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   Table of Contents - Current issue
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July-September 2017
Volume 30 | Issue 3
Page Nos. 637-970

Online since Wednesday, November 15, 2017

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REVIEW ARTICLES  

Review on personalized colorectal cancer Highly accessed article p. 637
Hussein Ageely
DOI:10.4103/1110-2098.218285  
Objective The aim of this work was to study biomarkers as indicators of personalization of medicine (PM) for colorectal cancer (CRC). Background PM is considered to be the medicine of the future, as the scope of interest has shifted to patient-specific treatments and remedies. The understanding of human genomics improves the capability of better understanding diseases from the genetic perspective, which is particularly useful in treating CRC. Biomarkers are considered indicators that help in evaluating the prognosis of CRC; in fact, they are now considered to be reliable indices for the diagnosis and leveling of the different stages of cancer. Methods The author performed a narrative synthesis of studies for biomarkers in personalization of CRC. Therefore, relevant publications were identified, reference lists were examined, and citation searches were performed. No restrictions on date or type of study were applied. Recent findings Biomarkers are actively engaged in managing PM of CRC, as determined for diagnosis, follow-up, and progress of the treatment and also to select the appropriate treatment. Conclusion It would be recommended to use these biomarkers in clinical practice worldwide. Nevertheless, challenges arise in the implementation of biomarkers as diagnostic and prognostic tools because logistical and infrastructural improvements are needed.
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Role of vitamin D and its deficiency in pediatric critical illness Highly accessed article p. 645
Ahmed A Khattab, Nagwan Y Saleh, Mohamed A El Monem Gohar
DOI:10.4103/1110-2098.218279  
Objectives The aim of this study was to assess the role of vitamin D and its deficiency in pediatric critical illness. Methods Medline databases (PubMed, Medscape, ScienceDirect) and all materials available in the Internet from 2003 to 2016. The initial search presented 98 articles, of which 32 fulfilled the inclusion criteria. The articles studied the role of vitamin D and its deficiency in pediatric critical illness. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was obtained, eligibility criteria were specified, there were appropriate controls, there was adequate information, and defined assessment measure. Comparisons were made by structured review with the results tabulated. Results In total, 32 potentially relevant publications were included. The studies have identified that vitamin D insufficiency and deficiency are associated with poor clinical outcomes in all pediatric age groups. These disorders are especially prevalent in critically ill patients. The data related to vitamin D deficiency and morbidity and mortality are varied, but in larger studies, it has been associated with major adverse effects on clinical outcome and mortality. Conclusion We found that vitamin D plays a major role during the course of several critical diseases in the body such as critical diseases of the cardiovascular, respiratory, nervous, endocrine, renal systems, etc. Vitamin D deficiency is associated with poor clinical outcomes in all populations. These disorders are especially prevalent in critically ill patients.
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Puberty disorders and environmental disruptors Highly accessed article p. 653
Mostafa G El Nagar, Alaa A Dawood, Marwa G Elsayed
DOI:10.4103/1110-2098.218294  
Objectives The aim of this study was to perform review studying the effect of different environmental disruptors on normal puberty and occurrence of its disorders. Data sources PubMed, Web of science, Wiley Online Library, Central Authentication Service, and Astrophysics Data System were searched. The search was performed from 1 September 2016 to 15 October 2016. Study selection The initial search presented 250 articles. The researches that met the inclusion criteria were six articled. The articles included physiology of puberty in male and female individuals, puberty disorders, endocrinal disruptors, and effects of endocrinal disruptors on puberty. Data extraction Data from each eligible study were independently abstracted in duplicate using a data collection form to capture information on study characteristics, interventions, and quantitative results reported for each outcome of interest. Data synthesis There was heterogeneity in the collected data. It was not possible to perform meta-analysis. Significant data were collected. Thus, a structured review was performed. Conclusion Puberty marks a transition between childhood and the adult reproductive stage. It is a vulnerable stage of life, and deregulation has been linked to increased health and psychosocial problems. Puberty development is a multifaceted process that is under the control of different hormonal regulatory mechanisms. Both steroid and nonsteroid hormones were vulnerable to disruption by environmental chemicals. It had also become clear that although the initial focus was on synthetic chemicals such as pesticides and industrial pollutants in the environment that disrupted endocrine activity, a wide variety of chemicals, including those in food, could alter endocrine signaling. Evidence is accumulating that exogenous hormone disruptors may advance or sometimes delay puberty.
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ORIGINAL ARTICLES Top

Study of osteopontin in chronic hepatitis C virus-related liver cirrhosis p. 657
Ashraf G Dalaa, Mohamad A Holwa, Eslam M Rashed
DOI:10.4103/mmj.mmj_725_16  
Background Osteopontin (OPN) is a phosphorylated acidic glycoprotein. Its expression increases during pathogenesis of hepatic fibrosis. However, its clinical usefulness in the pathogenesis of liver disease remains obscure. Objective We aimed to evaluate the role of OPN in the degree of hepatic fibrosis in chronic hepatitis C virus (HCV) patients and hepatocellular carcinoma (HCC) patients. Patients and methods This study was conducted on 85 patients who were divided into four groups. Group A consisted of 15 HCV patients with decompensated liver cirrhosis. Group B consisted of 20 HCV patients with HCC. Group C consisted of 35 HCV patients with compensated fibrosis. Group D consisted of 15 age-matched and gender-matched normal controls. All participants underwent full history taking, clinical examination, and laboratory investigations including tests for evaluation of complete blood count, alanine transaminase, aspartate transaminase, international normalized ratio, serum albumin, serum bilirubin, and serum creatinine, abdominal ultrasonography, Fibroscan, and determination of serum OPN level by ELISA. Results Plasma OPN level was highly significantly increased among HCV patients (153.9 ± 48.4) than among controls (47.1 ± 14.5). Also plasma OPN level was higher in group A (181.8 ± 20) than in groups B, C, and D (144.5 ± 12.7, 67.4 ± 18.4, and 47.1 ± 14.5 ng/ml, respectively). There was a significant positive correlation between OPN and both international normalized ratio and bilirubin and a significant negative correlation between OPN and both platelet and serum albumin levels. Moreover, there was a significant increase in OPN levels in patients with extensive fibrosis than in those with mild fibrosis (P = 0.001). The OPN level increased gradually from F1 to F4 (F1, 34.2 ± 4.50; F2, 62.1 ± 10.8; F3, 92.4 ± 16.4; and F4, 173.2 ± 61.5). Regarding the diagnostic validity of serum OPN in cases of liver cirrhosis (F4 versus F1, F2, and F3), the cutoff point was 91 ng/ml, specificity was 81%, sensitivity was 64%, and diagnostic accuracy was 73%. The area under the receiver operating characteristics curve was 0.839, suggesting its good diagnostic accuracy in the prediction of liver cirrhosis (F4). Conclusion The present study indicates that OPN level reflects the degree of hepatic fibrosis and can be used as a good biomarker for assessing the severity of liver fibrosis in HCV patients. Furthermore, serum OPN serves as a prognostic index of the progression of hepatic fibrosis to decompensated cirrhosis and HCC.
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Study of association between carboxymethyllysine and circulating soluble receptor for advanced glycation end products and cardiovascular dysfunction in nondiabetic chronic kidney disease p. 663
Hassan Abdel-Hady, Said S. A. Khamis, Hany Elbarbary, Seham A Khodeer, Heba E Kasem
DOI:10.4103/1110-2098.218252  
Objective The objective of this study was to evaluate the association between serum advanced glycation end products (AGEs) and their soluble receptors assessed on the basis of carboxymethyllysine (CML) and soluble receptor for advanced glycation end products (sRAGE) and the presence of cardiovascular dysfunction in nondiabetic chronic kidney disease (CKD) patients. Background AGE is involved in left ventricular hypertrophy (LVH) and myocardial damage, whereas sRAGE attenuates the progression of heart disease and prevents death in diabetic and nondiabetic CKD patients. Patients and methods Eighty nondiabetic CKD patients were subclassified according to estimated glomerular filtration rate (GFR) into two subgroups, CKD-3 patients with GFR between 30 and 59 ml/min/1.73 m2 and CKD-4 patients with GFR between 16 and 29 ml/min/1.73 m2 (CKD-4), using the modification of diet in renal disease formula. Our controls comprised 40 individuals with preserved kidney function of more than 90 ml/min/1.73 m2 matched by age and sex. Routine and specific investigations [serum CML and sRAGE measurement using enzyme-linked immunosorbent assay, carotid intima − media thickness (IMT) measurement using ultrasonographic scanning of the carotid artery, and conventional echocardiography] were performed. Results CML and sRAGE correlated negatively with estimated GFR (ml/min/1.73 m2) (r = −0.755 and − 0.668, respectively; P < 0.001). CML had a high significant correlation with LVH (r = 0.755; P < 0.001) and IMT (r = 0.617; P < 0.001) in CKD patients. In a logistic regression, plasma sRAGE was an inverse and independent predictor of LVH [odds ratio (OR): 15.6; confidence interval (CI): 2.5–98.9; P < 0.05], and CML was the independent risk factor for LVH (OR: 23.1; CI: 3.4–158.8; P < 0.001) and IMT (OR: 8.2; CI: 1.05–64.1; P < 0.05) in nondiabetic CKD patients. Conclusion AGEs assessed on the basis of CML can be a good predictor and a nontraditional risk factor for the occurrence of cardiovascular morbidity in nondiabetic CKD patients, whereas circulating sRAGE levels are associated in an inverse manner with carotid atherosclerosis and LVH.
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Assessment of safety measures in hemodialysis units in Qalyubia Governorate p. 672
Said S Ahmed Khamis, Mahmoud Abd El Aziz Kora, Hany S El Barbary, Sameh M Gharib
DOI:10.4103/1110-2098.218264  
Objective The objective of this study was to assess the infection-control measures that are considered one of the most important factors that threaten the safety of the patients and all workers in hemodialysis units. Background Patients undergoing hemodialysis are at risk for multiple infections, and preventing these infections in this high-risk population is a national priority. Patients and methods Nineteen hemodialysis units in Qalyubia Governorate were included in a descriptive study. A questionnaire was developed to assess infection-control measures in units. Results Most of the units studied were clean in general. Most dialysis units had enough basins, soap, and disinfectants to wash hands and an alternative disinfectant, but only 10.5% of the units studied showed commitment to wash hands or use an alternative disinfectant. Nonsterile gloves were available in 94.7% of the studied units, sterile gloves were available in 47.4% of units, and plastic gowns were available in 52.6% of the units, but none (0%) of the studied units showed full commitment to personal protection. All the units studied were keeping disinfectants and disinfection after repackaged bottles, skin disinfectant was available in 94.7% of the units, and sterile cotton enough for one patient was available in 78.9% of the studied units; 68.4% of the studied units showed that the be disposed of cotton unused after each patient, intravenous compressors reusable in 52.6% of the units, 52.6% of the studied units had no commitment to nontouch method. All employees had been vaccinated against hepatitis B virus in only 57.9% of the studied units. Finally, all units were ideal in terms of isolation of hepatitis C and B patients in separate halls, dealing with furniture and sheets, and data recording. Conclusion Hemodialysis units were ideal in terms of data recording, isolation, and dealing with furniture and sheets, but there was a clear error in hand hygiene, personal protection, methods to prevent pollution, environmental cleansing, dealing with waste products, and vaccination.
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The correlation between residual renal function and inflammation in chronic hemodialysis patients p. 679
Said S Ahmed Khamis, Yassin S Yassin, Ashraf A Dawood, Khaled M Amin El Zorkany, Elsayed G Mahros
DOI:10.4103/1110-2098.218266  
Objective The aim of the study was to study any possible correlation between inflammation and residual renal function (RRF) in chronic hemodialysis (HD) patients. Background RRF plays an important role in maintaining fluid balance, phosphorus control, nutrition, and removal of middle molecular uremic toxins. Decline of RRF also contributes significantly to anemia, inflammation, and malnutrition in patients on dialysis. Inflammation and activation of acute-phase responses are common in chronic kidney disease patients. The causes of inflammation in HD patients are multifactorial. Inflammatory reaction may originate from several sources, including graft or fistula infections, bioincompatible dialysis membrane, dialysate, endotoxin exposure, back filtration, chronic infections, and malnutrition. High-sensitivity C-reactive protein (hsCRP) assay is useful for sensitive detection of the inflammatory state. Patients and methods Fifty patients on regular HD were divided into two groups: group 1 comprising 25 patients with RRF and group 2 comprising 25 patients without RRF. Estimation of hsCRP and serum albumin and calculation of RRF were carried out. Results The mean and SD of hsCRP in HD patients without RRF was 14.90 ± 11.58 mg/l and that in HD patients with RRF was 5.71 ± 3.56 mg/l (P = 0.000). There was significant negative correlation between hsCRP and residual kidney function (r = −0.574) in group 1. There was no statistically significant difference between groups regarding serum albumin. Conclusion The levels of hsCRP were found to be elevated in chronic kidney disease on dialysis patients. There was a significant relationship between reduced glomerular filtration rate and hsCRP levels.
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Prevalence of mineral bone disorders among hemodialysis patients in Menoufia Governorate, Egypt p. 687
Hassan A. E. Ahmed, Khaled M. A. Elzorkany, Yasein S Yasein, Ahmed F Abd-Elsattar Saif
DOI:10.4103/1110-2098.218276  
Objective The aim of this study was to determine the prevalence of mineral bone disorders (MBDs) among hemodialysis (HD) patients in Menoufia Governorate. Background As kidney function declines, there is progressive deterioration in mineral homeostasis manifesting as disruption of serum and tissue concentrations of phosphorus and calcium (Ca), as well as changes in circulating levels of hormones such as parathyroid hormone (PTH). These mineral and endocrine functions are critically important in the regulation of both bone modeling and bone remodeling. Chronic kidney disease-MBD describes a broad clinical syndrome that develops as a systemic disorder of mineral and bone metabolism because of chronic kidney disease. Patients and methods This study was carried out on 100 patients with end-stage renal disease on regular HD in Menoufia Governorate. After obtaining informed consent, the included patients underwent the following examination: complete blood count, blood sugar level, lipid profile, blood urea level, serum creatinine level, albumin level, uric acid level, Ca level, phosphate level, alkaline phosphatase level, and PTH level. Results Hyperparathyroid bone disease was prevalent in 55% of the studied patients and low bone turnover in 30% of the studied patients, and both of the two groups showed highly significant association with serum Ca and phosphate levels. Suggestive MBD-related symptoms were prevalent in both high bone turnover and low bone turnover (60 and 70%, respectively). Hypocalcemia and hyperphosphatemia were observed in 64 and 74% of the studied patients, respectively. Conclusion The prevalence of MBD among the studied HD patients was 85% depending on abnormal PTH levels (55% of patients with high PTH level and 30% with low PTH levels). Most of patients with high PTH level (high bone turnover) had low serum Ca with high serum phosphorus levels (83.6 and 81.8%, respectively), whereas most of patients with low PTH levels (low bone turnover) had normal serum Ca with high serum phosphorus levels (60 and 63.3% respectively).
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Serum peroxiredoxin-3 as a useful biomarker for detection of hepatocellular carcinoma p. 693
Ehab A. A. Al-Atty, Gasser I Al-Azab, Alaa E. A. Al-Hamid, Yasser A. A. Alghobashy, Mohamed H. S. Al-Karafy
DOI:10.4103/1110-2098.218277  
Objective The aim of this study is to evaluate serum peroxiredoxin-3 (PRDX3) as a noninvasive serum marker for the diagnosis of hepatocellular carcinoma (HCC). Background Early diagnosis of HCC is the most important step in successful treatment. However, it is usually rare because of the lack of a highly sensitive and specific biomarker so that the HCC is usually fatal within a few months after diagnosis. PRDX3 is a c-Myc target gene that is required for mitochondrial homeostasis and neoplastic transformation. In our study, we attempted to evaluate the value of PRDX3 as a useful serum biomarker for the detection of HCC. Patients and methods PRDX3, α-fetoprotein (AFP), and other biochemical parameters were measured in serum samples from 50 patients. They were subdivided into three groups: 20 patients with cirrhosis and HCC (group I), 20 patients with liver cirrhosis (LC) without HCC (group II), and 10 healthy controls (group III). Correlations between serum PRDX3 expression and clinicopathological variables were analyzed. Results Serum PRDX3 was significantly higher in HCC patients than in the LC and healthy control groups. The sensitivity and specificity of serum PRDX3 for the diagnosis of HCC were 84.2 and 79.8%, respectively, at a cutoff of 162 ng/ml and the area under the curve was 0.877 compared with that of AFP (0.721) with a sensitivity of 70.1% and a specificity of 60%. Moreover, serum PRDX3 expression was strongly associated with AFP levels and focal lesion size. Conclusion Serum PRDX3 level, at a cutoff value of 162 ng/ml, could be a valuable marker for the detection of HCC in patients with LC.
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Evaluation of serum prolactin as a potential tumor marker in hepatocellular carcinoma p. 700
Ehab A AbdElatty, Elsayed I Elshayeb, Ashraf E AbdelGhani, Yasser A El Ghobashy, Mohamad A Abouhabal
DOI:10.4103/1110-2098.218290  
Objectives The aim of this study was to evaluate serum prolactin (PRL) as a potential tumor marker in the detection of hepatocellular carcinoma (HCC). Background HCC ranks fifth among the most prevalent cancers worldwide. In Egypt, the incidence of HCC had been doubling because of hepatitis C viral infection. New serum tumor markers are required for the diagnosis of HCC instead of α-fetoprotein (AFP) (the most widely used marker) due to its poor diagnostic accuracy. Prolactin receptor has been identified in a variety of human tissues, such as the liver. When PRL binds to its receptor, it leads to the activation of Janus kinase 2, a tyrosine kinase that can phosphorylate the STAT (signal transducer and activator of transcription) proteins and subsequently functions in cell proliferation and differentiation. Patients and methods Eighty adult patients were selected for this study. They were categorized as follows: group I, which included 10 healthy controls, age and sex matched; group II, which included 40 patients with cirrhosis; and group III, which included four patients with newly diagnosed HCC in addition to cirrhosis. Routine tests for liver cirrhosis and HCC were carried out. Serum PRL was measured using enzyme-linked immunosorbent assay. Results Serum PRL was significantly elevated in the HCC group when compared with the other two groups. There was a significant difference between single and multiple lesions as regards PRL level in the HCC group; it was higher in cases of multiple lesions. Significant positive correlations were found between PRL on one hand and AFP, aspartate aminotransferase platelet ratio index, and tumor size on the other hand. At a cutoff level of at least 44.5 ng/ml, serum PRL had 92.5% sensitivity, 77.5% specificity, 80.43% positive protective value, and 91.18% negative protective value for the diagnosis of HCC. Conclusion Significantly elevated serum PRL in HCC patients may act as promising and potentially complementary biomarker with AFP. It may offer more effective early detection of HCC.
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Vitamin D receptor polymorphisms as predictors of response to interferon/ribavirin-based therapy in Egyptians with chronic hepatitis C infection p. 706
S Shoeib, H Zaghla, S Dina, M Abd El Hafez, A Efat, A El Shormilisy, R Mohamed
DOI:10.4103/1110-2098.218296  
Objective The aim of the present study was to assess the influence of polymorphisms in vitamin D receptors (VDRs) Fok1 and Apa1 and interleukin 28B rs12979860 C/T on the response to interferon/ribavirin-based therapy in Egyptians with chronic hepatitis C. Background Vitamin D exerts immunomodulatory effects on the host response against infection with hepatitis C virus. Genetic polymorphisms affecting the VDR gene have been implicated in several immune disorders. Patients and methods This retrospective study was conducted on 80 patients who were divided into two groups: group I – the nonresponders group – comprised 40 patients and group II – the sustained virological response (SVR) group – also comprised 40 patients. The present study also included 20 healthy volunteers as controls. Two single nucleotide polymorphisms in VDRs Fok1 and Apa1 and in IL28B rs12979860 C/T) were determined by real-time PCR and restriction fragment length polymorphisms. Results Genotypes of IL28B rs12979860 (CC/CT/TT) were found in 23 (57.5%), 15 (37.5%), and two (5%) patients and of Apa1 (CA/AA/CC) in 24 (60%), 14 (35%), and two (5%) patients. Genotypes of Fok1 (TT/CC/TC) were found in 23 (57.5%), nine (22.5%), and eight (20%) patients, respectively, in the SVR group. Regarding IL28B rs12979860 polymorphisms, patients with a T-allele carrier had higher frequency among nonresponders (87.5%) in comparison with SVR (42.5%). Regarding VDR (Fok1) polymorphisms, patients with a C-allele carrier had higher frequency among nonresponders (92.5%) in comparison with SVR (42.5%). Regarding VDR Apa1 polymorphisms, patients with a C-allele carrier had higher frequency among nonresponders (92.5%) in comparison with SVR (65%). Conclusion Pretreatment vitamin D level was significantly higher in responders, and this can be used as a predictor of response to combination therapy for hepatitis C virus. VDR gene polymorphisms (Fok1 and Apa1) and IL28B rs12979860 polymorphism are independently related to response to interferon/ribavirin-based therapy in chronic hepatitis C.
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Assessment of serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis Highly accessed article p. 715
Moemena S El-Hamouly, Naglaa S.M. El-Abd, Ahmed R El-Gazzarah, Amira M. F. Shehata
DOI:10.4103/mmj.mmj_253_17  
Objective The aim of this study was to evaluate serum betatrophin concentrations in patients with chronic hepatitis C-related liver cirrhosis and to explore its potential relations with liver cirrhosis progression and insulin resistance (IR). Background Hepatitis C virus infection is a serious clinical condition that usually progresses to liver cirrhosis. Betatrophin is a newly discovered hormone that has been considered as important regulator of pancreatic β-cell proliferation. Patients and methods We analyzed 70 patients who were diagnosed with chronic hepatitis C-related liver cirrhosis. Patients were assorted into three groups according to Child–Pugh score. In addition, a control group was included and consisted of 20 healthy volunteers. Serum betatrophin and IR were evaluated for all patients and controls. Results Patients with cirrhosis showed significantly higher circulating betatrophin levels in comparison with healthy controls (P < 0.001). Additionally, positive correlation was observed between betatrophin concentration and the progression of liver cirrhosis as assessed by Child–Pugh score (r = 0.66; P < 0.001). Furthermore, a significantly higher IR was demonstrated in patients with cirrhosis than in controls (P < 0.001). Significantly positive association between betatrophin levels and homeostatic model assessment of insulin resistance was found (r = 0.96; P < 0.001). Conclusion Serum betatrophin was significantly increased in patients with chronic hepatitis C-related liver cirrhosis and its level positively associated with liver cirrhosis severity and IR.
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Study of serum hepcidin in patients with chronic hepatitis C p. 721
Ayman M El Lehleh, Rania A El Shazly, Rania R Hamza
DOI:10.4103/1110-2098.218262  
Objective The aim of the present work was to study serum hepcidin in patients with chronic hepatitis C (CHC) as an iron homoeostasis-regulating hormone. Background Persistent infection with hepatitis C virus (HCV) is a major cause of chronic liver disease. Many experimental and clinical studies suggest that excessive iron in CHC is a cofactor promoting the progression of liver damage and increasing the risk for fibrosis. Patients and methods In all, 40 patients with CHC (group 1) and 20 healthy individuals (group 2) who served as a control group were included in this study. All patients were subjected to the following: full and detailed history taking, complete clinical examinations, routine laboratory investigations such as complete blood count, liver function tests, prothrombin time, serum creatinine, antinuclear antibody, thyroid-stimulating hormone, α-fetoprotein, viral markers, PCR for hepatitis C, serum hepcidin (ng/ml), serum iron (μg/dl), serum ferritin (ng/ml) and serum total iron-binding capacity (TIBC) (μg/dl), abdominal ultrasound and liver biopsy for CHC patients only for histopathological examination according Metavir scoring. Results Serum hepcidin (ng/ml) was highly significantly lower in CHC patients than in controls (7.95 ± 1.72 and 17.09 ± 1.19, respectively; P < 0.001). Serum iron (μg/dl) was highly significantly lower in CHC patients than in controls (68.34 ± 8.24 and 120.56 ± 10.03, respectively; P < 0.001). Serum ferritin (ng/ml) was significantly higher in CHC patients than in controls (246.28 ± 15.12 and 101.21 ± 11.66, respectively; P < 0.001), and serum TIBC (μg/dl) was significantly higher in CHC patients than in controls (376.75 ± 10.46 and 295.6 ± 7.10, respectively; P < 0.001). Conclusion Hepcidin levels (ng/ml) in patients with CHC were significantly lower than that in HCV-negative individuals. It is an important factor in iron abnormalities and is detected in such cases in which serum iron (μg/dl) levels are significantly low. However, serum ferritin (ng/ml) and serum TIBC (μg/dl) were significantly high in CHC patients compared with HCV-negative individuals.
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The plasma zinc/serum copper ratio as a biomarker in children with autism spectrum disorders p. 727
Ghada M El-Meshad, Sameh A Abd El-Nabi, Nashwa M Moharam, Mahmoud S Abou El-Khair
DOI:10.4103/1110-2098.218255  
Objective The aim of this study was to assess the plasma zinc (Zn)/serum copper (Cu) ratio as a biomarker in children with autism spectrum. Background Autism is a complex, behaviorally defined neurodevelopmental disorder characterized by significant impairments in social interaction, verbal and nonverbal communication, and restrictive, repetitive, and stereotypic patterns of behavior. The possible etiologies that precipitate autism symptoms remain controversial in many cases, but both genetic and environmental factors have been implicated. Children with autism spectrum disorder (ASD) appear to be at risk for Zn deficiency, Cu toxicity, and often have low Zn/Cu ratio. Patients and methods The present study was designed to be of a case–control type. It enrolled 40 children. Twenty patients with autism diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision and the Childhood Autism Rating Scales were included. The control group enrolled 20 apparently healthy children, matched to the patients' age and sex. All of them were subjected to biochemical analysis for assessment of plasma Zn level and serum Cu, followed by calculation of plasma Zn/serum Cu ratio. Results Plasma Zn was decreased in patients than in controls. Serum Cu was higher in patients than in controls. Lower Zn/Cu ratio was observed in cases in comparison with controls. intelligence quotient was lower in patients than in controls. There was a correlation between age and Zn/Cu ratio, but there was no correlation between Zn/Cu ratio and BMI. There was a negative correlation between Childhood Autism Rating Scales and Zn/Cu ratio. Zn/Cu correlated negatively with some selected symptom severity in autistic children and Zn/Cu ratio. According to receiver operating characteristic curve, the optimal cutoff value of serum levels of Zn/Cu was projected to be 0.81, with a sensitivity of 85% and a specificity of 85%, and the area under the curve was 0.93. Conclusion Our results suggested an association between blood levels of Zn and Cu with ASD among our patients, and the Zn/Cu ratio could be considered a biomarker of ASD.
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Assessment of intellectual development in preschool children in west of Menoufia Governorate, Egypt p. 734
Soheir S Abou El-Ella, Maha A Mohammed Tawfik, Wafaa M Abo El-Fotoh, Amany A Kamal Baker Gomma
DOI:10.4103/1110-2098.218256  
Objective The aim of the present study was to assess intellectual development with screening of other domains of development in preschool children in west of Menoufia Governorate, Egypt. Background Ages and Stages Questionnaires (ASQ) is one of the validated developmental screening tools recommended by the American Academy of Pediatrics for the early detection of developmental delay in preschool children. Patients and methods This cross-sectional study was conducted on 502 children from the age group 24–60 months (304 children were recruited from three city centers and 198 from three villages located in the west of Menoufia Governorate). All children were screened by using the ASQ (which is specific for each age) in the first stage of assessment. A child with a score of less than or equal to the cutoff point for one or more of the developmental areas was considered as having suspected developmental delay (SDD), and further evaluation was carried out in the second stage of assessment (detailed history taking, clinical examination, and intelligence quotient and genetic counseling). Results Our results demonstrated that the overall prevalence of SDD for the age group 24–60 months was 3.6%, and for communication, gross motor, fine motor, problem-solving, and social-personal domains it was 2.4, 0, 2.2, 3, and 1%, respectively. Significant associations were found between children with SDD and paternal and maternal education, as well as consanguinity (P = 0.014, ≤0.001, ≤0.001, respectively). Boys had a higher percentage compared with girls among SDD children (72.2, 27.8%, respectively). The most observed problems in children with SDD were learning problems (33.3%), followed by specific language disorder (27.8%). Conclusion ASQ is the most valid and reliable developmental screening test for the early detection and intervention of developmental delay in preschool children, and we recommend that it should be used in our community as a preventive method.
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Assessment of intellectual development in preschool children in the East of Menoufia Governorate, Egypt p. 741
Soheir S Abou EL-Ella, Maha A Mohammed Tawfik, Naglaa F Barseem, Amany M Ali Mohammed Elatabany
DOI:10.4103/1110-2098.218257  
Objective The aim of the present study was to assess the intellectual development and other developmental domains in apparently normal preschool children in the east of Menoufia Governorate, Egypt. Background Assessing suspected developmental delays (SDDs) in preschool children is necessary for early intervention and decreasing developmental disabilities, because subtle disabilities, such as language impairment, mild intellectual and learning disabilities, are associated with poor health status. Patients and methods This cross-sectional study included 510 kindergarten children of both sexes chosen from the age group 24–60 months in the east of Menuofia Governorate, Egypt. The mean age of the children was 48.4 ± 10.2 years. The study was carried out in two stages. In the first stage, all children were screened by using the Ages and Stages Questionnaire (ASQ); those who scored below the cutoff point of the ASQ (which is specific for each age) were considered as having SDD, and were then passed onto the second stage for further evaluation (detailed history taking, clinical examination, and intelligence quotient and genetic counseling). Results Our results showed that the prevalence of SDD in the age group 24–60 months is 2.9%, and that of communication, problem-solving, fine motor, social and personal, and gross motor skills was 2.7, 2.2, 1.7, 0.6, and 0%, respectively. SDD was found to be more common among boys. Significant associations were found between children with SDD and paternal education, as well as consanguinity (P ≤ 0.001 and 0.01, respectively), which may indicate that the risk posed by genetic and environmental factors on child development is high. The most observed problem in children with SDD was a specific language disorder, followed by learning disability. Conclusion Developmental surveillance and screening is an important method of detecting delays in preschool children and the ASQ is the most valid and reliable developmental screening test, and should be used in our community.
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Critical illness myopathy and polyneuropathy in children admitted to the ICU p. 748
Ahmed T Mahmoud, Maha A Tawfik, Sameh A Abd El-Naby Abdella, Nahla M Said
DOI:10.4103/mmj.mmj_320_16  
Objective The aim of the present study was to detect critical illness polyneuropathy and myopathy in children admitted to the ICU in relation to clinical findings and therapeutic regimen. Background Critical illness polyneuropathy and myopathy is a frequent complication of critical illness, acutely and primarily affecting the motor and sensory axons. This disorder can cause severe limb weakness and prolonged weaning. Patients and methods This study included 75 patients with different diseases admitted to the pediatric ICU at Menoufia University and was conducted for the period of 2 years. The patients were divided into five groups. All patients underwent nerve conduction, and electromyography was carried out on the seventh day of admission to ICU. Results The mean age of the patients was 4.5 ± 2.3 years. Twenty-four (24%) patients developed critical illness neuropathy and myopathy, among whom 21 (28%) patients developed axonal polyneuropathy, one (1.3%) had demyelinating polyneuropathy, and two (2.7%) cases were myopathic. In children with sepsis the prevalence of axonal polyneuropathy was five (33.3%) cases, one case had axonal polyneuropathy and one had myopathy. Among children with chest diseases, four cases of the ventilated ones had axonal polyneuropathy, six (40%) cases of the sepsis ventilated children developed axonal polyneuropathy, and one was myopathic. One child of the ventilated children due to chest disease had demyelinating polyneuropathy, whereas the other five cases had axonal polyneuropathy. Overall, 66.7% of the deaths were of those who developed axonal polyneuropathy, and 85.7, 47.6, and 90.5% of the deaths were of those who were hyperglycemic, ventilated, and acidotic, respectively. Conclusion The incidence of critical illness axonal polyneuropathy was 28%, 1.3% for demyelinating polyneuropathy, and 2.7% for critical illness myopathy.
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Supportive aids for children with cerebral palsy p. 755
Soheir S Abou El-Ella, Naglaa F Barseem, Fatma L Abdallah Farag
DOI:10.4103/1110-2098.218268  
Objective The objectives of this study were to support families of children with cerebral palsy (CP), to improve their lifestyle, and decrease complications through effective interventions. Background CP is the most common physical disability of childhood with variable manifestations and comorbidities; many interventions are pursued to help children with CP. Patients and methods This study was conducted on 75 children with CP (37 males and 38 females), aged 2–15 years, with variable types, degrees, and severity of CP. They were selected randomly from an outpatient pediatric clinic of Menoufia University Hospitals. In the first 4 months, parents of these children were trained for solving difficulties of their children in weekly visits. Patients were evaluated at the end of these 4 months and then every 2 months to assess outcome; retraining was provided if needed. Results Our results showed prevalence of the following associated problems with CP: 84% had bowel incontinence, 80% had feeding difficulties, and 26.7% had convulsions. After following our training program, 60% showed adequate position and jaw stabilization during feeding, 46.7% became cooperative during feeding with shorter mealtimes, 34.5% developed bowel control by day time, 50% showed decreased frequency of convulsion attacks and reduced injury due to sudden attacks. Conclusion Conservative and behavioral modifications had positive outcomes in children with CP and their families through training parents for supportive aids.
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Celiac, thyroid diseases, and Helicobacter pylori infection in association with type 1 diabetes mellitus p. 761
Fady M Elgendy, Zein A El-Latif Omar, Neama H Zearaban, Heba S Elsaka
DOI:10.4103/1110-2098.218275  
Objectives To study the association between the diagnostic markers of celiac, thyroid diseases, and Helicobacter pylori infection with type 1 diabetes mellitus (T1DM) and the effect of these diseases on glycemic control. Background T1DM is a chronic metabolic disease characterized by chronic hyperglycemia because of defects in insulin secretion or action or both, and results from the autoimmune destruction of the insulin-producing β-cells in the pancreas. It is commonly associated with autoimmune diseases such as celiac and thyroid diseases. There is a higher prevalence of H. pylori infections in T1DM. Patients and methods This study included 60 patients who presented with T1DM ranging in age from 1 to 16 years, of both sexes, with different disease durations. Children with secondary diabetes, congenital anomalies in any part of the body, or other autoimmune diseases (systemic lupus erythematosus, nephrotic syndrome, rheumatoid arthritis) were excluded. The patients were compared with 32 normal children of the same age, sex, and socioeconomic status. Comparisons were made by structured reviews and the results were tabulated. Results The frequency of celiac disease at the diagnosis of T1DM is 0, the frequency of thyroid disease at diagnosis of T1DM is 5%, and the frequency of H. pylori infection in diabetic patients is 56.7%; however, in the control group, the frequencies were 15.6%. There is a significant relation between the frequency of H. pylori infection and increased duration of T1DM. Conclusion Screening for celiac disease, thyroid disease, and H. pylori infections at diagnosis of T1DM is important, and rescreening at regular intervals is important for the negative cases.
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A study of serum leptin level in both full-term and preterm newborns p. 765
Ahmed T Mahmoud, Maha A El-Rafea Elbassuoni, Dalia M Ellahony, Sarah M. A. Elmohsen Sheir
DOI:10.4103/1110-2098.218284  
Objective This study aims to compare serum leptin level in preterm and full-term newborns in relation to clinical findings. Background Leptin is a hormone made by fat cells that regulates the amount of fat stored in the body. Fetal and infant nutrition and growth have previously been correlated with disease in adulthood. The inadequate fat tissue in premature infants and infants with intrauterine growth restriction leads to impaired glucose metabolism and insulin resistance. Recent studies refer development of obesity, insulin resistance, and other metabolic disturbances later in life in patients born preterm or small for gestational age. Only few studies have been published regarding preterm infants and correlation of circulating leptin levels with birth weight and other anthropometric parameters. Patients and methods This is a follow-up (prospective) study included 40 neonates. All candidates had measurements of serum leptin level. Results The data show that there is a positive significant correlation between cord blood leptin level and gestational age, weight, and length. During the follow-up of neonates, we found that weight gain was significantly higher in formula-feeding compared with breastfeeding neonates. There was a positive significant correlation between cord blood leptin level and birth length. There was no significant difference between neonates delivered by normal vaginal delivery and those by cesarean birth and no difference between male and female. Conclusion The lower cord blood leptin levels were seen to be associated with a lower birth weight, but with a more weight gain in early infancy.
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Effect of abnormalities in leptin levels on pituitary–hypothalamic axis in patients with chronic hemolytic anemia p. 770
Farida H El-Rasheidy, Enas S Essa, Asmaa A Mahmoud, Ahmed T Lasheen
DOI:10.4103/1110-2098.218287  
Objective The aim this study was to investigate the serum leptin level and its pathological correlations in children with chronic hemolytic anemia. Background Thalassemia syndromes are hemoglobin disorders that result from significantly reduced or absent synthesis of either α-globin or β-globin chains. This results in chronic hemolytic anemia with high serum ferritin level, which affects serum leptin level through the influence of peripheral adipocytes. Patients and methods This is a comparative observational cross-sectional study carried out on 52 children diagnosed as having β-thalassemia major and 35 healthy children as controls. Patients with thalassemia were recruited from Pediatric Hematology–Oncology Unit of Menoufia University Hospital during the period from May 2015 to June 2015. All patients were assessed by full history taking, thorough clinical examination, and laboratory investigations including complete blood count; serum ferritin level; serum leptin level; thyroid function tests comprising thyroid stimulating hormone, T3, and T4; and blood sugar level. Results Weight, height, BMI, hemoglobin%, red blood cell counts, platelet count, and hematocrit were significantly lower in thalassemia group. Serum blood glucose level was significantly higher in thalassemia group. Serum ferritin level showed highly significant higher values in thalassemia group. Serum leptin, T3, T4, and thyroid stimulating hormone showed highly significant lower values in thalassemia group. There was a significant difference between male and female sex regarding serum leptin level. There were significant linear regression coefficients for correlations between leptin level and BMI, T4 level, and serum ferritin level. Conclusion Serum leptin level is significantly lower in patients with β-thalassemia major than healthy controls. This is associated with a significant inverse correlation between serum leptin level and serum ferritin level. There is a significant correlation between serum leptin and BMI and thyroxin hormone. Leptin deficiency proved to be a cofactor in the development of endocrinological complications in patients with thalassemia major.
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Serum neutrophil gelatinase-associated lipocalin as an early biomarker in acute kidney injury in the pediatric ICU of Menoufia University p. 778
Fady M El Gendy, Mohammed S Rizk, Nagwan Y Saleh, Atef M Ibrahim
DOI:10.4103/1110-2098.218289  
Objective The objective of the present study was to study the role of neutrophil gelatinase-associated lipocalin (NGAL) as an early biomarker of acute kidney injury (AKI) in the pediatric ICU (PICU) of Menoufia University. Background AKI represents a very devastating problem in critically ill children. Nephrologists are aware of the usefulness of serum NGAL as a biomarker of AKI. Participants and methods This study was carried out at the PICU of Menoufia University Hospital. This study included 80 participants. They were classified into group I (n = 20), including apparently healthy volunteers, and group II (n = 60), including children who were admitted to the PICU. All patients were subjected to full history and thorough clinical examination, routine investigations, and quantitative determination of serum NGAL levels. Results AKI developed in 18.3% of the cases. Cases had significantly higher levels of serum NGAL compared with the control group. There were significantly higher levels of serum NGAL among cases with AKI than in those without AKI. There were significantly higher levels of serum NGAL in septic AKI cases compared with septic non-AKI cases. The validity of serum NGAL for prediction of AKI, which documents the area under the curve, was 0.95 at a cutoff point of 155 ng/ml, sensitivity of 100%, specificity of 89.8%, positive predictive value of 68.8%, negative predictive value of 100%, and total accuracy of 91.7. Conclusion NGAL acts as a sensitive marker rather than a specific marker for AKI. At the same time, it presents a negative predictive value, more valuable than a positive predictive value, in detecting AKI.
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Anemia among pregnant women attending the family health center in Kafr Al-Sheikh city, Egypt (an intervention study) p. 784
Hala M El-Moselhy, Nora A Khalil, Rasha F Abd-Elhaleem
DOI:10.4103/1110-2098.218248  
Objective The aim of this study was to assess the prevalence of anemia among pregnant women and estimate the effect of iron supplementation on hemoglobin concentration among the anemic participants. Background Anemia in pregnancy is a major health problem. It is the most common cause of maternal mortality. Severe anemia is associated with preterm birth, low birth weights, and a fetus small for gestational age. Most of the complications are preventable through increased awareness and improving health status of pregnant women. Participants and methods This was a cross-sectional study conducted in the family health center of Kafr Al-Sheikh city. The study included 200 pregnant women attending the selected family health center during the period of data collection. The studied group was assessed regarding their socioeconomic characteristics, obstetric history, and dietary history. Then, the hemoglobin level was estimated for the diagnosis of anemia. The anemic group received iron supplementation according to the recommendations in National Practice Guidelines for Family Physicians. The hemoglobin level was re-estimated after 4 weeks of taking iron. Results The study results revealed that the prevalence of anemia among the studied group was 32%. The majority of anemic women had mild anemia (92.2%). The most significant risk factor for anemia among the studied groups was a histtory of anemia [P = 0.000, odds ratio (OR)=18.18], followed by a low socioeconomic standard (P = 0.089, OR = 17.4), and then a long duration of menstruation (P = 0.000, OR = 14.16). There was a significant improvement in hemoglobin concentration after intervention (4.04 ± 1.68%). Conclusion There was a significant improvement in the hemoglobin level among anemic pregnant women after 4 weeks of oral iron supplementation according to National Practice Guidelines for Family Physicians.
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Burnout and quality of life among physicians in primary healthcare facilities in Egypt: a cross-sectional study p. 789
Tagraeed M Farahat, Nagwa N Hegazy, Dalia H Mohamed
DOI:10.4103/mmj.mmj_442_16  
Objectives The aim of this study was to deter mine the prevalence of burnout among physicians in primary healthcare facilities and explore the relationship between perceived quality of life and levels of burnout among the physicians. Background Healthcare workers, particularly physicians, are exposed to high levels of stress at work. Burnout syndrome may increase the risk for medical errors and affects the physician's quality of life. Patients and methods The study was a cross-sectional one conducted on 76 physicians in El Kanater El Kharia primary healthcare units and centers in Qalyubia Governorate, Egypt. It was conducted during a period of 10 months. All participants were interviewed using Maslach Burnout Inventory and World Health Organizations Quality of Life – Brief Questionnaire. Results Approximately 66.7% of the general practitioners (GPs) had high burnout, whereas only 26.7% of specialists had high burnout. Emotional exhaustion was higher in GPs compared with family physicians and specialists. The incidence of emotional exhaustion was 80.7, 75, and 46.7%, respectively. High depersonalization of 89.5% was seen in GPs compared with 50 and 40% in family physicians and specialists, respectively. Approximately two-third of the specialists had high personal accomplishment in comparison with 40.3 and 22% of GPs and family physicians. There was a statistically significant negative correlation between the physical and the psychological domains of the quality of life and the burnout score. Conclusion These results viewed the importance of balanced life as a barrier against burnout and its implication on the quality of life.
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Anemia among the elderly attending a family health center, Menoufia University, Egypt p. 794
Enshad Badawy, Hala M Shaeen, Nagwa N Hegazy, Enshad E Mohammed
DOI:10.4103/mmj.mmj_479_16  
Objective The aim of the present study was to assess the prevalence of anemia and the associated cognitive and nutritional status among the elderly attending the Munshat Sultan Family Health Center. Background Anemia is a common health problem with serious consequences among the elderly. Multiple studies demonstrate that anemia is an independent risk factor for increased morbidity and mortality among the elderly. Patients and methods This case-controlled, cross-sectional study was conducted on 200 elderly persons of both sexes recruited from Munshat Sultan Family Health Center, Menoufia district, Menoufia governorate, Egypt. Initially, the sample size was calculated to be 163, which was then increased to 200. All participants underwent a comprehensive medical history and clinical evaluation, and then complete blood count was measured, and anemia was defined according to the WHO criteria (hemoglobin level <13 g/dl in men and <12 g/dl in women). Results The study revealed that the prevalence of anemia was 17.5% among the participants (19.3% among men and 16.7% among women), 16% had mild anemia, and 1.5% had moderate anemia, which significantly increased with age in the anemic group compared with the nonanemic group. Anemia increased significantly among participants with a history of blood loss and intake of NSAIDs (P = 0.01 and 0.003, respectively). The impact of anemia on functional status showed a significant difference between anemic and nonanemic groups as regards instrumental activity of daily living; moreover, there was a significant correlation between anemia and minimental state examination (P < 0.001), with worse performance among the anemic ones. Conclusion Anemia represented a significant health problem among the elderly with bad drawbacks on their functional level and cognitive function.
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Undiagnosed diabetes among adult attendants of a rural primary healthcare center in Menoufia Governorate p. 800
Ahmed M Zahran, Aml A Salama, Asma S Beddah
DOI:10.4103/1110-2098.218288  
Objective The present study aimed to estimate the prevalence of undiagnosed diabetes in adult attendants of a primary healthcare center in a rural area. Background The prevalence of diabetes is rapidly increasing worldwide. T2DM may remain undetected for many years, leading to severe complications and healthcare costs. Patients and methods We carried out a cross-sectional study on 1255 cases, with a mean age of 38.9±11.16 years. All participants were subjected to history taking, complete medical examination, and laboratory investigations (measurement of fasting blood glucose level and 2-h postprandial blood glucose level). We then compared our findings between the diabetic group and the normal group. Results The prevalence of undiagnosed diabetes in adults was 4.2%. Undiagnosed diabetes was significantly associated with age (P < 0.05), sex (P < 0.05), hypertension (P < 0.001), hyperlipidemia (P < 0.001), and smoking status (P < 0.05). Conclusion The prevalence of undiagnosed diabetes in adult attendants of the rural primary healthcare center was 4.2%.
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Risk factors of lung cancer among women in Menoufia governorate, Egypt p. 806
Naser M Abd ElBary, Nagwa N Hegazy, Marwa K Abo Aianh
DOI:10.4103/1110-2098.218298  
Objectives The objectives of this study were to assess the risk factors and distribution of lung cancer among women in Menoufia governorate. Background Lung cancer used to be thought of as a man's disease, but women now account for almost half of new cases and deaths from lung cancer. Patients and methods The study was a case–control study. Women were selected according to the following inclusion criteria: adult females above 18 years, histopathological proof lung cancer, controlled comorbidity. The recruited participants were 60 women from the clinical oncology hospital records from January 2011 to December 2015 in Menoufia University, Shebin Elkom, Menoufia Governorate. Sixty women were found meeting our inclusion criteria. A similar number of controls was recruited from the patients' female relatives. Both groups were subjected to a questionnaire and clinical examination for clinicoepidemiological study and determination of risk factors of cancer lung. Results The most common type of lung cancer among women was adenocarcinoma (56.7%). The risk factors for developing lung cancer in women were passive smoking smoking, performing oophorectomy before menopause and using coal for cooking or warming (P < 0.001). Conclusion The risk factors for developing lung cancer among women were passive smoking, smoking, oophorectomy before menopause, use of hormonal replacement therapy among smoking, and use of organic fuel (coal) for cooking or warming. Having breast cancer or having radiation therapy may influence the progress of lung cancer.
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Prevalence and risk factors of musculoskeletal disorders among natural gas field workers p. 813
Mahmoud E Abu Salema, Omaima A Mahrousa, Zeinab A Kasemya, Heba K Allama, Mohamed M Hasan El-Kholyb
DOI:10.4103/1110-2098.218274  
Objectives This work aimed at studying the prevalence of musculoskeletal disorders among workers in natural gas fields and studying the relationship between the resultant health disorders and the working conditions. Background Workers at natural gas fields are continuously exposed to numerous hazardous materials and working conditions that place them at continuous risk of injury or death. Participants and methods A cross-sectional study carried out on 172 workers in one of the natural gas fields in Egypt. Results The prevalence of regional musculoskeletal pain was 47.7% in the studied workers. Low back pain was the most prevalent (30.5%), followed by knee pain (17.1%), wrist pain (12.2%), neck pain (11.0%), shoulder pain (8.5%), elbow pain (7.3%), hand pain (6.1%), foot pain (4.9%), and ankle pain (2.4%), respectively. The percentage of musculoskeletal pain was significantly higher in workers with over 9 years' work duration (P = 0.00). Conclusion Musculoskeletal manifestations were prevalent among natural gas field workers due to their exposure to multiple stressors in the workplace. With increasing duration of work, musculoskeletal manifestations become more prominent.
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Hepatitis C as a risk factor for coronary artery disease in silent myocardial ischemia p. 818
Ashraf G Dala, Waleed Abdou Hamed, Mohammad H Badr, Ramy M Omar
DOI:10.4103/mmj.mmj_106_17  
Objective The aim of the present study was to evaluate the relationship between seropositivity of hepatitis C virus (HCV) and the severity of coronary artery disease in silent myocardial ischemic patients. Background Silent myocardial ischemia is defined as an objective evidence of myocardial ischemia occurring in the absence of symptoms. HCV was found to have a positive association with carotid artery plaque. Patients and methods We investigated 50 patients with silent myocardial ischemia. Patients were divided into two groups (group A included 25 HCV-seropositive patients and group B included 25 HCV-seronegative patients). Patients were subjected to history taking, clinical examination, and investigations such as 24-h Holter monitoring, complete blood count, liver and renal function tests, and random blood glucose, lipid profile, viral marker tests. Abdominal ultrasonography, echocardiography, and coronary angiography were carried out for all patients. The SYNTAX score was calculated. Results Fifteen patients of group A had left anterior descending disease versus seven of group B (P = 0.013). Thirteen patients of group A had left circumflex disease versus six of group B (P = 0.013). Fourteen patients of group A had right coronary artery disease versus six of group B (P = 0.0023).The SYNTAX score of group A was 15.76 ± 6.75, whereas the score for group B was 11.36 ± 7.64 (P = 0.0.036). Conclusion There was a positive relationship between HCV and number of diseased coronary vessels, and there was a positive relationship between HCV seropositivity and complexity of coronary lesions in the light of SYNTAX score as well.
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Assessment of right atrium function in hypertrophic cardiomyopathy by speckle-tracking echocardiography p. 823
Hala M Badran, Ghada M Sultan, Naglaa F Ahmed, Hatem A Mohamed
DOI:10.4103/1110-2098.218263  
Objective We sought to evaluate the regional and global longitudinal strain/strain rate (SR) profiles in the right atrial (RA) wall to quantify RA function in hypertrophic cardiomyopathy. Background According to previous studies on the deformational properties of the left atrium, the systolic strain and SRs represent the atrial reservoir function and the early and late diastolic SRs show the conduit and booster functions, respectively. Patients and methods Speckle-tracking echocardiography of the RA, right ventricle, and left ventricle was acquired from apical four-chamber view in 118 hypertrophic cardiomyopathic patients and 33 healthy individuals; all had normal left ventricular systolic function. Subendocardium was traced to obtain atrial volumes, ejection fraction, velocities, and strain (ε)/SR measurements. Results Hypertrophic cardiomyopathic patients had significantly lower global and regional peak RA reservoir function (εsys, SRsys) and conduit function (SRe) compared with the controls: global εsys52.9 ± 27.9 versus 77.8 ± 31.3, SRsys2.4 ± 0.84 versus 3 ± 1.2, SRe− 2.2 ± 0.70 versus − 3.99 ± 0.73, respectively (P 0.001). RA contractile function (SRa) did not differ between the groups studied. RA ejection fraction was significantly reduced in the hypertrophic cardiomyopathy group compared with the control group (56 ± 16.7 vs. 68.9 ± 9.3, respectively, P 0.0001). Conclusion RA reservoir and conduit function as measured by strain/SR were significantly impaired, whereas contractile function showed no difference between the groups studied.
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Coronary stent patency and in-stent re-stenosis in patients referred to multislice computed tomography coronary angiography p. 832
Ahmed A Reda, Ahmed M El-Kersh, Morad B Mena, Hend M Abdo El-Deeb
DOI:10.4103/mmj.mmj_389_16  
Objective Our aim was to assess the diagnostic accuracy of multislice computed tomography (CT) coronary angiography in the evaluation of coronary stent patency using different methods of image reconstruction. Background Over the past 25 years, catheter-based intervention has become the dominant form of coronary revascularization. Although the use of recently introduced drug-eluting stents has resulted in even further reductions in the occurrence of re-stenosis, in-stent thrombosis and neointimal hyperplasia may still occur and cause partial or complete obstruction. Conventional coronary angiography is still the technique of choice for the diagnosis of in-stent re-stenosis, but may involve major complications; therefore, multidetector CT can be useful to assess the condition of the whole coronary tree, as it provides information about the number, severity, and location of coronary lesions. Patients and methods We studied 30 patients with past history of percutaneous coronary intervention who were referred for coronary multislice CT coronary angiography using different methods of image reconstruction, either filtered back projection or iterative reconstruction, compared with the standard coronary angiography. Results By comparing filtered back projection and iterative reconstruction, we found that I46f showed statistically lower noise than B46f (29.8 ± 3.9 vs. 36.2 ± 3.2) (P < 0.001) regarding signal-to-noise ratio (14.8 ± 2.1 for I46f vs. 12.0 ± 3.7 for B46f) (P < 0.001). The contrast-to-noise ratio was also statistically better with I46f than with B46f (7.3 ± 0.9 for I46f vs. 5.9 ± 0.5 for B46f) (P < 0.001). Conclusion We concluded that the sharp kernel for each filter has higher image noise than the medium kernel, and when comparing both filters together we found that iterative reconstruction, sharp kernel (I46f), has the best image quality.
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Oral versus intravenous hydration in protection against contrast-induced nephropathy in patients undergoing coronary angiography p. 837
Mahmoud A Mahmoud Soliman, Awny G Shalaby, Mona E Mansour
DOI:10.4103/1110-2098.218273  
Objective The aim of this study was to evaluate the efficacy of oral hydration for prevention of contrast-induced nephropathy (CIN). Background CIN is related to increased long-term morbidity and mortality. Adequate intravenous hydration has been demonstrated to lessen its occurrence. Oral hydration with water is inexpensive and readily available. However, its role in CIN prevention is yet to be determined. Patients and methods This study included 200 patients (age 55 ± 7.55 years, 98 female/102 male) scheduled for diagnostic coronary angiography, who were divided into two groups. Eligible patients in group I (100 patients) were hydrated orally with 500 ml of water given 4 h before contrast; consumption of water was stopped 2 h before performing coronary angiography and was resumed with 600 ml after the procedure. Group II (100 patients) received intravenous hydration in the form of isotonic saline 0.9% at 3 ml/kg over 1-h before coronary angiography and 1 ml/kg over 6 h after the procedure. During the procedure all patients received contrast medium (Telebrix). The primary endpoint of the study was the evaluation of renal function before and 72 h after contrast medium administration. Results A total of 200 patients were included in the analysis, who were divided into two groups: group I comprised 100 patients who received per-os oral water. Group II comprised 100 patients who received intravenous saline. The incidence of CIN was statistically similar in the oral and intravenous arms (6 and 7%, respectively; P = 0.774). There was no significant difference between the two groups regarding serum creatinine elevation 48–72 h after contrast exposure (as P = 0.410). Conclusion Oral hydration with water is as effective as intravenous hydration with saline in preventing CIN. Oral hydration is cheaper and more easily administered than intravenous hydration.
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Association of echocardiographic epicardial fat with the extent of coronary artery disease p. 842
Walaa F Abd El-Aziz, Mahmoud K Ahmed, Wael A Badr
DOI:10.4103/1110-2098.218278  
Objective Epicardial adipose tissue is a metabolically active tissue that accumulates around the coronary arteries and is associated with presence of atherosclerotic coronary artery disease (CAD). Background The aim of the study was to evaluate the association of echocardiographic epicardial fat with the presence and severity of CAD. Patients and methods The present study was conducted on 140 patients, with 59 male and 81 female patients, and their mean age was 58.19 ± 9.98 years. Patients were admitted for coronary angiography and were divided into two groups (group 1 included 30 patients with normal coronary arteries and group 2 included 110 patients with CAD). The patients underwent transthoracic echocardiography and measurement of epicardial fat thickness in parasternal long-axis view and short-axis view. These echocardiographic measurements were compared with angiographic findings. Results The epicardial fat thickness was significantly higher in patients with CAD (6.9 ± 1.5) compared with patients with normal coronary arteries (4.4 ± 0.8) (P < 0.001). Gensini score was significantly correlated with epicardial fat thickness (r = 0.6, P < 0.001). Epicardial fat thickness of greater than or equal to 5.2 mm had an 85% sensitivity and an 81% specificity (receiver operating characteristic area: 0.914, P < 0.001, 95% confidence interval: 0.86–0.96) for predicting CAD. Conclusion Epicardial fat thickness is significantly correlated with the presence and severity of CAD.
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Thrombus aspiration versus standard technique in patients with ST-elevation myocardial infarction p. 850
AbdAlla M Kamal, Ghada M Sultan, Karim S Sobhy
DOI:10.4103/1110-2098.218283  
Objective The aim of this study was to assess the efficacy of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI). Background The idea of an occluding thrombus as an etiology for ST-elevation myocardial infarction (STEMI) and its dissolution as a treatment had been around since the 1950s. Patients and methods The study included 70 patients with STEMI undergoing PPCI within 12 h from symptoms. These patients were divided equally into two groups (35 patients each): TA group and standard PPCI (SP) group. Primary endpoints were ST-segment resolution 90 min after procedure and thrombolysis in myocardial infarction flow and myocardial blush grade at the end of procedure. Secondary endpoint was in-hospital major adverse cardiovascular effects. Results ST-segment resolution more than 70%, that is, complete reperfusion, was seen in 42.9% of patients in the TA group in comparison with 8.6% in the SP group (P < 0.005). Myocardial blush grade more than or equal to 2 was seen in 91.4% in TA group in comparison with 54.3% in SP group (P < 0.005). We reported death of three patients in the SP group; however, this did not reach statistical significance (P = 0.120). Conclusion TA has significantly improved the reperfusion in patients with STEMI and significantly decreased the incidence of no reflow. Thus, we recommend TA as a routine procedure in PPCI.
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Role of contrast-enhanced digital mammography in evaluation of breast lesions p. 855
Basma A Dessouky, Noha A Elsaid, Yasmin A Shaaban
DOI:10.4103/mmj.mmj_60_16  
Objective The purpose of this study was to assess the role of dual-energy contrast mammography (MX) in evaluating breast lesions. Background Contrast-enhanced digital mammography (CEDM) can significantly improve diagnostic quality such as clarification of mammographic and sonographic equivocal lesions, detection of occult lesions on MX, determination of the extent of disease, and assessment of recurrent disease. Patients and methods A total of 50 female patients were enrolled into the present study, with their ages ranging from 22 to 77 years (mean age of about 49.5), during the period between 2012 and 2014. All of them presented with benign or malignant breast lesions detected by sonomammography, categorized as Breast Imaging Reporting and Data System from 2 to 5. All were subjected to CEDM, and the images were obtained by a modified full-field digital MX system. The nonionic iodinated contrast agent was administered into the contralateral antecubital vein manually. The results were compared with the sonomammography results, and cases were histopathologically proven. Results In our study, 37/50 cases were histopathologically proven as malignant and 16/50 were benign, whereas three patients had double pathology. Different patterns of enhancement were depicted on contrast-enhanced digital mammography (CEDM) in all histologically proven breast carcinomas. Our results show that sensitivity was higher for MX + CEDM (83.3%) compared with pathology and Breast Imaging Reporting and Data System analysis, respectively, with no loss in specificity. Compared with MX associated with breast ultrasound, CEDM had a better diagnostic accuracy mainly because of improved specificity and better positive and negative predictive values (positive predictive value and negative predictive value were 86 and 64.7%, respectively). Conclusion The addition of dual energy contrast-enhanced MX technique to conventional sonomammography can significantly improve diagnostic quality and cancer detection rate.
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Staging of cholangiocarcinoma by multidetector computed tomography p. 862
Elsayed E Elsayed, Mohammed M Houseni, Rasha Ab Ali Abd Elwahab
DOI:10.4103/1110-2098.218254  
Objective The aim of this article is to describe the role of multidetector computed tomography (MDCT) in the staging of cholangiocarcinoma using surgery as the reference standard. Background Cholangiocarcinoma is associated with a dismal prognosis; however, curative resection may offer a chance of cure. Various factors should be considered in the staging of cholangiocarcinoma. These factors include the extent of bile duct involvement, vascular invasion, lymph node metastasis, peritoneal seeding, and distant metastases. Using high-quality volume data from MDCT and adequate postprocessing images, radiologists can provide various types of information that is imperative for curative resection of cholangiocarcinoma. Patients and methods This study included 50 patients (23 men and 27 women) who had finally been diagnosed with cholangiocarcinoma. Informed consent was signed by the patients. All patients were subjected to a proper assessment of history, clinical examination as well as routine laboratory investigations. Triphasic abdominal MDCT was performed using postprocessing techniques including multiplanar reformation, maximum intensity projection, and minimum intensity projection. Results Twenty-one patients had intrahepatic cholangiocarcinoma, 27 patients had perihilar cholangiocarcinoma, one patient had extrahepatic distal cholangiocarcinoma, and one patient had mixed (intrahepatic and perihilar) cholangiocarcinoma. The tumor was resectable in 13 patients, where 10 patients were consistent with preoperative MDCT findings and three patients were inconsistent. Conclusion MDCT images provide important information on the preoperative evaluation and staging of cholangiocarcinoma with reference to the surgical procedures and findings.
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Role of triphasic MRI in the diagnosis of hepatic focal lesions p. 870
Zeinab A Ali, Tarek F Abd Ella, Mostafa M Adel
DOI:10.4103/1110-2098.218261  
Objective The aim of this study was to highlight the role of triphasic (dynamic) MRI in the diagnosis of hepatic focal lesions. Background MR of liver depends on the signal characteristics (T1-weighted and T2-weighted signal intensities) and post-Gd imaging. The combination of these imaging techniques provides anatomic and functional imaging information to best detect and diagnose liver pathology. Liver lesions were classified as malignant or benign on the basis of a combination of imaging features such as enhancement pattern/presence of fat, necrosis, and clinical features such as the presence of new/growing liver lesions and uncontrolled systemic disease. Patients and methods The study was conducted in the Hepatic Oncology Unit of the National Liver Institute, Menoufia University on 40 patients with focal hepatic lesions. The study was performed between January 2015 and February 2016. Results Out of the 40 patients studied (28 male and 12 female), 39 were found to have hepatic focal lesions and one had a well-defined hyperechoic area by ultrasound and revealed focal fatty infiltration when examined with dynamic MRI. Their ages ranged from 30 to 71 years, with a mean age of 52 years. Dynamic MRI was successfully performed in all patients, revealing 18 focal lesions to be benign, 21 malignant lesions, and one area of focal fatty infiltration. Conclusion MRI was found to be of considerable value in diagnosing and differentiating between the different cirrhotic hypervascular nodules. This technique can be implemented simply and reliably. It offers the advantages of significantly shorter acquisition times, retrospective thin-section or thick-section reconstruction from the same raw data, improved three-dimensional rendering, and high-quality liver imaging with high intrinsic soft-tissue contrast. It also provides a global overview of the abdomen. Its relative contraindications include renal impairment and sensitivity to IV contrast.
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Role of ultrasonography in blunt abdominal trauma p. 876
Adel M Alwakil, Rehab M Habib, Sharehan Abdelmonem
DOI:10.4103/1110-2098.218269  
Objective The aim of the study was to assess the role of ultrasonography (US) focused assessment with sonography in trauma (FAST) at the time of presentation and ultrasound repeated after 12–24 h in early diagnosis of intra-abdominal injury (IAI) following blunt abdominal trauma (BAT) and for follow-up. Background US was used in patients with IAI. Trauma is the most common cause of mortality. The most common mechanisms resulting in BAT among patients were motor vehicle collisions (73%), motorcycle collisions (7%), auto–pedestrian collisions (6%), and falls (6%). Patients and methods This is a prospective study of 50 patients presented to the Emergency Room of Menoufia University Hospital with BAT who underwent US and FAST examination at the time of presentation and were followed up with US after 12–24 h. Of them, 12 patients were hemodynamically unstable, six patients had severe intra-abdominal hemorrhage and entered the operation theater urgently after FAST examination, and the other six patients entered the ICU for urgent care, FAST findings, and follow-up. US findings were correlated with patients' clinical data. Results US is very useful in the follow-up of patients with minor IAI and it decreases the use of computed tomography. However, ultrasound is operator dependent and could overlook lacerations of solid organs and gastrointestinal injuries. Therefore, contrast-enhanced computed tomography is still considered the gold standard in the evaluation of the exact site and the degree of IAI. Conclusion We concluded that ultrasound is considered the best modality in the initial evaluation of patients with BAT. However, repeated ultrasound in patients of BAT increases the sensitivity of ultrasound for causing intra-abdominal bleeding to 100%.
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Reticulated platelets in acute coronary syndrome patients p. 880
Khaled A Khalifa, Mohamed A Helwa, Asmaa M Mohammed Mousa
DOI:10.4103/1110-2098.218251  
Objective The aim of this study was to evaluate reticulated platelets (RP) as a predicting factor of the outcome in acute coronary syndrome (ACS) patients. Background ACS is due to rupture of an arterial plaque. RPs are newly formed platelets with a greater mass, residual amount of RNA, and an increased prothrombotic potential compared with mature platelets. In this study, the RPs were investigated as participating factors in the pathogenesis of ACS. Patients and methods A total of 50 patients with ACS [33 acute myocardial infarction (AMI) and 17 unstable angina] and 15 clinically healthy individuals as controls were investigated for RPs by means of flowcytometry analysis. Results RPs were highly significantly increased in AMI than in unstable angina and controls. Conclusion High levels of RPs are found in ACS patients and it can be used as a predictor for adverse outcome. Moreover, it can participate in the development of AMI due to its high thrombogenic potential.
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Plasminogen activator inhibitor-1 SERPINE1 4G/5G polymorphism in hepatocellular carcinoma patients p. 887
Rawhia H El-EdeL, Enas S Essa, Abdallah S Essa, Sara A. M. Hegazy
DOI:10.4103/1110-2098.218258  
Objective The aim of this study was to investigate the distribution of genotypes and the frequency alleles of plasminogen activator inhibitor-1 (PAI-1) 4G/5G polymorphism in patients with hepatocellular carcinoma (HCC). Background PAI-1 4G/5G polymorphism involves a guanosine insertion/deletion in the promoter region of SERPINE1 gene at the –675 bp position. Patients and methods This study was conducted on 49 HCC patients (39 male and 10 female). Their ages ranged between 44 and 84 years. They were selected from the inpatient and outpatient clinics of Shibin El-Kom Fever Hospital. Patients were genotyped for PAI-1 4G/5G polymorphism using PCR. Results In HCC patients, there were no statistically significant differences when comparing carriers of the three genotypes (5G/5G, 4G/5G, and 4G/4G) as regards sex, Child score, total bilirubin, direct bilirubin, albumin, serum glutamate pyruvate transaminase, alkaline phosphatase, γ-glutamyltranspeptidase, international normalized ratio, prothrombin, and α-fetoprotein (P = 0.81, 0.76, 0.46, 0.054, 0.99, 0.92, 0.22, 0.58, 0.49, 0.42, 0.54, and 0.85, respectively). On comparing the three genotypes (5G/5G, 4G/5G, and 4G/4G) among HCC patients as regards serum glutamic oxaloacetic transaminase, there was a statistically significant difference among them (P = 0.02). On comparing carriers of the three genotypes (5G/5G, 4G/5G, and 4G/4G) as regards different tumor characters (tumor size, tumor number, tumor side, and Barcelona Clinic Liver Cancer staging system), there were no significant differences among them (P = 0.16, 0.59, 0.42, and 0.14, respectively). Rate of thrombosis in the HCC group was 62.5% in 4G/5G genotype versus 41.2 and 12.5% in 5G/5G and 4G/5G genotype, respectively; there was a statistically significant difference (P = 0.04). Conclusion It could be concluded that PAI-1 4G/5G polymorphism was not associated with HCC.
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Candiduria in catheterized Menoufia patients: emerging microbiological trends p. 892
Amira A Alkilani, Abeer H El Shalakany, Walaa Y Mohamed Saif
DOI:10.4103/1110-2098.218265  
Objective The present study aimed to assess the prevalence of different Candida spp. as a cause of infections in the urinary tract infection (UTI) among catheterized patients and to test the susceptibility of Candida isolate to antifungal agents. Background UTIs are tied with pneumonia as the second-most common type of healthcare-associated infection. Catheter-associated UTI occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and thus causing mucosal irritation. Candida spp. accounts for almost 10–15% of the nosocomial UTIs. Patients and methods The study was conducted on 200 catheterized inpatients from ICU. The urine specimens were examined for Candida by using CHROMagar and Integral System Yeasts Plus. Results The API system is highly effective in diagnosing fungal infections. Candida infection was the highest among the age group more than 45 years and in females. The most sensitive antifungal drug for Candida infection was flucytosmine and the least sensitive were nystain and micoconazole. Conclusion There is a strong relationship between host risk factors (old age, antibiotic use, catheterization, female sex, ICU stay, diabetes mellitus, hospitalization) and the expression of various virulence factors of Candida spp. causing candiduria and their resistance to antifungals.
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Patatin-like phospholipase 3 rs738409C/G gene polymorphism in cirrhotic and hepatocellular carcinoma patients p. 899
Gehan K El Saeed, Rawhia H El-EdeL, Hala H El Said, Hosam E Abdellateef Taha, Rasha I Noreldin, Mohammad G Alhelbawy
DOI:10.4103/1110-2098.218270  
Objective The aim of the present study was to verify whether the rs738409C/G single nucleotide polymorphism of patatin-like phospholipase 3 (PNPLA3) gene may be associated with cirrhosis and hepatocellular carcinoma (HCC) complicating cirrhosis. Background PNPLA3 gene encodes a 481-amino acid protein of unknown function that belongs to the patatin-like phospholipase domain-containing family. PNPLA3 rs738409 polymorphism could be a risk factor for the development of HCC in cirrhosis patients. Subjects and methods This study included 50 individuals divided into three groups: group 1 (control group) included 10 apparently healthy age and sex-matched subjects; group 2 (cirrhosis group) included 20 patients diagnosed with cirrhosis and positive antihepatitis C virus (HCV) antibodies; and group 3 (HCC group) included 20 HCC patients. Liver function tests, viral markers, α-feto protein, and HCV RNA by using PCR were carried out for all participants. They were genotyped for PNPLA3 C>G polymorphism using PCR. Results There was significant difference in genotype distribution between the control and the HCC group [CG vs. CC: P = 0.01; odds ratio (OR)=18, 95% confidence interval (CI): 2.04–159.1, GG vs. CC: P = 002). OR showed that GG genotype was riskier than the CC 'reference group' by 18 (95% CI: 2.04–159.1). There was significant difference in the distribution of both alleles (C and G) between the two groups (P = 0.00). OR showed that G allele was riskier than C allele by 18.69 (95% CI: 3.76–92.9). There was significant difference in GG genotype distribution between the cirrhosis and the HCC group (GG vs. CC: P = 0.02; OR = 13.5, 95% CI: 1.80–101.1). OR showed that GG genotype was riskier than the CC 'reference group' by 5.06 (95% CI: 0.83–11.02). There were significant differences in the distribution of both alleles (C and G) between the two groups (P = 0.007). OR showed that G allele was riskier than C allele by 3.86 (95% CI: 1.53–9.75). Conclusion PNPLA3 rs738409 C>G polymorphism was associated with HCC in HCV cirrhotic patients.
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Assessment of T-regulatory cells in type 1 diabetes mellitus p. 906
Rawhia H El-Edel, Samar M Kamal Eldein, Wafaa M Abo El Fotoh, Samar S Salman
DOI:10.4103/1110-2098.218280  
Objective The aim of the study was to evaluate T-regulatory cells (Tregs) expression in the peripheral blood of children with type 1 diabetes mellitus (T1D). Background T1D is mainly a T-cell-mediated autoimmune disease characterized by the destruction of pancreatic β cells leading to insulin deficiency. It is a common autoimmune disorder in childhood, but the disease may become manifest at any age, even in adults. Tregs are subsets of T cells that have an essential role in maintaining tolerance; thus, these cells may play an important role in the pathogenesis of T1D. Patients and methods This study was carried out in the Clinical Pathology Department, Faculty of Medicine, Menoufia University, between August 2014 and November 2015. The study included 50 children, who included 30 children diagnosed as T1D and 20 age-matched and sex-matched apparently healthy children as controls. All children were subjected to complete blood count, glycated hemoglobin evaluation, and surface and cytoplasmic detection of Tregs by flow cytometry. Results This study showed that Tregs (CD4+ CD25+ FoxP3+) decreased in diabetic children in comparison with normal controls (P < 0.001). It also showed a higher decrease in the percentage of Tregs (CD4+ CD25+ FoxP3+) in uncontrolled diabetic children (hemoglobin A1c > 7.0%) in comparison with controlled diabetic children (hemoglobin A1c < 7.0%) (P < 0.001). Conclusion Diminished Tregs proved that breakdown of immune tolerance often leads to the development of autoimmune diseases including T1D, which confirms the essential role of Tregs in the pathogenesis of T1D.
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Immunomodulatory effect of mesenchymal stem cells on lymphocytes of rheumatoid arthritis patients p. 912
Maha A ELBassuoni, Gehan A Tawfeek, Heba A Esaily, Mai F Mohamed Abd El Rahim Badr
DOI:10.4103/1110-2098.218291  
Objectives The aim of this work was to isolate, expand mesenchymal stem cells (MSCs) from bone marrow (BM), and assess the immunomodulation potential of MSCs on T lymphocytes of patients with rheumatoid arthritis (RA). Background MSCs are multipotent adult stem cells present in all tissues. They are present in the BM, and possess remarkable immunomodulation properties that can inhibit the proliferation and function of the major immune cell populations. These unique properties make MSCs ideal candidates for clinical application in autoimmune diseases (e.g., RA). Patients and methods MSCs were cultured from BM aspirate and detected morphologically; peripheral blood (PB) mononuclear cells (MNCs) were separated from 30 RA patients and co-culture of BM-MSCs and PB-MNCs were set up. The sample groups were divided into the following groups: group 1, PB MNC culture without phytohemagglutinin (PHA) (negative control); group 2, PB MNC culture with PHA at a concentration of 10 μg/ml; and group 3, PB mononuclear culture with PHA and MSCs. The lymphocytes were harvested and their CD4+ and CD8+ were analyzed by means of flowcytometry. Results The results of this study showed a statistically highly significant difference between percentage of CD4+ and CD8+ T lymphocytes cultured with PHA and percentage of CD4+ and CD8+ T lymphocytes cultured without PHA (P < 0.001). There was also a statistically highly significant difference between percentage of CD4+ and CD8+ T lymphocyte cultured without MSCs and percentage of CD4+ and CD8+ T lymphocytes cultured with MSCs, being lower in culture with MSCs (P < 0.001). Conclusion MSCs have immunomodulatory effect on T lymphocytes of RA patients.
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Respiratory muscle strength in patients with allergic rhinitis p. 918
Nourane Azab, Ibrahim I El-Mahallawy, Mohammed A Agha, Ibrahim A Abd El-Shafy, Walaa M Abd El-Aziz
DOI:10.4103/1110-2098.218253  
Objective The aim of this study was to investigate respiratory muscle strength in patients with allergic rhinitis. Background Nasal obstruction and mouth breathing have an impact on respiratory muscle behavior, leading to changes in their power. Patients and methods This study included 27 adult patients aged 20–45 years with already diagnosed allergic rhinitis. In addition, 10 healthy age-matched and sex-matched controls were included in this study. Both groups were evaluated for pulmonary functions, including forced vital capacity, slow vital capacity, and respiratory muscle strength as assessed on the basis of maximal inspiratory and expiratory pressures (MIP and MEP). Results Patients with allergic rhinitis showed a significant decrease in MIP and MEP when compared with the control group (P < 0.05). Patients with allergic rhinitis showed a nonsignificant decrease in other respiratory functions. Patients with allergic rhinitis showed a significant decline in MIP and MEP with age (P < 0.05) and in the female population more than in the male population. The decrease in MIP and MEP was affected by the degree of severity of allergic rhinitis (P < 0.05). Conclusion Patients with allergic rhinitis have decreased respiratory muscle strength as expressed by decreased MIP and MEP. This decrease in MIP and MEP in patients with allergic rhinitis increases after the age of 40, was affected by the degree of severity of allergic rhinitis, and was more pronounced in female patients than in male patients.
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Diagnostic value of soluble triggering receptor expressed on myeloid cells-1 in pleural effusion p. 923
Ramadan M Bakr, Ibrahim I El-Mahallawy, Tawfik M Abdelmotaleb, Mohamed E Ibrahim
DOI:10.4103/1110-2098.218282  
Objectives The aim of this study was to assess the value of the pleural fluid soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in the diagnosis of the etiology of pleural effusion. Background The accurate diagnosis of pleural effusion remains a challenging problem even after thoracocentesis and closed pleural biopsy. TREM-1 is a recently described molecule that plays an important role in myeloid cell-activated inflammatory responses. Patients and methods We measured sTREM-1 levels from 20 patients with transudative effusion, 20 patients with malignant effusion, 20 patients with tuberculous effusion, and 20 patients with parapneumonic effusion using a specific enzyme-linked immunosorbent assay technique. Result sTREM-1 levels were significantly higher in parapneumonic effusion (45.50 ± 13.21 ng/l) than tuberculous effusion (34.90 ± 10.51 ng/l) and in malignant effusion (15.37 ± 5.01 ng/l) than transudative effusion (6.75 ± 3.35 ng/l). Conclusion Our study suggests that sTREM-1 can differentiate between infectious effusions (parapneumonic and tuberculous) and noninfectious effusions (malignant and transudative effusions).
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How to avoid the false diagnosis of venous leakage by pharmaco-penile duplex ultrasonography? p. 928
Abd Allah M. Attia, Hossam A Yasien, Mohamed S Abdullah, Mohamed S Abo Hola
DOI:10.4103/1110-2098.218292  
Objectives The aim of the present study to carefully reassess the erectile hemodynamic status in men previously diagnosed with venous leak on penile duplex ultrasonography (DUS) under the guidelines of the Australasian Society for Ultrasound in Medicine (ASUM). Background Erectile dysfunction (ED) is a widespread problem affecting men across all age groups (about 50% in 40–70-year age group) and disturbing the quality of life of sexually active men. Vascular insufficiency is one of the major causes of ED. DUS is a useful, minimally invasive method for evaluating penile hemodynamics in patients with ED, but has a propensity to inaccurately assign a diagnosis of venous leak. Patients and methods Fifty patients from 18 to 50 years olds selected from the Andrology Unit, Dermatology and Andrology Department, Faculty of Medicine, Menoufia University, Egypt were included in the study. All cases were subjected to the following: detailed history, thorough clinical examination, routine and hormonal investigations, and imaging studies including re-evaluation through DUS under the guidelines of ASUM. Results Overall, 50% of the patients previously diagnosed with venous leak were shown to be normal when re-evaluated under the guidelines of ASUM. The other 50% demonstrated a significant improvement in the value of end diastolic velocity (EDV). The study demonstrated a significant increase in the value of peak systolic velocity in repeated DUS with a mean difference of 10.29, and a significant decrease in the value of EDV with a mean difference of 4.19 compared with the original DUS. Our results indicated a significant negative correlation between age and value of peak systolic velocity, and an insignificant positive correlation between age and value of EDV for all participants, in both original and repeated DUS. Conclusion Careful assessment should be carried out when performing DUS, especially in younger men without a significant vascular risk factor in history for ED, to avoid misdiagnosis of venous leak.
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Screening of Helicobacter pylori in alopecia areata patients p. 935
Shawky M El-Farargy, Hossam Abd El-Hamied Yasien, Belal Abd El-Mohsen Montaser, Heba Rashad
DOI:10.4103/1110-2098.218293  
Objectives The aim of the present study was to clarify whether Helicobacter pylori plays a role in the pathogenesis of alopecic areata or not. Background Alopecia areata (AA) is an immune-mediated form of hair loss that occurs in all ethnic groups, ages, and both sexes. H. pylori has been associated with many extradigestive dermatological conditions. The causal relation between AA and H. pylori is discussed in this study. Patients and methods We screened patients with AA for the presence of H. pylori to determine any potential role in its pathophysiology. We prospectively studied 30 patients with AA and 20 healthy volunteers (control group) of similar sex for the presence of H. pylori stool antigen (HpSAg) (which is available according to the protocol) from February 2015 to January 2016 at El-Bagour Central Hospital. Results The values for H. pylori infection were positive in 25 of the 30 (83.3%) patients evaluated, whereas in five (16.7%) patients, the values did not support H. pylori infection. In the control group, seven out of 20 (35%) had positive results. There was a high significant difference between the patients (83.3%) and control (35%) groups as regards positivity of HpSAg. Furthermore, as per the quantitative estimation of the level of HpSAg. In the two groups, it was found to be significantly elevated with mean ± SD 1.73 ± 0.88 U/ml for patients and 1.04 ± 0.85 for controls (P = 0.009). Conclusion H. pylori infection may play a role in the pathogenesis of AA.
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Interleukin 10 gene polymorphism and lepra reactions: susceptibility and immunological correlation p. 940
Alaa H Maraee, Azza G Antar, Rania M. A. El-Shazly, Shaimaa F. G. El-Sayed
DOI:10.4103/1110-2098.218295  
Objectives The aim of the study was to evaluate interleukin 10 (IL-10) gene single nucleotide polymorphisms (SNPs) as a susceptibility gene in lepra reactions. Background Leprosy is a chronic dermatoneurological disease, caused by Mycobacterium leprae. Lepra reactions are immune inflammatory-related leprosy phenotypes that may occur before diagnosis of leprosy, during treatment, or after multiple drug therapy. IL-10 gene becomes widely used in studies of immune-mediated disease. It can be a marker of disease susceptibility as well as of disease severity. This work studies IL-10 gene polymorphisms as a susceptibility gene in lepra reactions which may be useful in preventing lepra reactions as a complication of leprosy. Patients and methods This study was conducted on 40 patients with leprosy (20 with reactions), who were recruited from the Menoufia Unit of Dermatology and Leprosy within a period of 1 year, in addition to 20 control subjects, without history of leprosy, from the same geographic area. SNPs –1082A/G, –819C/T, and –592 A/C were identified in cases and control groups by PCR-RFLP. Results The genotype C/C in the SNP-819 was associated with lepra reaction (P < 0.01). There was no association between –592 A/C (P > 0.05) and 1082A/G (P > 0.05) and lepra reaction. The haplotype –1082A–819C–592C/–1082A–819T-592A is considered a risky haplotype category. The study documents that –1082A–819C–592C/–1082A–819C–592C and –1082A–819T–592A/–1082A–819T–592A are considered protective haplotypes. According to the study, the haplotype – 1082G–819C–592C/–1082A–819C–592C has no effect genetically. Conclusion IL-10 gene 819 SNP (C/C) is a risky polymorphism which increases susceptibility to lepra reaction, whereas IL-10 1082 SNP and IL-10 592 SNP are not associated with lepra reactions.
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Clinicopathological differences between type I and type II endometrial carcinoma p. 946
Moshira M Abd El-Wahed, Asmaa G Abdou, Dalia R Al-Sharaky, Hend A Kasem
DOI:10.4103/1110-2098.218267  
Objective The aim of this study was to investigate the differences between type I and type II endometrial carcinoma (EC) as regards relevant clinicopathological features. Background EC is the most frequent gynecological malignancy in the USA accounting for 3% of deaths yearly. However, in Egypt, it accounts for 1.6% of total female cancers, ranking 13th. It is the third most common gynecological cancer after cancer of the ovary and the cervix constituting about 23%. Methods Data were collected from the archive of Department of Pathology, Menoufia University, during the period from 2010 to 2014. The slides presented were examined to meet the inclusion criteria. The slides were examined to differentiate between type I and type II EC. If the slides did not fulfill the inclusion criteria, they were excluded. Study quality assessment included adequate information and defined assessment measures. All slides were examined and comparisons were made between type I and type II EC and the results were tabulated. Results Forty-nine of 67 (73.1%) cases were of type I EC, whereas 18 (26.9%) cases were of type II EC. High grade (100%), advanced stage (55.6%), high mitotic count (mean ± SD: 6.72 ± 2.49), and low apoptotic count (mean ± SD: 8.28 ± 10.18) were in favor of type II EC. Conclusion Type I EC is more frequent compared with type II. Type II EC is more aggressive compared with type I and is manifested by presentation at high grade, advanced stage, high mitoses, and low apoptotic count.
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Role of interleukin-33 in rheumatoid arthritis patients from Menoufia University Hospitals p. 952
Ahmed A Salama, Ahmed B Mahmoud, Dina R Al-Sharaki, Alaa F Gomah
DOI:10.4103/1110-2098.218272  
Objectives The objective of this study was to detect the level of interleukin-33 (IL-33) in patients with rheumatoid arthritis (RA) and to explore the relationship between the level of IL-33 in the serum with the disease activity and functional performance. Background Cytokines are important mediators of immune functions in humans and animals. IL-33, a newly found IL-1 family cytokine, is involved in joint inflammation in RA. Therefore, we aimed to investigate the immunopathological roles of IL-33 in serum RA patients. Patients and methods This study was conducted on a total of 80 individuals: 60 of them were RA patients (55 female and five male) and 20 healthy controls (17 female and three male). All RA patients and controls were evaluated by measuring complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), anticitrullinated proteins (anti-CCP), and rheumatoid factor (RF). IL-33 level was measured in the serum of both RA patient group and control group. Results The mean erythrocyte sedimentation rate, serum CRP, anti-CCP antibodies, and RF in addition to the detection percentages of serum IL-33 were significantly higher in the RA group than in the control group. In the RA group, serum IL-33 showed significantly positive correlations with DAS-28, visual analogue scale, RF, CRP, and anti-CCP antibodies. Conclusion IL-33 has an important proinflammatory role in the pathogenesis of RA. Considering their correlation with disease activity, they may become potential therapeutic targets for RA.
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Corneal biomechanical changes in patients with thin cornea p. 958
Hatem M Marey, Adel G Zaky, Mahmoud A Elsayed Hassan
DOI:10.4103/mmj.mmj_12_17  
Objectives The aim of this study was to evaluate and compare corneal hysteresis (CH) and corneal resistance factor (CRF) in healthy eyes with a central corneal thickness of 470–500 μm with matched keratoconus (KC) and keratoconus suspect (KCS) cases. Background The ocular response analyzer is a device developed in recent years that reveals the biomechanical properties of the cornea. It reflects certain biomechanical properties of the cornea, such as CH and CRF. Patients and methods A total of 66 eyes in three groups were included prospectively based on clinical examination and topography: the normal (NL), KC, and KCS groups. CH and CRF were measured using the ocular response analyzer. CH and CRF were compared between the three groups using the analysis of variances test. Results The three groups consisted of 32 NL, 15 KC, and 19 KCS eyes. The mean CH measured was 8.55 ± 1.77, 9.03 ± 1.119, and 8.06 ± 0.85 mmHg in NL, KCS, and KC eyes, respectively. The mean CRF was 8.39 ± 1.47, 8.27 ± 1.09, and 7.24 ± 1.27 mmHg in NL, KCS, and KC eyes, respectively. On controlling the central corneal thickness (470–500 μm) and sex, only mean CRF was significantly different between the NL and KC groups (P < 0.05). There was no significant difference between NL and KCS eyes; there was no significant difference in the mean CH between each groups (P > 0.05). Conclusion Only CRF can be helpful in differentiating KC from NL eyes; however, it is not valuable for detecting KCS, which is the main concern for refractive surgery. CH is not beneficial in differentiating between the study groups. Future studies focusing on more accurate tests for identifying KCS using a consistent grading scale for defining KC and KCS are still warranted.
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Association of retinal nerve fiber layer thickness and degree of myopia using spectral-domain optical coherence tomography p. 966
Khaled El-Ghonemy Said-Ahmed, Asmaa M.A. A. Ibrahem, Ahmed A Salama
DOI:10.4103/mmj.mmj_539_15  
Objective The objective of this study was to assess the effect of myopia on the peripapillary retinal nerve fiber layer (RNFL) thickness by spectral-domain (SD) optical coherence tomography (OCT). Background Myopia is the most common ocular abnormality worldwide, and its high subtype is among the leading causes of blindness. Several studies proposed it as a potential risk for glaucoma. However, it is unclear how both are related. RNFL thickness, currently used for glaucoma monitoring, can be the missed link. The aim of this study is to assess the effect of myopia on the peripapillary RNFL thickness by SD-OCT, thus correlating it to glaucoma. Patients and methods Eighty-six eyes of 86 participants were included in this cross-sectional observational study and categorized into low, moderate, and high myopia groups. Study participants underwent thorough ophthalmological examination, autorefractometer, axial length measurement, and perimetry. Peripapillary RNFL thickness was measured in each quadrant using Spectralis SD-OCT. The effects of spherical equivalent, axial length, age, and sex on peripapillary RNFL thickness were evaluated using Pearson's correlation test. Results The mean age was 38.81 ± 7.76 years (range: 25–55 years), mean spherical equivalent was –5.31 ± 3.34 D (range: −0.41 to −12.5 D), with an average axial length of 25.73 ± 1.14 mm (range: 24.0–28.2 mm). The mean RNFL thickness was thinner in highly and moderately myopic eyes (81.77 ± 6.09 and 85.10 ± 5.10 mm, respectively, P = 0.0001) compared with low myopic eyes (98.14 ± 5.59). A significant correlation was noted between spherical equivalent and axial length with peripapillary RNFL thickness (P < 0.05). However, no correlation was noted between age and sex with peripapillary RNFL thickness (P > 0.05). Conclusion High myopia should be considered in the interpretation of OCT data because of thinning of RNFL thickness, and normative database corrected for refractive error and axial length should be incorporated.
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