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   Table of Contents - Current issue
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September-December 2019
Volume 4 | Issue 3
Page Nos. 231-377

Online since Monday, September 23, 2019

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ORIGINAL ARTICLES  

Correlation between modified shock index and severity index in predicting outcome in patients with hemorrhagic shock Highly accessed article p. 231
Hassan I. M. Kotb, Ayman A Mamdouh, Abualauon M Abedalmohsen, Sarah Abd El Mageed Mohammed
DOI:10.4103/JCMRP.JCMRP_52_18  
Introduction Trauma is the main cause of death in age group less than 45 years. A lot of clinical parameters including heart rate, pulse rate, blood pressure, shock index (SI), and modified shock index (MSI) are used to predict the severity of hemorrhage in trauma patients. In 2012 Choi and colleagues proposed for the first time a new index (NI) based on lactate concentration and peripheral perfusion index for assessment of shock in a rat model. In this trial, we propose for the first time a new severity predicting index (NI) based on lactate concentration/peripheral perfusion ratio as an indicator of hemorrhage-related mortality in humans. Materials and methods This prospective trial is a single-center study of 122 consecutive adult polytraumatized patients with hemorrhagic shock admitted to trauma center within 6 h of the trauma, and underwent resuscitation according to the advanced trauma life support protocol (2016). Protocol-related measurements were obtained immediately after admission and over 48 h postresuscitation for metabolic perfusion parameters, serum lactate, perfusion index, and other hemodynamic parameters. The period of the study corresponds to the outcome after 48 h of admission. Resuscitation measures were considered successful when lactate levels were less than or equal to 2 mmol/l in addition to stable macrohemodynamic parameters at the end of this period. Results Characteristically, the survivors had NI of 40 ± 2.7 on admission, compared with 87.1 ± 13 of nonsurvivors with highly significant difference. MSI showed a significant difference (nearly doubled) between survivors and nonsurvivors. SI showed nearly the same change, nearly doubled. NI showed lower prediction value for mortality than MSI and SI (P = 0.05) 0.884, 0.905, and 0.908, respectively. Conclusion This study confirms, for the first time in humans, the validity of severity index as independent parameter in prediction of mortality in comparison with MSI.
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Clinical audit on infection control of catheter-related bloodstream infection in neonatal ICU p. 237
Samia A Mohammed, Ahlam B Ali, Doaa H Mohammed
DOI:10.4103/JCMRP.JCMRP_54_18  
Introduction Intravascular catheters are indispensable in modern-day medical practice, particularly in neonatal ICU (NICU). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic infection complications. Patients and methods The study included 100 newborns, admitted to NICU at Assiut University Hospital, for whom umbilical venous catheter was inserted during the first week of life. Evaluation was done for all newborns for appropriateness of steps of infection control measures before, during, and after fixation of umbilical catheter. The included cases were followed during the period of admission till discharge. Results Infection control measures before umbilical catheter fixation were done 100%. During umbilical catheter fixation, the measures were defective in 100% in the form of defective use of a large drape to cover patient in sterile fashion as well as defective use of face mask. After fixation, only 20% did not maintain sterile technique while applying dressing. Conclusion Infection control measures must be appropriately done with special attention for defective steps during and after fixation. The decision to insert a central line should always be carefully considered for every newborn individually, and the benefits must be weighed against the risks.
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Effect of exposure to cadmium on the hippocampus in adult albino rat and the possible role of L-carnitine p. 240
Faten Y Mahmoud, Ashraf H. Abd El-Hakim, Ayman S El Deen Amer, Mariam W Fidal
DOI:10.4103/JCMRP.JCMRP_60_18  
Background The hippocampus is an important structure for formation of new memories. Cadmium is one of the most toxic agents that can affect hippocampal neurons. L-carnitine is an antioxidant. Aim of work To demonstrate the effects of cadmium on principal cells of hippocampus of adult rats and possible protective role of L-carnitine. Materials and methods A total of 42 adult rats aged 1 month were subdivided into four subgroups: group I was the control group, which received no treatment. Group II was administered cadmium given at a dose of 4 mg/kg/day for 1 month. Group III (sham control) was administered L-carnitine given at a dose of 200 mg/kg/day for 1 month. Group IV was administered cadmium and L-carnitine given to the rats at the same previous doses and duration. For each group, six rats were used for light microscopic study (gallocyanin chrom alum stain), and six rats were used for electron microscopy (group III studied only by light microscopy). Principal cell count and thickness were measured and statistically analyzed. Results Principal cells in group II showed degenerative changes. Morphometric data showed a significant decrease in measured parameters. In group III, the results were similar to those of the control group. In group IV, semithin sections and the ultrastructure of the principal cells showed obvious improvement of cells. Morphometric data also increased compared with those treated with cadmium. Conclusion Cadmium induces changes in the structure of the principal cells of the hippocampus in adult rats. L-carnitine plays an important in protection of the hippocampus.
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Treatment results of tuberculous patients in Assiut Chest Hospital p. 251
Eman M Monazea, Saeed S Abduljalil, Lamiaa H Shaaban, Ayat-Allah A Ahmed
DOI:10.4103/JCMRP.JCMRP_86_17  
Aims The improvement of the quality of TB treatment is essential to control of TB. The aims of this study were to identify the outcomes of TB treatment in patient recorded in Assiut Chest Hospital during the period from 2011 to 2015 and factors associated with undesirable treatment outcome and to estimate proportion of drug resistance among TB patients and identify factors associated with it. Patients and methods This study was a descriptive retrospective review of TB patients' registry. All tuberculous patients notified to the TB registry in Assiut Chest Hospital in the period from 1 January 2011 to 31 December 2015 and completed at least 6 months of treatment management were included in the study. Patients' records were reviewed for the following data: personal data, presenting symptoms, pattern of TB, regimen of treatment, and drug-resistant TB. Results The percentage patients with drug resistance were 60.9%. A total 75.1% of patients were cured and 5.1% of patients died. Cure rate was significantly higher in patients with extrapulmonary TB compared with 63.5% in pulmonary TB patients. The predictors for undesirable treatment outcomes were male sex, positive family history, pulmonary TB patients. Conclusion The success rate of all registered patients was satisfactory but, below WHO target, one-fifth showed failure of treatment was associated with male sex, illiterate, and drug-resistance Mycobacterium tuberculosis, success treatment was highest in extrapulmonary TB patients, cure rate was highest in nonresistant TB patients, drug resistance represented about two-thirds of all studied TB patients, and ~ 65% of pulmonary TB patients had drug resistance.
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Evaluation of efficacy and safety of daclatasvir and sofosbuvir in treatment of chronic hepatitis C infection p. 256
Abdel-Ghani Abdel-Hameed Soliman, Mohamed A. A. Ghaliony, Sahar M Hassany, Shymaa A.-B. Ahmed
DOI:10.4103/JCMRP.JCMRP_20_18  
Introduction The era of direct-acting analogs in the management of chronic hepatitis C virus (HCV) infection stared in 2011, and since then, many agents were approved for management of HCV infection. Aim To assess the efficacy and safety of daclatasvir and sofosbuvir in the treatment of chronic hepatitis C infection. Patients and methods A prospective study was done at El-Rajhi University Hospital. It included 100 patients (75 patients with chronic HCV infection and 25 patients with HCV-related compensated liver cirrhosis). They received dual therapy (sofosbuvir 400 mg plus daclatasvir 60 mg) for 12 weeks or 24 weeks for patients with chronic hepatitis C and patients with liver cirrhosis, respectively. Results Mean age of all patients was 51.48 ± 10.90 years. Overall, 64% were males, 52% were from rural areas, and 56% patients were unemployed. Sustained virological response (SVR) 12 was obtained in 98 (98%) patients included in our study, and only two (2%) patients failed to achieve sustained virological response: one patient had chronic hepatitis but took irregular course of therapy, whereas the other was a cirrhotic patient. It was noticed that 69 (69%) patients had no adverse effects during the course of therapy. Headache was the most frequent event occurred in 17 (17%) patients, comprising seven (9.3%) patients with chronic hepatitis C and 10 (40%) patients with liver cirrhosis. Conclusion This regimen of therapy has high success rate for viral eradication with minimal tolerable adverse effects.
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Microwave ablation versus hepatic resection in management of hepatocellular carcinoma p. 261
Mohammed Hussien, Sahar Hassany, Mohamed El Kassas, Ahmed M Ali, Ehab F. A. Moustafa, Osman A. H. Osman
DOI:10.4103/JCMRP.JCMRP_24_18  
Background Management of early hepatocellular carcinoma (HCC) in cirrhotic patients is still a challenge. Hepatic resection remains the best curative treatment, but more complications with a risk of HCC recurrence in cirrhotic patients make it less favorable. Few studies have recently started to evaluate microwave ablation (MWA) as a method of HCC eradication in cirrhotic patient and compare it by other ablative methods. The aim of this study was to evaluate patient with HCC before and after both MWA and hepatic resection. Patients and methods A prospective study was performed in Assiut University Hospital in collaboration with National Hepatology and Tropical Medicine Research Institute in Cairo. We recruited 40 patients; all of them had radiology-proved HCC with lesion up to 5 cm and amenable for MWA or surgical resection. Results There is a statistically significant difference between Child score after hepatic resection in comparison with the mean Child score for patients who underwent MWA (before ablation was 6.1 ± 0.7 and after ablation was 6.1 ± 1.0, but was 5.5 ± 0.6 and was 7.2 ± 1.4 after hepatic resection). There is marked decrease of α-fetoprotein after hepatic resection (as the mean level before resection was 172.73 and after liver resection was 10.95). Fewer complications were recorded after MWA in comparison with that after hepatic resection. Conclusion Hepatic resection is superior to MWA in HCC eradication as no residual activity. MWA is better than hepatic resection in maintaining the Child score, as it was more affected in patients who underwent hepatic resection than those who underwent MWA.
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Direct wrist magnetic resonance arthrography in triangular fibrocartilage lesions p. 268
Eman S Abdul Monem, Nagham N Mahmoud, Mohamad K Mahmoud, Waleed R Saleh
DOI:10.4103/JCMRP.JCMRP_46_19  
Objective The objective of this study was to assess the diagnostic accuracy of direct wrist magnetic resonance arthrography (MRA) compared with arthroscopy in the diagnosis of triangular fibrocartilage complex (TFCC) lesions. Patients and methods A total of 25 (12 men and 13 women) consecutive patients, in the age range from 16 to 49 years (mean age: 28 years) complaining of unexplained chronic wrist pain and suspected to have TFCC lesions were prospectively examined by direct MRA with arthroscopic correlation. Results Compared with arthroscopic results, the sensitivity, specificity, and accuracy of direct MRA for central TFCC lesions were 100% for all three and 100, 90.9, 96%, respectively, for peripheral lesions. Conclusion Direct MRA can diagnose TFCC lesions with very high sensitivity and specificity and can help in reducing arthroscopies for pure diagnostic purposes.
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Juvenile idiopathic arthritis: a clinical audit p. 272
Enas Mohamed Sayed, Mohamed Mahrous Eltellawy, Ismail Lotfy Mohamed
DOI:10.4103/JCMRP.JCMRP_36_19  
Background Juvenile idiopathic arthritis (JIA) is an autoimmune, inflammatory noninfective joint disease that includes different disease subtypes that are characterized by the onset of arthritis starting before the age of 16 years with symptoms lasting at least for 6 weeks. Objective The aim of this study was to evaluate the compliance of healthcare providers at the Pediatric Rheumatology Unit, Assiut University Children's Hospital, to the 2011 American College of Rheumatology recommendations for treatment of JIA. Patients and methods The study was conducted on 50 patients who were younger than 16 years and diagnosed as having JIA at the Pediatric Rheumatology Unit, Assiut University Children's Hospital, to assess compliance of the unit's healthcare providers to American College of Rheumatology recommendations for treatment of JIA. Results The patients were grouped according to age into two groups: from 1 to 7 and 8 to 16 years. Polyarticular JIA was the most common type among studied cases followed by systemic-onset JIA. All studied cases presented with arthritis at the time of diagnosis. Complete blood count and erythrocyte sedimentation rate were done for all studied cases at the time of diagnosis. Rheumatoid factor was done for 84%. The most common complications among the studied group were those related to treatment. NSAIDs and corticosteroids were the most common drugs used. Conclusion Treatment of JIA includes pharmacological and nonpharmacological interventions and surgical treatment. Pharmacological treatment includes NSAIDs, steroids, disease-modifying antirheumatic drugs, and biological agents. The degree of disease activity and the presence or absence of features of poor prognosis greatly affect onset of complications and treatment of JIA. Nonpharmacological interventions include psychosocial therapy, nutrition, physical and occupational therapy, lifestyle factors, and home remedies. Through this study, some defects were found. First, there was deficiency in data recording. Second, there was also deficiency in laboratory (mainly rheumatoid factor and antinuclear antibody/anti-double stranded DNA) and radiological workup. Moreover, nonpharmacological therapy and surgery were not considered. Lastly, there was deficiency in regular follow-up of safety drug monitoring.
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Comparison between dexmedetomidine, ketamine, or dexmedetomidine–ketamine combination for control of shivering during spinal anesthesia p. 277
Sherif S. A. Rehim, Ghada M Aboalfadl, Alaa M Abdelatif
DOI:10.4103/JCMRP.JCMRP_39_19  
Background Regional anesthesia, like general anesthesia, influences the thermoregulatory process. In this study, we aimed to compare the efficacy, hemodynamic stability, and adverse effects of dexmedetomidine (DEX), ketamine, and the combination between them when used for control of shivering that occurs during spinal anesthesia. Patients and methods In this double-blind study, 90 male and female patients of ASA status I and II with age 18 up to 60 years old scheduled to undergo elective lower extraperitoneal abdominal and lower limb surgery using spinal anesthesia were included. This study was done from January 2017 to July 2017. Results There was no significant difference in shivering control among the three groups, which was complete (when post-treatment shivering score declined to score 0) in 28 (93.3%) patients in DEX group, 27 (90%) patients in ketamine group, and 25 (83.33%) patients in combination group (P = 0.321), whereas incomplete (when the scores decreased but did not abolish the shivering completely) in two (6.67%) patients in DEX group, three (10%) patients in ketamine group, and five (16.67%) patients in combination group (P = 0.234). Conclusion We concluded that intravenous DEX 0.4 mcg/kg, intravenous ketamine 0.3 mg/kg, or combination between DEX 0.25 mcg/kg and ketamine 0.25 mg/kg significantly controlled the shivering that occurred during spinal anesthesia. However, DEX is superior to ketamine and the combination in prevention of shivering.
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Comparative study of shockwave lithotripsy for the treatment of large pediatric renal stones with and without stenting p. 284
Ashraf S Said, Mohamed A Shalaby, Mohamed A .B. Sayed, Ahmad M Abd El.Aziz
DOI:10.4103/JCMRP.JCMRP_34_19  
Objective Pediatric urolithiasis is an important renal disease encountered in clinical practice. So, this study was designed to assess the safety and efficacy of shockwave lithotripsy (SWL) in the treatment of large pediatric renal stones. Patients and methods Eighty-four children with large renal stones (2–3 cm) were enrolled with a range of age between 1 and 16 years. Patients underwent SWL and were divided into two groups according to the presence of JJ stent (J shaped stent); 44 underwent SWL sessions without prior stenting and 40 patients underwent SWL after JJ sent insertion. Regular follow-up was done at 2, 6, and 12 weeks after the SWL session by urinalysis and renal bladder ultrasound. Results It was noticed that all baseline characteristics had no significant differences between both groups with exception of stone bilaterally that was significantly higher in the case stented group (35 vs. 4.5%;P < 0.001). Patients with stent had higher frequency of lower urinary tract symptoms, longer duration of lower urinary tract symptoms, and hematuria. Conclusion SWL is a highly effective and safe modality for the treatment of children with large renal stones (2–3 cm) and could be used as an alternative to the more invasive stone therapy approaches.
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A retrospective study of the patent ductus arteriosus device closure in Assiut University Children Hospital p. 289
Ahmed Z Yassin, Zienab M. Mohy EL Deen, Duaa M Raafat, Amal El-Sisi
DOI:10.4103/JCMRP.JCMRP_43_19  
Aim The aim of the study is to demonstrate the experience of Pediatric Cardiology Unit, Assiut University Children Hospital, in the patent ductus arteriosus (PDA) closure, over 2.5 years, as a newly developing center in catheter interventions. Patients and methods The study included 47 patients who underwent transcatheter PDA closure at Pediatric Cardiology Unit of Assiut University Children Hospital from March 2014 till September 2016. Results Successful closure of the PDA was achieved in 93.6% (44/47) of patients, regarding efficacy (successful closure of the defect without residual shunt) and safety (no deaths or major complications).
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Diagnostic value of posttherapy brain single photon emission computed tomography/computed tomography with pentavalent 99mTc dimercaptosuccinic acid in patients with glioblastoma multiform: preliminary report p. 296
Yasser G Abdelhafez, Nsreen R Ali, Waleed A Diab, Wael M. A Abd El-Ghani, Mohammed A Mekkawy
DOI:10.4103/JCMRP.JCMRP_65_19  
Aim To evaluate the feasibility of performing 99mTc dimercaptosuccinic acid (DMSA) (V) brain single photon emission computed tomography/computed tomography (SPECT/CT) in patients with glioblastoma multiform after their definitive therapy. Patients and methods Patients with documented grade IV glioma were prospectively recruited for this study. 99mTc-DMSA (V) brain SPECT/CT imaging was acquired after a mean interval of 76 ± 46 days from therapy, 2–3 h. After intravenous injection of 555–740 mBq of the tracer. Scans were interpreted visually as positive or negative by three nuclear medicine physicians. Agreement between two or more physicians was considered a consensus decision. The consensus results of DMSA (V) SPECT/CT were compared against the reference standard which was based on subsequent clinical/neuroimaging follow up or pathology whenever resurgery is performed. Lesion quantitation was performed by one nuclear medicine physician by drawing a region of interest on the lesion site (L) and a mirror region of interest on the contralateral normal brain tissue (NL) then L/NL ratio was calculated. Results A total of 20 patients were enrolled in this study. According to the reference standard, recurrence was detected in 10 patients while 10 were disease free. Interreader kappa agreement ranged from 0.65 to 0.90. Consensus reading of DMSA (V) SPECT/CT correctly detected recurrence in 8/10 (sensitivity 80%) and correctly ruled out disease in 9/10 (specificity 90%). L/NL ratio for positive and negative cases were 6.6 ± 8 and 1.3 ± 1.1, respectively (P < 0.001). Conclusion 99mTc-DMSA (V) brain SPECT/CT is feasible and may be a specific noninvasive diagnostic tool for the follow-up of patients with glioblastoma multiform after chemoradiotherapy.
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Effect of curcumin-containing chitosan nanoparticle on caspase-3, carcinoembryonic antigen in colorectal cancer induced by dimethylhydrazine p. 302
Tahia H Saleem, Ghada M Ezzat, Heba M. S. Eldein, Eman R Mohamed
DOI:10.4103/JCMRP.JCMRP_48_18  
Background and aim Colon cancer is the third most common cancer for males and the fourth for females in Egypt. Previous studies have demonstrated that curcumin (CUR) is safely used against different cancers. This study was performed to evaluate the effect of curcumin-containing chitosan nanoparticles (CUR-CS-NP) against colon cancer induced by dimethylhydrazine (DMH) in rats. Material and methods The rats were randomly divided into four groups. The first group served as control group. The second group received DMH (20 mg/kg, subcutaneously) once a week. The third group was given DMH and CUR. Group 4 received DMH and CUR-CS-NP. The animals were sacrificed at the end of 10 weeks. Caspase-3 expression in colon tissues was determined by quantitative real-time PCR. Plasma levels of carcinoembryonic antigen (CEA) were determined by enzyme-linked immunoassay. Malondialdehyde (MDA), nitric oxide, and reduced glutathione were determined in plasma and colorectal tissues. Histopathological examinations of colon tissues were done. Results DMH treatment decreased caspase-3 expression, increased CEA, and oxidative stress levels. Pathologic lesions in the form of dysplasia and lymphocytic infiltration were seen in DMH-treated group. CUR-CS-NP and CUR treatments reduced the pathologic changes and increased caspase-3 expressions. Each treatment increased glutathione and reduced MDA, nitric oxide, and CEA levels. Conclusions Our study reveals that CUR and CUR-CS-NP have antioxidant and proapoptotic effects. So, it provides an insight towards the use of biological sources as promising anticancer agents.
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Occult hepatitis B virus infection in patients with hepatitis C virus-related cirrhosis with or without hepatocellular carcinoma p. 308
Magda S Hassan, Mohamed O Abdelmalek, Laila M Youssif, Sebak A Abou-Elmagd Hassanein
DOI:10.4103/JCMRP.JCMRP_58_18  
Introduction Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide, with incidence ranging between 3 and 9% annually. Globally, it is the fifth leading cause of cancer and the third leading cause of cancer death. In Egypt, HCC prevalence about 4.7% of patients with chronic liver disease. Hospital-based studies from Egypt have reported an overall increase in the relative frequency of HCC cancers in Egypt from ~ 4% in 1993 to 7.3% in 2003. Patients and methods This study was carried out in Tropical Medicine and Gastroenterology Department at Assiut University Hospital in Faculty of Medicine, Assiut University, Egypt, in the period between November 2016 and November 2017 on 200 patients, who were divided into two groups: the first group was formed of 100 patients with hepatitis C virus (HCV)-related liver cirrhosis (LC) and the second group was formed of 100 patients with patients with HCV-related LC and well-established diagnosis of HCC based on their medical profile, hepatitis B core antibody total, hepatitis B surface antigen, hepatitis B virus DNA PCR, HCV antibody, liver profile, complete blood count, ultrasound, triphasic computed tomography, and alpha-fetoprotein. Results The frequency of seropositive occult HBV infection among the studied patients was 11 (11%) patients in those with LC and 15 (15%) patients in those with HCC, which showed a statistically significant relation with development of HCC in general in comparison between HCC and non-HCC patients, but its role in the development of HCC in HCV-coinfected patients was less related, with a statistically insignificant relation. Conclusion Occult HBV infection leads to significant liver disease, and it is an important cause of HCC and may accelerate the underlying liver disease.
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Value of circulating neutrophil receptors in isolated chest trauma patients: can they predict acute respiratory distress syndrome? p. 314
Eman NasrEldin, Mahmoud Khairy
DOI:10.4103/JCMRP.JCMRP_158_18  
Background The dysfunctional immune system is one of the foremost reasons for trauma-related mortality. Severe thoracic injuries are related with serious life-threatening complications such as acute respiratory distress syndrome (ARDS) in spite of ongoing improvements in mechanical ventilation strategies and supportive care; in addition, the surgical intervention can intensify the condition. ARDS is distinguished by the activation of neutrophils and its recruitment into the alveolar space and interstitium of the lung. The exact pathogenesis of this inflammatory complication which follow chest trauma has varied etiologies and the mechanism is not entirely understood. The purpose of this investigation was to assess the neutrophil cells surface receptors expression in severe chest injury and its contribution to ARDS development. Patients and methods Blood samples were collected from 50 patients with severe isolated chest injury were examined for the neutrophil cell surface receptors expression profile at a varied interval within the initial 24 h after injury. Patients were followed for the occurrence of any inflammatory complications during this period. For comparison, 25 healthy participants were included as a control group. Results Seven patients developed inflammatory complication other than ARDS. Neutrophils showed diminished expression of L-selectin and C5aR and their levels stayed low until 24 h after trauma while both CXCR1 and CXCR2 levels were gradually increased. Furthermore CD11b expression level increased at 3 h and then gradually decreased. Serum level of CXCL8/IL-8 and IL-6 were increased and reach maximum levels after 24 h. Conclusion Activation of the circulating neutrophil is transient after isolated chest trauma and leads to a systemic inflammatory reaction to a degree not enough and needs another stimulus to cause ARDS.
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The impact of interferon therapy on the sexual function of hepatitis C male patients p. 319
Kamal Abdel Hafez, Sheref Kamel, Ahmed Abdel Aal, Ehab Mansour, Ali Mahran
DOI:10.4103/JCMRP.JCMRP_151_18  
Objective To evaluate the impact of interferon therapy on male sexual function. Patients and methods One hundred hepatitis C patients were included in the study. Fifty two patients were receiving interferon and 48 patients were not receiving interferon. All participants underwent history taking including International Index of Erectile Function (IIEF-5) score, general and local examination, assessment of hormonal profile, and pharmacopenile duplex Doppler ultrasonography. Results The IIEF-5 score of the noninterferon-treated group (18 ± 6.5) was significantly higher than the interferon-treated group (12 ± 4.5) (P = 0.022). Forty (76.9%) patients on interferon reported low sexual desire compared with 22 (45.8%) patients of noninterferon-treated group (P = 0.001). Total testosterone among interferon-treated patients (188 ± 0.32 ng/dl) was significantly lower than noninterferon-treated patients (270 ± 0.52 ng/dl) (P = 0.001). Similarly, free testosterone level among interferon-treated patients (3 ± 0.22 ng/dl) was significantly lower than noninterferon-treated group (7 ± 2.3 ng/dl) (P = 0.05). Estradiol levels among interferon-treated patients (80 ± 3.3 pg/ml) were significantly higher than noninterferon-treated patients (58 ± 2.3 pg/ml) (P = 0.01). However, prolactin level showed no significant difference between the interferon-treated (13 ± 1.3 ng/ml) and the noninterferon-treated groups (12 ± 1.5 ng/ml) (P = 0.59). Thirty eight (73%) patients on interferon showed vasculogenic erectile dysfunction compared with 32 (66.7%) patients not receiving interferon (P = 0.11). Twenty two (42.2%) patients on interferon showed veno-occlusive dysfunction which was significantly higher than noninterferon group (16.6%) (P = 0.03). Eighteen (37.5%) patients of the noninterferon group showed mixed vasculogenic erectile dysfunction compared with eight (15.4%) patients on interferon (P = 0.05). Conclusion Interferon had negative impact on libido, IIEF-5 score, and hormonal profile but did not affect penile hemodynamics.
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Time interval to definite diagnosis of Parkinsonism p. 322
Yahya M. T. El Dien Hassanien, Nageh F El-Gammal, Amal M Ali
DOI:10.4103/JCMRP.JCMRP_75_18  
Background Parkinsonism is a clinical syndrome characterized by tremors rigidity, bradykinesia, and postural instability. Over the past decade there has been an increasing recognition of the broad clinical presentations of the neurodegenerative forms of Parkinsonism. Nonmotor symptoms in these diseases, including psychiatric, cognitive, autonomic, and gastrointestinal dysfunction, appear to have a major impact on quality of life and disability. Aim of the study The aim of this study is to detect the time lapse till definite diagnosis of Parkinsonism and possible etiologies and social factors that cause prolongation of that time in a hospital based study. Patient and methods We studied 80 patients with definite diagnosis of parkinsonism with specific questionnaire designed to detect the cause of delayed diagnosis applied for two weeks on a sample of patients in our department. Results Median time from the first symptom till the first medical contact was 4 months with range between 1 and 12 months. It was noticed that duration from the first medical contact till definite diagnosis was significantly shorter in those who had neurological consultation as the first contact. Time interval till first contact and time interval till definite diagnosis were significantly lower in males than females [7 (1–29) vs. 12 (1–45) months]. Conclusion Patient knowledge about Parkinsonism plays a major role in early diagnosis; most patients did not immediately recognize that their symptoms could be part of a disease. Attending non-neurological doctors plays an important role in late diagnosis.
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The use of speckle tracking echocardiography and cardiac biomarkers for diagnosis of patients with peripartum cardiomyopathy p. 327
Doaa A Fouad, Safwat A Salman, Hanan G Abdel-Azeem, Hatem A. R. Helmy, Ahmed M Moheb El-Din
DOI:10.4103/JCMRP.JCMRP_2_19  
Context Peripartum cardiomyopathy (PPCM) is a well-known though poorly understood disease. Aim We aimed to provide new diagnostic tools for patients with PPCM using speckle tracking echocardiography (STE) and cardiac biomarkers. Patients and methods This is a case–control study. We recruited 20 patients with newly discovered PPCM and 20 control women. They were subjected to 2D traditional echocardiography, STE, and serum analysis for N-terminal probrain natriuretic peptide (NT-proBNP) and cardiac troponin I (cTn-I). Results The mean age of the patients was 29.7 ± 7.63 years. Overall, 75% of them presented in the postpartum period. Patient's left ventricular ejection fraction (LVEF) was impaired compared with controls at presentation (34.2 ± 8.84 vs. 62.65 ± 5.61%,P < 0.001). Their serum level of NT-proBNP was 1416.55 ± 590.23 versus 60.55 ± 26.398 pg/ml (P < 0.001) and for cTn-I, it was 0.1 ± 0.16 versus 0 ± 0 ng/ml (P = 0.014). The STE showed reduction of global longitudinal strain (GLS) (−10.02 ± 6.76 vs. −19.49 ± 2.82%,P < 0.001) and global circumferential strain (GCS) (−11.84 ± 3.34 vs. −23.63 ± 2.93%,P < 0.001). The GLS of apical four chamber view had 100% sensitivity and 40% specificity, GLS of apical two chamber view had 100% sensitivity and 60% specificity, GLS of apical three chamber view had sensitivity and specificity of 80%, and GCS of left ventricle had 100% sensitivity and 80% specificity for prediction of LVEF. Conclusion Global longitudinal and circumferential strains are depressed in patients with PPCM. GLS apical four chamber view, GLS apical two chamber view, and GCS had high sensitivity and 40–80% specificity for LVEF changes, so strain can be used as an objective marker of left ventricular dysfunction in patients with PPCM. NT-proBNP and cTn-I can help in the diagnosis of peripartum patients presented to emergency room with symptoms and signs of heart failure.
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The incidence of obstetric anal sphincter injuries following vaginal delivery: an observational study p. 332
Hany Abdelaleem Ali, Esraa Badran, Dina M Habib, Abdallah M Sayed
DOI:10.4103/JCMRP.JCMRP_88_19  
Background Obstetrical anal sphincter injuries (OASIS) involve third-degree and fourth-degree perineal tears after following vaginal delivery. The incidence of OASIS varies among different populations, and there are very few studies examining the incidence in Egypt. This study aimed to evaluate the incidence of OASIS, both overt and occult (ultrasound detected), among a cohort of primiparous women who delivered vaginally, and to assess the role of two-dimensional transperineal ultrasound (TPUS) in evaluating anal sphincter morphology. Patients and methods A prospective observational study included 124 primiparous women with singleton vaginal delivery during the first year after delivery. We excluded women with a history of chronic intestinal disease (Crohn's disease, ulcerative colitis), acute gastroenteritis within the week preceding consultation, those who underwent any surgical or diagnostic procedure involving the anal canal, and multiparous women. History was taken, examination was performed, and two-dimensional TPUS was performed. For the second objective, a control group of 43 primiparous women who delivered by cesarean section (CS) was recruited to compare the ultrasound findings with those of women who delivered vaginally with the same inclusion and exclusion criteria. Results Among the studied cohort of 121 women who delivered vaginally, no cases with overt OASIS were detected. Per rectal examination using pill-rolling motion to asses the thickness of the anal sphincter revealed 15 patients among the vaginal delivery group with poor thickness (representing 12.1%); on the other hand, in CS cases, all of them had normal thickness. Using TPUS for the evaluation of anal sphincter, we found three cases among those who delivered vaginally with disrupted mucosal star sign (2.4%) versus no cases in those who delivered by CS. The combined thickness of the internal and external anal sphincters was significantly thinner in the vaginal delivery group compared with the CS delivery group. Conclusions The study showed low incidence of both overt and occult OASIS among primiparous women who delivered vaginally; TPUS is a technique that is both simple and feasible to diagnose occult OASIS.
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Screening of type 2 diabetes mellitus after gestational diabetes in Assiut University Hospital p. 338
Lobna F El Toony, Walaa A Mohamed, Ahmed M Abdelregal
DOI:10.4103/JCMRP.JCMRP_33_19  
Objective To determine the percentage of development of type 2 diabetes after gestational diabetes mellitus (GDM) and to evaluate risk factors associated with increased susceptibility to developing type 2 diabetes mellitus (T2DM) after GDM. Patients and methods A prospective study included 1150 pregnant women not known to have DM before gestation, who presented to GDM outpatient clinic of Assiut University Hospital between the period of May 2016 and May 2017, where 150 women were found to have GDM according Diabetes in Pregnancy Study Group India criteria. Results Based on the result of 75 g oral glucose tolerance test 6–24 weeks after delivery, the study found that 12.7% of women with GDM had T2DM, 21.3% of GDM women had impaired fasting glucose, 13.3% of women with GDM had impaired glucose tolerance, and 52.7% of women with GDM had normal glucose tolerance. The study showed that predictors of the development of T2DM in women with GDM were family history of DM (P = 0.001), insulin therapy during pregnancy (P = 0.001), high glucose level at the time of diagnosis (P = 0.03), previous history of GDM (P = 0.002), and high BMI (P = 0.04). Conclusion Postpartum follow-up of patient with GDM is very important for early diagnosis of T2DM and early detection of prediabetic patients to prevent their progression to being diabetic.
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A comparative study between propofol–ketamine and propofol–fentanyl for sedation during pediatric diagnostic upper gastrointestinal endoscopy p. 344
Nawal A Gad EL-Rab, Mohamed G Abd El-Rahem, Mohamed K Mohamed
DOI:10.4103/JCMRP.JCMRP_58_19  
Background The aim of this study was to compare propofol–ketamine (ketofol) with propofol–fentanyl in pediatric patients undergoing diagnostic upper gastrointestinal endoscopy. Patients and methods This was a prospective, randomized, double-blinded study to compare the effect of propofol–ketamine and propofol–fentanyl on oxygen saturation, heart rate (HR), and systolic blood pressure (SBP) when used for sedation in pediatric patients undergoing elective upper gastrointestinal endoscopy. Sixty ASA I–II patients, aged 6–12 years were included in the study. Oxygen saturation, HR, and SBP of all patients were recorded perioperatively, after induction, 5 min later, and at the end of the procedure. All patients received propofol 1.5 mg/kg, intravenous + either fentanyl 1 μg/kg, intravenous (propofol–fentanyl group) or ketamine 0.5 mg/kg, intravenous (propofol–ketamine group). The procedure started when the sedation score was 4–6. Additional propofol (1 mg/kg) was administered when needed in either group. Demographic data, operative data, and intraoperative and postoperative side effects (hypoxia, nausea and/or vomiting, increased oral secretions, and emergence reactions, or hallucinations) were recorded. Results There were no significant differences between both groups regarding the demographic and operative data (duration of the procedures, onset of anesthesia, number of patients needed additional dose (s), recovery time, discharge time, modified Ramsay sedation scale). The mean values of oxygen saturation, HR, and SBP were significantly lower (P < 0.05) in the propofol–fentanyl group than the propofol–ketamine group after induction, 5 min later, and at the end of the procedure. No significant difference regarding intraoperative and postoperative side effects between both groups (P > 0.05). Conclusion Propofol–ketamine 3: 1 mixture was associated with hemodynamic stability and better oxygen saturation without affecting the recovery and without significant side-effects.
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Assessment of physicians' adherence to the guidelines for the management of gastroesophageal varices among patients with liver cirrhosis in Upper Egypt p. 350
Ehab Fawzy Abdo, Ahmad Farooq Alsayed Hasanain, Ghada M Kamal
DOI:10.4103/JCMRP.JCMRP_69_19  
Background Gastroesophageal varices are the most common lethal complication of liver cirrhosis, because their rupture results in variceal hemorrhage. Gastroesophageal varices are present in ∼ 50% of patients with cirrhosis. Variceal hemorrhage occurs at a yearly rate of 5–15%. This study was designed to assess adherence of physicians to guidelines regarding management variceal hemorrhage. Patients and methods A total of 154 physicians from Upper Egypt caring for cirrhotic patients with gastroesophageal varices were enrolled. A questionnaire with 23 items was distributed among the participants. It was formed mainly from personnel data of physicians and their experience in the management of variceal bleeding. Results The mean age of the participants was 40.22 ± 10.67 years, and 80% were younger than 40 years. The majority of them was males and had MBBCH. Duration of experience ranged between 1 and 25 years. Duration of experience had insignificant effect on physician adherence to guidelines. Conclusion Physicians had good adherence to guidelines in the management of variceal bleeding regarding management of active bleeding and secondary prophylaxis, but lacked knowledge about screening programs for gastroesophageal varices.
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Office cervicoscopy versus stationary colposcopy in cases with suspicious cervix: a randomized controlled trial p. 355
Momen A Kamel, Atef M Darwish, Kamal Zahran, Mostafa AboulEla
DOI:10.4103/JCMRP.JCMRP_43_18  
Objective To compare the diagnostic accuracy of small-caliber office cervicoscopy versus stationary colposcopy in diagnosis of ectocervical as well as endocervical lesions in women clinically presented with suspicious cervix. Patients and methods Eligible 112 cases with clinically suspicious cervix were randomized into group A (56 cases) and group B (56 cases) who were subjected to small-caliber office cervicoscopy and stationary colposcopy, respectively. The outcome was the diagnostic accuracy and safety of both tools for detection of ectocervical and endocervical cervical lesions. Results There were no statistically significant differences between both groups regarding parity, previous abortion, age at marriage, duration of marriage, and age at menarche and menopause. Group A significantly reported more spontaneous vaginal bleeding. On unaided naked eye examination of the cervix, there were no statistically significant differences between both groups. Office cervicoscopy was more sensitive than colposcopy for detection of cervical abnormalities. Conclusion Office cervicoscopy is more sensitive than stationary colposcopy for detection of cervical lesions in cases with suspicious cervix as an example of high-risk group for cervical cancer. Moreover, its widespread use by gynecologists is highly recommended as it is more available in hospitals and clinics. Its small-caliber allows easy, simple and fast diagnostic out-patient evaluation of the cervix. Its better evaluation of the endocervical canal and possible examination of the endometrial cavity are clear advantages over stationary colposcopy.
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Initial lymphocyte count's predictive value in immune thrombocytopenic purpura p. 362
Salwa S El-Din El-Gendi, Wael A Abbas, Dolagy N Naguib
DOI:10.4103/JCMRP.JCMRP_143_18  
Objective The objective of this study was to examine whether absolute lymphocyte count (ALC) at diagnosis correlates with the course of immune thrombocytopenia purpura (ITP) and could be considered as a prognostic factor in adults and children. Patients and methods A retrospective study of 250 patients diagnosed as having primary ITP, including 150 adult patients and 100 children, was conducted between July 2013 and July 2018 at Hematology Department and outpatient clinic. Results A highly significant decrease in mean ALC was noted in chronic ITP adult cases (1.55 ± 0.69) compared with newly diagnosed ITP cases (2.99 ± 1.23) (P = 0.000). Moreover, ALC less than 2.050/mm3 was associated with a significant risk for developing chronic ITP (P = 0.000), as only eight (26.7%) cases with ALC less than 2050/mm3 developed newly diagnosed ITP, whereas 97 cases with ALC less than 2050/mm3 (80.8%) developed chronic ITP. Thus ALC less than 2050/mm3 is considered a significant risk factor for developing chronic ITP in adults. In contrast, mean ALC in pediatric cases showed a significant decrease in chronic ITP cases (2.55 ± 1.01) compared with newly diagnosed cases (3.68 ± 1.34) (P = 0.000). Moreover, ALC less than 2050/mm3 was associated with a significant risk for developing chronic ITP (P = 0.001), as only one case less than 2050/mm3 (2.5%) developed newly diagnosed ITP, whereas 17 cases less than 2050/mm3 (28.3%) developed chronic ITP. Conclusion ALCs at diagnosis is statistically a strong predictor of the development of chronic ITP in adult and pediatric patients. ALC at cutoff less than 2050/mm3 is considered a significant risk factor for developing chronic ITP in adults and pediatric cases (P = 0.000 and 0.001, respectively).
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The role of preoperative breast MRI for surgical decision in patients undergoing therapeutic mammoplasty p. 368
Tarek A. M. Ahmed, Mahmoud R Shehata, Marwa Makboul, Moahamed A. M. Ibrahem, Ahmed M. A. Ahmed
DOI:10.4103/JCMRP.JCMRP_60_19  
Aim The aim of this study was to assess the role and contribution of MRI in preoperative planning of patients with breast cancer who are considered potentially suitable for therapeutic mammoplasty. Patients and methods A total of 30 female patients with breast cancer undergoing breast surgery were divided into two groups based on preoperative MRI findings: in one group, the surgical plan was changed, and in the other one, the surgical plan remained unchanged. Results Final surgical decision was changed in most patients (53.3%) owing to additional suspicious breast lesions detected on preoperative breast MRI, whereas the final surgical decision was the same in 14 (46.7%); the initial decision was unchanged. Conclusion Preoperative breast MRI may be helpful in surgical decision for patients considered for therapeutic mammoplasty.
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Frequency and possible associations of albuminuria in patients with essential hypertension: a single-center experience p. 373
Marwa Kamal Abdo Khairallah, Walaa H Muhammad Ibrahim
DOI:10.4103/JCMRP.JCMRP_71_17  
Background Microalbuminuria is associated with a high incidence of morbidity and mortality. It is considered as an early marker of kidney damage and a predictor for end-stage renal disease and cardiovascular disease. Thus, it is of great importance to study albuminuria in high-risk groups such as the hypertensive patients to decrease the morbidity and mortality by decreasing the progression of kidney diseases on those groups. Aims The present study was undertaken to find out the frequency and association of microalbuminuria in newly diagnosed essential hypertension. Patients and methods This is a cross-sectional hospital analytic study enrolling all the outpatients nephrology and internal medicine clinics within the period from 2016 January to 2017 March. We enrolled all the patients with the positive inclusion criteria and divided them into two groups; those who are recently diagnosed as essential hypertensive patients (85 patients) aged between 25 and 65 years and (415 normotensive) as normotensive healthy participants with the same age groups. Exclusion criteria were age less than 25 years and more than 65 years, diabetes mellitus, chronic kidney disease, end-stage renal failure, nephrotic syndrome, pregnancy, and under steroid therapy. Results The study showed that 17% of the patients were hypertensive; 28.8% of hypertension cases and 13.1% of normotensive patients had microalbuminuria in the total population (P = 0.000). Twenty-two percent of the hypertensive cases had macroalbuminuria and 3% of the normotensive patients had macroalbuminuria with a P value of 0.000. Advanced age is associated with the increase in the albumin–creatinine ratio (P = 0.000). Conclusion By showing the strong association between microalbuminuria and hypertension, our findings suggest that microalbuminuria could be a useful marker to assess risk management of cardiovascular disease and renal disease.
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