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ORIGINAL ARTICLES
Neutrophil gelatinase associated lipocalin: a new marker for early diagnosis of acute kidney injury in ICU
Hoda M El-Sayed, Hayam H Mansour, Essam Abd El-Aziz Abd El-Mobdy, Ragaa R Mohammed, Ahmed N Ajam, Haytham S Abd El-Hamid, Mohammed S El-Din Zaky, Mohamed H Biomy
May-August 2017, 1(1):1-6
DOI:10.4103/sjamf.sjamf_3_17  
Introduction Serum creatinine is a late marker of acute kidney injury (AKI) and its alterations are often not apparent until 48–72 h postinjury. Urine and plasma neutrophil gelatinase associated lipocalin (NGAL) measurements may represent early biomarker of AKI in intensive care, being able to predict this complication ∼2 days prior to the rise in serum creatinine. Aim To evaluate the role of plasma NGAL level as a marker for early diagnosis of AKI in ICU patients and if it is related to the severity of kidney injury and renal outcomes. Patients and methods Our study including 40 ICU patients, 20 patients admitted for surgical causes and 20 admitted for medical causes. For all participants, clinical examination, laboratory investigations were done in the form of serum creatinine, plasma NGAL, with daily measurement of urine output and estimation of glomerular filtration rate. Patients with AKI were classified according to Risk, Injury, Failure, Loss, End stage renal disease (RIFLE) classification, non-AKI patients served as controls for comparison. Results Out of 40 patients, 14 (35%) developed AKI, and according to RIFLE classification, seven (17.5%) were class R, four (10%) were class I, three (7.5%) were F. There was statistically significant comparison between operative time and development of AKI in surgical patients. Also patients who did not develop AKI had lowest NGAL level while AKI group showed rising level with RIFLE classes. Conclusion Plasma NGAL can be used as early biomarker for diagnosis of AKI and its level is increasing with the severity of AKI classes in ICU patients
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Prognostic factors of brainstem infarction in a sample of Egyptian patients
Sayed A El-Zayat, Tarek M Abd El-Hamid, Khaled M Sobh, Ahmed F Abd El-Aziz, Mohie EL-Din T Mohamed, Mahmoud S Attia
May-August 2017, 1(1):14-20
DOI:10.4103/sjamf.sjamf_6_17  
Background Ischemic brainstem stroke is estimated to constitute 10% of all first ischemic brain strokes. Because the brainstem is involved in almost all of the important functions of the central nervous system, brainstem infarction (BSI) is relatively dangerous with a high mortality. Early prediction of the severity and degree of disability and identification of high-risk patients are critical for the treatment of patients with BSI. Objective This study aimed to evaluate patients with BSI in terms of clinical, laboratory, and radiological factors to study the outcomes of these patients. Patients and methods Patients were admitted at the Stroke Unit and Internal Neurology Department of Al-Azhar University Hospitals (Al-Hussein and Sayed Galal Hospitals), over a period of 6 months, from 1 December 2016 to 30 May 2017, with a diagnosis of acute BSI, confirmed by computed tomography brain and MRI brain with diffusion. The study included 31 patients and were subjected to clinical, laboratory, radiologic assessment (by computed tomography brain and MRI brain with diffusion), and assessment of severity by the National Institute of Health Stroke Scale (NIHSS) score at the time of admission and discharge. The modified Rankin Scale (mRS) score at discharge was used to divide patients into three groups: patients with mRS less than or equal to 2 were considered to have achieved a good outcome, those with mRS greater than 2–5 were considered to have achieved a poor outcome, and those who died had mRS equal to 6. Results Overall, 14 (45.2%) patients had a good prognosis, 13 (41.9%) patients had a poor prognosis, and four (12.9%) patients died. Dysphagia, vomiting, cranial neuropathy, and high NIHSS score on admission were associated with a poor outcome. There was no relationship between the outcomes of the studied patients in relation to age, sex, hypertension, atrial fibrillation, diabetes mellitus, ischemic heart disease, high lipid profile, smoking, previous cerebrovascular stroke, obesity. Conclusion Dysphagia, vomiting, cranial neuropathy, and high NIHSS score were associated with a poor prognosis.
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Intrauterine lignocaine versus paracervical block for pain relief during cervical dilatation and endometrial curettage
Alaa El Deen Mahmoud Sayed, Ahmed Shaaban Mohamed
May-August 2017, 1(1):7-13
DOI:10.4103/sjamf.sjamf_8_17  
Background Dilatation and curettage and fractional curettage are commonly performed gynecological procedures. Randomized-controlled trials have concluded that topical anesthesia effectively reduces pain in endometrial sampling and hysteroscopy. A major obstacle to the successful completion of outpatient gynecologic procedures is pain. Most patients can tolerate pain to complete necessary procedures, but studies show that pain scores are often high. Objective The aim of this study was to compare the efficacy of intrauterine instillation of lidocaine, paracervical block, and a combination of both techniques to control pain during endometrial curettage in a randomized, double-blinded trial in premenopausal and postmenopausal women. Patients and methods A total of 90 patients scheduled for endometrial curettage were allocated randomly to three groups: group L, group P, and group LP according to the type of anesthesia that was administered. Group L received lidocaine 2% injected into the uterine cavity (n=30). Group P received paracervical block (n=30). Group LP received combined intrauterine lidocaine and paracervical block (n=30). Women were observed for pulse rate and the mean arterial blood pressure was monitored continuously and recorded manually. The pain score assessed using 10 mm visual analog scale. Also, types and incidence of adverse events were reported. Results In terms of heart rate changes, there was a statistically significant increase in both groups L and P than group LP. The changes in the mean arterial blood pressure showed no statistical significance difference among the study groups. Statistically significant differences were found in the number of patients who received fentanyl and the total fentanyl required among the three groups; this was less in group LP than the other two groups. Also, the number of patients who received propofol was significantly lower in group LP compared with the other groups. In terms of the quality of intraoperative analgesia, there was statistically significant adequate analgesia in group LP compared with the other groups. Conclusion This study concluded that intrauterine lidocaine in combination with paracervical block significantly provides adequate intraoperative and postoperative analgesia, whereas intrauterine lidocaine alone or paracervical block alone provides intraoperative analgesia that requires the addition of intraoperative opioid analgesics and sometimes hypnotics and mostly requires immediate postoperative analgesia.
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Pattern and clinical profile of thalassemia among pediatric patients attending the Yemeni Society Centers for Thalassemia and Genetic Blood Disorders in Yemen
Hala A Al-Kherbash, Ahmed Al-Awdi, Nawal S Hasan
September-December 2017, 1(2):43-56
DOI:10.4103/sjamf.sjamf_15_17  
Background Thalassemia is a type of inherited anemia. Its management is complex and expensive, and requires a multiple-team approach. Optimal and sufficient clinical care is demanding. Aim The aim of this study was to determine the magnitude, sex and age distribution, clinical profile, complications, investigation, and management of transfusion-dependent β-thalassemia major among Yemeni pediatric patients attending the Yemeni Society Centers for Thalassemia and Genetic Blood Disorders in Yemen as, to our knowledge, no similar previous study has been carried out in Yemen. Patients and methods This was a prospective, cross-sectional, descriptive study carried out during the period from January 2015 to December 2016. A total of 109 Yemeni pediatric transfusion-dependent β-thalassemia major patients who attended the Yemeni Society Centers for Thalassemia and Genetic Blood Disorders in Yemen were included. Detailed assessment of history, clinical examination, investigations, treatment, and follow-up were performed for every patient. The data were collected from the medical records of the patients. Results There was a slight male predominance (53.2%), with a male to female ratio of 1.14 : 1. Approximately 33% of the patients were in the age group 7–10 years, followed by the age group 3–6 years. The mean age of the cases was 7.68±5.8 years. Positive parent consanguinity was present (74.2%) and the majority (64.2%) were first-degree relatives. The best outcome of thalassemia was among those patients 1.7 years old or younger at the time of diagnosis and those patients 2 years old or younger at first blood transfusion. Earlier initiation of chelating therapy yielded better outcomes and reduced the mortality rate with a highly statistically significant difference. The usage of a combination of both oral chelation and subcutaneous iron chelation (iron pump) therapies led to a noticeably better outcome and reduced the mortality rate markedly. A proportional relation was detected between serum ferritin level and mortality among the cases, with a statistically significant difference. The complication rate was high (40.2%). The mortality rate was also high (27.5%). Cardiac dysfunction was the major risk factor of death among our thalassemic patients as about 60% of the deaths were because of cardiac complications, with a highly statistically significant difference. Conclusion Increasing awareness of the morbidity and mortality of transfusion-dependent β-thalassemia major among pediatric Yemeni patients, with an emphasis on the great importance of premarital screening before marriage in Yemen, is mandatory. For better outcomes, routine investigations to detect early complications with proper treatment of the predisposing factors and complications are necessary.
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Prospective, comparative, randomized, and controlled study of endotracheal intubation conditions without muscle relaxant in children receiving general anesthesia
Abdelazim A.T. Hegazy
May-August 2017, 1(1):21-25
DOI:10.4103/sjamf.sjamf_9_17  
Introduction Intubation without the need for a muscle relaxant is a common practice in pediatric patients. Many drugs are used; sevoflurane and propofol are used to improve the intubation score and to decrease the usage of a muscle relaxant and avoid its side effects. Aim This study aimed to compare intubation conditions and hemodynamic responses to two induction regimens, without a muscle relaxant using an anesthetic, sevoflurane versus propofol, in children, who required general anesthesia. Patients and methods A prospective controlled study was carried out on 90 patients with ASA physical status I and II scheduled for elective pediatric day case surgeries. Patients were divided into three equal groups of 30 patients each. The patients in the S group received inhalational induction sevoflurane. The P group received 3 mg/kg propofol intravenously. The C group received 2 mg/kg succinylcholine after 3 mg/kg propofol intravenously as a control group; maintenance was performed by inhalation using sevoflurane after intubation in all groups. The intubation conditions, hemodynamic parameters (heart rate, peripheral oxygen saturation) induction time, and recovery time were all recorded and statistically analyzed. Results With respect to the intubation conditions, no patient in any of the two groups (S and P groups) needed rescue a muscle relaxant for intubation. The S group showed more acceptable and excellent intubation conditions versus the propofol groups (100 and 96.7%, respectively). The heart rate was comparable in all groups at all readings; except during intubation, reading was highly significantly low in the sevoflurane group. Induction time was longer in the sevoflurane group than in the other groups. The recovery time was short in the S group than in the propofol group. Conclusion Endotracheal intubation without neuromuscular blocking agents in pediatric patients undergoing day case surgeries was achieved with no severe respiratory or hemodynamic adverse events by using propofol (3 mg/kg) or sevoflurane 8% at induction and then reduced to a maintenance level after intubation.
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Comparison of endoscopic retrograde cholangiopancreatography then laparoscopic cholecystectomy and laparoscopic common bile duct exploration in patients with common bile duct stones
Hazem A.M Badr, Ashraf A Elsharkawy
September-December 2017, 1(2):69-74
DOI:10.4103/sjamf.sjamf_1_18  
Background Choledocholithiasis is concomitant with gallstones in ∼3–10% of patients. In the pre-endoscopic and prelaparoscopic era, the standard treatment for patients suffering from gallstones accompanied with common bile duct stones (CBDS) was open cholecystectomy and common bile duct (CBD) exploration. With the advent of laparoscopic and endoscopic techniques, several alternative treatments, such as laparoscopic cholecystectomy (LC), preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and laparoscopic common bile duct exploration (LCBDE), have been developed to treat cholelithiasis. The management of stones in the CBD in the laparoscopic era is controversial. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the LCBDE and ERCP with sphincterotomy, in patients with CBDS. Patients and methods The study was performed on 60 patients suffering from CBDS who were admitted and treated in our department in Al-Zahra Hospital and Al-Ameen Hospital, KSA between January 2014 and January 2016.The patients were divided into two groups according to the method of treatment. Group A included 20 patients who were treated by LCBDE whereas group B included 40 patients were treated by ERCP with sphincterotomy. Results This study was carried out on 60 patients with CBD stones. The patients were divided into two groups according to the method of treatment. Group A included 20 patients who were treated by LCBDE, whereas group B included 40 patients who were treated by ERCP with sphincterotomy. Conclusion The optimal management of patients with CBDS should depend on the condition of the patients, and the expertise of the operators. LCBDE is a feasible, safe, and effective procedure that carries low morbidity and mortality and will decrease the need for unnecessary ERCP in the future for suspected or proved choledocholithiasis.
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Neurofilaments as a biomarker of axonal loss in multiple sclerosis
Hoda Mohamed Ali Massoud, Eman Mohamed Saif Eldeen, Sahar Saied Khattab, Ghada Saed Abd Alazim
September-December 2017, 1(2):63-68
DOI:10.4103/sjamf.sjamf_14_17  
Background Neurofilaments (NF-H) might be a potential biomarker of CNS tissue damage in MS, but their potential predictive value for the future disease course, disability, disease progression, and treatment response needs to be investigated. Aim of the work The aim of this study is to evaluate the role of serum phosphorylated neurofilament H as a marker in multiple sclerosis and correlate it’s level with clinical expanded disability status scale (EDSS) and magnetic resonance imaging findings. Subjects and methods Study included 40 patients and 20 healthy control, 20 patients with relapsing remitting multiple sclerosis (RRMS) and 20 patients with secondary progressive multiple sclerosis (SPMS). All patients in this study were subjected to full history taking and clinical examination and scoring according to the EDSS scores, routine laboratory investigations, measuring of serum phosphorylated neurofilament-H (PNF-H) levels and neuroradiological assessment. Results Patients with secondary progressive multiple sclerosis were more likely to have a high serum (PNF-H) titer compared to patients with relapsing remitting multiple sclerosis, and these levels were significantly correlated with EDSS scores in both patients groups. Conclusion The increase in (PNF-H) titer during the progressive phase of the disease together with the correlation of (PNF-H) levels with all clinical scales and radiological lesions (e.g. gadolinium-enhanced lesions and black holes) suggests that cumulative axonal loss is responsible for sustained disability and that high (PNF-H) level is a poor prognostic sign.
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Comparative study between loupe-assisted and conventional subinguinal varicocelectomy
Hazem A Megahed, Hatem A Megahed, Salah G Ziada, Amr A Sarhan, MasoudKh El-Syed
September-December 2017, 1(2):75-79
DOI:10.4103/sjamf.sjamf_3_18  
Introduction In this prospective randomized study, the outcome and the complication rates of loupe-assisted subinguinal varicocelectomy (LASV) are compared with conventional subinguinal varicocelectomy. Patients and methods Between December 2014 and June 2017, 66 patients aged from 20 to 38 years old were enrolled in this study in Al-Azhar University Hospital, New Damietta, and Al-Zahraa University Hospital, Cairo. The patients were randomly subdivided into two groups: group A included 33 patients who underwent LASV using surgical loupes with three times magnification, group B included 33 patients who underwent conventional open subinguinal varicocelectomy. Postoperative complications along with preoperative and postoperative (3 months) seminal parameters were compared between the two groups. Moreover, the number of identified internal spermatic arteries was also compared between the two groups. Results The hydrocele formation was significantly lesser in group A treated by LASV [none of the patients (0%)] than group B treated by conventional subinguinal varicocelectomy (three patients; 9.09%). The recurrence rate was better in group A (one patient; 3.03%) than group B (two patients; 6.06%), but the result was nonsignificant regarding recurrence rate. Testicular hypertrophy does not occur in both groups. The average number of preserved arteries was more in group A than group B (0.95±0.51 in group A vs. 0.88±0.47 in group B). Semen parameters including semen concentration, sperm motility, and percentage of abnormal forms were improved in both groups, but the improvement was nonsignificantly better in group A than group B, so the improvement was nonsignificantly between the two groups, but it was significant between the preoperative and postoperative results within each group. Conclusion LASV is better than conventional open subinguinal varicocelectomy as loupe allows clear visualization of the testicular artery, lymphatics, and small venous channels, resulting in decrease in the incidence of complications, including hydrocele formation, testicular artery injury, and varicocele recurrence.
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Treatment of genu valgum in children by percutaneous transverse metaphyseal osteotomy of the distal femur
Aly M Elgeuoshy, Galal M Mansour, Mohamed M Hegazy, Alhassan M Abdelhamid
September-December 2017, 1(2):57-62
DOI:10.4103/sjamf.sjamf_17_17  
Purpose The aim was to measure and correct the angular deformity of 15 patients with genu valgum by a new percutaneous technique. Materials and methods We conducted a prospective study to evaluate the results of using percutaneous supracondylar femoral osteotomy technique with casting as a minimally invasive surgical intervention for the treatment of genu valgum. Results The youngest patient was 7 years and the oldest was 20 years with an average age of 14 years. The range of hospital stay is from 1 or 2 days, but it decreased with the late cases in the study, which can be explained by the improvement in the learning curve of the technique. The least time of follow-up is 6 weeks, but two cases have been followed for 57 weeks with a mean of 24.90 weeks. Conclusion The percutaneous technique provides the privileges of acute correction without the need for dissection, minimizes the formation of ugly scar or keloid, minimizes the risk of infection, and allows for accurate correction. There is no need for plate fixation or a staged operation to remove hardware.On the other side, the percutaneous osteotomy has a learning curve and the compliant patient is crucial for a close assessment of the condition.
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Percutaneous fixation of acute scaphoid fractures: a retrospective study
Ismail Yassin, Mohammad El-Nahas, Mostafa Awadallah
May-August 2017, 1(1):26-28
DOI:10.4103/sjamf.sjamf_10_17  
Objective The aim of this study were to determine whether the functional outcome of the evaluation of the effectiveness of percutaneous retrograde (volar) approach of insertion of cannulated Herbert’s screw to stabilize acute scaphoid fractures and to evaluate the functional outcome after this minimally invasive operative management of this problematic fracture. Background Scaphoid fracture is the most common carpal fracture. It accounts for ∼60–90% of carpal and 11% of hand fractures. Scaphoid fracture is a common fracture affecting mainly young active people during their work or while participating in sports activities. Patients and methods This is a retrospective observational study of patients undergoing surgery for percutaneous fixation of acute scaphoid fracture. In our study, 12 patients with less than 14-day-old fractures were fixed percutaneously by Herbert’s screw and reviewed for a minimum of 12 months (average of 24 months). The functional outcome of this method was assessed. Results Fracture union was achieved in 11 (91.6%) cases at a mean of 8.29 weeks (6–12 weeks), whereas one case was ununited. Conclusion This study proves that fixation of acute scaphoid fractures results in predictable satisfactory union rate and functional outcome. Moreover, it proves that percutaneous Herbert’s screw insertion carries no risk of damage to soft tissues or vascular supply.
  80 15 -
Effect of female increased body mass index on intracytoplasmic sperm injection outcome
Mohamed Shehata
May-August 2017, 1(1):36-41
DOI:10.4103/sjamf.sjamf_12_17  
Background BMI is calculated by dividing the weight in kilograms by height in meters squared (kg/m2). It is known that the reproductive potential in obese women is decreased and to be associated with suboptimal outcomes after assisted reproductive technologies. Objective The aim of this study was to evaluate the effect of increased BMI on pregnancy outcome in women undergoing intracytoplasmic sperm injection (ICSI) cycle. Patients and methods This retrospective study was conducted on 200 Women at Assisted Reproductive Technology Unit, International Islamic Centre for Population Studies and Research (IICPSR), Al-Azhar University. Data were recruited from patient files at IICPSR from January 2013 to December 2015, who had ICSI trial during this period. Patients who were included in the study were subdivided into two groups according to BMI − first group: normal-weight women with BMI between 18 and 24.9 kg/m2 (100 cases); secondgroup: overweight and obese women weighing at least 25 kg/m2 (100 cases). The outcomes in the two groups were demonstrated in all stages of ICSI. Results The duration of infertility was progressively higher as BMI increased. Basal luteinizing hormone, follicle-stimulating hormone, and estradiol levels were higher in group 2 than in group 1. Higher total doses of gonadotropin were required in group 2 to obtain equivalent ovarian response than in group 1. No significant difference was observed on ovarian response and embryonic parameters. Serum estradiol level on ovulation triggering day was significantly higher in group 2. Ovarian hyperstimulation and cycle outcome were not significantly different between both groups. Conclusion Overweight and obesity appear to have independent adverse effects on ovarian response to stimulation and outcomes in women undergoing ICSI.
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Cerebrovascular reactivity and neurogenic inflammation in migraine
Manal H Maabady, Ghada Saed, Seham El-Said, Eman M Saif Eldeen
May-August 2017, 1(1):29-35
DOI:10.4103/sjamf.sjamf_11_17  
Background The exact mechanism of migraine is still unknown; however, it is believed to be a neurovascular disorder, where the cerebral vascular reactivity is malfunctioning. Although several studies have found alterations in velocity of blood flow and in cerebral vasomotor reactivity of intracranial arteries in migraineurs in headache-free periods, as well as during migraine attacks, the results are inconclusive. Another theory of migraine is the neurogenic inflammation involving the release of various vasoactive neuropeptides, which evoke a cascade of events that have a role in migraine attacks. Aim of work To evaluate the role of both vascular and inflammatory theories in migraine with and without aura. Objective The objective of this study was to examine the cerebrovascular reactivity to repetitive flash stimulation during interictal period of migraine and determine the serum levels of transforming growth factor β-1 (TGFβ-1) as an inflammatory mediator in migraine with and without aura. Patients and methods The changes in peak systolic volume (PSV) of both middle cerebral and posterior cerebral arteries in response to repetitive flash stimulation were evaluated by transcranial Doppler in 35 migraineurs (23 patients with aura and 12 without aura), during interictal period, and in 25 age-matched and sex-matched apparently healthy control participants. Moreover, serum levels of TGFβ-1 were determined in both the patients and control participants. Results The middle cerebral artery in migraineurs shows significant increase in PSV after flash stimulation in comparison with control participants who showed a habituation in PSV levels in response to stimulation. In posterior cerebral artery, compared with normal participants, migraineurs showed significant increase in PSV measures and PSV changes at the beginning and after the end of stimulation. The lack of habituation is significantly pronounced in patients with migraine with aura, in comparison with those without aura. Regarding TGFβ-1 serum levels, they were significantly higher in migraineurs than control participants. Moreover, patients with migraine without aura show significantly higher serum levels of TGFβ-1 in comparison with patients with migraine with aura. Conclusion Lack of habituation of the cerebrovascular response in migrainers might contribute to a disturbance in the metabolic homeostasis of the brain that might induce migraine attacks. Neurogenic inflammation has a role in migraine attacks.
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