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   Table of Contents - Current issue
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January-March 2019
Volume 32 | Issue 1
Page Nos. 1-387

Online since Wednesday, April 17, 2019

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REVIEW ARTICLES  

Platelet-derived growth factor in patients with liver fibrosis Highly accessed article p. 1
Enas S Essa, Fikry G Eskander, Amira Z Badawy
DOI:10.4103/mmj.mmj_468_17  
Objective To asses the changes in platelet-derived growth factor (PDGF) in liver fibrosis. Data sources The data were sourced from the PubMed database from the start of the database to 2017 and from all materials available in the Internet. Study selection The initial search presented 423 articles of which 39 met the inclusion criteria. The articles studied the relation between PDGF and liver fibrosis. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included when ethical approval was obtained, eligibility criteria defined, sufficient information, convenient controls, and known assessment measures. Data synthesis Comparisons were made through structured review with the results tabulated. Findings In total, 39 potentially relevant publications were included. The studies indicate an association between PDGF and liver fibrosis as PDGF increases in patients with hepatic fibrosis and correlates well with the grade of fibrosis. The majority of studies were performed on the effect of PDGF antagonists on liver fibrosis and they found that interference of PDGF pathway leads to reduction of liver fibrosis. Conclusion We found that PDGF levels increase in patients with liver fibrosis and its level correlates well with the stage of fibrosis; thus, PDGF can be used as a potential noninvasive marker for liver fibrosis either alone or in association with other fibrosis markers. Further, antagonizing the pathway of PDGF may offer a promising strategy for the treatment of liver fibrosis.
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Immunotherapy for advanced bladder cancer: a new era Highly accessed article p. 8
Eman Abd ElRazek, Suzan Alhassanin, Hagar Al Agizy, Alshimaa M Alhanafy, Eman Helmy Desoky
DOI:10.4103/mmj.mmj_768_17  
Objectives The aim of this study was to analyze data and current trends in immune checkpoint targeting therapy for bladder cancer. Data sources A systematic literature search was performed for clinical trials in the Medline databases (Google Scholar, ClinicalTrials.gov, Cochrane, http://www.ekb.eg) and all materials available in the Internet from 2014 up to 2017 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study selection The initial search yielded 35 articles, of which 30 fulfilled the inclusion criteria. The articles studied the role of Immune checkpoint targeting therapy in bladder cancer. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was obtained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Data synthesis Comparisons were made by structured review, with the results tabulated. Findings Humanized monoclonal antibodies that block CTLA-4 (ipilimumab, tremelimumab), PD-1 (nivolumab, pembrolizumab), or PD-L1 (atezolizumab, durvalumab, avelumab) have all shown antitumor activity in patients with urothelial carcinoma (UC). Atezolizumab and nivolumab are approved by the Food and Drug Administration for second-line therapy for advanced UC and a number of other checkpoint inhibitors are in clinical trials. Conclusion Immunotherapy for UC remains a promising and active area of research; intravesical Bacillus Calmette-Guerin has been used as a form of immunotherapy in nonmuscle invasive disease. Also, numerous agents, particularly the monoclonal antibodies targeting checkpoint inhibition pathways, are showing encouraging signs of clinical activity.
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Aortic stiffness is increased with premature coronary artery disease: a tissue Doppler imaging study Highly accessed article p. 14
Ahmed M Emara, Wessam E. H. El Shafey, Nader Nabil
DOI:10.4103/mmj.mmj_569_17  
Objective The objective of this study was to review the relationship of the aortic wall structure velocities evaluated by tissue Doppler imaging echocardiography in coronary artery disease (CAD). Materials and methods Data resources included Medline directories (PubMed, Medscape, Research Direct) and all material available in the internet from 1985 to 2017. The original search offered 104 articles, of which 47 fulfilled the inclusion standards. The articles analyzed aortic rigidity in patients with early CAD. Studies that did not fulfill the inclusion criteria were excluded. Research quality evaluation included determining whether honest authorization was gained, eligibility conditions were specified, appropriate settings were used, enough information was present, and whether assessment measures were described. Evaluations were created by organized review with the results tabulated. Results Altogether, 47 possibly relevant magazines were included. The studies suggested that aortic rigidity is increased in patients with early CAD. Conclusion Increased aortic rigidity has been named a predictor of cardiovascular incidents. Our conclusions verify this finding. Pulse-wave tissue Doppler imaging of the ascending aorta is an easily available way for estimating aortic flexible properties, and early aortic velocities are correlated with recently defined variables of aortic rigidity. Thus, early aortic velocities may show increased aortic rigidity in patients with early CAD. The medical use of the parameter needs further investigation.
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Relationship of coronary artery disease with testosterone level in young men undergoing coronary angiography Highly accessed article p. 18
Hala M Badran, Mahmoud A Soliman, Ibrahim Elmadbouh, Waleed A Ibrahim, Sameh F El Masry
DOI:10.4103/mmj.mmj_657_17  
Objective This study aimed to investigate the relation of testosterone level with the extent of coronary artery disease (CAD) in young adult male undergoing coronary angiography. Materials and methods Medline databases (PubMed, Journal of Clinical Endocrinology and Metabolism, British Medical Journal, Journal of American College of Cardiology and European Heart Journal) and also materials available in the internet were searched. The search was performed in the electronic databases from 2014 to 2017. The initial search presented 127 articles of which 61 met the inclusion criteria. The articles studied premature CAD, relation of testosterone level to CAD, and testosterone replacement therapy. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Comparisons were made by structured review with the results tabulated. Findings In total, 61 potentially relevant publications were included. The studies indicate that the serum levels of both total and free testosterone were significantly lower in young males with CAD, and both were significantly correlated with the severity of CAD as assessed by Gensini score. Conclusion The low testosterone level is associated with both the incidence and severity of premature CAD in young adult males.
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Theory of mind: its development and its relation to communication disorders: a systematic review p. 25
Mohammed Baraka, Hossam M El-Dessouky, Eman E Abd El-Wahed, Shimaa S Allam Amer
DOI:10.4103/mmj.mmj_628_17  
Objective To define theory of mind (TOM), its development, its significance, its assessment, its deficits and intervention. Data sources Medline databases (PubMed, Medscape and Science Direct) and all materials available in the Internet from 1990 to 2016. Study selection The initial search presented 250 articles of which 47 met the inclusion criteria. The articles studied the development, assessment, deficits and intervention of TOM. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information and defined assessment measures. Data synthesis Significant data were collected. It was heterogeneous. Thus, a structured review was performed with the results tabulated. Conclusion TOM is the ability to infer the mental states such as (beliefs, thoughts, intentions) to one-self and to the others. Joint attention is an early precursor of TOM development. Theoretical accounts of TOM mechanism are, the Theory Theory, Simulation Theory and Modularity Theory. Many tools used in its assessment as false belief tasks (e.g., Sally and Anne task) and TOM test. It is impaired in autism, attention deficits hyperactivity disorder, hearing impairment, schizophrenia and dementia. Intervention solutions for the deficit are undertaken. Phoniatritions should be aware of TOM as a cognitive capacity that plays a big role in our communication. They should initiate appropriate assessment and interventions for disorders having TOM deficits.
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The role of growth factors in the treatment of voice disorders: systematic review p. 31
Mohamed K. M. El-Sharnoby, Mohamed A. S. Baraka, Hossam M El-Dessouky, Eman E Abd El-Wahed, Amina G Abd El-Aleem
DOI:10.4103/mmj.mmj_209_18  
Objective The aim of this study was to present a review about the role of growth factors (GFs) in the treatment of some voice disorders. Materials and methods The data sources consisted of Medline databases (PubMed, Elsevier, and Wily Library) and all materials available in the internet from 1990 to 2017. The initial search presented 150 articles, of which 57 met the inclusion criteria, with level II-2 as the level of evidence. The articles studied the function, uses and the efficacy of basic fibroblast growth factor (bFGF) on vocal outcomes of patients with vocal fold (VF) lesions. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria were specified, appropriate controls were used, adequate information was given and whether the studies defined assessment measures. Significant data were collected. It was heterogeneous. Thus, a structured review was performed with the results tabulated. Conclusion VF lesions and paralysis induced severe dysphonia, and the fundamental therapy for these diseases is voice therapy; however, this approach is ineffective for severe dysphonia. Surgical approaches have been attempted, but the outcome varies. The aim of surgical treatment has recently changed to stimulate the regeneration of VF structures. GF therapy is considered to be a 'trigger' for jumpstarting biological processes. One promising GF is bFGF. Cases of severe dysphonia that were treated by the single, transoral bFGF injection method showed significant improvements in the vocal functions after injection. The single injection method is easy to perform as an office procedure. The use of bFGF injection to treat severe VF lesions and VF paralysis is still controversial.
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Language processing in a bilingual child p. 38
Mohamed Baraka, Hossam El-Dessouky, Eman Ezzat, Fatima M Al-Sharif
DOI:10.4103/mmj.mmj_151_18  
Objectives To review the language processing, 'central and linguistic processing,' in bilingual children. The age of second language acquisition, a factor which may impact language processing, was also reviewed. Data sources Medline databases (PubMed, Medscape, and Science Direct) using the terms 'bilingual' or 'bilingualism' with the word 'children' as the search criteria. The resulting materials available in the internet from 1980 to 2017 were further screened for the terms 'processing,' 'cognition,' or 'age of acquisition.' Study selection Our refined search included 124 articles and book's chapters out of which 83 met our selection criteria. Those data related to late bilingualism were excluded. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, adequate information, and defined assessment measures were made. Data synthesis Significant data were collected. It was heterogeneous. Thus, a structured review was performed with the results tabulated. Conclusion An unresolved issue in bilingualism is how different languages are represented in the brain and which cognitive mechanisms are required to regulate their use. In learning a second language, the brain has to build on a neural network that enables the segregation of the new language from the native one. A bilingual child can create languages' activation and inhibitory links at the lexical and the morphological level and also can develop the ability to select a word and its syntactic characters correctly.
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ORIGINAL ARTICLES Top

Assessment of phonological awareness in children with delayed language development p. 45
Mohamed Baraka, Hossam El-Dessouky, Eman Ezzat, Eman F El-Domiaty
DOI:10.4103/mmj.mmj_16_17  
Objective To study the relationship between language disorders in children and phonological awareness (PA) to identify children with reading difficulties as early as possible. Background PA is an important determiner of success in learning to read and spell. Early speech and early language difficulties are considered to be risk factors associated with future reading difficulties. Children with language difficulties are particularly at risk for poor literacy outcomes. Patients and methods Fifty cases (aged from 5 to 8 years) with delayed language development of average intelligence quotient participated in our study at Phoniatrics unit outpatient clinic in Menoufia University Hospital, from March 2015 to March 2016. They were divided into three groups (A, B, and C) and assessed by Arabic Phonological Awareness Test and Standardized Arabic Language Test. The results of cases were compared with the results of 50 controls matched for age and sex. Moreover, the results of the PA test were correlated with the results of standardized Arabic language test. Results By comparing the performance of PA skills for cases and control in the three age groups, there were significant differences in all skills (P < 0.05), except in segmenting words into syllables (P = 0.06) and blending syllables (P = 0.1) in group A. By studying the correlation between PA age and total language age, receptive language age, expressive language age, and semantics age, there were highly significant positive correlations (P = 0.000). Significant positive correlation was found between PA age and articulation (P = 0.029). Moreover, there was a significant negative correlation between PA score and the gap between language age and chronological age (P = 0.045). Conclusion Children with specific language impairments require specific therapy that includes explicit focus on PA and letter identification.
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Laryngeal assessment of patients with rheumatoid arthritis using laryngeal photodocumentation p. 54
Mohamed Baraka, Hossam El-Dessouky, Alaa Labeeb, Eman Ezzat, Asmaa El-Dessouky
DOI:10.4103/mmj.mmj_221_18  
Objective The aim was to assess the prevalence of dysphonia and laryngeal changes upon videolaryngoscopic examination of patients with rheumatoid arthritis (RA). Background RA effects on larynx vary from mild asymptomatic effect to life-threatening conditions. Many authors have emphasized the need of studies in different communities on its effect. In Egypt, the knowledge regarding its manifestations on the larynx, as well as its laryngeal alterations, is limited. Patients and methods A total of 79 patients diagnosed as having RA in Menoufia University Hospitals from March 2015 to March 2017 were assessed by taking history and asking about different laryngeal complaints followed by telescopic videolaryngeal examination. Results The estimated prevalence of laryngeal complaints in patients with RA was 57%. The most frequent complaints were globus pharyngeus in 53.2% of patients followed by phonasthenic symptoms in 32.9% of the patients. Dysphonia prevalence was 25.3%. Regarding videolaryngoscopic findings, the prevalence of changes was present in 86.15% of the patients. Most common finding has been posterior laryngitis, which was found in 78.5% of patients, followed by glottic gap in 34.2% and vocal folds rheumatoid nodules in 26.6% of them. Conclusion Laryngeal complaints and videolaryngoscopic morphological findings are prevalent among patients with RA, with a prevalence rate of 57 and 86.15%, respectively. The most frequent complaints were globus pharyngeus in 53.2% of patients followed by phonasthenic symptoms in 32.9% of the patients. Most common videolaryngoscopic findings have been posterior laryngitis, which was found in 78.5% of our patients, followed by glottic gaps in 34.2%.
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Study of peripheral neuropathy in patients with type 2 diabetes mellitus p. 62
Wafik M El-Sheikh, Ibrahim E Alahmar, Gelan M Mohamed, Mohamed A El-Sheikh
DOI:10.4103/mmj.mmj_29_16  
Objectives To compare serum levels of tumor necrosis factor-alpha (TNF-α) in patients with peripheral neuropathy and patients without neuropathy in type 2 diabetes mellitus (T2DM) and study the relation between nerve conduction studies of motor and sensory nerves and the serum level of TNF-α in T2DM. Background TNF-α presence in the serum of diabetic patients can be used as an indicator for the development of neuropathy with nerve conduction studies. Patients and methods This cross-sectional study was conducted in diagnosed T2DM patients. They were divided into two groups: group I (n = 40) with clinically detectable diabetic peripheral neuropathy (DPN) of shorter duration and group II (n = 40) with clinically detectable DPN of longer duration. They were compared with patients without clinical neuropathy (n = 40); clinical diagnosis was based on Neurologic Severity Score (NSS) and National Disability Services (NDS) for signs. Blood samples were collected for the estimation of serum TNF-α. Nerve conduction velocity was measured in the upper and lower limbs. Median, ulnar, common peroneal, and posterior tibial nerves were selected for motor nerve conduction study and median and sural nerves were selected for sensory nerve conduction study. Results The serum level of TNF-α in type 2 diabetic patients with peripheral neuropathy is higher than those without neuropathy. The serum level of TNF-α shows statistically significant negative correlation with nerve conduction velocities which is higher in type 2 diabetic patients (5–10 years duration) with peripheral neuropathy. Conclusion A high level of TNF-α in the serum of T2DM patients with neuropathy shows possible contribution in the development of neuropathy. This cytokine might be used as a biomarker for DPN.
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Effect of transcranial magnetic stimulation in patients with Parkinson disease p. 67
Wafik M El-Shiekh, Rasha A El-Kabbany, Aktham I El-Emam, Ibrahim E Al-Ahmar, Mohamed A Eltantawi
DOI:10.4103/mmj.mmj_261_17  
Objective The aim was to study the possible effect of repetitive transcranial magnetic stimulation (rTMS) as a treatment option in patients with Parkinson disease (PD) whose conditions become complicated owing to either progression of the disease or adverse effects of the drugs. Background PD is the second most common neurodegenerative disease. Drug-related motor complications, for example, dyskinesias, or nonmotor complications, for example, depression, happen in the later stages of the disease, even among those on levodopa therapy. Transcranial magnetic stimulation (TMS) has been used in a wide range of diseases associated with motor dysfunction. rTMS has shown good improvement of clinical condition among patients with PD. Patients and methods The study is a prospective case–controlled clinical trial. A total of 40 patients with PD were included in the study and divided into two groups: group I underwent active rTMS (20 patients) and group II underwent sham stimulation (20 patients). Results Overall, 40 patients with complicated PD completed the study (group I included 20 patients and group II also had 20 patients). There was no statistically significant difference between the groups regarding age, sex, duration of illness, or stage of the disease (P > 0.05). After rTMS application, group I showed significant results regarding the stage of the disease (P < 0.05) and showed highly significant results regarding the severity of motor affection and complications (P < 0.001), whereas group II showed no significance (P > 0.05). Conclusion rTMS maybe a good addition to the management of motor symptoms and complications in complicated PD.
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Study of calcitonin gene-related peptide level in peripheral blood of episodic and chronic migraine patients p. 74
Wafik M El Sheikh, Aktham I Alemam, Ibrahim E Alahmar, Hedra H Gaed
DOI:10.4103/mmj.mmj_448_17  
Objective The aim of this study was to determine the level of calcitonin gene-related peptide (CGRP) in peripheral blood of patients with episodic migraine (EM) and chronic migraine (CM) compared with the control group. Background Migraine is a common disabling multifactorial recurrent hereditary neurovascular headache disorder. It is burden to the person, the society, and affects one's quality of life. It occurs in childhood and puberty. CGRP increased from trigeminal nerves and play an important role in the painful phase of migraine. Patients and methods A cross-sectional study was conducted on 40 participants suffering from CM and EM and 20 healthy participants as a control group. Venous blood was taken and plasma separated to be stored at −70°C. CGRP was determined by enzyme-linked immunosorbent assay kit. All participates were subjected to full detailed general medical, neurological, and psychiatric history and examination. Results Insignificant difference was recorded among migrainous patients and the control group regarding age, sex, distribution of computed tomography/MRI, fundus examination, and electroencephalogram, whereas migraine patients differ significantly regarding the symptoms such as nausea, vomiting, phonophobia, and photophobia. Moreover, no significant difference was found between men and women in their CGRP levels. Conclusion The level of CGRP plasma was clearly higher in peripheral blood in large series of CM and a lower degree for EM women versus control group in migraine attack.
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Comparison between typical and atypical antipsychotics according their effects on metabolism in schizophrenia patients p. 80
Wafeek M El Sheikh, Afaf Z Rajab, Amr S Shalaby, Ahmed G Shaheen
DOI:10.4103/mmj.mmj_645_17  
Objective This study aimed at assessing the risk factors causing metabolic dysregulations in schizophrenia patients on antipsychotics treatment. Background Schizophrenia is a devastating mental illness with wide prevalence of high mortality and morbidity rates associated with high prevalence of metabolic syndrome that is characterized by hyperglycemia, obesity, dyslipidemia, and hypertension. Patients and methods This is a cross-sectional study conducted on 40 patients suffering from schizophrenia taking typical and atypical antipsychotics only (groups I and II, respectively). Detailed general medical, neurological history, examination, and psychiatric history were taken from patients. Results Results revealed insignificant difference among groups regarding gender, age of onset ( first episode, last episode), duration of last period of treatment and total illness, blunted effect, poor rapport, emotional withdrawal, lack of spontaneity of conversation, and difficulty in abstract and stereotyping thinking; in contrast, the number of relapses were increased significantly in groups. However, insignificant differences were detected between baseline and after 6 months regarding blood elements, triglyceride, 2 h postprandial, and liver and kidney function. Conclusion Schizophrenia as a syndrome can by itself produce metabolic abnormalities. It is usually treated with first-generation and/or second-generation antipsychotics, which also can produce metabolic adverse events, but the second-generation antipsychotics can produce more frequently and severely. There were some dysregulations obvious only with typical antipsychotics. The lipid and glucose metabolism were significantly dysregulated after 6 months, but it did not reach the threshold of diagnosis of diabetes mellitus or pathological dyslipidemia. In addition, healthier lifestyle, low carbohydrate and fatty meal consumption, good premorbid metabolic parameters, and good choice of antipsychotic help in prognosis of metabolic status of schizophrenic patients.
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Morphological identification of house dust mite species in Menoufia Governorate and their antigen effect in immunoglobulin E response in allergic patients p. 88
Wafaa M El Kersh, Mona M. K. El Sobky, Nancy M Harbah, Hany M Heikl, Doaa I. M. Abou Galalah
DOI:10.4103/mmj.mmj_80_16  
Objective The aim was to identify and differentiate different species of house dust mites (HDMs) from dust samples from different areas in Menoufia Governorate, with preparation of antigen from each HDM identified species for estimation of specific immunoglobulin E (IgE) and total monoclonal IgE in selected allergic patients. Background The HDMs are considered the commonest sources of airborne allergens worldwide. Diagnosis of HDM allergy is a challenge, which is reflected in the treatment and prophylaxis of allergy. Materials and methods Dust samples were collected from houses in different areas in Menoufia Governorate. Mites were isolated and morphologically classified, and crude antigens were prepared from each identified species. A total of 42 allergic patients were selected, in addition to 10 control healthy individuals. Total and specific HDM monoclonal IgE levels were measured by conventional enzyme-linked immunosorbent assay technique. Results Rural areas showed higher density of HDM, with a higher significant difference than urban areas, Melig was the highest infested rural area, with significant difference. The predominant species were Dermatophagoides pteronyssinus (72.6%), Dermatophagoides farina (51.2%), and Tyrophagus putrescentiae (42.6%). Total monoclonal IgE estimation revealed high levels in all studied patients. D. pteronyssinus antigen showed highly significant difference in diagnosis of 95% of patients with asthma. Moreover, D. farina antigen showed significant difference in diagnosis of 90.9% of patients with atopic dermatitis, whereas T. Putrescentiae antigen showed high rate (72.7%) in patients with atopic dermatitis although insignificant difference in the diagnosis of different allergic patients. Conclusion D. pteronyssinus represented the most common HDM species in dust samples detected in selected areas, whereas D. pteronyssinus and D. farina antigens are the most common sensitizing HDM antigens in the studied patients. The use of these antigens in diagnosis, vaccination, and hyposensitization is recommended.
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The diagnostic value of magnetic resonance imaging in the diagnosis of nonpalpable undescended testis p. 97
Adel M Al Wakeel, Sameh M Azab, Mohamed M Soliman
DOI:10.4103/mmj.mmj_267_17  
Objective The aim of this study was to assess the value of MRI to localize undescended nonpalpable testis before laparoscopy operation. Background Conventional MRI sequences when combined with diffusion-weighted imaging sequence is a good tool for tissue characterization as they provide functional and structural information about tissues. It could detect the site and viability of nondescended testes. Patients and methods During a period of 12-month duration from January 2016 to December 2016, 20 male patients ranging in age from 5 months to 25 years (mean = 9.86 ± 6.91 years) were included in this study. All patients selected were referred to the MRI scanning for assessment of nonpalpable undescended testes that are clinically diagnosed before laparoscopy. Results Conventional MRI combined with diffusion-weighted images gives better results as regards the location of undescended testis and also detection of viability of testicular tissue. This technique had the highest sensitivity (100%), specificity (90%), and accuracy (90%). Conclusion Conventional MRI with fat-suppression technique when combined with diffusion-weighted imaging gives the highest accuracy for localization and detection of viability of undescended nonpalpable testis.
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Role of elastography in characterization of solid breast masses p. 101
Mohamed A Maaly, Hayam A Abdel Lattif, Mahmoud M Elsakhawy, Hanan M Khallaf
DOI:10.4103/mmj.mmj_405_17  
Objectives The aim of this study was to study the diagnostic performance of elastography in characterization of solid breast masses. Background Elastography is an imaging modality that can calculate the elasticity of tissues, based on the well-established principle that benign lesions are soft and malignant lesions are hard. It is an easy procedure with high diagnostic performance, which can be easily integrated with the B-mode ultrasound examination in the same session to improve its specificity. Patients and methods A total of 30 female patients were included in this prospective study in the period from February 2016 to February 2017 with a complaint of breast mass. We examined the patients using ultrasonography and strain elastography. Then, we compared the findings of ultrasonography and elastography with pathology findings to assess their diagnostic performance. Results Among the 30 breast masses, 14 were benign and 16 were malignant. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography were 100, 43, 67, and 100%, respectively. Qualitative elastography (Tsukuba score) had a sensitivity of 69%, specificity of 86%, PPV of 85%, and NPV of 71%. Quantitative elastography, assessed using the strain ratio, was a good discriminant for malignancy (area under the receiver operating curve = 0.94, P = 0.001). Our results revealed a cutoff point for malignancy of more than2.7; by using this threshold, the diagnostic performance of the strain ratio was 94% sensitivity, 86% specificity, 88% PPV, and 92%NPV. Conclusion Elastography has great diagnostic performance in distinguishing between benign and malignant breast masses.
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The role of MRI in the differentiation between benign and malignant ovarian lesions p. 106
Adel M El-Wekil, Mohammad S Abdullah, Sara S El-Kholy
DOI:10.4103/mmj.mmj_548_17  
Objective To determine whether conventional MRI and diffusion-weighted imaging (DWI) could help accurately in distinguishing benign from malignant adnexal masses. Background Characterization of ovarian lesions is of great importance in order to plan adequate therapeutic procedures. Ovarian neoplasms may be benign, borderline, or malignant. Using an imaging-guided approach based on their morphological appearance, we classified adnexal masses into three main groups: cystic, solid and complex cystic and solid. We also used DWI as an advanced magnetic resonance technique to achieve more accuracy of diagnosis. Materials and methods Thirty patients with initial undetermined ovarian lesions underwent pelvic MRI on 1.5-T magnet with a pelvic-phased array coil. The MRI protocol was done. All cases are operated; their pathological and laparoscopic results were compared with preoperative MRI results. Results In all, 62.5% of malignant cases are complex (cystic/solid); 95% of benign cases have no vegetations or papillary projections; 85.7% of heterogeneously enhanced lesions were malignant 62.6% of malignant cases show septations. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of conventional MRI have increased from 87.5, 86.4, 70, 95, 86.7%, respectively, for conventional MRI to 100, 93.3, 88.9, 100, 95%, respectively, for DWI. Conclusion MRI is an accurate modality for the differentiation of benign and malignant adnexal masses, especially with diffusion MRI which gives more accuracy.
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Computed tomography perfusion correlated with shear wave elastography in assessing the severity of chronic liver diseases p. 112
Mohamed R El-Kholy, Waleed A. F. Mousa, Mahmoud M Elsakhawy, Bassuoni A. A. Bassuoni
DOI:10.4103/mmj.mmj_129_18  
Objective The objective of this study was to assess the efficacy of computed tomography (CT) perfusion for quantitative measurement of hepatic perfusion as an useful tool in the evaluation of the severity of chronic liver diseases in correlation with shear wave elastography. Background CT perfusion is a noninvasive, safe technique for quantifying hepatic perfusion parameters, which is correlated significantly with the severity of chronic liver disease. Patients and methods This prospective study was carried out from October 2016 to December 2017, 80 patients with chronic liver disease and 20 patients without liver disease (control group) underwent CT perfusion and shear wave elastography (acoustic radiation force impulse imaging). Using the Child–Pugh classification for chronic liver disease patients, 35 patients were classified as Child A, 35 as Child B, and 10 as Child C. Total blood flow, total blood volume, hepatic perfusion index (HPI), mean transit time, and total liver perfusion for both liver lobes were measured for all patients. Results Total blood flow tended to decrease with the severity of chronic liver disease. HPI of the control group was significantly different from those of Child B and C, so HPI correlated significantly with the degree of fibrosis and linear relationship with acoustic radiation force impulse imaging results. However, there were changes in total blood volume and mean transit time between each groups, but not significant. Conclusion CT perfusion is a noninvasive technique for quantifying hepatic perfusion parameters and is useful tool for the evaluation of the severity of chronic liver diseases.
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Epidemiology of dental caries among preparatory school children (12–15 years old) in Shebin El-Kom District, Menoufia Governorate p. 120
Gaafar M Abdel-Rasoul, Omima A Mahrous, Hewaida M El-Shazly, Hala M Gabr, Yousra A Alghalban
DOI:10.4103/mmj.mmj_449_15  
Objective Estimating the prevalence of dental caries in preparatory school children as well as identifying the possible risk factors and determining the correlation between dental caries and total antioxidant capacity in saliva in the studied group. Background Dental caries is one of the most common chronic diseases affecting millions of people globally, with high prevalence even in adolescents, ranging from 60 to 90%, and it is a major cause of tooth loss, pain, and discomfort worldwide. However, it does not have an inevitable outcome as some of the risk factors can be modified and caries can be prevented. Patients and methods A case–control design nested in a cross-sectional study was carried out in Menoufia Governorate. This study was carried out in Shebin El-Kom district. The study sample consisted of 1283 (651 males and 632 females) children. Saliva samples and questionnaire were collected through school visits. Total antioxidant capacity in saliva was assessed in all of the collected samples. Results Prevalence of dental caries was 62.8%, with decayed, missed, and filled Teeth index score of 1.3 ± 1.32. There was a significant relationship between children with dental caries and ones without caries regarding dietary habits and habitual optimal teeth brushing (P < 0.05). Conclusion Prevalence of dental caries is high among preparatory school children. To face this problem, there should be a program carried out by the government, especially Ministry of Education and Ministry of Health, targeted toward both children and their parents through different public media approaches. Programs should focus on the optimal teeth brushing and the healthy nutritional habits needed for better teeth health.
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Adherence to Egyptian pediatric acute otitis media guideline in Egypt p. 127
Ahmed Ragab, Hala M Elmoselhy Shaheen, Nagwa N Hegazy, Alaa A. A. El-Sweedy
DOI:10.4103/mmj.mmj_321_16  
Objective The aim of this study was to assess the adherence of different specialties (family physicians, pediatricians, and otolaryngologists) to Egyptian clinical practice guideline dealing with pediatric acute otitis media (AOM) in Egypt. Background Egyptian clinical practice guideline for AOM has been promoted as a strategy to measure and improve the quality of patient care. However, more efforts have been expended on creating guidelines than implementing them. Patients and methods It was a cross-sectional descriptive study. Participants from different specialties, such as family physicians, pediatricians, and otolaryngologists were selected by systematic random techniques from the list of participants in the conferences. A self-administered questionnaire with 26 items that covered all the aspects of management of Egyptian clinical practice guideline for AOM was distributed to the participants to assess their adherence to the Egyptian guideline of AOM. Results Poor adherence to the Egyptian guideline of AOM was detected in all specialties without significant differences (92.5% of family physicians, 100% of otolaryngologists, and 100% of pediatricians). A physician's age, sex, scientific degree, and experience did not significantly affect the adherence. Conclusion Poor adherence of different specialties to the Egyptian guideline of AOM in Egypt was observed. Resolving this challenge will require comprehensive policy appraisal and harmonized actions at different AOM health care providers. Mere dissemination of evidence and promotion of guidelines will not help.
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Study of mastitis comorbidities among lactating mothers in El-Batanoon village, Menoufia governorate p. 133
Hala M Shahin, Nagwaa N Hegazy, Heba A Elgohary Taman
DOI:10.4103/mmj.mmj_484_16  
Objective This study aimed to deter mine the prevalence of mastitis among lactating mothers in El-Batanoon and to assess the risk factors of mastitis. Background Mastitis is one of the most common frequent breastfeeding problems among lactating mothers and is frequently associated with comorbid illnesses. Patients and methods A case–control study of breastfeeding women, 45 patients (women with mastitis), and 355 control participants was carried out in El-Batanoon family health facilities. All the women attending the vaccination sessions for the children in the family health center on Mondays from 9 a.m. to 2 p.m. for 6 months were assessed. Data were collected using a predesigned structured questionnaire for history of the mothers and the babies, complete physical examination for them and assessment of breastfeeding technique. Results The prevalence of mastitis in the groups studied was 14%. The prevalence of mastitis was higher among women who had nipple crack, 39 (86.2%) patients, those who had breast engorgement, 27 (60.5%) patients, and those who had improper position with her baby during breastfeeding, 30 (67.6%) patients. A high prevalence of mastitis affects breastfeeding and decreases the benefits for the mothers and the babies. Conclusion According to our results, the current study showed that mastitis is a major problem that affects mothers and their babies, with a prevalence of 11.25% among lactating mothers attending the family health center in rural areas, Menoufia governorate.
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Risk factors for overactive bladder in postmenopausal women attending Kafr El-Baramoon Family Health Unit, Egypt p. 139
Tagreed M Farahat, Fatma A El Esergy, Safaa A. Y. El Shopaky
DOI:10.4103/mmj.mmj_355_17  
Objective The aim of this study was to assess the prevalence of overactive bladder (OAB) among postmenopausal women attending Kafr El-Bramoon Family Health Unit and to identify risk factors for OAB among studied group. Background OAB is a common urological abnormality with adverse effects on quality of life. In women, postmenopausal status has been associated with an increase in OAB symptoms. Participants and methods This was a case–control study nested in a cross-sectional design conducted on 200 postmenopausal women aged 45–65 years attending the selected family health unit. Each participant was assessed using a predesigned questionnaire. It consisted of three sections (sociodemographic, medical history, and OAB symptoms score). The OAB symptoms score contains questions about OAB symptoms (frequency, urgency, and urge incontinence). The studied women were divided into two groups: patients in group I had OAB and those in group II did not have OAB. Results This study revealed that among 200 studied patients, the frequency of OAB was 38.5%. OAB was more significant among postmenopausal women who were more than 60 years old (63.6%) (P < 0.001) and those who had literate certificate level of education (41.1%) (P < 0.05). Obesity (P < 0.01), menopausal duration more than 5 years (P < 0.001), parity (P < 0.001), and history of previous gynecological surgery (P < 0.001) were potential risk factors for OAB. Conclusion This study concluded that about one-third of postmenopausal women had OAB. The most important risk factors were advanced age, high parity, gynecological surgery, and obesity. Therefore, the study recommends frequent screening of OAB in postmenopausal women.
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Risk factors for constipation among elderly attending family health center in Damietta District, Damietta Governorate, Egypt p. 145
Taghreed M Farahat, Fatma A El-Esrigy, Wafaa El-Said Ibrahim Salama
DOI:10.4103/mmj.mmj_388_17  
Background Approximately one-third of adults 60 years or older report at least occasional constipation, and in nursing home residents, the prevalence is 50% or more. It accounts for ~2.5 million physician office visits yearly. Aim The aim of the present work was to assess the prevalence and risk factors of constipation among the studied elderly population. Patients and methods A cross-sectional study was conducted on 258 elderly population (>60 years old) attending the Hai Tany Family Health Center, Damietta Governorate, from 1 November 2015 to 1 January 2016. A predesigned questionnaire was used to assess the presence of constipation and its risk factors. It included four parts: sociodemographic characteristics, Bristol scale and ROME III diagnostic criteria for constipation, mini-mental status examination (to assess cognitive function), and mini-nutritional assessment scale (to assess nutritional status). Results The results of this study revealed that 64/258 of the studied population had primary (functional) constipation. Constipation was more significant in patients older than 75 years (P < 0.001). The most important risk factors associated with constipation in the studied group were advanced age, nutritional impairment, and cognitive impairment. Conclusion This study concluded that about one-fourth of the studied population had (functional) constipation. The most important risk factors associated with constipation in elderly population were advanced age, nutritional impairment, and cognitive impairment. Therefore, the study recommends prevention and treatment of constipation through nutritional education and screening for cognitive impairment in elderly.
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Clinicopathological differentiation between biliary atresia and other causes of neonatal cholestasis p. 151
Mona A Kandil, Hayam A Aiad, Dina S El-Azab, Shereen F El-Goday, Mona S Tantawy
DOI:10.4103/mmj.mmj_366_16  
Objective To differentiate biliary atresia (BA) from other causes of neonatal cholestasis (NC) regarding clinicopathological features. Background There is a high degree of overlap in clinical, biochemical, and histological characteristics of BA and other causes of NC. There is an increased need of early diagnosis of BA, as timely surgical portoenterostomy is necessary to prevent liver cirrhosis. Patients and methods This retrospective study included 61 (32 diagnosed as BA and 29 as non-BA) infants. Data were collected from the medical records of the Pediatric Hepatology Department, National Liver Institute, and paraffin blocks from the archives of the Pathology Department, National Liver Institute, Menoufia University, during the period from January 2014 to December 2015. Results The study showed that clinically, clay stool (P < 0.0001), hepatomegaly (P = 0.003), and noncontractile gallbladder (P < 0.0001) emerged as the best indicators of BA. Regarding laboratory parameters, the mean levels of each of γ-glutamyl transferase (P < 0.0001), aspartate aminotransferase (P = 0.025), alanine aminotransferase (P = 0.012) and platelets (P = 0.002) were significantly higher in BA than that in non-BA cases. γ-Glutamyl transferase was the most accurate test in discrimination between BA and non-BA groups. Of all histopathological data, portal changes [portal tract edema (P < 0.0001), fibrosis of portal tracts (P < 0.0001), bile ductular proliferation (P < 0.0001) and bile plugs (P < 0.0001)] were more prominent in BA than that in non-BA cases, whereas parenchymal changes [hepatocellular swelling (P = 0.004) and extramedullary hematopoiesis (P = 0.004)] were more prominent in non-BA cases. Conclusion Combined clinical, laboratory, and histopathological parameters are greatly helpful in differentiating BA from other causes of NC. All of these investigations should be done for all suspected cases of BA to decrease the frequency of negative laparotomy finding and achieve cost–benefit with reduced morbidity.
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Impact of percutaneous coronary intervention on regional myocardial function in patients with chronic stable angina p. 160
Walaa F Mousa, Ahmed M Elkersh, Abdulaziz A Shaheen
DOI:10.4103/mmj.mmj_336_17  
Objective To determine the impact of percutaneous coronary intervention (PCI) on regional myocardial function by tissue Doppler echocardiography (TDE) in patients with chronic stable angina and normal baseline ejection fraction. Background The impairment of left ventricular longitudinal function may precede the circumferential dysfunction in patients with ischemia and this impairment cannot be detected by conventional echocardiography. Successful PCI may improve this impairment and this can be detected using TDE. Patients and methods Between October 2013 and August 2015, this follow-up study in our teaching hospital included 25 consecutive patients with chronic stable angina and normal baseline ejection fraction who underwent PCI and were studied by TDE before, and 1 day and 6 weeks after PCI. Myocardial tissue peak velocities (E', A' and S') were recorded at the septal, lateral, anterior, and inferior angles of the mitral annulus and at the lateral tricuspid annulus. Results There was a highly significant improvement in E', A' and S' velocities of the mitral valve 1 day and 6 weeks after PCI at all sites: septal, lateral, anterior, and inferior (P > 0.001). Also, there was a highly significant improvement in the E' and A' velocities of the tricuspid valve 1 day and 6 weeks after PCI (P > 0.001). The S' velocity of the tricuspid valve showed a significant improvement on the first day after PCI (P = 0.02), which increased 6 weeks' after PCI to become highly significant (P > 0.001). Conclusion TDE parameters of diastolic and systolic functions improve early after successful PCI, and this effect persists up to 6 weeks after PCI.
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Platelet to lymphocyte ratio as a predictor of severity of coronary artery disease p. 167
Ahmad A Reda, Mohammad A Moharram, Ali ElGhareeb Rasheed
DOI:10.4103/mmj.mmj_450_17  
Objective The objective was to research the value of platelet to lymphocyte ratio (PLR) as an indicator of severity of coronary atherosclerosis. Background Cardiovascular disease is the commonest cause of death worldwide. The process of coronary atherosclerosis is greatly dependent on several factors. New inflammatory markers were believed to be valuable as indicators of severity of coronary atherosclerosis. Patients and methods We conducted a randomized prospective observational study in our Coronary Intervention Unit, Menoufia University hospital. One hundred and thirty patients qualified for elective coronary angiography were arranged into three groups based on their Gensini score. Group I patients with normal coronary angiography, group II patients with mild atherosclerotic coronary disease, and group III included patients with severe atherosclerotic coronary disease. Results There was a significant positive correlation between PLR and severity of coronary atherosclerosis estimated by Gensini score. Regarding group I, the mean PLR value is 102.8 whereas in group II, the mean PLR value is 114.98 and in group III, the mean PLR value is 141, providing a cut-off value of PLR 126.5 that predicts severe coronary atherosclerosis. Conclusion PLR is a powerful marker for the prediction of severity of coronary atherosclerosis and should be widely used for risk stratification of ischemic patients. Moreover, PLR should be considered when choosing the management strategy of such patients either conservatively or interventionally.
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Association between uric acid and coron ary collateral circulation in stable coronary artery disease patients p. 172
Ghada M Soltan, Naglaa F Ahmed, Ahmed G El-Sayed El-Raei
DOI:10.4103/mmj.mmj_454_17  
Objective The aim of this study was to investigate the association between serum uric acid levels and the development of coronary collateral circulation (CCC) in patients with stable coronary artery disease. Background Serum uric acid can cause atherosclerosis. High serum uric acid levels may be associated with poor CCC in patients with stable coronary artery disease. Patients and methods A cross-sectional study was carried out on 100 patients with stable CAD who underwent coronary angiography and documented total occlusion in one or more of the major coronary arteries in Cardiovascular Department Menoufia University Hospital during the period from 1 February 2016 to 30 January 2017. Development of CCC will be graded according to the Cohen–Rentrop method: grades 2–3 will be classified as good CCC (group A) and grades 0–1 as poor CCC (group B). Results A significant relationship between high level of serum uric acid and poor coronary collaterals was observed. Mean value of uric acid in group A was 4.72 ± 1.69 mg/dl and mean value of uric acid in group B was 6.68 ± 2.36 mg/dl (P < 0.001). The receiver-operating characteristic analysis curve made between uric acid and two groups provided a cutoff point of 5.3 mg/dl, with 81.63% specificity and 64.71% sensitivity to detect poor CCC. Conclusion The measurement of uric acid level provides a good predictor of poor CCC in stable coronary artery disease patients.
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Assessment of viable myocardium by nitrate-augmented technetium-99m sestamibi myocardial perfusion imaging p. 177
Mahmoud A Solimana, Awny G Shalabya, Ahmed S Esawyb
DOI:10.4103/mmj.mmj_590_17  
Objective The aim of this study was to assess the role of nitrate-augmented technetium-99m (99mTc) sestamibi imaging in the evaluation of viable myocardium in patients who had ischemic heart disease with depressed left ventricle (LV) systolic function. Background In the setting of acute myocardial infarction, stunning can occur, which is the persistent LV dysfunction following opening of the occluded coronary artery; recovery of function occurs usually within months. In the setting of chronic LV dysfunction, the pathophysiology underlying the dysfunction is referred to as myocardial hibernation. Various imaging techniques have been introduced to detect viability and discriminate this from scar tissue. Patients and methods Between November 2015 and November 2016, 100 patients with a history of myocardial infarction 'functional class II and III' or/and LV dysfunction were included in this multicenter prospective study. All patients underwent 99mTc sestamibi myocardial perfusion imaging under both rest and rest with nitrate conditions. Results Nitrates improved viability detection by myocardial perfusion imaging in patients with depressed LV systolic function. There was significant decrease in the total perfusion defect in rest with nitrate study in comparison with the rest study (P = 0.006). Conclusion In patients with chronic ischemic heart disease with depressed LV systolic function, the use of nitrate-augmented Tc-99m sestamibi protocol in cardiac single photon emission computed tomography imaging results in improved detection of viable but hypoperfused segments. It is a good indicator for differentiating viable tissues from the scar.
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The correlation between serum adiponectin levels and severity of coronary artery disease p. 181
Walaa Farid, Rehab Ibraheem, Alshaimaa A Ahmed
DOI:10.4103/mmj.mmj_558_17  
Objective To evaluate the correlation between serum adiponectin levels and the severity of coronary artery disease (CAD) as assessed by coronary angiography. Background CAD is the leading cause of death worldwide. Adiponectin is a protein hormone that modulates a number of metabolic processes, including glucose regulation and acid oxidation. The severity of hypoadiponectinemia correlates with coronary lesions. Indeed, adiponectin levels are lower in patients having CAD. Patients and methods This cross-sectional study included 90 patients, comprising 36 patients with normal coronary arteries and 54 patients with CAD. Patients with CAD were subdivided into four groups according to the number of vessels affected. The severity of coronary lesions was assessed using the modified Gensini score. Serum adiponectin levels were measured in all patients. Results There was a significant negative linear correlation between serum adiponectin level and severity of CAD using modified Gensini score (r=−0.903; P < 0.001). There was significant decrease in serum adiponectin levels in patients with multivessel disease compared with patients with two-vessel disease and more significant decrease compared with patients with single-vessel disease. There was no significant difference between the both groups regarding mean age, smoking, hypertension, dyslipidemia, and family history. Conclusion Serum adiponectin levels decreased in patients with CAD compared with normal coronary arteries group. This decrease is more prominent with increasing levels of CAD severity, which may be helpful in risk stratification.
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A comparative analysis of the level of high-sensitivity C-reactive protein in individuals with and without hypertension p. 187
Walaa F Abd El Aziz, Elsayed S Abou Elnour, Morad B Mena, Reda M El-brol
DOI:10.4103/mmj.mmj_210_15  
Objective The objective of this study was to compare the level of serum high-sensitivity C-reactive protein (hs-CRP) in hypertensive and normotensive individuals. Background Hs-CRP production is part of the nonspecific acute-phase response to most forms of inflammation, infection, and tissue damage. The association between hs-CRP and hypertension (HTN) could be related in part as follows: correlation between elevated CRP and arterial stiffness; association between CRP and metabolic syndrome, one of whose criteria is HTN and the possibility that CRP may directly contribute to reduced nitric oxide synthesis in endothelial cells, leading to increased vascular resistance. Patients and methods Our study comprised 80 patients, divided into two groups: the first group consisted of 55 patients with blood pressure more than140/90 mmHg recorded in at least two separate clinic-based measurements after ruling out secondary causes. The second group consisted of 25 normotensive individuals with a blood pressure of 100–120/60–80 mmHg as a control group. All individuals were subjected to full history taking, complete medical examination, 12-lead ECG, conventional echocardiography, routine laboratory investigations, and measurement of hs-CRP by CRP HS enzyme-linked immunosorbent assay. Results The study showed that the mean age of the studied group was 43.9 years; 58.8% were male individuals. Mean systolic and diastolic blood pressure was 146.4 and 91.5 mmHg, respectively. There were highly significant differences between the patient and control groups with regard to age, blood pressure, left ventricular mass, left ventricular mass index, lipid profile, and hs-CRP (higher in the patient group). The study showed also highly significant positive correlations between hs-CRP and age, blood pressure, left ventricular mass and left ventricular mass index. There was a significant positive correlation between hs-CRP and total cholesterol. Conclusion The levels of hs-CRP were elevated in hypertensive individuals, which suggests the possibility of an inflammatory pathogenesis in HTN.
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Study of serum YKL-40 level in patients with chronic obstructive pulmonary disease p. 194
Nourane Y Azab, Ahmed A Khames, Maha Yousif, Ibrahim S El Madbouh, Doaa S Fouda
DOI:10.4103/mmj.mmj_68_17  
Objective The aim of the paper was to investigate the relationship between serum YKL-40 levels and severity of chronic obstructive pulmonary disease (COPD). Background COPD is a major health problem with increasing morbidity and mortality throughout the world. A newly recognized biomarker, YKL-40, is a chitin-binding glycoprotein, and its serum level is elevated in inflammatory diseases. However, it has not been thoroughly investigated in COPD. Patients and methods A total of 30 patients with stable COPD and 10 healthy individuals as a control group were enrolled for estimation of modified Medical Research Counseling dyspnea scale, spirometry, and serum YKL-40 levels. Results Serum YKL-40 level was increased significantly in patients with COPD compared with healthy controls. There was a positive correlation between serum YKL-40 level and each of modified Medical Research Counseling dyspnea scale severity and age, and a negative correlation with forced expiratory volume in the first second percent of predicted. Conclusion High serum YKL-40 levels were correlated with severity of COPD.
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Ultrasonographic assessment of diaphragm in patients with chronic obstructive pulmonary disease in correlation with spirometric parameters p. 198
Amal A Abd El Aziz, Rabab A El Wahsh, Gehan A Abd Elaal, Mohammed S Abdullah, Rehab A Saad
DOI:10.4103/mmj.mmj_141_17  
Objective Ultasonographic assessment of the diaphragm in patients with chronic obstructive pulmonary disease (COPD) and studying its correlation with spiromertric parameters. Background COPD represents a model of respiratory muscle dysfunction. The diaphragm is the main respiratory muscle, and its assessment is mandatory in the evaluation of patients with COPD. Ultrasonography can be used to assess diaphragmatic thickness, thickening, and excursion. Patients and methods This study included 40 patients with COPD and 10 healthy controls. All participants underwent detailed history taking, clinical examination, chest radiographies, 6-min walk test, spirometry [measurement of forced expiratory volume in one second/forced vital capacity (FEV1/FVC), FVC, FEV1, and maximum voluntary ventilation percentage of predicted], and ultrasonographic examination to measure diaphragmatic thickness (TD) at different lung volumes and capacities, thickening, and excursion. Results A highly statistically significant difference (P < 0.001) between patients with COPD and controls regarding FEV1/FVC, FEV1, and maximum voluntary ventilation percentage of predicted and a statistically significant difference (P = 0.04) between both groups regarding FVC% of predicted were found. There was a highly statistically significant difference (P < 0.001) among patients with COPD with different grades of severity regarding diaphragmatic thicknesses (TDRV, TDFRC, and TDTLC), diaphragmatic thickening (TDTLCFRC), and diaphragmatic excursion. There was a statistically significant difference (P = 0.002) among different COPD grades regarding diaphragmatic thickening (TDTLCRV). Measurements of diaphragmatic thicknesses (TDFRC and TDTLC) and thickenings (TDTLCRV and TDTLCFRC) decrease significantly in female patients more than in male patients (P = 0.049, 0.031, 0.005, and 0.044, respectively). Conclusion Diaphragmatic thickness, thickening, and excursion decrease in patients with COPD and in female more than in male patients. These ultrasonographic measurements negatively correlate with the severity of the disease.
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Can C-reactive protein predict metabolic syndrome in chronic obstructive pulmonary disease patients? p. 206
Ahmad A Ali, Nourane Y Azab, Sami S Eldahdouh, Eman M. S. Abdelsalam
DOI:10.4103/mmj.mmj_151_17  
Objectives The aims of this study were to assess whether metabolic syndrome (MetS) is more common in chronic obstructive pulmonary disease (COPD) patients and to elucidate the role of C-reactive protein (CRP) as a marker of MetS in COPD patients. Background MetS is closely related to COPD as proved in many previous studies. This association is attributed to the presence of systemic inflammation in both conditions. CRP may play a role as a predictor of MetS in COPD patients. Patients and methods This case–control study included 30 COPD patients and 20 controls recruited from the Chest Department, Faculty of Medicine, Menoufia University and Shebin El-Kom Chest Hospital between August 2014 and August 2016. All participants underwent clinical, spirometric, and laboratory assessments. Patients were staged according to Global initiative for Obstructive Lung Disease classification, and MetS was diagnosed according to International Diabetes Federation criteria. Results Patients had significantly higher systolic and diastolic blood pressures, cholesterol, low-density lipoprotein, fasting blood glucose, CRP, and serum uric acid compared with controls (P < 0.001, 0.002, <0.001, 0.007, <0.001, <0.001, and < 0.001, respectively). High-density lipoprotein was significantly lower in controls. MetS in patients (60%) was more common compared with controls (30%) (P = 0.03). CRP levels were higher in COPD patients with MetS compared with COPD patients without MetS (P < 0.001). CRP more than 14 mg/l predicts the presence of MetS in COPD patients with specificity of 83.33% and sensitivity of 88.89%. Conclusion MetS is a common comorbidity associated with COPD. CRP can be a useful predictor of MetS in COPD patients.
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Estimation of serum testosterone and luteinizing hormone levels in male patients with chronic obstructive pulmonary disease p. 212
Osama F Mansour, Rabab A El Wahsh, Maha Y El Hefnawy, Eman M Abd El Gayed, Ibrahim A Albana
DOI:10.4103/mmj.mmj_372_17  
Objective The aim of this study was to assess serum testosterone in patients with chronic obstructive pulmonary disease (COPD) and discuss the impacts of decreased serum testosterone levels as an anabolic hormone. Background Decreased levels of anabolic hormone may occur in COPD patients; thus, both serum testosterone and luteinizing hormone levels should be investigated. Participants and methods This case–control study was carried out in El-Mahalla Chest Hospital from October 2015 to February 2016. A total of 55 individuals were enrolled in the study: 35 adult male COPD patients and 20 age-matched men as a control group. All participants were subjected to a detailed assessment of history, clinical examination, chest radiography, O2saturation, spirometry [measurement of forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC), FVC, FEV1% of predicted], complete blood picture, liver function tests, kidney function tests, and random blood sugar; also, both serum testosterone and luteinizing hormone levels were measured using direct chemiluminescent technology. Results The smoking index of the COPD patients was 66.06 ± 6.83 pack-years and that of the control group was 11.25 ± 1.86 pack-years, with a highly statistically significant difference between both groups (P < 0.001). Oxygen saturation of COPD patients was 92.51 ± 1.77% and that of the control group was 96.45 ± 0.69%, with a highly statistically significant difference between the two groups (P < 0.001). In terms of the FEV1/FVC ratio, FEV1% and FVC% were highly statistically significantly lower in COPD patients compared with the control participants (P > 0.001). Testosterone was highly statistically significantly lower in COPD patients compared with the control group (P > 0.001). Conclusion Disturbances in serum testosterone hormone levels in COPD patients were correlated with smoking, FEV1, and hypoxemia.
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Study of serum leptin in patients with active pulmonary tuberculosis p. 217
Osama F Mansour, Ahmed A Khames, Esam El-Din I. Radwan, Maha Yousif, Mai M. A. Elkhatib
DOI:10.4103/mmj.mmj_514_17  
Objective To assess the level of serum leptin in patients with active pulmonary tuberculosis (TB). Background One of the most important and common complaint of patients with TB, which also affects the immune status, is weight loss. When TB infection occurs, a variety of chemokines and cytokines are secreted from infected cells and tissue macrophages. Leptin is a 16-kDa protein, and its level varies with active pulmonary TB. Patients and methods Serum leptin level was measured in 40 newly diagnosed patients with active pulmonary TB (group I) and 20 matched control (group II). Results Serum leptin level was significantly lower in patients with active pulmonary TB than controls. There was a highly significant positive correlation between leptin level and BMI. Serum leptin had a significantly negative correlation with grades of Ziehl–Neelsen stain and chest radiography. The cutoff point of leptin was found to be 0.54 ng/ml for discrimination of patients with active pulmonary TB. Conclusion Serum leptin hormone level was lower in patients with tuberculosis than in controls, which indicates that leptin plays a role in diminishing appetite, weight loss, and increasing susceptibility to infection.
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Vitmain D level in female pattern hair loss with normal androgen level p. 221
Magda M Hagag, Maathir El-Shafie, Rasha A Darwish
DOI:10.4103/mmj.mmj_236_17  
Objectives The aim of this study was to assess serum vitamin D level in women with female pattern hair loss (FPHL) to approve its relation in this disorder. Background FPHL is the main cause of diffuse hair loss in adult women and majorly affects patient's personal satisfaction. FPHL is the preferred term for androgenetic alopecia in women as the relation between androgens and this illness is not proved. Androgen excess has not been demonstrated in FPHL. The connection between serum 25-hydroxy vitamin D and FPHL has not been considered altogether. Patients and methods In this case–control study, we studied serum vitamin D level concentration among 31 FPHL patients aged 20–40 years in comparison with 31 healthy female controls matched for age, skin phototype, socioeconomic level, and outdoor exposure. Measurements were conducted by enzyme-linked immunosorbent assay. The study was conducted within a 4-month period, from July to October 2016. Results The mean serum vitamin D level was significantly lower in FPHL patients (18 ± 7.57 ng/ml) than in controls (35.09 ± 15.39 ng/ml; P < 0.001). This result supports the suggestion that the decreased hair density present in patients with FPHL may possibly be associated with decreased levels of mean serum vitamin D levels. Significant difference was found between the three Ludwig's degrees regarding the mean serum vitamin D level (20.04 ± 7.49, 17.77 ± 6.98, and 8.43 ± 0.75 ng/ml, respectively) between degrees I and III and between degrees II and III. Conclusion The lack or inadequacy vitamin D may assume a conceivable part in the pathogenesis of FPHL.
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A study on chronic idiopathic urticaria and Helicobacter pylori infection p. 226
Magda M Hagag, Azza G. A. Farag, Nesreen G Elhelbawy, Eman G. D. El-Gendy
DOI:10.4103/mmj.mmj_247_17  
Objective The aim of this paper was to assess the effect of successful eradication of Helicobacter pylori (H. pylori) infection on the activity of chronic idiopathic urticaria (CIU) in patients with CIU infected with H. pylori. Materials and methods Medline databases including PubMed, Medscape, ScienceDirect, and EMF-Portal and all materials available in the Internet from 2005 to 2016 were searched. The initial search presented 28 articles, of which six met the inclusion criteria. The articles studied the relation between CIU and H. pylori infection and the effect of H. pylori eradication on the disease activity. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Comparisons were made by structured review, with the results tabulated. Findings In total, six potentially relevant publications were included, and they were all human studies. Several studies showed high prevalence of H. pylori infection in patients with CIU, with clinical improvement of the disease activity after H. pylori eradication, whereas other studies concluded that there is no evidence that eradication of H. pylori improves the outcome in patients with CIU. The high rate of spontaneous remission and the coexistence of multiple foci will always obscure the evaluation of any specific antimicrobial therapy. Conclusion We found that H. pylori may play a role in the pathogenesis of CIU, and H. pylori eradication therapy must be tried for positive cases with CIU.
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Study of serum and seminal carnitine levels in Egyptian men with chronic hepatitis C p. 231
Abdalla M Attia, Hossam A Yasien, Mona S Habib, Wesam A El-Degwy
DOI:10.4103/mmj.mmj_304_17  
Objective The aim of the study was to evaluate the serum and seminal carnitine levels in Egyptian men with chronic hepatitis C virus (HCV) infection. Background In 2015, HCV still affects a substantial proportion of the Egyptian population, in the 1–59 year age, 5.3 million persons are positive for HCV antibodies. Numerous studies have investigated the benefits of carnitine supplementation on improving the complications of viral hepatitis, like steatosis and hepatic encephalopathy. Patients and methods A cross-sectional study was conducted on 35 patients with HCV attending the hepatitis outpatient clinic, in Shebin El-Kom Teaching Hospital, Egypt. Moreover, 20 healthy individuals were also included as a control group. They were all subjected to history taking and serum and semen carnitine level examination. Results Results revealed an insignificant difference between patients with HCV and healthy individuals concerning age, residence, and serum urea level. However, a significant difference was found between the groups regarding serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, creatinine level, prothrombin activity (%), and serum and semen carnitine levels. Moreover, a nonsignificant positive correlation (r = 0.331, P = 0.052) was founded between serum and semen carnitine levels in patients with HCV; in addition, a nonsignificant negative correlation (r = −0.364, P = 0.301) was found between serum and semen carnitine levels in the control group. Conclusion Results concluded that patients with HCV had significantly higher serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, urea, and creatinine level. However, they had significantly lower prothrombin activity and serum and semen carnitine levels compared with the healthy group. Moreover, an insignificant correlation was detected between serum and semen carnitine levels for patients with HCV. So, many studies on various world population with this trend are warranted.
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Relation between anti-phenolic glycolipid-1 seropositivity and other factors among the household contacts of Egyptian leprosy cases p. 238
Magda M Hagag, Manal A Safan, Dalia M Abdou
DOI:10.4103/mmj.mmj_320_17  
Objective The aim of this study was to evaluate the relationship between anti-phenolic glycolipid-1 (anti-PGL-1) seropositivity and the presence of other risk factors and signs suggestive of leprosy in household contacts (HCC) of leprosy cases. Objective Leprosy is a chronic infectious disease. Its prevalence has declined after the introduction of multidrug therapy; however, efforts are needed for early case identification. Relation of anti-PGL-1 antibody (Ab) levels in HCC and other risk factors is a point of concern. Patients and methods In this cross-sectional study, we studied serum anti-PGL-1 Ab levels among 90 HCC of leprosy cases that were reported during the period from January 2010 to May 2016 using enzyme-linked immunosorbent assay. Results The mean serum level of anti-PGL-1 Ab was significantly higher in the children category with a mean of 71.98 ± 67.88 pg/ml and in those with positive signs suggestive of leprosy with a mean of 148.91 ± 62.01 pg/ml. The mean was significantly higher when the number of residents per bedroom was more than two with a mean of 80.78 ± 72.49 pg/ml, when the number of damaged nerves was two in the leprosy cases with a mean anti-PGL-1 Ab level of 117.22 ± 79.01 pg/ml, and when the cases were of grade 2 disability at the time of diagnosis with a mean of 104.53 ± 78.11 pg/ml. Conclusion High levels of anti-PGL-1 Ab may be considered as a risk factor for leprosy. Measurement and follow-up examination of its levels may contribute to early diagnosis of leprosy in parallel with clinical assessment.
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Effect of Vitiligo Area Scoring Index on the quality of life in patients with vitiligo p. 244
Mustafa A Hammam, Hossam A Yasien, Asmaa F Algharably
DOI:10.4103/mmj.mmj_399_17  
Objective The aim of this study was to find out the relation between the vitiligo severity and quality of life of patients with vitiligo. Background Vitiligo is the chronic pigmentary disorder of the skin. It greatly affects psychological well-being, and patients experience poor body image and low self-esteem, which may lead to lower level of life quality. Patients and methods Overall, 203 patients with vitiligo were studied. Disease severity was assessed using Vitiligo Area Scoring Index (VASI), and patients were asked to answer the Dermatology Life Quality Index (DLQI) questionnaire. DLQI scores and subscores were calculated, and disease characteristics were evaluated. Results Mean age of all patients was 26.21 years. The overall DLQI mean score was 5.80 ± 5.04. The DLQI mean score was 6.68 and 3.16 in women and men, respectively. In 18.2% of patients with vitiligo, no effect was seen on the DLQI, little effect was reported in 35% of patients, moderate effect was seen in 32.5% of patients, and extremely high effect was seen in 3% of them. VASI, duration of diseases, and site of lesion were significantly positively correlated with DLQI score. Conclusion VASI, duration of the disease, and site of the lesion were positively correlated with DLQI score. Concentrating on patient's life quality is essential in the management of patients with vitiligo. Moreover, significantly strong gathering-based consultations and treatments are additionally imperative arms for dealing with vitiligo.
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Role of calgranulin C protein in psoriasis p. 250
Mohamed A Basha, Wafaa A Shehata, Sally M El-Hefnawy, Shimaa A Ibrahim
DOI:10.4103/mmj.mmj_323_18  
Objective The objective of this study was to clarify the possible role of calgranulin C (Cal C) protein in psoriasis and to correlate its level with disease severity. Background Psoriasis is a chronic inflammatory disease that affects 2–3% of world population. Cal C protein has been implicated in the pathogenesis of various inflammatory diseases. The relation between psoriasis and Cal C protein is discussed in this study. Patients and methods This case–control study was conducted on 25 patients with psoriasis vulgaris and 15 age-matched and sex-matched healthy individuals. All patients were subjected to history taking and complete medical examination. Serum levels of Cal C protein were measured by enzyme-linked immunosorbent assay technique. Serum levels of Cal C protein were statistically analyzed in relation to Psoriasis Area and Severity Index score. Results High serum level of Cal C protein among cases showed highly significant difference compared with control group (P < 0.001). Moreover, there was a highly significant difference between moderate and severe cases (P < 0.001 for both). There was a significant positive correlation between Cal C protein and Psoriasis Area and Severity Index score (P = 0.01). Conclusion Cal C protein was higher in patients with plaque psoriasis than normal population, so it may play a significant role in the pathogenesis of psoriasis and may provide important clues to assist in the development of new therapeutic strategies for patients with psoriasis and also may be used as a marker of psoriasis severity.
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Association of HLA-G gene polymorphism with hepatocellular carcinoma in Egyptian population p. 255
Maha A El Bassiouny, Ahmed A Elshaarawy, Gehan A Tawfeek, Mai I Elashmawy
DOI:10.4103/mmj.mmj_293_17  
Objective The aim of this work was to study the association of human leukocyte antigen-G (HLA-G) gene polymorphism with hepatocellular carcinoma (HCC) in Egyptian population. Background HCC represents an international public health concern as one of the most common and deadly cancers worldwide. It is the third most common cause of cancer-related death worldwide. In Egypt, HCC is the second most common cancer among men and the sixth most common cancer among women. In most cases, HCC develops within an established background of chronic liver disease (70–90% of all patients). The worldwide heterogeneous incidence reflects variations in the main risk factors, which include cirrhosis, chronic infection of hepatitis B virus and hepatitis C virus, aflatoxin, exposure to pesticide, and genetic host factors. Patients and methods This study was conducted on 100 participants: 40 patients with HCC, 40 patients with chronic hepatitis C with no radiological evidence of HCC who presented to the Hepatology Department, National Liver Institute, Menoufia University, and 20 age-matched and sex-matched healthy control group during the period between February 2015 and February 2016. HLA-G gene polymorphism was determined using PCR. Results Our study revealed no statistical difference between patients with HCC and those with chronic hepatitis C, nor between patients with HCC and the control group as regards HLA-G gene polymorphism. Conclusion HLA-G gene polymorphism is not associated with an increased risk for HCC development.
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Platelet-rich plasma in lower limb ulcers p. 261
Rawhia H El-Edel, Rasha I Noreldin, Abeer M Basiony, Yahia M El-Khateep
DOI:10.4103/mmj.mmj_495_17  
Objective The aim of this study was to evaluate the role of platelet-rich plasma gel in patient with lower limb ulcers: diabetic and varicose ulcers. Background Diabetic foot ulcer is a major complication of diabetes mellitus. Platelet-rich plasma (PRP) is used for managing diabetic foot ulcers. PRP contains alpha- granules that release growth factors on activation such as platelet-derived growth factor (PDGF) which are important for wound healing by being angiogenic and helping stem cell differentiation and maturation. Patients and methods The study included 30 patients with chronic ulcers who were selected from vascular surgery department of Menoufia University Hospitals in the duration between February 2016 and March 2017. Patients were categorized into group I (15 patients with diabetic ulcers) and group II (15 patients with varicose ulcers). PRP gel was applied every 2 weeks for a maximum of 6 weeks. PRP was evaluated for concentration of PDGF-AB before and after activation by immunoassay. Results There was significant increase in PRP platelets count and PDGF-AB concentration after activation (P < 0.001). PRP platelets count and PDGF-AB concentration after activation were significantly higher in patients with completely healed ulcers than those with incomplete healing (P = 0.04 and 0.03, respectively). Healing rate percent showed significant positive correlation with activated PRP platelets count and PDGF concentration (r = 0.514, P = 0.004 and r = 0.525, P = 0.003, respectively). Conclusion Autologous PRP gel is an efficient and a safe source of growth factors for managing lower limb ulcers.
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A study on the relationship between tissue factor expression and liver damage in diabetic patients with hepatitis C virus-related cirrhosis p. 267
Rawhia H El-Edel, Dalia H Abou-El-Ela, Nahla F Osman, Mona F. M. Salama
DOI:10.4103/mmj.mmj_496_17  
Objective The aim of this study was to identify a possible role for tissue factor (TF) in the pathogenesis of hepatic damage in patients with hepatitis C virus (HCV)-related cirrhosis with type 2 diabetes mellitus (T2DM). Background HCV infection and T2DM are both prevalent diseases worldwide. The exact mechanism by which type 2 diabetes worsens liver function is needed to be clarified. TF is a key link that connects hemostatic, immune, and inflammatory processes. Materials and methods The study included 80 participants divided into three groups: 30 patients with HCV-related cirrhosis and T2DM, 30 cirrhotic patients, and 20 healthy controls. Flow cytometry analysis was used for measuring TF (CD142) and the costimulatory molecule (CD86) on lipopolysaccharide-activated monocytes (CD14 positive cells) in peripheral blood in different studied groups. Results Our results have shown higher TF and CD86 expression in cirrhotic patients with T2DM compared with those with cirrhosis and healthy controls (34.06 ± 5.99, 24.65 ± 6.76 and 11.90 ± 3.04 for TF and 72.09 ± 12.57, 49.38 ± 15.07 and 9.35 ± 3.07 for CD86, respectively; P < 0.001). In addition, higher TF expression was associated with deteriorated liver function and higher Child–Pugh grade (P = 0.01). Conclusion On the basis of our data, we suggest a possible role for TF in the pathogenesis of liver damage through exaggerating the inflammatory process. This can, at least partially, explain the worsened liver function in HCV-related cirrhosis in patients with T2DM.
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Cytochrome p450-2J2 gene polymorphism in patients with coronary artery disease p. 275
Rasha I Noreldin, Ayman A Azzam, Rehab I Yaseen, Aliaa A El Feshawy
DOI:10.4103/mmj.mmj_584_17  
Objective The objective of this study was to study the CYP2J2 gene polymorphism in patients with coronary artery disease (CAD). Background Cytochrome P450 (CYP) 2J2 is expressed in the vascular endothelium and metabolizes arachidonic acid to epoxyeicosatrienoic acids. Epoxyeicosatrienoic acids are vasodilators and inhibitors of vascular inflammation. Patients and methods This case–control study was carried on 80 participants; 55 of them had CAD and 25 control participants had no coronary artery stenosis. They were selected from Cardiac Catheterization Laboratory of Menoufia University Hospital from November 2015 to March 2017. They underwent a full history, clinical examination, ECG, random blood glucose level, lipid profile (triglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol), and CYP2J2 polymorphism assessment by real-time PCR assay. Results The CYP2J2 genotype, alleles, and the dominant model (CC vs. CT + TT) distributions of single-nucleotide polymorphism (rs2280275) showed a significant difference between patient and control groups for total participants and males (for genotype: P < 0.001; for allele: P < 0.001; for dominant model: P < 0.001 respectively). The multiple logistic regression analysis for total participants and males showed that those who had either TT or CT were 1.08 and 1.09 times, respectively, to have CAD. The CYP2J2 genotype, alleles, and the dominant model distributions showed a significant difference between the two vessel groups (for genotype: P = 0.032; for allele: P = 0.007; for dominant model: P = 0.029). Conclusion The obtained results suggested that CYP2J2 polymorphism was associated with an increased risk of CAD.
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RECK gene promoter polymorphisms in patients with hepatocellular carcinoma along with chronic hepatitis C viral infection p. 282
Dalia H Abou-Elela, Aymen A AlGhoraie, Heba A Mostafa
DOI:10.4103/mmj.mmj_763_17  
Objective The aim was to study possible associations of reversion-inducing cysteine-rich protein with Kazal motifs (RECK) gene polymorphisms (rs11788747 and rs16932912) with the risk of developing hepatocellular carcinoma (HCC) among hepatitis C virus (HCV)-infected Egyptian patients. Background RECK is a membrane-anchored glycoprotein. Downregulation of RECK was found in a variety of neoplasms to be associated with poor survival and distant metastasis. Patients and methods The study included three groups: group I comprised 30 apparently healthy participants as a control group, group II comprised 35 patients with cirrhosis having HCV infection, and group III comprised 35 patients with cirrhosis having HCC along with HCV infection. PCR-restriction fragment length polymorphism was used for detection of RECK gene polymorphisms (rs11788747 and rs16932912). Results Regarding rs11788747, mutant AG/GG genotypes were statistically higher in HCC (60.0%) than in HCV and control groups (34.3 and 13.3%, respectively) and demonstrated 9.75 times (95% CI: 2.79–34.07) more risk of developing HCC compared with AA genotype (P < 0.001). G allele was statistically higher in HCC (51.4%) than HCV and control groups (22.9 and 8.3%, respectively). Regarding rs16932912, wild-type GG genotype was higher in HCC (71.4%) than in HCV and control groups (48.6 and 70.0%, respectively). G allele was statistically higher in HCC (81.4%) than HCV and control groups (71.4 and 83.3%, respectively) but without any statistical significance among groups regarding alleles. Conclusion RECK rs11788747 polymorphism could be involved in the pathogenesis of HCC, and rs16932912 polymorphism was not associated with the pathogenesis of HCC.
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Tissue factor expression on platelets in patients with acute coronary syndrome p. 289
Amr A Fathy, Mohamed A Soliman, Mohamed A Helwa, Rehab E Yasin, Nermeen H. A. El-Sattar
DOI:10.4103/mmj.mmj_123_16  
Objective To investigate the expression of tissue factor (TF) on platelet monocyte aggregates (PMA) and platelets as a participating factor in pathogenesis of acute coronary syndrome (ACS). Background ACS is due to rupture of an arterial plaque. TF on platelets and PMA may provide potential distal sites for generation of new thrombi. In this study, the expressions of TF on PMA and platelets are investigated as participating factors in pathogenesis of ACS. Patients and methods Twenty-five patients with acute myocardial infarction, 25 patients with stable angina, and 20 clinically healthy patients as control are investigated for TF on PMA, as well as platelet-associated TF by flow cytometry analysis. Results TF on platelets and PMA were highly significant in patients with acute myocardial infarction than those with stable angina and controls. Conclusion The greater expression of TF on platelets and PMA strengthens the link between platelet activation, blood coagulation, and thrombus formation and may further contribute to the hypercoagulability associated with the disease.
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Association between survivin gene polymorphism and colorectal cancer p. 296
Waleed M Fathy, Mohamed S Amar, Belal Montaser, Mona Maamoun Ahmed
DOI:10.4103/mmj.mmj_155_18  
Objective To study the possible association of genetic polymorphism of survivin gene (rs9904341) with the risk of developing colorectal cancer (CRC) in Egyptian patients and explore the mechanisms of survivin polymorphism in the development of CRC. Background Survivin gene is an inhibitor of apoptosis, plays an important role in cell cycle regulation, and may be involved in the development and progression of cancer. Structurally, the human survivin gene comprises four exons and three introns spanning 14.7 kb, which encodes a 16.5 kDa protein. Survivin gene is expressed mostly at the G2/M phase and declines rapidly in the G1 phase of cell cycle. This is largely transcriptionally controlled and involves cell cycle-dependent elements and cell cycle homology regions located in the survivin gene promoter. This mutation can depress cell cycle-dependent transcription of the survivin gene and result in the overexpression of survivin at mRNA and protein levels. Survivin −31G/C polymorphism may be associated with CRC. Patients and methods A case–control study was carried out between November 2016 and December 2017 at the Clinical Pathology Department, Faculty of Medicine, in collaboration with the General Surgery Department and Oncology Department, Menoufia University. The case–control study included 100 participants divided into two groups. Group I included 50 diagnosed CRC patients and group II included 50 apparently healthy participants as a control group. PCR-restriction fragment length polymorphism was used for the detection of survivin gene polymorphisms (rs9904341). Results Mutant CC genotypes was statistically higher in the CRC group (42%) than in the control group (18%) (P = 0.01). C allele was statistically higher in the CRC group (62%) than in control group (43%) (P = 0.007). Conclusion The −31CC genotype of survivin gene is associated with CRC and may be a risk factor for the development of CRC.
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Screening intelligence of children p. 301
Ali M El-Shafie, Dalia M El-Lahouny, Zein A Omar, Shereen R. A. El-Shiemy
DOI:10.4103/mmj.mmj_309_17  
Objective Screening intelligence of primary school children using the draw-a-person test (DAPT) in Tanta District El-Gharbia Governorate. Background Drawing is a form of expression and children draw what they know. The drawing tests were used since its conception for evaluating the personality, sensory deviates and intellectual development. Patients and methods One thousand apparently healthy primary school children from 6 to 12 years old in Tanta District, El-Gharbia Governorate are included in our study. All students were subjected to DAPT; their parents were asked to fulfil a questionnaire that included full name, date of birth, parent's job, degree of parents education and family income. Results Of the 1000 children, 501 were girls and 499 were boys, the mean age was 9.02 ± 1.41 (6–12) years. Significant correlations were found between intelligence quotient levels, socioeconomic standard, school achievement, BMI, residence and sex. Conclusion The DAPT is a useful developmental screening tool which can be used by pediatricians as a measure of intellectual maturity.
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Prevalence of diabetes mellitus among school-age children p. 305
Fahima M Hassan, Ahmed A Khatab, Wafaa M Abo El-Fotoh, Ibrahim N. T. Ganh
DOI:10.4103/mmj.mmj_324_17  
Objective The aim of this research was to study the prevalence of diabetes mellitus (DM) among school-age children in Menoufia governorate. Background DM is a metabolic disorder of multiple etiologies. Type 1 DM can occur at any age, but it is most common in juveniles. Its importance is detected from the number of patients and new cases acquiring it. Estimation of its prevalence could be used to study its varied etiology, and the effect of inheritance and environment in its genesis. Patients and methods In all, 8000 school-age children from rural and urban areas in Menoufia governorate aged between 6 and 15 years between September 2015 and September 2016 had been subjected to filling a written questionnaire based on criteria of WHO (2010) for diagnosis of DM, and detection of glucose in urine (Glucotest), as well as estimation of random blood glucose for children with positive glucotest. Results A total of 300 children showed positive data suggesting DM in the written questionnaire, 35 children gave positive glucose in urine, 30 were newly diagnosed diabetics (18 urban and 12 rural; 20 male and 10 female; 26 with positive family history of type 1 DM and 14 with positive consanguinity), and five were false positive for glucotest. Therefore, the overall prevalence of juvenile DM was found to be 3.75/1000. Conclusion The prevalence rate of juvenile DM among school-age children in Menoufia governorate was 3.75/1000.
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Effect of omega-3 on tumor necrosis factor-α in children on hemodialysis p. 311
Ghada M El-mashad, Sayed I El Gebaly, Belal F Montaser, Eman H Dawood
DOI:10.4103/mmj.mmj_475_17  
Objectives The aim of this study was to assess the effect of high-dose omega-3 supplementation on tumor necrosis factor-α (TNF-α) in children on long-term hemodialysis. Background Patients who are on hemodialysis have elevated serum levels of inflammatory markers. Giving high doses of omega-3 supplementation results in significant decrease in TNF-α (one of the inflammatory markers). Patients and methods This study was conducted at a pediatric dialysis unit in Menoufia University hospital, and included 26 patients from January 2015 to April 2015. The study commenced after approval of the local institutional ethical committee of Menoufia University hospital and obtaining written consents from all the participants in our study. Results The mean age of the 26 patients was 13.4 years (range: 8–17 years). There were 13 (50%) males and (50%) females. The comparison of the studied variables before and after supplementation with omega-3 fatty acids showed that there were statistically high significant differences between the level of TNF-α before (147.62 ± 13.57 mg/dl) and after (79.73 ± 16.884 mg/dl) supplementation with omega-3 fatty acid (P < 0.001). Conclusion The use of omega-3 caused significant decrease in serum levels of TNF-α in children on hemodialysis, and omega-3 may need to be taken in larger doses to exert its anti-inflammatory effect.
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Screening intelligence of primary school children using Draw-a-Person test p. 317
Ali M El-Shafie, Dalia M ElLahony, Mohamed A Samir, Khaled M Biram
DOI:10.4103/mmj.mmj_580_17  
Objectives The aim of this study was to screen intelligence among primary school children using Draw-a-Person test (DAP) in Alexandria, Egypt. Background DAP test was created by Dr. Florence Goodenough in 1926. It measures multiple developmental streams of progress like learning, cognitive, visual, and motor by having the child to draw any person, with scoring based according to the presence and quality of features. By comparing the raw score to the typical rates of drawing, the child's intelligence quotient (IQ) is obtained. Patients and methods This study was carried out on 1000 apparently healthy primary school children aged from 6 to 12 years in Alexandria, Egypt. Students were subjected to medical evaluation. Parents were given a personal/family data questionnaire by the students to assess their socioeconomic standard (SES), which also contained a part for the student's medical history to exclude any serious medical problems or chronic diseases that might affect test score. School achievement data were obtained from student's school file. Thereafter, the students performed the test. Results The study showed that the number of children with gifted intelligence was 24 (2.4%), with superior intelligence was 85 (8.5%), with average intelligence was 816 (81.6%), with borderline intellectual function was 41 (4.1%), and lastly, with mild and moderate mental retardation was 34 (3.4%). Positive correlations were found between IQ and SESs, school achievement, and residence. No correlation was found between IQ and sex. Conclusion The DAP test provides pediatricians with an easy and low-cost developmental screening device, alerting them to the possibility of developmental disorders.
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C-reactive protein as a marker of pediatric hemodilaysis adequacy p. 323
Ghada M El-Mashad, El S. I. El-Gebally, Tarek H Mohamed Afifi
DOI:10.4103/mmj.mmj_591_17  
Objective To compare the C-reactive protein (CRP) levels with the delivered dose of dialysis in terms of index of hemodialysis adequacy (Kt/V) in patients undergoing maintenance hemodialysis (HD). Background According to different studies, the target Kt/V should be 1.2 per session, while weekly Kt/V should be 4.5 for thrice-weekly HD patients to maintain adequate HD. Patients and methods This is a comparative, cross-sectional survey study. Patients who fulfilled the inclusion and exclusion criteria were enrolled in the present study. The delivered dose of HD, Kt/V was assessed by online clearance module (OCM) in Fresenius machines at the end of every session of dialysis and the weekly Kt/V was determined by adding all the three Kt/V values. On the other hand, serum CRP was determined after each session of HD. Both weekly Kt/V and CRP values were entered in a predesigned proforma. Results Of 30 patients on maintenance HD, high serum CRP level (>6 mg/dl) was found in nine patients. When the Kt/V was compared with the CRP level, there was a negative correlation between the two parameters (r = −0.4, P < 0.001). Low Kt/V means dialysis inadequacy, which is associated with CKD state, resulting in high CRP levels. Conclusion Low Kt/V means dialysis inadequacy, and is associated with chronic inflammatory state resulting in high CRP levels. To reduce the rate of morbidity and mortality, we concluded that the quality of life of dialysis patients can be improved by offering an adequate dose of HD reflected by Kt/V of at least 4.5 per week in all patients with end-stage renal disease.
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Draw-a-person test as a tool for intelligence screening in primary school children p. 329
Ali M El-Shafie, Dalia M El Lahony, Zein O Abd El Latif, Mohamed O. A. Khalil
DOI:10.4103/mmj.mmj_603_17  
Objective The aim was to conduct a study for screening intelligence of primary school children using draw-a-person (DAP) test in Meit Ghamr District, Al-Dakahlia Governorate. Background The significance of children's drawings has been thought to provide indications of visual motor development, levels of cognitive functioning, and intellectual maturity. One of the earliest drawing tests was the DAP test devised by Goodenough to assess children's creativity, mental age, and visual motor intellectual maturity by coding features of their drawing of a man. Participants and methods This study was carried out in 1000 apparently healthy primary school children aged from 6 to 12 years old in Meit Ghamr District, Al-Dakahlia Governorate. All students were subjected to an adequate assessment of history, full clinical examination, socioeconomic level, school achievement, and also DAP test. Results The study showed that children with superior intelligence, with high average, with average, with low average, and with below average were 1.5, 9.9, 64.6, 21.1, and 2.9%, respectively. Moreover, positive correlations were found between intelligence quotient (IQ) levels and socioeconomic standards, school achievement, and residence. There was no correlation between IQ levels and children's sex. Conclusion There were a positive correlation between IQ levels obtained by DAP test and socioeconomic standards, residence, and school achievement. Moreover, no correlation was found between IQ levels and sex.
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The effect of high-dose omega-3 supplementation on lipid profile in children on chronic hemodialysis p. 335
Ali M Elshafie, Zein A Omar, Belal A Montser, Mohamed A. M. E. Farahat
DOI:10.4103/mmj.mmj_632_17  
Objective The aim was to assess the changes in the lipid profile of children with end-stage renal disease (ESRD) on chronic hemodialysis after administration of high-dose omega-3. Background Children with ESRD on chronic hemodialysis have many factors that increase their risk of cardiovascular disease (CVD) such as dyslipidemia, hypertension, and physical inactivity. CVD is considered to be one of the major causes of morbidity and mortality in these children. Some studies were done on the omega-3 effects on lipid profile, the results of which were promising that omega-3 can improve the lipid profile which has a good impact on saving the ESRD patients from dyslipidemia and CVD. Patients and methods This interventional prospective study had included 26 children with ESRD on chronic hemodialysis in the Pediatric Hemodialysis Unit at the Menoufia University Hospital, who were treated daily with a high dose of omega-3 (2000 mg) for 3 months (from January to April 2016) and lipid profile was done and compared before and after omega-3 supplementation. Results After supplementation of high-dose omega-3, there were statistically highly significant decrease (P < 0.001) in total cholesterol by 30%, triglyceride by 32%, and low-density lipoprotein by 23%, together with a statistically highly significant increase (P < 0.001) in high-density lipoprotein by 26%. Conclusion The use of high-dose omega-3 had caused significant improvement in the lipid profile of ESRD children on chronic hemodialysis, so supplementary omega-3 may be a suitable treatment for these patients.
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Effect of high-dose omega-3 on inflammatory markers in children on long-term hemodialysis p. 340
Ali M Elshafie, Zein A Omar, Belal A Montser, Alaa M Mohamed K Bassiouny
DOI:10.4103/mmj.mmj_665_17  
Objective The aim of this study was to evaluate the effect of high-dose omega-3 on inflammatory markers in children on long-term hemodialysis. Background Children with end-stage renal disease (ESRD) on hemodialysis have elevated serum levels of inflammatory markers. Prevention and treatment of inflammatory syndrome is of high priority in patients who are on hemodialysis. Omega-3 fatty acids have been postulated to reduce inflammatory markers. Patients and methods This prospective study included 26 children with ESRD on long-term hemodialysis in the Pediatric Hemodialysis Unit at Menoufia University Hospital who received 2 g omega-3 per day orally for 3 months, and inflammatory markers were assessed and compared before and after omega-3 supplementation. Results A total of 26 children were included in the study, and their mean age was 13.4 years (range: 8–17 years). The number of males was 13 (50%), and the number of females was 13 (50%). The comparison of the studied variables before and after supplementation with omega-3 fatty acids showed that there was a highly statistically significant difference between the level of interlukin-6 (IL-6) and C-reactive protein (CRP) before and after omega-3 supplementation. IL-6 level was 149.45 ± 13.477 mg/dl before supplementation, which decreased to 96.19 ± 7.299 mg/dl after supplementation of omega-3 (P < 0.001). CRP level was 10.54 ± 0.884 mg/dl before supplementation, which decreased to 6.499 ± 1.113 mg/dl after supplementation of omega-3 (P < 0.001). Conclusion The use of omega-3 fatty acids (2 g/day) caused significant decrease in serum levels of inflammatory markers (IL-6 and CRP) in children with ESRD on long-term hemodialysis.
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Plasma levels of von Willebrand factor in maintenance hemodialysis patients: its relation to vascular access thrombosis p. 345
Hassan Abd El-Hady, Mahmoud A Kora, Khaled M. A. El-Zorkany, Belal A Montaser, Amira M. E. Yousuf
DOI:10.4103/mmj.mmj_416_17  
Objective The aim of this study was to assess von Willebrand factor (VWF) plasma levels in patients under maintenance hemodialysis (HD) to determine its role in the occurrence of vascular access thrombosis (VAT) in such patients. Background HD process is associated with increasing thrombotic trend especially owing to platelets and clotting factor activation. Vascular access complications increase morbidity and contribute to 20–25% of all hospitalizations in HD patients, of which ~ 85% of these cases are because of thrombosis. VWF is an important component of the hemostatic system and a hypercoagulability state biomarker. Patients and methods This case–control study was conducted on 60 patients on HD for more than 6 months classified into two groups: group I (GI) included 30 patients with VAT, whereas group II (GII) included 30 patients without VAT. Moreover, 20 healthy individuals served as a control group. History taking, clinical examination, and investigations (complete blood count, kidney function tests, liver function tests, lipid profile, fasting blood sugar, postprandial blood sugar, and serum VWF) for all cases were done. Results Mean VWF serum level was found to be higher in HD groups (GI 1361.47 ± 270.38 and GII 950 ± 138.12) than control group (351.5 ± 34.8), with highly statistical significance. A cutoff level of VWF at 1277 ng/ml is accurate (46.67%) for ocurrance of VAT in GI patients, with sensitivity of 93.33%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 93.8%. Conclusion High VWF levels related to development of VAT.
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Therapeutic effects of human stem cells in experimentally induced acute kidney injury in rats p. 352
Mahmoud A El-Aziz Kora, Ahmed M Zahran, Ahmed R Tawfiq, Yahya M. Naguib Abd El-Salam, Hussain M Hussain Kholaif
DOI:10.4103/mmj.mmj_530_17  
Objective The aim of this study was to evaluate the effect of stem cell therapy in drug-induced acute kidney injury in rats. Background Acute kidney injury (AKI) is defined as a rapid decrease in renal functions within few days; thus drug-induced AKI is a frequent entity in clinical medicine. Stem cell therapy provides a hopeful prospective for injured tissues and for repairing damaged organs. Materials and methods A total of 30 male Swiss albino rats were used in the present study. The animals were randomly divided into three groups. Group I: control group (10 rats). Group II: AKI group (10 rats), gentamicin-induced AKI rat models were used. Group III: stem-cell-treated AKI group (10 rats). Rats with established AKI were injected with CD34-positive stem cells. The three studied groups were assessed for serum urea, blood urea nitrogen, serum creatinine, and kidney injury molecule 1 (KIM-1). At the end, all the rats were killed and their kidneys were excised for histopathology and immunohistochemical studies. Results Serum KIM-1 level was significantly higher in the AKI group in comparison with both control group and stem-cell-treated group (P = 0.001), whereas no statistically significant difference was found between control group and stem-cell-treated group regarding serum KIM-1 level (P = 0.755). The results of the immunohistopathological studies have shown no significant changes between control group and AKI-stem-cell-treated group. Conclusion This study showed that AKI markers improved after treatment by stem cells in AKI-induced group.
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Diagnostic value of serum Dickkopf-1 as a predictor of hepatocellular carcinoma in patients with liver cirrhosis p. 359
Ashraf G Dala, Mohammed H Badr, Mona S Habib, Ahmed E El-Shandalaty
DOI:10.4103/mmj.mmj_694_17  
Objective The aim of this study was to evaluate the significance of Dickkopf-1 (DKK-1) as a tumor marker for the diagnosis of hepatocellular carcinoma (HCC) in cirrhotic patients. Background HCC is a major health problem and its prognosis still remains dismal. Patients and methods This cross-sectional study included 50 cirrhotic patients with HCC, 50 cirrhotic patients without HCC, and 20 healthy age-matched and sex-matched participants as controls. All patients and controls were subjected to the following: full history taking, full clinical examination, and investigations as complete blood count, kidney function tests, liver function tests, serum α-fetoprotein (AFP), serum DKK-1, abdominal ultrasound, and triphasic computed tomography scan were done. Results DKK-1 level was significantly higher in the HCC group than in cirrhotic and control groups (P = 0.002). DKK-1 was significantly higher in multiple focal lesions (P = 0.010) and large focal lesions greater than 5 cm (P = 0.014). The best cut-off value of DKK-1 was 1.122 with a sensitivity of 80%, specificity of 77.1% with an area under curve of 0.810 and P value of less than 0.001. The validity of combined serum AFP and DKK-1 in the diagnosis of HCC showed an increased sensitivity of 92%, specificity of 77.1% with an area under curve of 0.882 and P value of less than 0.001. Conclusion DKK-1 was more sensitive and specific than AFP in the early diagnosis of HCC in cirrhotics. Combined use of DKK-1 and AFP increased the sensitivity and specificity for the diagnosis of HCC than serum AFP or DKK-1 alone.
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Study of serum endotoxin in patients with liver cirrhosis with and without hepatic encephalopathy p. 363
Ayman M El-Lehleh, Ayman A Algamal, Rania A El-Shazly, Enas F El Mezain
DOI:10.4103/mmj.mmj_653_17  
Objective To study serum endotoxin in patients with liver cirrhosis with and without hepatic encephalopathy (HE). Background HE is a common complication of liver cirrhosis. Studies suggest that endotoxin and ammonia play an important role in its pathogenesis. Patients and methods This prospective study was conducted from November 2016 to May 2017 on 30 patients with liver cirrhosis without HE as group I, 30 patients with HE (group II) and 30 age-matched and sex-matched healthy individual as the control group. All were subjected to history taking, complete medical examination, and thorough laboratory and radiological investigations. Serum endotoxin was measured by enzyme-linked immunosorbent assay technique and arterial ammonia was measured by the enzymatic method. Results There were significant increase in endotoxin and arterial ammonia in cirrhotic patients than controls, with the highest levels in group II and higher levels in comatosed patients than those in precoma. There was a positive correlation between endotoxin and ammonia in group I (r = 0.62, P < 0.001) and group II (r = 0.92, P < 0.001). To predict cirrhosis, serum endotoxin had a sensitivity of 92%, specificity of 80%, and a cutoff point of 0.28 EU/ml, while at a cutoff point of 38 μmol/l arterial ammonia had a sensitivity of 80 and a, specificity of 77%. To predict HE, serum endotoxin had a sensitivity of 93%, specificity of 77% at a cutoff point of 0.42 EU/ml, while at a cutoff point of 75.5 μmol/l arterial ammonia had a sensitivity of 80% and a specificity of 73%. Conclusion Serum endotoxin and arterial ammonia were elevated in patients with liver cirrhosis with higher levels in HE and the highest in hepatic coma.
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Maternal and neonatal outcomes of placenta accreta: a descriptive case series study p. 368
Mohamed A. S. Kandil, Tarek M Sayyeda, Abdelhaseeb Salaha, Nehal M. A. Al Gilanyb
DOI:10.4103/mmj.mmj_673_17  
Objective The objective of this study was to evaluate maternal and neonatal outcomes of placenta accreta. Background Placenta accreta is the leading cause of maternal and neonatal morbidity and mortality. Patients and methods This descriptive case series study included 40 pregnant women with placenta accreta and was carried out at Department of Obstetrics and Gynecology of Menoufia University Hospitals for 10 months. The study cohort included all admitted pregnant women with the diagnosis of placenta previa accreta whether presenting with or without vaginal bleeding after 28 weeks of gestation confirmed by ultrasound scan. Data were collected and confirmed by positive ultrasonographic criteria of placenta accreta. The study outcomes included maternal mortality, urinary tract injuries, cesarean hysterectomy admission to ICU, preoperative and postoperative hospital stay, perinatal mortality, neonatal birth weight, Apgar score at 1 and 5 min, admission to neonatal ICU, or any other complications. Results Our study included 40 patients, and there was a highly significant statistical difference between patients who underwent hysterectomy (n = 21) and who did not (n = 19) regarding type of cesarean delivery (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040). Conclusion Morbidly adherent placenta is becoming an increasingly common complication of pregnancy with increasing rates of cesarean births. Prenatal diagnosis and management is the most important factor in optimizing the treatment and outcome of women with adherent placenta.
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Evaluation of femtosecond laser-assisted implantation of intracorneal ring segments in cases of keratoconus p. 375
Abd El-Rahman El-Sebaey, Farid M. W. Farid, Alia M Nagy
DOI:10.4103/mmj.mmj_45_18  
Objective To evaluate the clinical outcomes after implantation of the intracorneal ring segments (ICRSs) by means of femtosecond laser technology in eyes with keratoconus. Background Corneal modeling by inserting intrastromal implants has been proposed and investigated as an alternative treatment option in corneal ectasia. Femtosecond laser technology allows the surgeon to program a corneal stromal dissection at a predetermined depth with an extremely high degree of accuracy, which avoids the potential inaccuracies of a mechanical dissection. Patients and methods A total of 35 eyes of 28 patients were included in the study. All cases presented with reduced best spectacle corrected visual acuity, contact lens intolerance, and pachy apex of more than 380 μm. ICRSs, selected according to special nomogram depending on spherical and cylindrical correction and site of cone, were implanted in all cases into an intrastromal corneal tunnel created by means of femtosecond technology. Visual, refractive, corneal topography, and pachymetric changes were evaluated during a 1-month follow-up. Results Significant improvement in best-corrected visual acuity was observed after surgery (P = 0.0001), which was consistent with the significant reduction in sphere (P = 0.001) and cylinder (P = 0.001). Furthermore, a significant corneal flattening of a mean value of 2.68 D was found (P = 0.001). Corneal thickening was also observed postoperatively in the pachy apex, which was statistically significant (P = 0.001). Conclusion ICRSs implantation using femtosecond technology in keratoconus allows significant improvement in visual, refractive, and keratometric outcomes.
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Superiorly based septal mucosal flap for endoscopic repair of nasal septal perforation p. 380
Adel T Atallah, Yaser A Khalil, Ibrahim A Abdelshafi, Ashraf A El-Demerdash, Ahmad M Hamdan
DOI:10.4103/mmj.mmj_72_18  
Objective To assess the outcome of endoscopic superiorly based septal mucosal flap technique in the repair of nasal septal perforation. Background Septal perforations are a common problem with many surgical options for closure using either closed or open approach. Patients and methods This case series study included 14 patients with anterior septal perforation with idiopathic or iatrogenic etiology recruited from Otorhinolaryngology Department, Menoufia University, during the period from July 2015 to July 2017. The patients were assessed using history taking, anterior rhinoscopy, endoscopic examination, and computed tomography. Preoperative symptoms were assessed using visual analog scale. All patients were subjected to superiorly based septal mucosal flap. The success rate was assessed with operative duration, operative blood loss, and postoperative symptom scores. The success of the operation was correlated with vertical and anteroposterior diameters of the perforation. Results The success rate of the technique was 71.4%. The mean operative duration was 2.23 ± 0.44 h. The mean blood loss was 93.6 ± 13.9 ml. There was a highly significant improvement in all symptom scores except for whistling, which showed a significant improvement (P < 0.001 and P = 0.002, respectively). There was a significant relationship between the success of the operation and the anteroposterior diameter (P = 0.002) but not the vertical diameter (P = 0.7). Conclusion Our flap technique is a new and good option for repair of septal perforations with a success rate of 71.4%. It is most effective with limited anteroposterior diameters. Large anteroposterior diameters need other flap designs or an open approach.
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LETTER TO THE EDITOR Top

Patient satisfaction and compliance in family: a comment p. 387
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/mmj.mmj_631_17  
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