabetic neuropathy in nerve roots of the foot p. 1
Mohamed Abdel Latief Mahmoud, Ashraf T Yousef, Said S Said, Doaa M.M Abd El-Sameea
Background Neuropathies are characterized by a progressive loss of nerve fiber function. Diabetic peripheral neuropathy is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes. The diagnosis of diabetic neuropathy is based primarily on characteristic symptoms and is confirmed with nerve conduction studies (NCS), which are time-consuming, slightly invasive, and occasionally not well tolerated for repeated evaluations. In contrast, ultrasonographic (US) examinations can be performed to assess peripheral nerves with less discomfort and have already been used for the evaluation of several disorders of the peripheral nervous system such as carpal tunnel syndrome. Patients and methods A total of 50 patients were included in the study, with 40 patients with type 2 diabetes and 10 controls. All cases underwent clinical history, local clinical examination, NCS, and real-time high-resolution US. Ultrasound examination The patients were examined in supine position, and the foot was bolstered with a pillow to expose the anterior and medial portion of the lower leg and foot. The transducer was placed immediately above the medial malleolus to locate the tibial nerve in the transverse (short axis) and the longitudinal (long axis) views. The 5.0–12.0-MHz multifrequency linear array probe was used for tibial nerve scanning. The instrument used was Philips HD3 ultrasound scanner. Result There was a statistically significant difference between case and controls regarding US cross-sectional area done for right and left tibial nerves, with high mean among cases (0.18±0.02 and 0.17±0.02, respectively). There was a statistically significant difference between US and NCS. There was no statistically significant difference between the two groups regarding the other measurements. Conclusion High-resolution US can be used as adjuvant tool for the NCS for diabetic patients suspected to have neuropathy.
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Motor and sensory blocking effect of intrathecal fentanyl versus dexmedetomidine as adjuvants to bupivacaine for cesarean section p. 6
Tawfik M.N El-Din, Mahmoud M.A Helmy, Medhat N Abd-El-Naby, Salem M.R Al-Ganady
Background Intrathecal α2 agonists prolong the duration of action of local anesthetics and reduce the required dose. Dexmedetomidine is an α2 receptor agonist, and its α21 selectivity is eight times higher than that of clonidine. Aim The aim of this study was to determine the effect of adding dexmedetomidine and fentanyl to intrathecal bupivacaine on the onset time and duration and intensity of motor and sensory blocks for cesarean section. Patients and methods The study was carried out on 40 adult female patients who were randomly classified using closed envelope method into two equal groups, with 20 patients in each: group D patients received intrathecally 2.5 ml volume of 10 mg (2 ml) 0.5% hyperbaric bupivacaine and 10 µg dexmedetomidine in 0.5 ml (prepared by diluting 1 ml dexmedetomidine in 5 ml of normal saline), and group F patients received intrathecally 2.5 ml volume of 10 mg (2 ml) 0.5% hyperbaric bupivacaine and 20 µg fentanyl in 0.5 ml (prepared by diluting 2 ml fentanyl in 2.5 ml of normal saline). The aim was to evaluate motor and sensory block. Sensory block assessment: the onset and duration of sensory block was assessed by ice cube method, and time taken from intrathecal injection to the highest level of sensory block and sensory regression to the L1 dermatome were recorded. On achieving T7 sensory blockade level, surgery was allowed. Motor block assessment: onset and degree of motor block was assessed by Bromage scale: 0, no paralysis; 1, inability to raise extended leg; 2, inability to flex the knee; and 3, inability to flex the ankle (complete motor block). Results Sensory and motor block onset times were shorter in group D than in group F. The regression of the sensory block to S1 dermatome and Bromage 0 were longer in group D than group F. The two-dermatome regression time was longer in group D than group F. There was a statistically significant decrease in group F regarding systolic, diastolic, and mean arterial blood pressures and heart rate than group D. There was no statistically significant difference among the two groups regarding arterial oxygen saturation and respiratory rate. Neonatal outcome was normal in all groups. Conclusion Intrathecal dexmedetomidine addition to bupivacaine for spinal anesthesia synergistically increases block duration and shortens sensory and motor block onset time without any significant adverse effects.
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Iatrogenic biliary injuries in patients who underwent laparoscopic cholecystectomy p. 11
Hazem A.M Bader
Background The rate of biliary injuries (BIs) is more common after laparoscopic cholecystectomy (LC) than open surgery especially in the case of acute cholecysititis. Aim The present work was performed to study the causes, clinical presentation, diagnosis, and treatment of BIs after LC. Patients and methods The study was carried out on 60 patients presented with BIs after LC, the rate being more common after LC than open surgery especially in the case of acute cholecysititis and complicated cases. The BIs in patients who underwent an LC was classified according to the site of injury as follows: (a) partial transection of the common bile duct, (b) injury to common hepatic duct due to clips or cautery, (c) cystic duct stump leaks, and (d) bile leaks from bile duct or radicals in the liver bed. The main causes were misapplication of clip at the cystic duct. Results The results of this study has shown that the symptoms and signs appeared between the fifth and seventh postoperative days. The clinical presentation is in accordance with the magnitude of the bile leak and the time of diagnosis. The guarding and rebound tenderness is the principal manifestation with abdominal bile collection. The endoscopic retrograde cholangiopancreatography gives the most definitive information of the status of the biliary system and allows visualization of retained common duct stones. Conclusion The ideal treatment in these cases is a minimally invasive procedure, but since the diagnosis is frequently delayed, open surgery was done. The endoscopic retrograde cholangiopancreatography with internal stent has become the treatment of choice in patients with bile leak after LC.
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Ultrasound guidance versus nerve locator for infraclavicular brachial plexus block: a comparative clinical study p. 15
Tawfik M Noor El-Din, Yousry M Abd-Elslam, Abd-Elwahab A Saleh, Ahmed Mohamed Makled
Background The use of ultrasound (US) guidance for nerve blocks has dramatically increased over the past 20 years. The success rate of infraclavicular block is improved by US guidance compared with nerve locator (NL). Aim In this study, we aimed to compare conventional block using NL and US-guided techniques in the infraclavicular approach to the brachial plexus for upper limb surgeries (forearm and hand surgeries, either elective or emergency). Patients and methods The study was carried out on 40 adult patients of both sexes who were randomly classified using closed envelope method into two equal groups, with 20 patients each: All patients undergoing either conventional block using NL or US-guided block were premedicated with 0.02 mg/kg of midazolam. The technique was done by identification and blocking the cords of brachial plexus by administration of 15-ml 0.5% bupivacaine and 15-ml of 2% lignocaine with adrenaline 1 : 200 000 in both groups. Onset of the block, success rate, patient satisfaction, and the complications were recorded. Results Sensory and motor block onset times were shorter in group B than in group A. The success rate and patient satisfaction were more in group B than in group A. Patients in group B had fewer complications than in group A. Conclusion To conclude, our results showed less time to perform ICBPB in group B and the onset of complete block as well as high success rate, patient satisfaction, and fewer incidences of complications.
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The role of adiponectin, insulin resistance, and vitamin D as predictors of transformation of fatty liver to hepatocellular carcinoma p. 20
Amany K Mohammed, Faiza S AbdelRehem, Olfat M Hendy, Eman R Mohammed, Walaa S.M Ibrahim
Introduction Hepatocellular carcinoma (HCC) is considered the fifth most common cancer in the world and is responsible for 5% of all malignant tumors in humans. Most HCC cases are related to chronic hepatitis C virus (HCV) infection, chronic hepatitis B (HBV) infection, and alcohol abuse. Approximately 15–50% of HCC cases were classified as idiopathic, suggesting that other risk factors are responsible for its rising incidence. Recent studies have suggested that nonalcoholic fatty liver disease (NAFLD) can be associated with these ‘idiopathic’ cases. Aim The aim of the study was to evaluate the levels of both serum 25(OH)VD and adiponectin, as well as homeostatic model assessment insulin resistance as predictors of transformation of NAFLD to HCC among patients with NAFLD, HCV, HBV positive patients and HCC patients. Patients and Methods This is a case–control study which was conducted on 100 patients at the Internal Medicine Department in ElMataryia Teaching Hospital. They were classified into 20 patients with NAFLD, 20 patients with HBV positive, 20 patients with HCV positive, and 20 patients with HCC, in addition to 20 age-matched and sex-matched healthy participants,. Full medical history, clinical examination, and laboratory investigations including complete blood count, alanine transaminase, aspartate transaminase, prothrombin time, international normalized ratio, fasting blood sugar, glycated hemoglobin, homeostatic model assessment insulin resistance, hepatitis B antigen, hepatitis B antibody, serum vitamin D, and serum adiponectin, abdominal ultrasound were done. Statistical analysis using SPSS was done. Results The level of adiponectin showed a decrease in NAFLD cases (2 μg/ml), but there was an increase in HBV (18 μg/ml), HCV (10.5 μg/ml), and HCC (13 μg/ml) in comparison to the control group (3.75 μg/ml). Further, the cut-off points for adiponectin to detect HCC in NAFLD was found to be greater than 3.2, with a sensitivity of 100% and specificity of 100%. Conclusion Serum adiponectin is an excellent marker to predict the transformation of NAFLD to HCC.
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Serum magnesium level in maintenance hemodialysis and cardiovascular calcification p. 26
Hayam H Mansour, Ragaa R Mohamed, Manal F Khaled, Esraa M Khalil
Background Patients with chronic kidney disease have a high prevalence of vascular calcification, and cardiovascular disease is the leading cause of death. Magnesium (Mg) is a natural calcium antagonist and many studies have shown that low circulating levels of Mg are associated with vascular calcification. Aim of the work The aim of the study was to assess the relationship between serum Mg levels and vascular calcification in chronic hemodialysis (HD) patients. Patients and methods A cross-sectional study conducted on 60 patients with end-stage renal disease on regular HD in Al-Zahraa University Hospital (group I) compared with 30 healthy controls (group II), from June to December 2017. Patients with evidence of infection, chronic diarrhea, ileostomy, and those receiving Mg-based phosphate binders were excluded from the study. All studied groups were submitted to clinical examination, renal function, lipid profile, serum albumen, calcium, phosphorus, intact parathyroid hormone, Mg, carotid duplex, echocardiography, ECG, and lateral view plain abdominal radiograph. Results There were highly significant differences regarding Mg and carotid intimal medial thickness (CIMT) in group I compared with group II: 1.51±0.28, 0.89±0.30 and 2.47±0.18, 0.45±0.08 respectively, P<0.001. Echocardiographic findings showed calcified mitral and aortic valves in 12 (20%) patients and calcified abdominal aorta by abdominal X-ray radiograph in 20 (33.33%) patients. There were highly significant negative correlation between serum Mg and CIMT and abdominal aortic calcification in group I. Conclusion The patients on maintenance HD have lower serum Mg levels. It was associated with increased CIMT and vascular calcification if compared with healthy group and concomitant use of proton pump inhibitors may aggravate this hypomagnesemia. So serum Mg level in maintenance HD patients could be a potential biomarker for cardiovascular calcifications.
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Self-fixating Parietex ProGrip mesh in inguinal and paraumbilical hernia repair p. 32
Ashraf I.A El-Sharkawy, Hazem A Mostafa Badr, Rasha Abd El-Aziz Abd El-Gany
Background Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years till using self-fixating Parietex ProGrip mesh. This mesh can be placed by an open approach which is becoming increasingly common in many countries. Objectives This study investigated the recent surgical treatment of open inguinal and paraumbilical hernia patients using self-fixating ProGrip Parietex mesh. Immediate complications reported were seroma, cellulitis, postoperative pain, mesh sepsis, testicular atrophy, and recurrence. Patients and methods This study was conducted between January 2015 and January 2017 at Al-Zahra Hospital Al Azhar University, and Al-Ameen Hospital, KSA with a 1 year follow-up. The patients underwent general, spinal, or epidural anesthesia. A dose of third-generation cephalosporin was administrated during the induction of anesthesia. Self-fixating Parietex ProGrip mesh with or without lateral slit with a rough surface placed on the floor of the inguinal canal for the repair of inguinal hernias or in subcutenous plane on anterior abdominal wall musculature in paraumbilical hernias. Results Self-fixating Parietex ProGrip mesh was used with a lateral slit for the spermatic cord, maked right and left for indirect inguinal hernia patients (69.79%) and direct hernia patients (27.01%). Self-fixating ProGrip Parietex mesh without slit with a rough surface was placed in the subcutaneous plane in patients with paraumbilical hernias (3.1%). Immediate complications such as seroma, cellulitis, and postoperative pain were studied. The mean operative time was ±35 min and the mean hospitalization discharge time was ±1.5 days. Conclusion The use of self-fixating Parietex ProGrip mesh technique for the repair of inguinal and paraumbilical hernias in this study seemed effective and safe, and is not associated with postoperative pain. No recurrence of hernia and no mesh sepsis were detected, with 1 year follow-up.
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