Background Laryngopharyngeal reflux (LPR) can be defined as chronic symptoms or laryngeal mucosal damage caused by the abnormal reflux of gastric contents into the upper airway. LPR plays an important role in up to 50% of laryngeal complaints that present in the otolaryngeal clinic, and the symptomatology of LPR has more different presentation. LPR is suspected in the presence of symptoms of hoarseness, dysphagia, cough, globus, excessive mucus, throat pain, throat clearing, and laryngospasm. Diagnosis of LPR is confirmed using the following: reflux symptom index (RSI), laryngoscopic examination [reflux finding score (RFS)], and esophagogastroduodenoscopy. Patients and methods A cross-sectional study was conducted on 60 patients with typical gastroesophageal reflux disease (GERD) symptoms and laryngeal complaints; these studied patients were recruited from patients who attended the outpatient clinic of Tropical Medicine and Gastroenterology, and Phoniatric Unit, Assiut University Hospital. The symptom questionnaire and the classification proposed by Belafsky and his colleagues (RSI) are used and upper endoscopy is performed for the diagnosis of GERD patients. Nasofibrolaryngoscopy for all these patients was performed to compare the results (RFS). Psychiatric assessment was performed by a psychiatric specialist using symptoms checklist revised 90. Patients with a score more than 60 will be re-evaluated using the following questionnaires: Hamilton checklist of symptoms of depressive illness and Hamilton rating scale for anxiety. Results All studied patients showed positive RSI (100%) and diagnostic endoscopy showed GERD in 58 (96.7%) patients, and 32 (53.3%) of them were found to have a positive finding in laryngoscopy; the findings were as follows: vascular congestion and vocal cord hyperemia in 32 (100%) patients, vocal cord edema in 26 (81%), phonatory gap in 13 (40%), subglottic edema in 12 (37%), vocal cord swelling in 10 (31.25%), and contact granuloma in eight (25%). A positive significant correlation was detected between phonasthenia symptoms, mostly lump sensation, hoarseness, throat clearing, and dry mouth (symptoms), and laryngeal finding (RFS), except for difficulty in swallowing saliva. There is a strong association between psychological symptoms and the presence of LPR; the most commonly detected manifestation was anxiety, and there was a positive significant correlation with anxiety and a negative significant correlation between depression and reflux symptoms. Conclusion RSI and RFS could be useful for the diagnosis and evaluation of LPR in patients with GERD complaining of laryngeal symptoms. Psychological intervention can improve the general well-being and quality of life of patients with gastrointestinal symptoms.

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Background Scorpion stings represent an important and serious public health problem worldwide owing to their high incidence and potentially severe and often fatal clinical manifestations. Children are at greater risk of developing severe cardiac, respiratory, and neurological complications owing to lesser body surface area. Prazosin, a postsynaptic alpha blocker, is an effective drug in the treatment of serious scorpion envenomation with significant sympathetic symptoms. Aim of the study To study the role of prazosin in the management of scorpion envenomation in children at Assuit University Children Hospital. Patients and methods The study included 60 patients with scorpion stings admitted to Assuit University Children's Hospital from November 2016 to November 2017. Their ages ranged from 1 to 18 years. Patients were randomized into two groups: group A underwent conventional therapy and prazosin and group B underwent conventional therapy. Results Our results showed that addition of prazosin to antivenom induced earlier clinical recovery than in cases treated with conventional therapy. Administration of prazosin is one of the most useful strategies to reduce mortality in scorpion envenomation. A total of 60 cases of scorpion envenomation were observed during the study time period. Male children predominated over female. Conclusion Scorpion sting envenomation is an acute life-threatening emergency, and recovery from scorpion sting is hastened by simultaneous administration of scorpion antivenom plus prazosin compared with antivenom alone.

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Background Pulmonary embolism (PE) is a critical chest disease resulting in high mortality rates if undetected. This study aimed to evaluate the role of noncontrast multislice computed tomography in the detection of PE. Patients and methods One hundred patients requested for computed tomography (CT) pulmonary angiography and underwent noncontrast and contrast-enhanced CT images of the chest, which were reviewed separately. The average CT attenuation differences between the high-attenuation clots and pulmonary arteries were computed. Findings in the noncontrast images were correlated with the contrast-enhanced images. Results Twenty-six of 100 patients were positive for PE in computed tomography angiography; the mean age (±SD) was 56.73 (±9.11) years, and 17 (65.4%) were female individuals. The hyperdense lumen sign has an overall sensitivity of 50% and specificity of 98.6%. As for the other 13 patients, 10 of them had more than one indirect sign. The peripheral wedge-shaped opacity was the most common indirect sign that revealed high specificity (91%) and was statistically significant. Conclusion Noncontrast chest CT scan has a good role in the evaluation of PE through detection of the hyperdense lumen sign, which is a good indicator of acute pulmonary thromboembolism, particularly in cases involving the central pulmonary arteries or peripheral wedge-shaped opacity, as a useful indirect sign.

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Background Repeated access to the circulation is essential to perform adequate maintenance hemodialysis. Dysfunction of fistulas is the most common reason for secondary intervention and recurrent hospitalization. Aim The aim of this study was to report our experience regarding incidence, diagnosis, and different modalities of treatment of complications of arteriovenous fistula. Patients and methods This study was conducted prospectively on 239 end-stage renal disease patients who presented to the Department of Vascular Surgery of Assiut University Hospital with complicated arteriovenous (AV) accesses from January 2014 to January 2015. All patients underwent detailed history taking, and data were collected on age, sex, cardiovascular risk factors, history of previous accesses, and any complications that developed since the use of the access. Patients were further evaluated using clinical examination, duplex ultrasound, and fistulography if needed. Results There were 137 (42.7%) males and 102 (42.7%) females with a mean age of 57 ± 4 years. Hypertension was the risk factor in 103 (43.1%) patients, whereas diabetes mellitus was present in 45 patients. Of the 239 patients, 57 (23.8%) presented with infected AV access, 42 (17.6%) with thrombosed AV accesses, 33 (13.8%) with bleeding, and 31 (12.9%) with pseudoaneurysms. Venous hypertension was the presenting complication in 26 (10.9%) patients, whereas aneurysmal dilatation, hematoma, and ischemic steal were the presenting complications in 25 (10.5%), 20 (8.4%), and 5 (2.1%) patients, respectively. Conclusion Complications of hemodialysis access create significant problems for nephrologists and the healthcare system. Access interventions are often costly, challenging, and may require specialized surgical expertise. Management of complications associated with AV access is an integral part of planning individual hemoaccess procedures.

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Introduction Auditory brainstem response using click stimuli enable global objective estimation of hearing threshold. Recently, it has been suggested that a chirp stimulus may produce a synchronous response from a large portion of basilar membrane. The chirp was designed to produce simultaneous displacement maxima along the cochlear partition by compensating for frequency-dependent traveling-time differences. Material and methods In this study, response characteristic of both click and chirp stimuli are compared in children. We compared latency and amplitude of wave V at different intensity levels and waves I and III at high level. Results and conclusion Results show that wave V on using chirp stimuli could be detected easier with shorted in latency and larger in amplitude than in click auditory brainstem response. However, click stimulus was better than chirp stimulus at high-intensity levels with respect to the identification of waves I and III.

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Background Neural tube defects (NTDs) occur because of a defect in the neurulation process. Meningocele and meningomyelocele are the most common forms of spinal dysraphism. Most cases of myelomeningocele and meningocele can be closed by direct repair, but sometimes a problem is faced intraoperatively during skin closure in some cases. The aim of our work is to describe and make a plan for proper operative management during the clinic visit for ideal repair and closure of the back skin defect. This depends on the area of the defect measured preoperatively to close the defect by properly designing the method of closure by either a flab or a graft. Patients and methods This is a prospective hospital-based study that included 60 patients. According to the defect size (we measured the defect preoperative and intraoperative by sterile ruler), we classified the patients into three groups. The first group was closed directly by simple repair, the second group was closed by local skin fasciocutaneous flap (either by two rhomboid flaps or one rotational flap), and the third group was closed by skin graft (split-thickness skin graft) owing to a large defect with immobile skin-for-skin flap. Results In 75% of cases, closure was done by direct repair, in 16.7% by rotational flap, and in 8.3% by skin graft. According to the size of the defect, we found that a defect with a total surface area of 18 cm² and less was closed by simple direct repair, that with a total surface area of 18–80 cm² was closed by rotational flap, and that with a total surface area of more than 80 cm² was closed by a skin graft. Conclusion Good preoperative assessment is needed for every patient with spina bifida skin defect. Choice of coverage depends on the surface area and the extent of the lesion, which help in getting the best results for skin repair.

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Background Chronic kidney disease (CKD) is one of the common causes of renal failure. Renal sonography is an essential diagnostic tool in nephrology. Renal sonographic dimensional parameters could be of great utility, providing indirect but valuable information about the morphostructural changes occurring in the kidney in the course of CKD. Aim To determine whether there is a relationship between renal cortical thickness and renal length measured on ultrasound and the degree of renal insufficiency in patients with CKD. Patients and methods From December 2016 to October 2017, 50 patients with clinically stable chronic renal insufficiency participated in this study. Renal sonographic parameters including length of the kidney, cortical thickness, and renal echogenicity were measured. Serum creatinine was used for estimated glomerular filtration rate using Cockcroft and Gault equation for all patients. Results The most common cause of CKD in our patients was systemic lupus (22%) followed by hypertension (16%). The mean renal length was 97.6 ± 12.2 mm, the mean cortical thickness was 9.38 ± 1.79 mm, the mean serum creatinine level was 2.46 ± 1.74 mg/dl, and the mean value of estimated glomerular filtration rate using Cockcroft and Gault equation was 60.95 ± 53.78 ml/min. There was a high statistically significant relationship between cortical thickness and creatinine clearance (r = 0.67,P < 0.001), and also statistically significant correlation of renal length with creatinine clearance (r = 0.42, P = 0.002) was reported, but the strongest relationship was for mean cortical thickness. Conclusion Renal cortical thickness measured at ultrasound appears to be more closely related to the degree of renal impairment in patients with CKD than renal length.

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Introduction Type 2 diabetes mellitus is known for its morbidity and mortality worldwide. It has been demonstrated in recent studies that abnormal levels of adipocytokines may contribute to insulin resistance and type 2 diabetes. Objective The aim of the present study was to assess the relationship between serum leptin levels and insulin resistance syndrome in type 2 diabetic patients. Patients and methods A total of 80 individuals were enrolled into this study, and were divided into two groups –20 healthy persons comprised the control group and 60 patients with type 2 diabetes mellitus comprised the disease group. The disease group was further divided into those with evidence of metabolic syndrome (30 patients) and those without (30 patients). Parameters such as age, sex, and anthropometric measures and biochemical indicators such as fasting and postprandial blood sugar, HbA1c, lipid profile, leptin, and fasting insulin were determined. Results Higher leptin and insulin levels were observed in patients with metabolic syndrome (P < 0.001). Conclusion High serum leptin is a good indicator and can act as a minimally invasive marker for early detection of insulin resistance syndrome.

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Erectile dysfunction is a common problem in cerebrovascular stroke patients. It may have a significant impact on the quality of life of sufferers and their partners. Consequential to stroke is often low self-esteem, depression, anxiety, rejection by a partner or spouse, impotence, problems communicating due to aphasia or unwillingness to communicate, and role changes. Mobility problems, fatigue, previous illnesses, and medication also have a negative effect on sexual activity. However, it is often neglected during rehabilitation along with the psychological issues that may affect sexual dysfunction.

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Background Ginkgo biloba extract 761 (EGb761) was studied for its nephroprotective effects in experimentally induced hypertension. Hypertension is increasingly a cause of end-stage renal diseases. Increased cytokine release and oxidative stress are mechanisms that appear to be involved in the pathogenesis of hypertensive renal damage. EGb has antioxidant and anti-inflammatory effects and can attenuate hypertensive renal damage. Methods and results Male adult Wistar rats were used in this study. Hypertension was induced in these rats by administering l-N^G-nitroarginine methyl ester (l-NAME) (10 mg/kg/day, intraperitoneal) for 12 weeks. Another group of rats received l-NAME and EGb761 (100 mg/kg/day, orally) starting from the ninth week to the end of treatment. It was found that the blood pressure was reduced at the end of 12^th week in rats treated with EGb761 compared with l-NAME-treated (hypertensive) rats. EGb761-treated rats showed lower renal tissue malondialdehyde level and renal tissue tumor necrosis factor-α level when compared with l-NAME-treated rats (hypertensive). Conclusion EGb761 has antihypertensive effect; it can protect the kidney from hypertension through the reduction of renal inflammation and oxidative stress.

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Introduction Alopecia areata (AA) is a common cause of nonscarring alopecia that occurs in a patchy, confluent or diffuse pattern. It may involve loss of hair from some or all areas of the body, usually from the scalp. The aim of this study was to evaluate the effect of cryotherapy in the treatment of AA. Patients and methods Through a nonrandomized and nonblinded study, 17 patients with 20 recalcitrant patchy AA lesions were recruited at the outpatient dermatology clinic, Assiut University Hospital, between August 2014 and September 2016. The lesions were treated with liquid nitrogen cryotherapy spray once weekly for 6 weeks. The lesions were sprayed for 2–3 s, until it became slightly frozen. After the frozen area was thawed (∼3–5 s), a second spray was done in the same manner. The lesions were assessed by direct scalp observation for the size and hair regrowth and by taking photographs. The therapeutic response of the lesions to cryotherapy was evaluated in relation to the age of the patients, the size of the lesions, and the duration of the disease. Results A positive therapeutic response was noted in 13 (65%) lesions. By studying the clinical response to cryotherapy in relation to the age of the patients, we found that 53.8% of the lesions which responded to cryotherapy were in patients aged more than 30 years compared with 46.2% in patients aged less than 30 years. Lesions less than or equal to 3 cm have shown a better clinical response than those of more than 3 cm (76.9%). The clinical response of AA lesions was better (84.6%) when the disease duration was less than 6 months. Conclusion Superficial cryotherapy with liquid nitrogen is a therapeutic option with a good treatment outcome. It has the privilege of being simple, convenient, short-term and office-based technique, especially in mild to moderate recalcitrant AA.

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Introduction and aim Chronic hepatitis C infection is a global problem with an increasing burden on healthcare, particularly in Egypt. Even with the advent of highly sensitive techniques, a subset of patients with positive hepatitis C virus antibody (HCV-Ab) and negative HCV-viremia remain challenging to treat. Therefore, we tried to determine the prevalence of occult HCV infection (OCI) in peripheral blood mononuclear cells (PBMCs) of patients presenting with a positive serologic test for anti-HCV-Ab and negative serum HCV-RNA-PCR (spontaneously cleared patients) and followed up those patients. Patients and methods Between March 2010 and March 2015, a prospective study was designed to include all consecutive patients with HCV-Ab positivity and HCV-RNA negativity who attended the Assiut Unit for treatment of viral hepatitis - the National Committee for Control of Viral Hepatitis. A total of 25 patients were recruited. Spontaneous clearance of serum HCV infection was approved on the basis of HCV-Ab positivity using two third-generation enzyme-linked immunosorbent assay tests and serum HCV RNA negativity on three consecutive occasions, each 6 months apart. Follow-up serum HCV RNA levels were evaluated for patients with OCI every 6 months. The RNA extraction step was performed by a protocol modified from that of the QIAamp viral RNA kits. Blood samples for separation of PBMCs were collected from all patients. PBMCs were obtained using Ficoll-Hypaque density gradient of EDTA anticoagulated blood according to the manufacturer's instructions (Lymphoflot). Detection of HCV viral load was performed with the kit supplied by Applied Biosystem (HCV RT-PCR Kit lot No.). Results A total of 25 patients (21 men, mean age 36.2 ± 9.1) cleared HCV spontaneously (HCV-Ab positive and serum HCV RNA negative). Genomic HCV RNA was detected in PBMCs of three (12%) of 25 patients. These three patients with OCI were followed up for 18 months by measuring their serum HCV RNA using highly sensitive real-time PCR every 6 months. Only one patient became overt HCV with a low level of viremia. Conclusion OCI was detected in a considerable prevalence in patients who cleared HCV spontaneously, that entails corporations of HCV-viral assay in PBMCs into the diagnostic algorithm.

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An incre asing prevalence of obesity has led to an increase in the incidence of sleep disordered breathing in the general population. Obesity is associated with anatomic alterations that predispose to upper airway obstruction during sleep, leading to complete or partial cessation of respiration called obstructive sleep apnea. The awareness of this global issue is rising, and health care systems are providing preventive measures, diagnostic, and treatment options for both conditions. To decrease obesity, lifestyle modification (eating behaviors, smoking, drinking alcohol, etc.) and understanding the importance of exercise are needed. If these lifestyle modifications are widely applied, then not only obesity and sleep apnea will be reduced but also the incidence of serious consequences such as cardiovascular disease and health care costs will decrease greatly.

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Background Ophthalmic surgery shares some similarities with general surgery in its basis as a surgery; cataract surgery, however, is in essence microscopic surgery and technically different. The current mainstream ophthalmology training curriculum does not require prior surgical experience. This study compares cataract surgery outcomes among ophthalmology trainees who possess experience of previous general surgery training than those without. Materials and methods Retrospective analyses were done on cataract surgeries performed in 2015–2019. Surgeon name, patient demographics, and visual acuity with refractive outcomes before and after cataract surgery data were extracted. Eyes with preoperative detectable morbidity other than cataract were excluded. The first 30 independent clear-corneal incision extracapsular cataract extractions of each trainee were included. Eyes identified were grouped into two groups, according to their surgeons with and without prior general surgery training. Statistical analyses were performed using t tests and χ² tests. Results A total of 180 eyes were included for analysis. Six resident trainees were included: three without any general surgery training, whereas three trainees underwent prior 6 months of basic general surgery training in a university teaching hospital. Postoperative corneal astigmatism increment was found to be 1.16 D (P = 0.002, 95% confidence interval, 0.46–1.86) less for cataract surgeries performed by residents with prior general surgery training. Otherwise, postoperative visual acuity improvement and complication rates were not statistically significant between the two groups. Conclusions Residents with previous general surgery training achieved better cataract surgery functional outcomes, in terms of postoperative corneal astigmatism but had similar visual acuity outcome. General surgery training is not a prerequisite to general ophthalmology training.

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Introduction Peripheral neuropathy in chronic obstructive pulmonary disease (COPD) has received scanty attention. The purpose of this study was to evaluate objectively the functional changes in the peripheral nervous system in COPD by different electrophysiological parameters and to determine the frequencies of these changes in patients with COPD. Aim Assessment of peripheral nerve conduction by evaluation of the motor and sensory nerve conduction (SNC) in COPD patients. Patients and methods In this case–control study, we recruited 25 COPD patients and matched 25 healthy controls. Motor and SNC studies for ulnar and median nerves were evaluated by means of electrophysiological nerve study. Motor nerve conduction velocity and sensory nerve conduction velocity (SNCV), distal latencies (DLs), and amplitude of compound motor action potential were recorded. Arterial blood gases including partial pressure of oxygen and carbon dioxide (PaO₂and PaCO₂), oxygen saturation (SaO₂), and arterial pH were measured. Pulmonary function test was done and forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and FEV₁/FVC ratio were measured. Results There was a significant difference between COPD patients and the control group in all spirometric and gasometric parameters recorded, except for the arterial pH. On studying motor nerve conduction through median and ulnar nerves, there was an increase in DL, decrease in motor nerve conduction velocity, and longer F-wave latency in the COPD group than in the control group in both nerves. SNC study of the median nerve revealed a decrease in SNCV and an increase in DL in the COPD group than in the control group. Median nerve motor neuropathy was proved in 28% of patients, ulnar nerve motor neuropathy was proved in 36% of patients, whereas sensory nerve study of median nerve proved that 68% of patients have sensory axonal neuropathy and 12% have demyelinating sensory neuropathy. Median nerve Distal Latency (DL) shows negative correlation with FEV₁and FEV₁/FVC ratio. SNCV of the median nerve was positively correlated to oxygen tension level. Conclusion The incidence of neuropathy is high. The rate of axonal neuropathy was significantly higher than other types. Our study showed a significant positive correlation between the degree of hypoxemia and severity of neuropathy, whereas it showed negative correlation between spirometry parameters (FEV₁and FEV₁/FVC ratio) and median nerve DL.

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Introduction Postoperative complications can involve several organs and have a major effect on in-hospital stay length and quality of life of the children after discharge from the hospital. Although the complications are strictly related to the surgical procedure, postoperative pulmonary complications represent an important and probably underestimated cause of morbidity and mortality in postoperative pediatric heart surgery. Aim The aim of this study was to evaluate the relation between complication and the overall outcome. Patients and methods This retrospective descriptive study included 100 children (ages from 0 to 18 years old, excluding preterm babies) who underwent open heart surgery in Cardiothoracic Surgery Department of Assiut University in a 1-year period. The preoperative and intraoperative parameters included technique of operation, cardiopulmonary bypass time, and aortic cross-clamp time. The postoperative parameters included occurrence of postoperative complications, such as arrhythmias, heart failure, pulmonary congestion with chest infection, wound infection, and bleeding, and hospital stay of the patients. Results The occurrence of complications after congenital heart surgeries using cardiopulmonary bypass has significant relation with the cardiopulmonary bypass time; therefore, the longer the cardiopulmonary bypass time, the more the probability of cardiac and extracardiac complications. This study shows the same result as studies in adult surgery, demonstrating that complications after heart surgery significantly are associated with increased hospital stay time. Conclusion Surgery is the optimal and the final treatment for congenital heart diseases; nearly a quarter of the patients who undergo congenital heart surgery experience postoperative complications, complex congenital heart diseases with different degrees of heart failure, or respiratory failure, and carry more risk for complications. So close monitoring and timely intervention and treatment are very critical to avoid occurrence of multiple complications as reported in our study.

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Objective The aim of the study was to determine the effectiveness of dynamic multidetector computed tomography (MDCT) using 'eee' phonation in the detection and delineation of extension of various laryngeal lesions in comparison with conventional nonfunctional MDCT. Patients and methods The study included 60 patients with suspected laryngeal pathology who underwent precontrast and both prephonation and during-phonation contrast-enhanced MDCT. Each imaging study was evaluated for pyriform sinus and ventricle involvement, vocal cord mobility, and local tumor staging of malignant laryngeal lesions. All patients subsequently underwent direct laryngoscopy. Detailed endoscopic findings were reported and compared with MDCT findings. Results Dynamic MDCT using 'eee' phonation is effective in the assessment of pyriform sinus and ventricle involvement with high sensitivity (100% for both), high specificity (97.83 and 97.44%, respectively), and high accuracy (98.3% for both), compared with lower accuracy of conventional nonfunctional MDCT, which is 78.3% and 93.3%, respectively. It is also highly accurate in the assessment of vocal cord mobility (94.6%) and it increases the accuracy of MDCT in local tumor staging of malignant laryngeal lesions to 80.4% compared with 76.1% accuracy of conventional nonfunctional MDCT. Conclusion Dynamic MDCT using 'eee' phonation is effective in the detection and delineation of extension of various laryngeal lesions and is more accurate than conventional nonfunctional MDCT.

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Introduction Maternal near-miss (MNM) is one of the related concepts to maternal mortality. MNM is a special category of survivors, whose stories provide unique insights and valuable information on maternal mortality. Measuring MNM beside maternal mortality and identifying its causes is essential, and should be calculated regularly for the purpose of planning, monitoring, and evaluation of provided maternal healthcare. Objectives The objectives of the study were to determine the magnitude and to identify the patterns of MNM among cases admitted to Women's Health Hospital, Assiut University, Egypt. Methodology This paper is a part of a larger case–control prospective study; however, for this analysis, we are presenting only the findings of the MNM cases. (The full profile of the cases and controls was presented in another paper.) The study was conducted at Women's Health Hospital, Assiut University and included 342 MNM cases by total coverage of all eligible cases who met the criteria of MNM identification published in WHO bulletin (2011) throughout the 12 months' period of the study. A checklist was used to collect data from the hospital records of eligible respondents. Results During the 12 months' period of the study, there were 17 503 deliveries and 16 972 live births. The maternal mortality ratio was 276 per 100 000 live births and the MNM incidence ratio was 20 per 1000 live births. This means that there was one maternal death for every seven cases of MNM. The mean age of MNM cases was 28.4 ± 8.5, whereas the mean gestational age of MNM was 35.66 ± 8.6 weeks. The main direct obstetric causes of MNM were hypertensive disorders of pregnancy (49.8%), obstetric hemorrhage (38.3%) and dystocia (32.5%). On the other hand, cardiovascular disorder was the most prevalent nonobstetric cause among MNM cases (48.8%). The peak frequency of the cases occurred during the summer season. Conclusions and recommendations MNM and maternal mortality are alarmingly high. Hypertensive disorders of pregnancy and obstetric hemorrhage were the two main direct obstetric causes of near misses that require strict and quick management protocols.

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Purpose To assess the efficacy of levator recession with adjustable sutures in treatment of upper eyelid retraction. Patients and Methods Patients with upper eyelid retraction were included in this prospective, non-randomized, interventional case series study. All patients underwent correction of upper eyelid retraction with levator recession using adjustable sutures ,and were followed up every week for a month, then monthly for three months. In each visit, the margin reflex distance (MRD1) and palpebral fissure (PF) were measured. Results The included patients of the present work were classified into 3 groups: Group A: lid retraction secondary to over correction of ptosis, group B: thyroid related lid retraction, and group C congenital lid retraction. Among the 17 patients that participated in the follow-up examination, mean age ± SD was 21.12 ± 13.73 years (range 7–52 years). Eight were males and nine were females. Mean ± SD (range) of central height of the palpebral fissure was 13.79 ± 1.37 mm (10–16 mm) preoperatively, and 11.04 mm (9–12 mm) at follow up. Mean ± SD (range) of MRD1 was 6.77 ± 0.86 mm (5–8 mm) preoperatively, and 4.78 mm (4.5–5 mm) at follow-up. Conclusion Levator recession with adjustable sutures is effective technique in treatment of upper eyelid retraction of all degrees with different causes. However,increase the number of cases with long term follow up are recommended.

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Acute-on-chronic liver failure is a new syndrome characterized by multiple organ (s) failure and high short-term mortality. This review article focuses on the definitions, diagnosis, and different treatment options for this syndrome. Patient education, anticipation, early identification of the acute insult, and early detection of chronic liver disease would be immensely helpful to prevent the disease.

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Background The adequate functioning of the maternal thyroid gland plays an important role in ensuring that the offspring develop normally. Therefore, maternal hypothyroidism and hyperthyroidism are associated with offspring abnormalities. Aim of the work This study was carried out to examine the effect of maternal hypothyroidism on the postnatal development of the pituitary–thyroid axis in the albino rat. Materials and methods Thirty pregnant female albino rats were divided into two groups. Group I was the control group and group II was the hypothyroid group whose rats were given carbimazole in a dose of 5 mg/rat/day through the intragastric intubation from the gestational day 10 until the postnatal day 20. The offspring of both groups were killed at the ages of newborn, 10, 30, and 60 days. The pituitary and thyroid glands were extracted from the pups of control and treated animals and processed for light and electron microscopy and morphometric analysis. In addition, an immunohistochemical study was carried out on the pituitary specimens for the detection of thyrotrophs. Results The present study revealed that the maternal hypothyroidism caused morphological changes in the pituitary–thyroid axis of the offspring. The changes started to appear in the newborn age and persisted throughout the postnatal life. The light microscopic examination revealed shrunken thyroid follicles. The follicular epithelial height increased and was composed of tall columnar cells with a vacuolated cytoplasm. The colloid decreased or was completely absent. Regarding the pituitary gland, there were many large pale vacuolated cells with dark nuclei and sometimes the vacuolation affected most of the cells. The electron microscopic examination of the thyroid follicular cells and thyrotrophs showed ultrastructural signs of an increased activity, which included dilated endoplasmic reticula, well-developed Golgi, enlarged mitochondria, and a decreased number of the secretory granules. Large cytoplasmic vacuoles were also observed. The immunohistochemical study of the pituitary gland revealed an increased number of thyroid-stimulating hormone immunopositive cells. The morphometric analysis of the pituitary and thyroid sections showed a significant decrease in the thyroid follicular diameter and a significant increase in the thyroid follicular epithelial height and in the number of the thyrotrophs per reference area. Conclusion From this study, it could be concluded that the experimentally induced maternal hypothyroidism disturbed the pituitary–thyroid axis of the offspring.

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Introduction Psoriasis is a T-cell-mediated inflammatory disease where T-helper (Th) lymphocytes (Th1, Th17, and Th22) play an important role in its pathogenesis. The aim of the present study was to assess the serum levels of interleukin (IL)-22 and its correlation with disease severity. Materials and methods The present study included 25 psoriatic patients and 25 healthy controls. Using serum samples collected from psoriatic patients and healthy controls, the concentrations of IL-22 were examined using ELISA kits. The severity of psoriatic skin lesions was assessed using psoriasis area and severity index scores. Results IL-22 concentrations were significantly higher in psoriatic patients in comparison with the control group. A significant, positive correlation between the concentrations of IL-22 and the severity of psoriasis was found. Conclusion The results of our study suggest that Th22 along with its cytokine responses may contribute to the skin and systemic inflammatory conditions characteristic of psoriasis. It seems that early identification of soluble biomarkers and initiation of well-matched treatment may prevent exacerbation and progression of psoriasis.

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Background Lymphedema is one of the most problematic complications after breast cancer treatment. The risk factors (RFs) for breast cancer-related lymphedema (BCRL) are multifactorial and are not fully understood. Aim The aim of this study was to determine the RFs for breast cancer-related upper-arm lymphedema. Patients and methods This is a case–control study including patients with arm lymphedema as cases and patients without arm lymphedema as controls. The included patients had breast carcinoma (n = 128) and all had operable breast cancer that could undergo locoregional therapy (surgery ± radiotherapy). Diagnosis of lymphedema was made by the measurement method, in which a difference of up to 2 cm either above or below the olecranon process between the two arms is generally accepted for diagnosis of lymphedema. Assessment of lymphedema and RFs was performed by logistic regression. Results Univariate analysis showed significant difference between the groups of patients with and those without lymphedema with respect to older age (0.016), BMI greater than 30 (0.007), hard work (0.004), ipsilateral dominant arm (0.021), history of injury (0.001) and infection (0.001) to the ipsilateral arm, positive lymphadenopathy (0.020), advanced stage of cancer (0.009), positive human epidermal growth factor receptor-2/neu receptor (0.001), level III axillary dissection (0.001), and lack of information about BCRL and/or not following prophylactic advice (0.001). Meanwhile, multiple logistic regression analysis showed only old age (0.005), history of injury (0.016), cellulitis (0.033), level III axillary dissection (0.011), lack of information about BCRL, and not following prophylactic advice (0.012) to have a significant relation to lymphedema. Conclusion Healthcare personnel and patients must be aware of the prevention and early treatment of lymphedema.

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Background Immunohistochemistry plays a crucial role in the diagnosis of hepatocellular carcinoma (HCC) and in its distinction from other primary and metastatic neoplasms. In this study, we examined the expression of MOC-31 (Anti-epithelial cell adhesion molecule monoclonal antibody, clone number-31), hepatocyte paraffin 1 (Hep Par 1), and N-cadherin in primary carcinoma and metastatic adenocarcinoma (AC) in the liver. Aim The aim of this study was to evaluate the usefulness of MOC-31, Hep Par 1, and N-cadherin in the differential diagnosis of primary carcinoma and metastatic AC in the liver. Materials and methods The present study included 56 specimens from cases of primary and metastatic liver tumors, including 20 primary HCCs in the liver, five intrahepatic cholangiocarcinomas, and 31 metastatic ACs in the liver. They were studied to evaluate MOC-31, Hep Par 1, and N-cadherin expression using immunohistochemistry. Results The sensitivity of MOC-31 for AC in the studied group was 97.2%, whereas its specificity was 90%. The sensitivity of Hep Par 1 for HCC was 75%, whereas its specificity was 100%. The sensitivity of N-cadherin for primary liver carcinoma was 72%, whereas its specificity was 83.9%. Using the combination of the three antibodies, a final diagnosis could be established in 52 of 56 (92.9%) cases of studied group. In conclusion, a panel of these three antibodies can be helpful in the distinction between primary carcinoma and metastatic AC in the liver.

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Irritable larynx is a condition of laryngeal dysfunction at which there is abnormal spasmodic closure of both vocal folds during inspiration. Patient complains of many symptoms as stridor, dysphonia, chocking, globus sensation, and dyspnea. These symptoms are not specific for irritable larynx only, but; they are frequently confused with other disorders such as gastroesophageal reflux, asthma, and different causes of chronic cough. The golden method for diagnosis is to visualize both vocal folds abducted during inspiration in acute attack by indirect laryngoscopy. To review recent available literature concerning irritable larynx syndrome to get essential recent data as a primary step for understanding this disorder.

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