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   Table of Contents - Current issue
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April-June 2018
Volume 31 | Issue 2
Page Nos. 365-716

Online since Monday, August 27, 2018

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ORIGINAL ARTICLES  

Effect of oxygen therapy on the incidence of contrast-induced nephropathy in patients undergoing coronary angiography Highly accessed article p. 365
Walaa F Abd El Aziz, Ahmed A Emara, Awny G Shalaby, Maged M Hanna
DOI:10.4103/mmj.mmj_376_15  
Objective This study aimed to evaluate the effect of oxygen therapy on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography. Background CIN has been the third leading cause of hospital-acquired renal failure, accounting for 11% of cases. Patients with cardiac diseases are particularly at risk: 49% of CIN occurs after cardiac catheterization and coronary angioplasty in which repeated injections of contrast media are often required. Patient and methods We randomly assigned 200 consecutive patients who underwent elective coronary angiography to two groups: an oxygenation group, in which oxygen was administered through nasal cannula at a rate of 2 l/min from 15 min before the procedure until the end of the procedure (n = 100) and the control group (room air: n = 100). Arterial blood sample was drawn at the beginning of the procedure (coronary angiography) to estimate PaO2level. Baseline and follow-up serum creatinine was compared to diagnose CIN. Results A total of 200 patients were enrolled in the study. There were no significant differences as regards patient characteristics and risk factors for CIN. The PaO2at the baseline was significantly higher in the oxygen preconditioned group than in the control group (115.730 ± 15.774 vs. 84.140 ± 7.916 mmHg, P < 0.001). CIN occurred in 14 (7%) of 200 patients. The incidence of CIN was significantly lower in the oxygen preconditioning group than in the control group [3/100 (3%) vs. 11/100 (11%), P= 0.027], indicating that oxygen preconditioning concomitant with standard isotonic saline hydration suppressed CIN. Conclusion Oxygen preconditioning concomitant with standard isotonic saline hydration decreased the incidence of CIN in patients undergoing coronary angiography.
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Left ventricular deformation in idiopathic-dilated cardiomyopathy: a two-dimensional strain imaging study p. 372
Hala M Badran, Ghada M Sultan, Naglaa F Ahmed, Alaa M Yasser
DOI:10.4103/mmj.mmj_497_16  
Objective The aim of the present study was to review left ventricular (LV) deformation in idiopathic-dilated cardiomyopathy (DCM). Materials and methods The following data sources were searched: medical text books, medical journals, and medical websites that have updated researches with keywords 'left ventricle speckle tracking' in the title of the article. Systematic reviews that addressed LV speckle tracking and studies that addressed idiopathic-DCM were selected for the presents study. A special search was conducted at midline with the keywords 'left ventricle speckle tracking' in the title of the paper; extraction was performed, including the assessment of the quality and the validity of the papers that fulfilled the prior criteria that described the review. Each study was reviewed independently; the data obtained were rebuilt in a new language according to the need of the researcher and arranged into topics through the article. Results Speckle tracking echocardiography is an ideal tool for the assessment of the LV because of its regional and global functional characterization, angle independence, and high temporal resolution. The dimensions and function of the LV have been proven to be important indicators of LV impairment, primarily in patients with LV pressure and/or volume overload. This includes mainly patients with cardiomyopathy, heart failure, congenital heart disease, pulmonary hypertension, coronary artery disease, or arrhythmia. Conclusion LV speckle tracking would be an interesting diagnostic and prognostic entity to study DCM.
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Pattern of risk factors and management strategies in patients with acute coronary syndrome p. 378
Ahmed A Reda, Mourd B Mina, Ahmed N Taha Hussein
DOI:10.4103/mmj.mmj_602_16  
Objective The aim of the study was to assess the pattern of risk factors of acute coronary syndrome (ACS) in patients with coronary artery disease (CAD) in different age groups and sex categories. Background ACS refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction to presentations found in non-ST-segment elevation myocardial infarction or in unstable angina. Patient and methods This is a prospective, observational, noncontrolled study including 200 patients with ACS who were admitted at As-Salam International Hospital from August 2015 to March 2016. The patients were classified into four groups according to age: patients younger than 45 years, patients between 45 and 55 years, patients between 55 and 64 years, and patients aged 65 years or older. Further, a comparison was made between male and female patients. Results There was a significant difference between the studied groups as regards the prevalence of diabetes mellitus (DM), hypertension (HTN), and cigarette smoking, with no significant difference as regards positive family history of premature CAD. There was significant difference between male and female patients as regards the prevalence of DM, HTN, and cigarette smoking, with no significant difference as regards positive family history of premature CAD, dyslipidemia, and lipid profile. Conclusion The youngest patients had a higher incidence of smoking, were mostly male, had a positive family history of premature CAD, a low BMI, and had a poor lipid profile compared with other groups. In contrast, they had a lower incidence of other risk factors as diabetes, HTN, and low high-density lipoprotein values. The oldest patients (group 4) had the lowest incidence of some risk factor as DM, HTN, smoking, total cholesterol (TCh), low low-density lipoprotein levels, waist circumference, and BMI, which gave rise to the suspicion that age alone is an important risk factor for CAD. Female patients had a higher incidence of HTN, dyslipidemia, high levels of BMI, and atherogenic lipid profile compared with male patients. In contrast, they had a lower incidence of DM, positive family history of premature CAD, and smoking.
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Incidence of atrial fibrillation in ischemic and nonischemic dilated cardiomyopathy p. 387
AbdAlla M Kamal, Ahmed A Omara, Neveen I Samy, Kareem M AlAraby
DOI:10.4103/mmj.mmj_644_16  
Objective The aim of this study was to identify the incidence of atrial fibrillation (AF) in ischemic dilated cardiomyopathy (IDCM) and nonischemic dilated cardiomyopathy (NIDCM). Background AF is a common arrhythmia and is associated with an increased risk for embolic events, congestive heart failure, and total mortality. It lowers the quality of life and has been shown to be associated with worsening of outcome in patients with congestive heart failure of different etiologies. Materials and methods Patients were recruited during scheduled outpatient visits to the outpatient clinic in the Menofia University Hospital and Health Insurance Hospital, over the period from July 2015 to March 2016. All patients underwent full physical examination, and ECG, echocardiogram, and coronary angiography were performed to differentiate between IDCM and NIDCM. Results Totally, 50 patients had dilated cardiomyopathy (DCM) with left ventricular dysfunction. They were classified into two groups: the NIDCM group (20 patients) and the IDCM group (30 patients). AF was found to be more frequent in IDCM patients than in NIDCM patients (P = 0.006). Dyslipidemia (P = 0.002), diabetes mellitus (DM) (P = 0.05), and the mean left atrial (LA) diameter (5.127 ± 0.798) (P = 0.03) were statistically significant in IDCM patients. The univariate analysis identified the following as predictors of AF incidence: DM (P = 0.006), dyslipidemia (P = 0.016), left ventricular end diastolic diameter (P = 0.022), LA diameter (P = 0.000), and IDCM (P = 0.006). The multivariate regression analysis identified that DM, dyslipidemia, and LA diameter (>4.8 cm) had a more independent predictor value of AF incidence among DCM patients despite etiological cause. Conclusion The incidence of AF is more frequent in IDCM than in NIDCM patients. There is no significant difference between the two groups as regards age, sex, BMI, and hypertension. LA dilatation is more significant in IDCM. DM, dyslipidemia, and dilated LA proved to be independent predictors of AF in DCM patients.
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Right ventricular mechanics in patients with idiopathic dilated cardiomyopathy using strain imaging p. 395
Hala M Badran, Naglaa F Ahmed, Ehab E Mahdy
DOI:10.4103/mmj.mmj_671_16  
Objectives The aim of this study was to assess right ventricular (RV) mechanics in patients with idiopathic dilated cardiomyopathy (DCM) using two-dimensional (2D) strain imaging technique. Background Imaging using strain and strain rate (SR) was recently applied as a promising tool to analyze global and regional myocardial function in different disease entities, including DCM. 2D strain echo would be especially useful in assessing DCM as an accurate, time-sparing method. Patients and methods A total of 104 patients with documented DCM as proved by echocardiography were investigated using 2D echo, and 25 age-matched and sex-matched individuals served as control. Off-line 2D strain analysis was performed for the assessment of global and regional strain of the RV, including the RV free wall and the interventricular septum. Results RV deformation parameters showed loss of longitudinal systolic strain and SR base to apex gradient and significantly declined values in the DCM group. The averaged RV free wall segment systolic strain (−9.84 ± 6.73 vs. −30.86 ± 4.44%), systolic strain rate (SRsys) (−0.88 ± 0.47 vs. −1.75 ± 0.68 s−1), and early systolic strain rate (SRe) (0.67 ± 0.50 vs. 2.08 ± 1.08 s−1) were significantly reduced in the DCM group compared with the control group (P < 0.0001). These findings were also apparent in global RV deformation and gave similar significance (P < 0.0001) with the exception of late diastolic SR (P = NS). Intraventricular dyssynchrony was verified and showed a significant increase in time-to-peak standard deviation in the DCM group (75.71 ± 47.76 vs. 44.18 ± 26.72 ms, P < 0.002) compared with the control group. Conclusion In conclusion, our results suggest that the same cardiomyopathic pathology affects the RV as much as it affects the left ventricle with reduction in both RV systolic and diastolic functions. We have made an attempt to understand RV mechanics in different cardiac pathologies.
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Correlation between serum triiodothyronine level and inflammation in hemodialysis patients p. 402
Mostafa M Elnagar, Alaa E Abdel-Salam Dawood, Eslam M Abdelwahab Elshewy
DOI:10.4103/1110-2098.239722  
Objective The aim of this work was to study the correlation between serum free triiodothyronine (FT3) level and inflammation in hemodialysis (HD) patients. Background End-stage renal disease (ESRD) is associated with a markedly increased mortality risk, with cardiovascular diseases being the most common cause of death. FT3 is a marker of comorbidity in ESRD and in many acute and chronic diseases. Patients and methods This case–control study included 30 patients with ESRD on maintenance HD (17 men and 13 women) (mean age 43.93 ± 12.12 years), 20 patients with chronic kidney disease not on HD (12 male and eight female) (mean age 42.4 ± 12.42 years), and 20 healthy controls (12 male and eight female) (mean age 37.25 ± 10.52). Serum FT3 and thyroid-stimulating hormone concentrations were determined. C-reactive protein (CRP) was used as a marker of inflammation. Demographic data and laboratory values were evaluated. Results Our results showed a significantly lower serum FT3 level in the HD group compared with the chronic kidney disease and control groups (P < 0.001). Moreover, it showed nonsignificant differences in the serum thyroid-stimulating hormone levels between all groups (P = 0.765). In the HD group, there was a significant negative correlation between serum FT3 and CRP level (ρ=−0.83; P= 0.001), between serum CRP and albumin levels (ρ=−0.37; P= 0.004), and between serum FT3 level and number of dialysis years of patients (ρ=−0.455; P= 0.012). In contrast, a positive correlation was noticed between serum CRP levels and number of dialysis years of patients (ρ=0.371; P= 0.044). Conclusion The results of this study indicate a significant inverse correlation between CRP and plasma T3 circulating levels in patients undergoing HD. This investigation suggested that inflammation might be involved in the low T3 syndrome in HD patients. Thus, we suggest that FT3 levels can be used as a marker for inflammation in ESRD patients.
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Interleukin-18 in lean polycystic ovary syndrome patients p. 407
Nabil A Elkafrawy, Mohamed A Shabaan, Said A Saleh, Alaa A Dawood, Rasha I Noor El-Din, Shimaa K Zewain
DOI:10.4103/1110-2098.239733  
Objectives The aim of the study was to evaluate interleukin-18 (IL-18) levels in lean patients with polycystic ovary syndrome (PCOS). Background PCOS is one of the common causes of infertility in women. Several studies have attempted to find the etiology and pathophysiology but with no definitive theory to date. Insulin resistance with obesity was considered a causative factor for a long period of time. In recent times researchers have been considering PCOS as a chronic low inflammatory state with subsequent elevation of inflammatory markers, which were correlated with the disease at different stages as diagnostic, staging, prognostic, or predictor markers. Materials and methods Between September 2015 and May 2016 this multidisciplinary prospective observational study recruited 20 consecutive lean patients (BMI < 25 kg/m2) who presented with infertility disorder at the obstetrics and gynecology clinic and were diagnosed with PCOS according to Rotterdam criteria. Patients with hypertension, diabetes mellitus, and fever within the last 3 weeks, or were currently smokers, or were receiving statins, aspirins, corticosteroids, and insulin-sensitizing drugs were excluded. An endocrinologist assessed the patients, and anthropometric measures were collected. Also, blood samples were collected and sent for estimation of lipid profile, insulin assessment, and IL-18. Results Our study included 20 nonsmoker, nondiabetic, and nonhypertensive lean PCOS patients of a mean age of 24.7 years, mean BMI of 23, and mean waist-to-hip ratio of 0.8. The mean systolic blood pressure was 106.5 and the mean diastolic blood pressure was 70. Glucose homeostasis indices revealed mean fasting blood glucose of 84.9 with a mean fasting insulin of 14.2 and homeostatic model assessment (HOMA-IR) of 2.97. Mean IL-18 was 315. Conclusion Despite previous studies associating high IL-18 levels with obesity related to PCOS, we found that IL-18 is elevated in lean PCOS patients as well, revealing chronic low inflammatory state in those patients, which suggests that the pathophysiology of PCOS is not solely connected to obesity.
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Predictors of sustained virological response to therapy with pegylated interferon plus ribavirin in hepatitis C virus patients p. 412
Ehab A Abdelatty, El-Sayed I El-Shayeb, Ahmad G El-Feky
DOI:10.4103/mmj.mmj_508_16  
Objective The aim of this study was to determine the factors that may affect the response to combined therapy of pegyated interferon (PEG-INF) and ribavirin (RBV) in chronic hepatitis C virus (HCV) Egyptian patients for achieving sustained virological response (SVR), which means negative PCR 12 weeks after end of treatment. Background HCV is a global disease whose morbidity and mortality are increasing. HCV is a single-stranded RNA virus classified in the genus hepacivirus of the flaviviridae family, consisting out of 9600 nucleotides and stored inside the nucleocapsid. Six major HCV genotypes and over 70 subtypes have been identified. HCV-G4 is the most common genotype in Egypt. Patient and methods This study was carried out on 500 naive HCV-infected Egyptian patients attending Kafr El-Sheikh Liver Research Center for receiving combined antiviral therapy (PEG-INF and RBV) for 48 weeks. They were divided into two groups: group I, including 368 patients who had negative PCR 24 weeks after end of therapy (SVR); and group II, including 132 patients who had positive PCR 24 weeks after end of therapy (non-SVR). Results We found that many factors either related to the virus as viral load or related to the host as normal serum albumin level, lower levels of serum transaminases, low bilharzial titre level, and low grade of liver fibrosis could be a good predictors of response to antiviral therapy in chronic HCV Egyptian patients achieving SVR. Conclusion Normal serum albumin, lower level of serum transaminases, low bilharzial titre, low grade of liver fibrosis, and low baseline serum viral load all are good predictors for achieving SVR in chronic HCV Egyptian patients treated with combined PEG-INF and RBV therapy.
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Study of L1 cell adhesion molecule in patients with hepatocellular carcinoma p. 417
Ibrahem M Baghdady, Khaled A Abou Alaela, Hala S El-Rebey, Samar M Kamal, Ahmed E.A. Moustafa
DOI:10.4103/1110-2098.239738  
Objective The aim of this study was to investigate the presence of L1 cell adhesion molecule (L1CAM) in the serum and tissue of patients with hepatocellular carcinoma (HCC) and determine its efficacy in the detection of early HCC. Background HCC meets the criteria of a tumor that would benefit from a surveillance program, but the poor sensitivity and specificity of currently available tools have prevented the widespread implementation of surveillance. Patient and methods This study included 105 patients from Menoufia University Hospitals and National Liver Institute. They were classified into four groups: group I, the healthy control group (15 individuals); group II, which included patients with hepatitis C-related liver cirrhosis (45 patients); group III, which included patients with early HCC (25 patients); and group IV, which included patients with advanced HCC (20 patients). All patients were subjected to thorough history taking, complete physical examination, liver function tests, serum α-fetoprotein evaluation, and serum L1CAM evaluation. Two biopsies were obtained from each patient in group III, one from neoplastic tissue and another one from adjacent cirrhotic tissue to detect the expression of L1CAM by immunohistochemistry. Results The mean serum L1CAM level was highly significantly higher in both the early and advanced HCC groups than in all subgroups of liver cirrhosis. The expression of L1CAM was highly significantly higher in tumor tissues than in adjacent cirrhotic tissues. Conclusion This study suggests that L1CAM is accurate in differentiating patients with HCC even in early stage from those with nonmalignant chronic liver disease.
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Safety measures in Dakhlia hemodialysis units p. 429
Said S.A. Khamis, Yasin S Yasin, Mahmoud M Omara, Nagy E.N. Saleh
DOI:10.4103/mmj.mmj_564_16  
Objective The aim of this study was to assess safety measures in hemodialysis (HD) units in Dakhlia governorate. Background Healthcare-associated infections lead to death, disability, and excess medical costs. Infection is considered the second cause of death in patients with end-stage renal disease after cardiovascular disease, and septicemia accounts for more than 75% of these infection-related deaths. Annual death rates due to pneumonia and sepsis are markedly higher in dialysis patients compared with the general population. Patient and methods We obtained this questionnaire from the Ministry of Health and Population. It was designed to assess infection control measures in HD units, which is one of the most important areas of safety risk in dialysis facilities. A survey was performed on 18 units in Dakhlia governorate. The questionnaire is divided into sections as follows: general information about the unit, cleanliness of the place, hand washing, personal protection, methods for preventing pollution, dealing with furniture and sheets, environment cleansing, dealing with waste products, occupational health, isolation, and records. Results In our study we found (generally) that most of the dialysis units are in a large percent clean in general. The medical team does not commit enough to wash hands despite the availability of disinfectants. Moreover, there is no commitment with regard to the use of personal protective equipments. The studied units showed satisfactory percentage for all points as regards methods for preventing pollution, except commitment of the medical team to a septic nontouch technique. All studied units showed very good results in all items as regards environmental cleansing, but there was a clear error in separation between storage areas and the patient treatment area and in dealing with blood stains. We found that all studied units were ideal in dealing with furniture and sheets and recording data, but there were a lot of mistakes in dealing with waste products. Conclusion The results of this study indicate a significant correlation between the number of staff and implementation of infection control measures and decreasing mortality and morbidity in patients undergoing HD, as infection control is considered one of the most important aspects of safety that improves the quality of life of these patients.
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Quality of life in patients with irritable bowel syndrome in Qaliobeya Governorate, Egypt p. 438
Mahmoud A Qora, Mohamed M EL Kot, Aml A Salama, Manar S Abd El Rahman
DOI:10.4103/1110-2098.239748  
Objective The aim of this study was to assess the effect of irritable bowel syndrome (IBS) on health-related quality of life (QOL). Background There has been an underestimation of the impact of IBS on an individual's functioning and QOL. The general health status of both young and elderly individuals with IBS is generally found to be poorer than that of the general population. Patient and methods This cross-sectional study included 400 IBS patients who attended to randomly selected family health center and two family health units of Qaliobeya Governorate in Egypt. All IBS patients who attended to the selected family health center and units and fulfilled the criteria of ROM III were included in the study sample. QOL was assessed through the 34-item, IBS-QOL questionnaire. Results Older patients (≥30 years), female sex, receiving antispasmodic drugs, being overweight, and low socioeconomic standard were associated with better QOL. Patients who suffered dyspepsia, stomach pain, and flatulence encountered lower QOL. Conclusion QOL in patients with IBS is affected by age, sex, BMI, and presence of symptoms such as dyspepsia, flatulence, and stomach pain that may awake the patients at some nights.
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Assessment of safety measures in hemodialysis units in Menoufia p. 443
Said Khamis, Mahmoud Koura, Ahmed Ragheb, Asmaa Ezz-El-Din
DOI:10.4103/mmj.mmj_601_16  
Objective The aim of this study was to assess the safety measures for patients in hemodialysis units, aiming to improve the quality of medical services provided by the hemodialysis units in Menoufia Governorate and to evaluate hemodialysis units from the safety point of view. Background Hemodialysis is the most well-established form of treatment for end-stage renal failure. Standard precautions with additional measures are recommended specifically for dialysis centers to prevent transmission of bacteria and viruses from patient to patient. Patient and methods The study was conducted on 19 units of hemodialysis. All patients with end-stage renal disease under regular hemodialysis in these units were included. A questionnaire from the ministry of health and population was used. Results The percentage of working machines to total machines ranged from 77.4 to 100%. Practicing routine handwashing was 'good' in 60% of units, application of infection control measures was 'good' in half of the units, application of environmental infection control measures was 'good' in 12 units, and waste management was 'good' in 18 units. Workers were totally vaccinated against hepatitis B virus in eight units. Hepatitis B virus-positive patients had complete isolation. The level of safety in the studied units was 'good' in three units and 'fair' in 16 units. Conclusion More than 25% of the dialysis machines exceeded the recommended working hours/duration. Personal protective clothes and cleaning materials were available with shortage in usage. There was a shortage in the medical staff, especially in governmental hospitals. There was shortage in infrastructure of the most of dialysis units.
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Red blood cell distribution width to estimate lupus activity p. 449
Sabry A Shoeib, Mohamed A Abd Elhafez, Alaa E Abd El-Hamed, Heba G Sherief
DOI:10.4103/1110-2098.239752  
Objective The aim of the study was to study red blood cell distribution width (RDW) in systemic lupus erythematous (SLE) patients as a lupus activity marker. Background SLE is a multifactorial systemic autoimmune disease that can affect multiple organs. The general pathogenesis of this disease still needs a better understanding. RDW is a measure of the red blood cell size variation. Patient and methods This prospective study was carried in the Internal Medicine Department, Menoufia University Hospital, from March 2016 to August 2016. Our study included 58 patients with SLE activity, which was measured using the Systemic Lupus Erythematous Disease Activity Index. RDW was measured as one of the parameters of complete blood count. RDW was reported on the Sysmex XT. In this study we excluded any other causes of anemia and other connective tissue diseases. Results The study included 58 SLE patients: 20 systemic lupus patients with high activity and 38 systemic lupus patients with very high activity. RDW was higher in systemic lupus patients with very high activity than in systemic lupus patients with high activity. There was a highly significant correlation between RDW and Systemic Lupus Erythematous Disease Activity Index. There was a highly significant correlation between RDW and erythrocyte sedimentation rate. Conclusion There was statistically higher RDW in lupus patients with very high activity than in those with high activity; therefore, RDW can be used as a lupus activity marker. RDW was associated with the inflammatory process of SLE.
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Vitamin D receptor gene polymorphism in immune thrombocytopenic purpura p. 455
Mohamed Abdelhafez, Enas S Esaa, Mohamed Sakr
DOI:10.4103/mmj.mmj_621_16  
Objective The aim of this study was to assess the association of vitamin D receptor (VDR) gene polymorphism BsmI in cases of primary immune thrombocytopenic purpura (ITP). Background Recently, several studies have demonstrated the role of VDR polymorphisms in the development of autoimmune diseases. Vitamin D affects both innate and adaptive immune responses, which have been held responsible in ITP pathogenesis. Patient and methods VDR polymorphism BsmI (rs1544410) was detected by PCR followed by restriction fragment length polymorphism analysis. DNA samples were extracted from the peripheral blood of 40 ITP patients and 60 geographically and ethnically matched healthy controls. Results A statistically significant difference was found in the BsmI polymorphism between ITP patients and controls (χ2 = 8.77, P = 0.01). The BsmI polymorphism B allele was higher in ITP patients compared with controls but with a statistically insignificant difference (χ2 = 2.125, P = 0.145). The bb genotype played a protective role in ITP incidence. Conclusion This is the first published report on VDR gene polymorphisms in adult ITP patients. The BsmI genotype was associated with increased risk for ITP incidence with no obvious effect on bleeding severity, platelet count, or site of bleeding.
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Effect of ultrasound-assisted debridement on wound healing and infection outcomes in diabetic foot p. 462
Ahmed M Abd El Fattah, Mohamed Shaaban, Hanan Gawish, Noha El Mashad, Alaa El Deen Dawood
DOI:10.4103/mmj.mmj_658_16  
Objective The objective of this study was to determine the efficacy of low-frequency ultrasound (LFU) in chronic wound healing and infection outcome in diabetic foot ulcers. Background Around 15% of patients with diabetes will develop foot ulcers at some point in their life, making them 30–40 times more likely to undergo amputation due to a nonhealing foot ulcer than the nondiabetic population. Debridement plays a significant role in the healing of diabetic foot ulcers. Patient and methods This randomized clinical trial was conducted on 46 patients with diabetes, recruited from the Diabetic Foot Clinic at Mansoura and Menoufia Universities, Egypt. All patients with diabetes (type I and type II) who had chronic diabetic foot ulcers without severe arterial insufficiency, with ankle brachial indices of at least 0.6, and without severe limb-threatening infections were included. Results Patients were divided into two groups – group 1 received ultrasound-assisted wound (UAW) therapy in conjunction with standard wound care (n = 23), and the other group received only standard wound care. Patients were followed-up for 3 months. The complete healing rate in the present study population was 30.34% (control group = 17.39%, UAW group = 43.47%). The mean wound size reduction was significantly higher in the UAW group only in the second-week and third-month follow-ups. The number of infected ulcers was reduced by ultrasound debridement more than surgical debridement (control group = 5, UAW group = 11) at the end of the study, but with no significant difference (P = 0.148). A significant difference in healing ratio was found in patients with ultrasound debridement and initial wound culture (P = 0.01). Conclusion In diabetic foot ulcers, LFU debridement accompanied by standard wound care has a beneficial effect on wound healing and wound infection. LFU debridement can initially accelerate ulcer healing; however, there was no significant difference between the two modalities in the healing rate after 3 months.
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Serum vitamin D level in obese school-aged children p. 467
Maha A Tawfik, Naglaa F Barseem, Seham A Khodeer, Sara M Zayed
DOI:10.4103/mmj.mmj_667_16  
Objective The aim of this study was to assess vitamin D status in obese school-aged children and to correlate vitamin D levels with other clinical and laboratory investigations. Background Obesity and vitamin D deficiency have been classified as epidemics throughout the world; many studies have shown that vitamin D status and fat mass are inversely correlated. Patient and methods This study was carried out on 80 children ranging in age from 6 to 18 years divided according to BMI into two groups: an obese group [40 children (12 boys and 28 girls)] and a control group [40 apparently healthy children (17 boys and 23 girls)]. All children were subjected to a full assessment of history, clinical examination, and laboratory investigations including complete blood picture, qualitative C-reactive protein (CRP), fasting lipid profile (serum cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein), serum calcium (total), phosphorus, alkaline phosphatase, and serum 25(OH)-vitamin D. Results Our results showed that obese children had significantly higher values than the controls on all anthropometric measurements except the upper/lower segment ratio; they had significantly higher blood pressure, lower levels of hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and higher levels of all parameters of the lipid profile except high-density lipoprotein, which was lower. Positive CRP was detected in 80% of the children in the obese group, with 100% negative CRP in the control group. They had significantly lower 25(OH)-vitamin D than the controls; vitamin D deficiency was detected in 52.5% of obese children, and 47.5% of these children had vitamin D insufficiency. However, 52.5% of the controls had 25(OH)-vitamin D insufficiency. A significantly positive correlation was detected between triceps skinfold thickness and fasting serum cholesterol in the obese group. Conclusion Obese children are prone to hypertension, dyslipidemia, microcytic hypochromic anemia, inflammatory process, and vitamin D deficiency; apparently healthy children may have undiagnosed vitamin D insufficiency.
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Serum chemerin and its association with coronary heart disease in diabetic and nondiabetic patients p. 474
Mostafa M Elnajjar, Alaaeldin A Dawood, Mahmoud A Soliman, Gihane I Khalil, Khaled M Amin Elzorkany, Mohamed F.M. Aglan
DOI:10.4103/mmj.mmj_698_16  
Objective Chemerin is a novel adipokinine that is associated with inflammation and adipogenesis. Our aim was to study the relationship between serum chemerin and coronary artery disease (CAD) in angiographically documented participants and participants without CAD among patients with diabetes mellitus and those without diabetes mellitus. Background Chemerin is one of the adipokines that is linked to fat metabolism and thought to be linked to atherosclerosis and CAD. Patient and methods This cross-sectional study was conducted on 80 patients recruited from among patients presenting to the catheter laboratory of Sharq Al-Madina Hospital in Alexandria. Participants were divided into the following groups: group 1 included 20 diabetic patients with CAD; group 2 included 20 diabetic patients without CAD; group 3 included 20 nondiabetic patients with CAD; and group 4 included 20 participants as controls. Patients of groups 1 and 3 had angiographically documented CAD. Serum chemerin, glycemic control parameters (fasting blood sugar, glycated hemoglobin, fasting insulin, and homeostasis model assessment for insulin resistance), lipid profile, and urinary albumin–creatinine ratio were assessed. Results The results of the present study showed that there was a statistically significant increase in mean serum chemerin level in group 1 compared with groups 2 and 4 (P = 0.007and 0.001, respectively), as well as compared with group 3, but this increase was not statistically significant. There was also a statistically significant increase in serum chemerin in group 3 compared with groups 2 and 4 (P = 0.001 and 0.003, respectively). However, there was no statistically significant difference between the two CAD groups (groups 1 and 3) with regard to the Gensini score. There was no statistically significant correlation among the other studied parameters. Conclusion Serum chemerin level was increased in CAD patients, irrespective of whether they were diabetic or nondiabetic, but did not increase as the severity of CAD increased when assessed by the Gensini score.
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Study of paraoxonase 1 as a marker of atherosclerosis in young patients with subclinical hypothyroidism p. 481
Nabil A El-Kafrawy, Mostafa M El-Najjar, Hany S El-Barbary, Ahmed M El-Kersh, Mohamed A Helwa, Mai A Ibrahim
DOI:10.4103/mmj.mmj_731_16  
Objective The aim of this study was to investigate the paraoxonase 1 (PON-1) activity, which is accepted as a marker of atherosclerosis, in serum of patients with subclinical hypothyroidism (SCH). Background There is now strong evidence that PON-1 plays an important role in lipoprotein metabolism and thus may affect the risk of atherosclerosis in the general population. SCH and its correlation with the atherosclerosis and atherosclerotic cardiovascular diseases is a subject of debate. Patient and methods This study included 40 young patients (<43 years old) from Menoufia University hospitals after exclusion of all known cardiovascular risk factors. They were classified into two groups: group I, healthy controls group (20 patients) and group II, patients with SCH (20 patients). All patients were subjected to thorough history taking, complete physical examination, thyroid function tests, lipid profile, and PON-1 activity. Results The mean of PON-1 activity was highly significant higher in group II than control, and there are a significant negative correlation between PON-1 activity and thyroid-stimulating hormone. SCH group was more dyslipidemic as evidenced by decreased high-density lipoprotein and increased total cholesterol, triglycerides, and low-density lipoprotein. Conclusion This study suggests that SCH is an independent risk factor for atherosclerosis, and the higher the thyroid-stimulating hormone level and the lower the PON-1 activity, hence the higher the atherosclerotic cardiovascular risk.
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Primary assessment of radiofrequency ablation combined with transarterial chemoembolization for the treatment of hepatocellular carcinoma, a comparative study with traditional transarterial chemoembolization p. 487
Mohammed S Abd Allah, Mohamed S Eldin El Zawawi, Osama L El Abd, Mohamed K Abd El-Mageed
DOI:10.4103/1110-2098.239720  
Objectives This study aimed to evaluate the role and efficacy of combined transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) in the management of patients with large unresectable hepatocellular carcinoma (HCC) in comparison with traditional TACE alone. Background Surgery is still the treatment of choice for patients with HCC when diagnosed at an early stage. Unfortunately, most HCCs are diagnosed at intermediate or advanced stages. RFA is an alternative to partial hepatectomy for early HCC less than 3 cm. TACE is classified as palliative therapy in patients with intermediate-stage HCC. However, neither TACE nor RFA can result in adequate control of large-sized HCCs. Sequential application of TACE and RFA is increasingly being used in the treatment of medium-sized or large-sized HCC to overcome the limitations of each technique. Patients and methods This prospective study included 40 patients (men/women ratio: 31/9) who had a large unresectable HCC (<5 cm in maximum diameter). Patients were divided into two groups: the first group was treated with combined therapy (TACE–RFA) whereas the second group was treated with traditional TACE. Finally, the therapeutic response was evaluated by 1-month postprocedure triphasic computed tomography. Results The 1-month postprocedure triphasic computed tomography indicated that a complete response was achieved in 19/20 patients in group I and 8/20 patients in group II, whereas a partial response was achieved in 1/20 patients in group I and 10/20 patients in group II. A stable disease was observed in 2/20 patients in group II alone. Finally, no evidence of disease progression could be observed in both groups. Conclusion Combined therapy TACE–RFA is superior to TACE alone in achieving better therapeutic effects for patients with large unresectable HCC.
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Role of magnetic resonance imaging in the diagnosis of perianal fistulae p. 494
Mohamed S Elzawawi, Mohamed S Abdullah, Mohamed E.M. Bakr
DOI:10.4103/mmj.mmj_386_16  
Objective The aim of this study was to clarify the role of MRI in the diagnosis and classification of perianal fistula and to evaluate the additional clinical value of preoperative MRI and its benefit to the surgeon. Background An anorectal abscess originates from an infection arising in the cryptoglandular epithelium lining of the anal canal that can penetrate through the internal sphincter. Extension of the infection can involve the intersphincteric space, ischiorectal space, or even the supralevator space. Patient and methods This prospective study included 20 (15 men and five women; age range: 19–59 years; mean age: 36.85 years) patients selected from 34 patients referred to the Radiodiagnosis Department with clinically suspected perianal fistula. The study was conducted between March 2013 and November 2015 after preoperative clinical examination. Pulse sequences used were STIR, T2WI, T1WI, and T1WI after contrast with fat suppression sequences in axial, coronal, and, sometimes, sagittal planes. Results MRI revealed six (30%) patients with grade 1 simple linear intersphincteric fistula, five (25%) with grade 2 intersphincteric fistula with abscess or secondary track, three (15%) with grade 3 trans-sphincteric fistula, four (20%) with grade 4 trans-sphincteric fistula with abscess or secondary track, and two (10%) with grade 5 supralevator and translevator disease. One of the two supralevator fistulae showed horseshoe extension. MRI findings were concordant with the surgical findings in 18 (90%) patients (P = 0.003). Fallacies of MRI were observed in two (10%) patients, which proved to be sinus at surgery. Conclusion Our results support that MRI is the imaging technique of choice for preoperative evaluation of perianal fistulae, providing a highly accurate, rapid, and noninvasive means of performing presurgical assessment as it displays the anatomy of the sphincter muscles orthogonally with a background of good contrast resolution.
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Role of magnetic resonance imaging in differentiation of benign and malignant breast lesions p. 502
Adel M Elwakeel, Suzan F Omar, Aml R.A. Bayoumy
DOI:10.4103/mmj.mmj_623_16  
Objective This study was conducted to determine the role of MRI in differentiation of benign and malignant breast lesions. Background Breast MRI is an information-rich imaging modality that produces clear anatomic representation of soft tissue and also reflects underlying tissue dynamics. Patient and methods The current study included 30 female patients with clinically suspicious breast lesions. Their age ranged from 30 to 65 years. The study was conducted in Menoufia University Hospital. Cases were referred from General Surgery Department in Menoufia University Hospital. All cases were subjected to the following protocols: full history taking with special emphasis on age, parity, medications taken, previous allergic reactions, and family history of breast cancer, as well as clinical examination of both breasts to palpate any masses. An informed consent was obtained from patients included in the study. Sonomammography and dynamic contrast-enhanced (DCE) MRI were performed for all patients on high-field Toshiba Vantage1.5 T machine, respectively, in Menoufia University Hospital, Radiology Department. Results In this study the 27/30 enhanced breast lesions, their time–signal intensity curve were assessed, regarding their initial rise (slow, medium, or rapid) and their delayed phase (persistent, plateau, or washout). DCE-MRI revealed 16 (53.3%) lesions with progressive rising time/signal intensity curve (type I curve). Six (20%) lesions showed slow wash-in and slow washout with plateau curve (type II curve). Eight (26.7%) lesions showed rapid slope-up and rapid washout (type III curve). Three (10%) lesions were not enhanced. Conclusion The use of DCE-MRI decreases the number of breast biopsies taken, and it is very impressive in postsurgical follow-up (lumpectomy or mastectomy), as it can detect small lesions that can be missed by sonomammography.
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Role of computed tomography angiography and color Doppler ultrasonography in the evaluation of diabetic foot p. 508
Elsayed E Elsayed, Ashraf A Zytoon, Ameer M Eltelwany
DOI:10.4103/mmj.mmj_670_16  
Objective The aim of this study was to highlight the role of computed tomography angiography (CTA) and color Doppler ultrasonography (DUS) in the evaluation of patients with diabetic foot disease. Background The risk for ulceration and amputation is much higher in diabetics compared with nondiabetics. CTA is more frequently used to assess peripheral vascular disease of the diabetic foot. Patient and methods This prospective study included 30 diabetic patients who presented with diabetic foot vascular lesions and referred from outpatient clinics of vascular surgery to the Radiology Department, National Liver Institute, Menoufia University Hospital and Private Center. The present study was performed in the period between January 2015 and January 2016. Their ages ranged from 47 to 86 years; 22 of them were men and eight were women. All cases underwent Doppler examination as a rapid, noninvasive complementary diagnostic tool, and the findings were compared with those of CTA. Results In the present study, the number of segments was 399 for 57 limbs, and each arterial tree of one limb was divided into seven segments (common femoral, superficial femoral, popliteal, anterior tibial, posterior tibial, peroneal, and dorsalis pedis arteries). In this study, the number of stenotic segments was 38 (9.5%) and 42 (10.5%) on multidetector computed tomography angiography (MDCTA) and DUS, respectively. The number of occluded segments with distal collateral refilling was 16 (4%) on both MDCTA and DUS. The number of segments with total occlusion was 65 (16.2%) and 63 (15.7%) on MDCTA and DUS, respectively. Conclusion The use of CTA and DUS increases the ability to better delineate vascular anatomy, localize the obstruction, assess the severity of stenosis, and detect the presence of collaterals and distal run-off.
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Role of magnetic resonance imaging in the assessment of chronic hip pain in adults p. 514
Mohammed S El Din El Zawawi, Rehab M Habib, Dalia Abd El Raouf El Zefzaf
DOI:10.4103/mmj.mmj_682_16  
Objectives This study aimed to evaluate the diagnostic value of MRI in the assessment of painful hip joints in adults. Background Hip pain has different etiologies. MRI is the method of choice for characterizing various disorders and for assessing the full extent of osseous, chondral, and soft-tissue abnormalities of the hip joint. Patient and methods This retrospective study was conducted on 35 patients with painful hip joints. The following MR sequences were performed on all patients: Coronal T1, T2, and STIR-weighted images (WIs,) axial T1 and T2 WIs, axial T1 WI, and sagittal T1 WI after contrast injection in five patients. Patient history, local examination of the diseased hip, and laboratory investigations were performed. Results The male-to-female ratio was 20: 15, and their ages ranged from 15 to 75 years with a mean value of 45 years. The final MRI diagnoses in 35 patients were as follows: avascular necrosis in 10 (28.57%), transient synovitis in eight (22.86%), septic arthritis in four (11.43%), malignant neoplasm in four (11.43%), osteoarthritis in two (5.71%), bone marrow contusion in three (8.57%), migratory osteoporosis in one (2.86%), bursitis in one (2.86%), and stress fractures in two (5.71%) patients. Conclusion MRI of the hip joint is a safe, reliable, diagnostic, and accurate imaging modality for the assessment of hip pain and is sufficient for delineation of different hip joint pathologies.
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The role of fibroscan in assessment of liver cirrhosis in patients with chronic liver disease p. 520
Mohamed S Elzawawy, Shaimaa A Hassanein, Rasha M El Nomrosy
DOI:10.4103/mmj.mmj_26_17  
Objective The aim of this study is to evaluate the accuracy of fibroscan in the assessment of liver cirrhosis in chronic liver disease. Background Fibroscan is a noninvasive imaging study for measuring liver stiffness by transducer probe-induced elastic share wave that propagates through liver tissue to measure its velocity. Patient and methods The present study was conducted on 50 patients with chronic liver disease. There were 32 males and 18 females, and their ages ranged from 34 to 75 years, with mean age of 51 years. The study was conducted in the hepatology units of Menoufiya University Hospitals, and the disease was confirmed by standard diagnostic criteria. All cases were subjected to the following protocol: full history, clinical examination, laboratory investigation, and ultrasound examination. The patients were subjected to fibroscan examination. The elasticity is directly correlated with the degree of hepatic fibrosis, and 7 kPa has been proposed as a cut-off for fibrosis equal to or greater than F2, and 12.5 kPa for cirrhosis. Results Liver stiffness was significantly correlated with liver cirrhosis. The fibroscan technique has high sensitivity and high specificity of 100%, with the area under the receiver operating characteristic curve (95% confidence interval) of 1.00, at the cut-off level of 14.5 kPa. Conclusion Transient elastography is a promising noninvasive method for detection of cirrhosis in patients with chronic liver disease. Therefore, fibroscan can be used regarding the decision of treatment and follow-up of patients with cirrhosis for screening and detection of the complications.
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Role of computed tomography-guided percutaneous celiac plexus neurolysis in relieving pain caused by abdominal malignancy p. 525
Elsayed E Elsayed, Mohamed S Elwarraky, Tarek F Abd Ella, Hesham M.A. Soliman
DOI:10.4103/mmj.mmj_50_18  
Objective This study aims to assess the efficacy of computed tomography (CT)-guided celiac plexus neurolysis (CPN) to relieve pain caused by abdominal malignancy. Background The management of severe pain in patients with cancer is a challenging matter faced by medical care providers. CPN is an effective method that can alleviate pain caused by abdominal malignancies. It leads to marked decrease in the analgesics daily dose or even not needing it. Patient and methods CT-guided CPN was done for 20 (90%) adult patients experiencing abdominal cancer pain using ethanol as a neurolytic agent. To assess the degree of pain relief, the visual analog scale score was used to assess pain immediately, 1 week, 1 month, and 3 months after CPN. Results Marked decrease of the pain intensity in all the patients was noted. The visual analog scale score at baseline was 9.1 ± 0.85. One day after CPN, pain severity decreased to 1.3 ± 0.71; 1 week later, it was mostly maintained at the same level at 1.7 ± 0.89; 1 month after CPN, the pain severity was also maintained at the same level at 1.9 ± 0.79; and 3 months after CPN, pain severity still decreased significantly to 2.3 ± 1.02. The decline in pain severity at its average before and at different sequences after CPN recorded high significant statistical difference (P value less than 0.001). Conclusion CT-guided CPN is an effective and safe method for relieving severe pain owing to abdominal cancer.
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Role of computed tomography in prediction of tumor necrosis of hepatocellular carcinoma after chemoembolization p. 531
Basma A Dessouky, Waleed A Mousa, Amgaad F Abd El-Shafy
DOI:10.4103/mmj.mmj_131_17  
Objective The aim of this study was to assess the role of triphasic computed tomography to predict tumor necrosis of hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE). Background Triphasic computed tomography is a promising tool in prediction of HCC response after TACE. HCC exhibiting favorable criteria in triphasic computed tomography would be more likely to benefit from TACE. For HCC without these favorable criteria, alternative or adjuvant treatments or even no treatment may be considered. These favorable criteria are small size, solitary, well-defined margin, peripherally located, and typically enhanced HCC tumors. Patients and methods A total of 50 patients were included in the study. All patients underwent complete history taking, clinical examination, laboratory investigations, and then triphasic computed tomography examination of the liver as a baseline assessment. Thereafter, the patients were treated with TACE. Finally, the therapeutic response was evaluated after 21 days by triphasic computed tomography scan of liver according to modified response evaluation criteria in solid tumors. Results Of the 50 patients, 23 showed complete necrosis, 22 showed partial necrosis, four were stable, and one showed progressive disease. Tumor size, its enhancement, and number were statistically highly significant, with a P value of less than 0.001. Location and margin of the tumor were statistically significant, with P value of 0.04. Conclusion Triphasic computed tomography is the most commonly used standard imaging technique for predicting and evaluating the therapeutic response in patients with HCC after TACE.
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Real-time shear wave elastography for assessing liver fibrosis in patients with chronic hepatitis C p. 538
Zeinab A Ali, Ashraf A Zytoon, Mahmoud M Elsakhawy, Ramadan M Algamal
DOI:10.4103/mmj.mmj_638_17  
Objective The aim of this study was to evaluate the diagnostic accuracy of real-time shear wave elastography (SWE) in assessment of liver fibrosis in patients with chronic hepatitis C compared with the liver biopsy. Background Chronic hepatitis C is a global disease and one of the most intractable clinical problems in Egypt with drastic consequences. Diagnosis and grading of hepatic fibrosis is one of the chief clues in selection of appropriate plan of treatment and follow-up. Patient and methods This study included 161 patients (male/female = 112/49) with chronic hepatitis C and 30 healthy control (male/female = 25/5). Liver biopsy and transient elastography were done for all patients before SWE examination. Results Different liver fibrosis stages were observed (13.7% F0, 20% F1, 11.2% F2, 23.6% F3, and 31.1% F4); the reference range of liver stiffness in the diseased group by SWE was 5.2–22.5 kPa and control group was 2–4.5 kPa. There was significant discrimination between mild fibrosis (F1), with reference range from 4 to 5.3 kPa, and significant fibrosis of at least F2, with area under the receiver operating characteristic curve of 0.994 and P value of less than 0.0001, and between mild fibrosis F2 (5.7–12.2 kPa) and severe fibrosis F3 (13.2–21.6 kPa) and F4 cirrhosis of at least 22.1 kPa, with area under the receiver operating characteristic curve of 0.995 and P value of less than 0.0001. There was strong correlation between SWE staging of fibrosis and that of liver biopsy (Kendall's τ-b was 0.892). Conclusion Being noninvasive and regarding its accuracy SWE can replace liver biopsy with its related complication dilemma. SWE can also replace transient elastography for being a real-time treatment with enhanced accuracy.
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Duplex ultrasound in the evaluation of early renal hemodynamics alteration in type I diabetics p. 544
Zeinab A Ali, Waleed A Mousa, Sherif M Shalaby
DOI:10.4103/mmj.mmj_795_17  
Background Diabetic nephropathy affects ~40% of patients with type I diabetes mellitus. Once fully developed, it carries a poor prognosis, where relative mortality is almost 40–100 times that of nondiabetics. Evaluation of vascular resistivity at multiple points of renal parenchyma may suggest structural or functional changes within the kidneys and can provide useful diagnostic and prognostic information. Objective The aim of this study was to detect possible changes of renal blood flow and vascular indices in children and adolescents with type I diabetes mellitus, using duplex ultrasonography, and to correlate these changes with clinical and laboratory parameters results. Participants and methods Twenty-five type I diabetic child and adolescent and 25 nondiabetic child and adolescent (control) were included in the study. After ethics committee approval and obtaining patient consent, the study included 13 females and 12 males in each group, with mean age of 10.3 years ± 4.31 SD in both groups. All patients are subjected to: full history, fasting blood sugar analysis, creatinine level, HBA1C, microalbuminuria, and albumin/creatinine ratio. Renal Doppler ultrasound for each case was done. Results Statistically significant differences were detected between diabetic and control cases regarding resistive index of main renal, segmental, and interlobar arteries. The results were compared against serum creatinine, albumin/creatinine ratio, and glycated hemoglobin. Conclusion Our study showed some differences in the resistive index of main renal, segmental, and interlobar arteries between children with type I diabetes and age-matched healthy controls. Moreover, there is a significant positive correlation between the resistive index of these arteries and duration of diabetes, albumin/creatinine ratio (mg/mmol), and serum creatinine level (mg/dl).
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Role of cellular immunity in the pathogenesis of immune thrombocytopenic purpura in children p. 550
Mohammed A. R. Soliman, Samar M Kamal Eldeen, Mahmoud A Elhawy, Ola H Ahmed Elshafey
DOI:10.4103/mmj.mmj_238_16  
Objective This study aimed to determine CD4+, CD8+ T cells, CD4/CD8, CD4+ 25+ cells, and regulatory T cells (CD4+ CD25+ Fox P3+) in children with immune thrombocytopenic purpura (ITP). Background ITP is an immune-mediated hemorrhagic condition characterized by the production of autoantibodies against platelet antigens. Primary immune thrombocytopenia is characterized by isolated thrombocytopenia with normal bone marrow or increased bone marrow megakaryocytes; if this condition persists for more than 12 months, it is known as chronic immune thrombocytopenia. Regulatory T cells play a major role in controlling immune homeostasis and preventing autoimmunity. Immune thrombocytopenic patients show decreased numbers of CD4+ CD25+ FoxP3+ regulatory T cells. Patients and methods The study included 45 children: 15 children with acute ITP, 15 children with chronic ITP, and 15 controls. Three microliters of venous blood samples were obtained. A complete blood count was performed first. Flow cytometric analysis of lymphocytes was carried out to detect CD3+, CD8+, CD4+, CD4+ 25+ cells, and regulatory T cells (CD4+ CD25+ FoxP3+). Results No significant difference was recorded between the three groups in CD4+, CD8+, CD4+ 25+ cells, or the CD4/CD8 ratio. A significantly lower percentage of regulatory T cells was found in chronic patients in comparison with the controls (P = 0.00) and a significantly lower percentage of regulatory T cells was found in chronic patients in comparison with acute patients (P = 0.00), but no significant difference was recorded between acute patients and control (P > 0.05) in regulatory T cells. Conclusion The present study showed that regulatory T cells are significantly lower in chronic immune thrombocytopenic patients, indicating its role in the pathogenesis of ITP.
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Vitamin D receptor (BsmI) gene polymorphism and type 2 diabetes mellitus in an Egyptian population p. 557
Waleed M Fathy, Gehan A Tawfeek, Ahmed R Tawfeek, Shimaa M Aboelyazeid Ellayen
DOI:10.4103/mmj.mmj_604_16  
Objective The aim of this study was to evaluate the association between vitamin D receptor (VDR) (BsmI) gene polymorphism and genetic susceptibility to type 2 diabetes mellitus (T2DM) in an Egyptian population. Background The VDR gene is a candidate gene for susceptibility to several diseases. Studies on the association between VDR polymorphisms and T2DM in different ethnic populations are yet inconclusive. Patient and methods The present study was a case–control study conducted at the Department of Clinical Pathology, College of Medicine, Menoufia University, during the period from May 2015 to December 2016. We included 120 patients, who were divided into two groups: group A included 40 healthy patients, which served as the control group, and group B included 80 T2DM patients. Participants were subjected to the following: complete history taking and clinical examination, assessment of BMI, fasting blood sugar, 2-h postprandial, glycated haemoglobin, and lipid profile, renal function tests and PCR-restriction fragment length polymorphism for determining the genotype of BsmI gene polymorphism. Results Genotype distribution and allele frequencies of the VDR gene polymorphism differed significantly between patients and controls. The Bb genotype was higher in the T2DM group (42.5%) than in the control group (12.5%), and the bb genotype was higher in the T2DM group (7.5%) than in the control group (5%), but without statistical significance. The b allele was higher in the T2DM group (28.8%) than in the control group (11.3%). The Bb allele was found to be more risky than the BB allele by 5.610 [confidence interval (CI)=1.97–15.96], whereas the bb allele was found to be more risky than the BB allele by 2.475 (CI = 0.46–13.09). The b allele was found to be more risky than the B allele by 3.18 (CI = 1.47–6.90). Conclusion Our data suggest that VDR (BsmI) gene polymorphism genotype is associated with the risk of T2DM
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Role of CD305 and CD38 in Chronic Lymphocytic Leukemia Clinical Relevance p. 564
Iman A Ahmedy, Suzan A Alhassanin, Noha S Moussa
DOI:10.4103/mmj.mmj_775_17  
Objective This work aimed to study CD305 and CD38 expression in chronic lymphocytic leukemia (CLL) patients and its relation to clinical and prognostic criteria of the disease. Background CD305 is an inhibitor of B-cell receptor mediated signaling, and has been reported to be of lower expression in high risk CLL patients. Studies addressing CD305 in CLL and its relation to biological variables and standard prognostic factors had been so scarce yet .On the other hand, CD38 expression, a well established prognostic factor, in CLL, is associated with an aggressive clinical behavior. Patient and methods Our study included 54 patients. Forty CLL consecutive patients and 14 age-matched and sex-matched apparently healthy controls. Clinical examination and laboratory investigations were done for all of the studied groups. Results CD305 showed a positive correlation with lymphocyte doubling time. However it showed a negative correlation with; β2microglobulin, lactate dehydrogenase, modified ray staging and Coombs' test. CD38 expression showed a positive significant correlation with modified ray staging, white blood cells, β2microglobulin, lactate dehydrogenase and Coomb's test however it showed a negative correlation with CD305 and lymphocyte doubling time. 55% of patients did not receive chemotherapy were CD305 positive. The remaining 45% of patients received chemotherapy and were CD38+. Conclusion CD305 and CD38 expression can be used as simple reliable, inexpensive independent prognostic factors in CLL patients and they can even predict at presentation patients who will initiate chemotherapy early.
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Cell-free DNA as a biomarker of breast cancer p. 569
Rawheyia H El Edel, Ahmed S El Gamaal, Hala H El Said, Rasha I Noreldin, Marwa M. M. Omar
DOI:10.4103/mmj.mmj_239_17  
Background Circulating plasma cell-free DNA (CFDNA) is comprised of nucleic acids in fringe blood of healthy persons and patients with several diseases that start from cell death. Apoptotic tumor cells may discharge DNA into the peripheral blood, and this may hold possibilities for the early detection of breast cancer. Objective This study aimed to assess CFDNA (glyceraldehyde 3-phosphate dehydrogenase) concentration in patients with malignant and benign breast lesions and healthy controls to investigate its role as a noninvasive marker for early detection of breast cancer. Patients and methods This study included 50 patients divided into three groups: group I included 30 newly diagnosed breast cancer female patients; group II included 10 female patients with benign breast lesions; and group III included 10 individuals of apparently healthy female individuals. CFDNA was extracted from plasma using NucleoSpin Plasma XS Kit. Concentration of CFDNA (glyceraldehyde 3-phosphate dehydrogenase) was measured using QuantiTect Probe PCR Kit by real-time PCR. Results The results revealed that there was a highly significant difference in the mean level of CFDNA cycle threshold between the malignant breast lesions and each of the benign lesions (34.31 vs. 40.30, P= 0.001) and controls (34.31 vs. 41.25, P= 0.001). However, there was no significant statistical difference between benign lesions and controls. Our study provides valuable data on the utilization of the concentration of free DNA for breast cancer recognition. Conclusion CFDNA level in plasma was observed to be higher in patients with breast cancer. It may have potential for the early identification of breast cancer.
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Androgen receptor expression in estrogen receptor-negative breast cancer p. 575
Belal M Meligy, Noha M Elkady, Hagar Alagizy, Enas A El Khouly, Eman A Tawfik, Mohamed A Shehata
DOI:10.4103/1110-2098.239737  
Objective The aim of this study was to estimate the expression of androgen receptors (ARs) in patients with estrogen receptor (ER)-negative breast cancer. Background Growth of breast cancer is hormone dependent. Estrogen and progesterone play a fundamental role in the pathogenesis and treatment of patients with ER-positive breast cancer and those with progesterone receptor-positive breast cancer. Patients who lack the expression of these receptors receive no benefit from hormonal treatment and are considered to have a poor prognosis. AR is a member of nuclear steroid receptors with ambiguous role in patients with breast cancer. There is growing evidence about its prognostic and predictive value in patients with breast cancer. Patient and methods This study included 56 patients who presented to Department of Clinical Oncology, Menoufia University, between January 2012 and December 2014. We included patients with pathologically proven invasive breast cancer and negatively expressing ER. Immunohistochemical study was done to evaluate the expression of AR using paraffin-embedded formalin-fixed tissue sections. Data were collected regarding clinicopathological characteristics, treatment modalities, and survival analysis including progression-free survival and overall survival. Results AR was expressed in 34% of patients and was correlated with advanced axillary nodal involvement and human epidermal growth factor receptor overexpression. It has a poor effect on overall survival in patients with triple-negative breast cancer and good effect on patients with ER-negative human epidermal growth factor receptor-positive disease. Conclusion AR is a possible prognostic factor in breast cancer. Patients with triple-negative breast cancer could be classified into those with AR-negative disease and AR-positive disease.
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Cancer statistics in Menofia University Hospital 2012–2013: a trial of cancer registry in Menofia University Hospital p. 582
Mohamed S El-Senbawy, Naser M Abd El Bary, Mohamed A Shehata, Ehab A Shaltout
DOI:10.4103/mmj.mmj_649_16  
Background The purposes of a hospital-based cancer registry are by definition different from those of a population-based registry. The purpose of the hospital-based registry is to serve the needs of the hospital administration and the hospital's cancer program, guide planning and evaluation of cancer control programs, and provide information for the national database of cancer incidence. Objective The aim of this work is to describe cancer statistics in Menoufia University Hospital among cases who had presented to the clinical oncology department in 2012–2013. Patients and methods A retrospective descriptive study was carried out at Menoufia University Hospital, Clinical Oncology Department, describing cancer registry among all cases who had presented in 2012–2013. Data were collected from patients' records, paper file. This study described the total number of cases in 2012 and 2013 and, in each year, the number of patients of both sexes, cancer site frequency, and the most common cancers for both sexes and for each sex. Cases with incomplete data were excluded. Results In 2012, 1413 patients presented versus 1475 patients in 2013, with a total of 2888 patients; ~52% of the cases were women and ~48% of cases were men. Breast cancer was the most frequent cancer, followed by lymphohematopoietic malignancies, gastrointestinal tract tumors, urinary tract tumors, lung and pleura cancers, metastasis of unknown origin, gynecological tumors, head and neck cancers, sarcomas, central nervous system tumors, male genital system tumors, skin tumors, endocrinal tumors, and miscellaneous, respectively. Conclusion In our study, the male to female ratio was less than 1. The most frequent tumor sites are breasts, lymphohematopoietic system, gastrointestinal tract, urinary tract, and lung and pleura, respectively.
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Correlation of thrombocytopenia with grading of esophageal varices in chronic liver disease patients p. 588
Mohamed A El-Din Nouh, Khaled A El-Momen Ali, Amira M Badawy, Ahmed H El-Daly
DOI:10.4103/1110-2098.239725  
Objective The aim of this study was to determine the correlation of thrombocytopenia with esophageal variceal grading in chronic liver disease patients. Background Esophageal varices (EVs) are a serious consequence of portal hypertension in patients with chronic liver disease. Several studies have evaluated possible noninvasive predictors for the presence and size of varices, including platelet count. Materials and methods This study included 210 patients who presented with chronic liver disease in Menouf Fever Hospital. The diagnosis was based on history, clinical, laboratory, and imaging data. They were divided into two groups: group I and group II. Group I included 140 patients with EVs and was subdivided into group IA, which included 60 patients with grade I, group IB, which included 40 patients with grade II, and group IC, which included 40 patients with grade III, and group II included 70 patients without EVs. Correlation of thrombocytopenia with the grading of EVs was assessed using Spearman's correlation. Results Platelet count was significantly lower in patients with EV grades I, II, and III (mean ± SD; 100.5 ± 19.8, 65.2 ± 13.0, and 60.3 ± 14.1 × 103/mm3, respectively) than in those without EVs (152.1 ± 17.1 × 103/mm3). Moreover, it was significantly lower in patients with grades II and III (large EVs) (65.2 ± 13.0 and 60.3 ± 14.1 × 103/mm3, respectively) than in patients with grade I (small EVs) (100.5 ± 19.8 × 103/mm3) (P < 0.001). The cutoff value of platelet count as a predictor for the presence of EVs was less than or equal to 130 × 103/mm3, with a sensitivity of 95% and specificity of 95%. Moreover, the cutoff value as a predictor for the presence of large EVs was less than or equal to 80 × 103/mm3, with a sensitivity of 91.2% and a specificity of 86.7%. There was a significant negative correlation between platelet count and grading of EVs (r=−0.756; P < 0.001). Conclusion Thrombocytopenia is a good noninvasive predictor for the presence and size of EVs in chronic liver disease patients. There was a significant negative correlation between platelet count and grading of EVs.
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Liver stiffness measurement by fibroscan for predicting esophageal varices in patients with chronic liver diseases p. 594
Ayman M El Lehleh, Hosam El Din M. Seleem, Mona M Abdelmaksoud
DOI:10.4103/1110-2098.239745  
Objective The aim of the present study was to measure liver stiffness by fibroscan to predict esophageal varices (EV) in patients with chronic liver diseases. Background Fibroscan is a novel, noninvasive, ultrasound-based technology that allows measuring liver stiffness. It is a noninvasive method for assessing EV, developed as an alternative to endoscopy. Patient and methods A total of 75 patients with chronic liver diseases were included in a case–control study from January 2015 to January 2016, aged greater than 18 years, with BMI less than 30 kg/m2, no history of previous endoscopic intervention for EV, no treatment with β-adrenergic receptor blockers, and absence of hepatocellular carcinoma or ascites. Patients underwent clinical examination, laboratory investigations, abdominal ultrasonography, upper endoscopy, and fibroscan. They were divided into the following groups: group I, no varices; group IIa, small varices (grades 1 and 2), and group IIb, large varices (grades 3 and 4). Results The mean liver stiffness values were higher in group II (35.29 ± 10.07 kPa) compared with group I (22.80 ± 8.01 kPa), with high statistically significant differences (P < 0.001) and the best cut-off value (22.7 kPa) for the presence of varices. The sensitivity was 90%, and specificity was 56%. The mean liver stiffness values were higher in patients with large varices (group IIb) (46.50 ± 5.99 kPa) than in patients with small varices (group IIa) (31.75 ± 8.38), with high statistically significant differences (P < 0.001) and the best cut-off value (37 kPa) for the presence of large varices. The sensitivity was 91%, and specificity was 79%. Conclusion Liver stiffness measurement can predict the presence of EV and can also detect large-sized varices.
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Study of serum neutrophil gelatinase-associated lipocalin level in inflammatory bowel disease patients p. 600
Mohamed A Nooh, Hosam I Mohammed, Safaa I Taiel, Heba M. E. El Hagary
DOI:10.4103/mmj.mmj_629_16  
Objective This study aimed to evaluate the role of neutrophil gelatinase-associated lipocalin (NGAL) in the determination of disease activity and response to treatment in inflammatory bowel disease (IBD) patients. Background IBDs are among the most important gastrointestinal diseases. Confirmation of the diagnosis and detection of disease activity mostly entails utilization of invasive procedures. NGAL is a protein mainly secreted by neutrophils. Previously, in IBD, overexpression of NGAL in colon epithelium has been shown. Patient and methods This study was conducted on 35 naive patients with clinical, laboratory, endoscopic, and histopathological findings of active IBD, including active ulcerative colitis (UC) and active Crohn's disease (CD), and the same patients of the first group while on remission by medical therapy. In addition, 20 non-IBD patients were enrolled as the control group. Patients and controls were subjected to laboratory investigations, abdominal ultrasound, lower gastrointestinal endoscopy, and biopsy taking for histopathology and quantitative measurement of serum NGAL using enzyme-linked immunosorbent assay kits. Results There was a highly significant elevation of serum NGAL in active IBD patients (active UC and active CD) (P < 0.001) compared with inactive IBD patients (inactive UC and inactive CD) and the control group. In addition, there was a highly significant elevation of serum NGAL in inactive IBD patients (P < 0.001) when compared with the control group. Serum NGAL correlated positively with inflammatory markers, UC activity index, histopathological activity, and clinical CD activity index. Conclusion Serum NGAL is valuable noninvasive marker in the assessment of IBD patients regarding disease activity and response to treatment.
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Correlation between plasma leptin hormone in diabetic patients and the extent of coronary artery disease p. 607
Ahmed Abdelaziz Emara, Mohamed Abdelaziz Moharam, Ahmed E Reyad
DOI:10.4103/mmj.mmj_632_16  
Objective The aim of this study was to assess the correlation between the level of plasma leptin hormone in diabetic patients with atherosclerotic coronary artery disease (CAD) and the extent of coronary artery lesion using coronary angiography. Background Leptin is a hormone secreted from adipose tissue and is increased in obese patients in whom there is an increased risk for atherosclerotic coronary disease which can be assessed by means of coronary angiography. Patient and methods A total of 50 diabetic patients with CAD were studied for the assessment of plasma leptin hormone level and its correlation with the extent of CAD by means of angiography. Results There was a positive correlation between the level of leptin hormone and the extent of CAD. Conclusion The study suggests that leptin is a significant cardiovascular risk factor for atherosclerotic CAD independent of traditional cardiovascular risk factors. Leptinemia is associated with several biochemical disorders, suggesting that leptin may be a pathogenic factor in cardiovascular disease.
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Family planning counseling sessions in primary healthcare facilities in Sadat City District, Menoufia Governorate p. 613
Hewaida M Anwar Elshazly, Nora Abd Elhady, Eman Tolba Elsaid Tolba
DOI:10.4103/1110-2098.239727  
Objectives The aim of the study was to assess the quality of family planning counseling sessions and assess clients' satisfaction with family planning counseling sessions. Background Family planning (FP) is now acknowledged as one of the most successful development interventions, with potential benefits on maternal and child health outcomes, educational advances, and economic development. Participants and methods This was a cross-sectional study conducted in family health facilities in Sadat City District, Menoufia Governorate, including all FP services providers in the studied family health facilities using a checklist and self-reported questionnaire to assess the qualification of providers of FP counseling and the availability of services and resources. The study also included 200 clients who were randomly selected from attendants of the studied facilities for FP services to assess their satisfaction regarding the counseling session. Results There was a significant difference between physicians and nurses regarding performance of FP counseling sessions, where nurses showed better performance than physicians in all steps of the checklist. There was also a significant difference between physicians and nurses regarding duration of experience and previous FP counseling training courses. Total satisfaction score was better among clients in rural facilities. Conclusion Balanced counseling strategy gave better scores for nurses than for physicians in providing counseling sessions for clients.
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Shiftwork-related problems among nurses working in Benha University Hospital, Egypt p. 619
Mahmoud A Saleh, Hala M Elhady, Mohamed H Waly, Shewikar T Elbakry, Hanaa E Baioumy, Mariam S Zaki
DOI:10.4103/1110-2098.239740  
Objective This study aimed at studying the effects of shiftwork on health in nurses in Benha University Hospitals. Background Approximately one-fourth of hospital workers work in shift system. Shiftwork stress has been linked to negative effects on health. However, the studies on shiftwork effects are limited. Patient and methods This cross-sectional study targeted all nurses in Benha University Hospitals, Qualubeyia, Egypt, over the period from beginning of January 2014 to end of December 2014. The nurses completed Standard Shiftwork Index questionnaire and had a physical examination, including measurement of random blood sugar level, blood pressure for cardiovascular condition, and vital signs, especially pulse to assess arrhythmias, body weight, height, and BMI for obesity. Results The study recruited 803 nurses, and all of them were females; 43% aged more than 40 years, with a mean duration in shiftwork of 18.99 years. Most nurses were married. The surgical departments' nurses had significant higher BMI, digestive, and languidiness scores than medical departments' nurses. Both diastolic blood pressure and systolic blood pressure were higher in married nurses who had dependent households. Nurses who worked up to 40 h/week in night and afternoon shifts had a significantly higher sleep disturbance score. Cardiovascular score was significantly higher among nurses aged of at least 40 years, and who worked in shift system for 20–40 years; there were significant positive correlations between diastolic blood pressure and number of households and between cardiovascular problems and age and work duration in the shift system. Conclusion Shiftwork was associated with health hazards, which mandated guidelines to protect nurses from the negative effect of shiftwork.
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Resources allocation and their relation to antenatal and natal health service utilization in rural and urban primary healthcare units in Zagazig District, Sharkia Governorate, Egypt (2015/2016) p. 629
Taghreed M Farahat, Hala M Shaheen, Aml A Salama, Hanaa S Said
DOI:10.4103/1110-2098.239741  
Objective The objective of this study was to assess resource allocation of antenatal and natal health services and its effect on utilization of these services among the urban and rural strata in Zagazig District, Sharkia Governorate. Background More than half of the Egyptian population (57%) living in rural areas according to Egypt Health Profile (2011), especially poor rural areas, have access to fewer healthcare resources. Improving resource allocation of healthcare greatly influences the utilization of health services. Patient and methods A cross-sectional study was conducted on 400 married women during the child bearing period. Stage 1: four primary healthcare facilities (units and centers) were chosen by simple random technique. Stage 2: from each health facility, the sample size was estimated according to the total number of registered women in each site through proportional allocation method. Women who attended to these health facilities for antenatal care or regular check-up visits (child vaccination, outpatient) were interviewed by a predesigned questionnaire. Utilization rates were estimated and compared regarding residence. Resources were assessed by the resource allocation checklist which was adapted from the Egyptian Ministry of Health. Checklist explains the minimal required resources needed to provide the service according to the Egyptian Ministry of Health instructions. Results The study revealed high utilization rate of antenatal and natal health services in urban facility than in the rural one, with availability of most of health resources needed for providing the services in urban units with their limitation and even unavailability in rural units. Conclusion Resources allocation affects greatly health services utilization. Health resources are more available in urban residences over rural ones. So urban residences are more likely to use health services more than rural one.
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KAP of Umra and Haj travelers toward travel-related health problems in Menoufia Governorate p. 635
Hala Shaheen, Mohammad El-Kot, Fatma Ahmed, Hala E. A. Ghonaim
DOI:10.4103/1110-2098.239742  
Objectives The aim of the present study was to assess the awareness about travel-related health problems among Umra and Haj travelers in Menoufia Governorate, Egypt. Background Several surveys have demonstrated that high proportions of travelers are unaware about travel-related health problems. These problems vary in significance, from relatively minor to life threatening conditions, including infectious and noninfectious diseases. Patient and methods This cross-sectional, descriptive study was carried out in the Shebin El-Kom District, Menoufia Governorate, during the period from 1 April 2013 till the end of October 2016. A predesigned questionnaire was used that included questions related to the participants' socioeconomic status, travel circumstances, and travel knowledge, attitude, and practices. Results The study included 400 participants – 16.2% males and 83.3% females. Their mean age was 45.96 ± 14.16 years. About two-thirds had no knowledge regarding common infectious diseases (60%) and mode of disease transmission (62.5%). Most of the participants had no knowledge about the importance of vaccination (76.2%), and also, most of the participants had a positive attitude toward different items related to travel as they agreed regarding practice. In addition, more than half of the participants had never sought any advice before travel, and only 10% reported starting preparation 2 weeks before travel. Conclusion The review demonstrated an inadequate level of travelers' knowledge, poor utilization of travel medicine services, and poor practising of seeking pretravel health advice, thus indicating a low knowledge, attitude, and practices among the studied participants. This highlights the need for an increase in the awareness about travel-related health problems among Haj and Umra travelers.
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Risk factors for gestational diabetes mellitus among pregnant women attending Monshaat Sultan Family Health Center, Menoufia Governorate p. 640
Waleed M Fathy, Nora A Khalil, Nareiman S Mahmoud
DOI:10.4103/1110-2098.239759  
Objectives The aim of the present study was to examine the prevalence of gestational diabetes mellitus (GDM) among pregnant women attending a family health center between 24 and 28 weeks of gestation, and to assess the risk factors. Background GDM is defined as any degree of glucose intolerance with onset of, or first recognized during, pregnancy. Screening for GDM during pregnancy is recommended. Patients and methods This cross-sectional study was conducted on 250 pregnant women between 24 and 28 weeks of gestation who attended the Monshaat Sultan Family Health Center. Risk factors for GDM were estimated using a self-designed questionnaire and initial screening was carried out by a glucose challenge test with 50 g glucose. If 1-h blood glucose level exceeded 130 mg/dl, then a 3-h oral glucose tolerance test with 100 g glucose was carried out and diagnosis was established. Results The prevalence of GDM among the studied group was 8%. Risk factors found to be significantly associated with GDM were advanced age, BMI greater than or equal to 30, high blood pressure, multiparity, preeclampsia, family history of diabetes, induced labor, abortion, preterm deliveries, large-sized baby, and smoking. However, socioeconomic status, small-sized baby, still birth, previous history of hypertension, and family history of hypertension failed to demonstrate significant associations with GDM. Conclusion The prevalence of GDM among pregnant women attending Munshaat Sultan Family Health Center was found to be relatively high compared with other studies. Controlling risk factors and screening for early detection are mandatory for better maternal and fetal health.
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Evaluation of hematopoietic stem cells in chronic discoid lupus erythematosus p. 646
Iman Seleit, Ola A Bakry, Rehab M Samaka, Dalia Nassif
DOI:10.4103/1110-2098.239734  
Objective The aim of the present study was to investigate the role of hematopoietic stem cell (HSC) and nonhematopoietic stem cells in lupus erythematosus through exploring the immunohistochemical expression of CD34 and c-kit. Backgrounds Chronic discoid lupus erythematosus (CDLE) is the most common type of cutaneous lupus erythematosus whose pathogenesis is still debated. The presence of autoantibodies in CDLE and the association between stem cell defects and autoimmunity encouraged us to investigate the possibility of HSC abnormality in CDLE through their immunohistochemical localization in skin samples of this disease using CD34 and c-kit antibodies. Materials and methods In total, 25 CDLE cases were selected, with 15 age-matched and sex-matched healthy individuals as a control group. Results CD34 showed positive expression in spindle-shaped dermal cells in 96% of CDLE cases with mild to strong intensity. CD34 was downregulated in CDLE cases compared with normal skin. Strong dermal intensity and higher Histo score (P < 0.001 for both) were significantly associated with normal skin. Regarding c-kit, spindle-shaped dermal cells showed positive immunoreactivity in 84% of cases, with mild to moderate intensity. Strong dermal intensity and higher dermal Histo score (P < 0.001 for both) were significantly associated with normal skin compared with CDLE cases. Conclusion We can conclude that HSCs are defective in CDLE cases as proved by CD34 and c-kit immunostaining. Further research is needed to investigate bone marrow HSCs and the underlying molecular mechanisms for such defect. Experimental studies using HSC transplantation for resistant or disseminated CDLE cases may be evaluated.
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Second-to-fourth digital length ratio in male patients with acne vulgaris p. 654
Mohamed A Shoeb, Azza G. A. Farag, Asmahan M Mansour
DOI:10.4103/1110-2098.239747  
Objective The aim of this study was to evaluate second and fourth digit length ratio in acne vulgaris male patients compared with controls, and to assess the association of this ratio with the clinical aspects of that disease. Background The ratio of second-to-fourth digit length (2D:4D) has been hypothesized to reflect prenatal androgen exposure and an individual's sensitivity to androgens. Patient and methods The current study was carried out on 169 male patients with different degrees of acne vulgaris severity selected from the Dermatology Outpatient Clinic, Faculty of Medicine, Menoufia University Hospital, Mansoura Dermatology Hospital, from January 2015 to December 2015, in addition to 63 age and sex-matched healthy volunteers as a control group. Results Acne patients' ages ranged from 12 to 26 years with a mean age of 19.87±4.487 years, whereas the age of controls ranged from 13 to 36 years with a mean age of 19.54±3.809 years. The control group comprised 63 male patients. There were nonsignificant differences between patients and controls as regards age. No significant differences were found between right digit 2D:4D, left digit 2D:4D, and total digit 2D:4D ratio in male patients and controls. There was a significant positive correlation between severity of acne lesion and right 2D:4D, but nonsignificant correlations were found as regards left and total 2D:4D. Significant negative correlations were found between right, left, and total 2D:4D ratio and disease duration. However, nonsignificant correlations were found between right, left, or total 2D:4D ratio and age of onset of acne lesion. Conclusion In male acne cases this 2D:4D ratio might be a good predictor of acne duration only and to the same extent its severity, but not its development.
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Frequency of scabies among patients attending dermatology outpatient clinic in Qwesna Hospital, Menofia Governorate p. 660
Mohamed A Pasha, Hala Shaheen, Amira M Abdallah
DOI:10.4103/mmj.mmj_681_16  
Objective The aim of the paper was to assess and describe frequency of scabies in patients attending dermatology outpatient clinic in Quesna Hospital, Menoufia Governorate. Background Scabies is a neglected health problem worldwide. It is a highly contagious skin disease that affects both males and females of all socioeconomic status. It is related primarily to poverty and overcrowding. Clinically, it presents as a small erythematous papulovesicular rash, generally symmetrical. Patient and methods This was a descriptive cross-sectional study conducted in the outpatient clinic of dermatology at Quesna Hospital. The calculated sample was 370 patients. Patients were assessed using semistructured questionnaire. Examination was conducted for all patients. Data collected were analyzed using Microsoft Excel SPSS version 16 software programs. Results In this study, 27 cases were diagnosed as having scabies, giving a frequency rate of 7%, and 343 (93%) patients were diagnosed as not having scabies. Of the patients with scabies, 48.1% were males and 51.9% were females. The most common age ranged from 30 to 49 years (33.3%). Scabies was more prevalent among families of larger size (44.4%), with crowding index less than 2 (55.6%), and with low socioeconomic level (92.6%). Itching increased at night in 96.3% of the patients. Conclusion It is clearly shown by our study that personal hygiene plays an important role in the development of scabies. Respondents who share towel with others are more prone to development of scabies.
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Effect of zinc supplementation on serum zinc and leptin levels in children on regular hemodialysis p. 664
Ghada M El-Mashad, El-Sayed I El-Gebally, Sally M El-Hefnawy, Asmaa M El-Sayed Saad
DOI:10.4103/1110-2098.239739  
Objective The aim of this study was to determine the effect of zinc supplementation on serum levels of zinc and leptin in pediatric patients on hemodialysis (HD). Background Zinc is an essential trace element for human nutrition, and its deficiency which could result in anorexia, poor nutritional status, high rates of infections, and growth retardation. Many patients on maintenance HD exhibit zinc deficiency. Leptin may offer a tool for making clear the physiology of zinc deficiency–induced anorexia based on a relationship between zinc and leptin levels. Patient and methods The study was carried out on 42 children divided into two groups: group I included 22 children on HD who received 50-mg zinc gluconate twice daily for 90 days, and group II included healthy children as controls. Anthropometric measurements were taken, and serum zinc and leptin levels were determined the day before supplementation and at day 90 of the study. Results Serum level of zinc is decreased and serum leptin level is increased in children on regular HD. There is an increase in zinc level and a decrease in serum leptin level after zinc supplementation. Conclusion Zinc supplementation increased serum zinc level and decreased serum leptin level among males and females in the studied patients. Enhancement of serum zinc level improves appetite and stimulate food intake.
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Evaluation of the role of adrenomedullin in febrile neutropenia p. 671
Fady M El-Gendy, Mahmoud A El-Hawy, Saly M El-Hefnawy, Dina M. Adel Ahmed Shalaby
DOI:10.4103/mmj.mmj_4_17  
Objective The aim of this study was to evaluate the role of adrenomedullin (ADM) as a new marker in febrile neutropenia (FN). Background ADM has an effective role in FN episode in pediatric patients with acute lymphoblastic leukemia (ALL). Patient and methods This is a prospective study of 25 patients with ALL, recruited from the Hematology and Oncology Unit, Menoufia University Hospital, Egypt, from January to June 2016 diagnosed with ALL and suffering from FN episode. Complete blood count with differential count, C-reactive protein (CRP), ADM, Na, K, Ca, creatinine, and serum glutamate-pyruvate transaminase level were evaluated on the first and fifth days of FN. Results ADM level was higher on the fifth day than on the first day of FN. It showed higher sensitivity and specificity compared with CRP and has greater area under the curve compared with CRP, with a cutoff of point 6 for CRP and 50 for ADM. CRP level was higher on the first than on the fifth day of FN. Conclusion ADM was higher on the fifth day than on first day of FN episode and has higher sensitivity and specificity compared with CRP and has greater area under the curve. Therefore, it can be considered as a new diagnostic marker in FN episode in patients with ALL. Nevertheless, CRP is still an effective cheap marker that should be used in FN episode.
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E/A ratio and troponin I level as measures of mortality in patients with shock in pediatric intensive care units p. 677
Basim A Elgazzar, Fahima M Hassan, Ahmed A Khattab, Rania S Elzayat
DOI:10.4103/mmj.mmj_675_16  
Objective The aim of this study was to assess the value of E/A ratio and troponin I level as indexes of mortality in patients with shock in a pediatric intensive care unit (PICU). Background The E/A ratio is the ratio between the E wave and the A wave, and is used as an index of the diastolic function of the heart. Troponin I is specific of myocardial injury. Its level reflects the systolic and diastolic functions of the heart. Patients and methods A total of 50 children with shock in our PICU were studied. Clinical assessments, complete blood analysis, liver and renal function tests, and detection of troponin I levels were carried out. Echocardiographic assessment was carried out, including the assessment of ejection fraction% and E/A ratio. Results The group of dead patients had a significantly lower E/A ratio and a significantly higher troponin I level. Conclusion The E/A ratio and troponin I levels can be used as mortality indexes in patients with shock admitted to the PICU.
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Stromal-derived factor-1 (CXCL12) and its receptor (CXCR4) in neonatal sepsis p. 681
Fady M El-Gendy, Hassan S Badr, Mohamed A Helwa, Ahmed M. S. El-Hanafy
DOI:10.4103/1110-2098.239761  
Background Neonatal sepsis remains a major cause of morbidity and mortality in newborns. The C-X-C motif chemokine 12 (CXCL12) and its receptor α-chemokine receptor type 4 (CXCR4) are now known to play an important role in inflammatory states and mediate lymphocyte migration in response inflammation. However, it is unclear how chemokines respond to late-onset neonatal sepsis (LOS). Objective The aim of this study was to assess the value of measuring the serum levels of stromal-derived factor-1, also named CXCL12, and lymphocyte expression levels of its receptor CXCR4 in the diagnosis of LOS in relation to clinical and hematological sepsis scores. Patients and methods Levels of CXCL12 in serum and lymphocyte expression of CXCR4 were determined using enzyme-linked immunosorbent assay technique and flow cytometry, respectively, in 38 full-term neonates; 23 cases of LOS (13 male and 10 female) and 15 healthy neonates (six male and nine female) were included in the study. Results Serum levels of CXCL12 and lymphocyte expression levels of CXCR4 were significantly higher in neonates with LOS when compared with nonseptic neonates. At a cutoff point of 30 pg/ml, the diagnostic accuracy of CXCL12 in the diagnosis of neonatal sepsis was 100%, with a sensitivity of 100% and a specificity of 100%, whereas the diagnostic accuracy of mean fluorescence intensity of lymphocyte expression of CXCR4 in the diagnosis of neonatal sepsis was 84%, with a sensitivity of 87%, specificity of 80%, positive predictive value of 87%, and negative predictive value of 80% at a cutoff point of 150. Conclusion CXCR4 and CXCL12 levels increase significantly in septic neonates and they are valuable markers in the diagnosis of neonatal sepsis.
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Study of levels of protein Z as a risk factor for thrombosis in children with nephrotic syndrome p. 689
Ahmed A Khatab, Ghada M El-Mashad, Seham Z Khodair, Mohammed H Youssef
DOI:10.4103/mmj.mmj_589_16  
Objective The aim of this study is to assess the level of protein Z (PZ) as a risk factor for thrombosis in children with nephrotic syndrome (NS). Background NS results from any of several well-described primary glomerulopathies that are defined by histopathology and clinical criteria. The main pathomechanism of complications originates from the large loss of plasma proteins in the urine of nephrotic children, and thromboembolism is among the most serious complications. PZ plays an important role in inhibiting coagulation, serving as a cofactor for the inactivation of activated factor X by plasma-PZ-dependent protease inhibitor. Decreased PZ may contribute to an increased risk of thromboembolic complications in children with NS. Patient and methods The study included 45 children divided into three groups: group I included 15 patients in active stage of NS, group II included 15 patients in remission stage, and group III included 15 apparently healthy age-matched and sex-matched patients as controls. Patients were subjected to the following: history taking and clinical examination, assessment of weight, height, and edema, platelet count, prothrombin time, activated partial thromboplastin time, creatinine, urine protein/creatinine ratio, serum albumin, cholesterol, and antithrombin III (ATIII) level assay by radial immunodiffusion and PZ level assay by enzyme-linked immunosorbent assay. Results There were highly statistical significant differences regarding platelet count (P = 0.000), urine protein/creatinine ratio (P = 0.000), serum albumin (P = 0.000), cholesterol (P = 0.000), ATIII (P = 0.000), and PZ (P = 0.000) between the studied groups. Conclusion PZ level in plasma and ATIII level were found to be lower in children with NS in active stage, and this may contribute to an increased risk of thromboembolic complications in children with NS.
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Assessment of circulating vascular endothelial growth factor in patients with stable and exacerbated chronic obstructive pulmonary disease p. 695
Nourane Y Azab, Mahmoud M El-Habashy, Maathir K El-Shafie, Dalia I El-Gammal
DOI:10.4103/1110-2098.239736  
Objective This study aimed to evaluate the diagnostic value of serum vascular endothelial growth factor (VEGF) assessment during stable and acute exacerbations of chronic obstructive pulmonary disease (COPD). Background VEGF is a cytokine that has potent angiogenic and vascular permeability-enhancing activities. VEGF serum level was found to increase in a number of inflammatory disorders. Patient and methods This study was carried out in the Chest and Medical Biochemistry Departments, Faculty of Medicine, Menoufia University and El-Mahalla Chest Hospital in the period from July 2015 to March 2016. It included 75 patients, with a mean age of 54.7 ± 7.55 years. The patients were subjected to clinical examination and standard spirometric measures including percentage of predicted forced vital capacity, percentage of predicted forced expiratory volume in the first second, and forced expiratory volume in the first second/forced vital capacity ratio. Measurement of VEGF serum levels was done in patients with acute exacerbations of COPD on the first day of hospitalization, whereas for patients with stable COPD and for the healthy controls, the sample was taken on the same day of the spirometric maneuver. Results VEGF level was significantly elevated in patients with stable chronic obstructive pulmonary disease (COPD) compared with controls and also was significantly higher in patients with acute exacerbations of COPD compared with patients with stable COPD. Conclusion VEGF is significantly elevated in patients with acute exacerbations of COPD and is proportional to the severity of stable COPD. Therefore, it can be used as a biomarker for COPD.
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Prevalence of interstitial lung disease in patients with gastroesophageal reflux disease p. 703
Lamia I Atwa, Hisham S Abd Elaaty, Ibrahim I EL-Mahallawy, Ayman M EI-Lehleh, Sami S. A . Eldahdouh
DOI:10.4103/1110-2098.239744  
Objective The aim of the study was to investigate the prevalence of interstitial lung diseases in patients with gastroesophageal reflux disease (GERD) and to show the correlation between them. Background Interstitial lung diseases are a common complication in patients with GERD because of repeated aspiration of gastric acid. Patient and methods One hundred patients with GERD (25 patients with GERD grade A, 25 patients with GERD grade B, 25 patients with GERD grade C, and 25 patients with GERD grade D) with no past history of pulmonary diseases, collagen vascular diseases, chronic liver diseases, or ascites were enrolled in this study. All patients were subjected to the following after obtaining their oral consent for participation: complete medical history, examination, laboratory investigations, upper gastrointestinal endoscopy, radiological investigation [plain chest radiography and chest high-resolution computed tomography (HRCT)], and pulmonary function tests [spirometry and diffusing lung capacity of carbon monoxide (DLCO)]. Results When the severity of GERD increased the mean percentage of DLCO decreased (patients with GERD grade D had the lowest DLCO (75.4 ± 26.8). There was a statistically significant negative correlation between the grades of GERD, DLCO, and forced vital capacity%. There was a highly statistically significant difference as regards grades of GERD in relation to chest HRCT results (P < 0.001) and a statistically significant positive correlation between chest HRCT and grades of GERD (when the grade of GERD increased, the degree of ILD patterns in chest HRCT increased). Conclusion The present data support and extend the theory of a high incidence of pulmonary involvement in GERD patients even in those patients free of respiratory symptoms.
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Prevalence of depressive symptoms among healthcare providers in Shibin El-Kom city in Menoufia governorate p. 708
Lamiaa G El-Hamrawya, Nagwa N Hegazy, Samah M. I. El-Halawany
DOI:10.4103/mmj.mmj_85_17  
Objective The aim of the study was to estimate the prevalence of depressive symptoms among healthcare providers in Shibin El-Kom city in Menoufia governorate and to identify the risk factors among the healthcare providers. Background Depression is common in medical students and residents; physicians have a rate of depression similar to that in the population. Poor mental health among nurses and doctors hinder professional performance and lowers the quality of the care provided by them. Patient and methods This was cross-sectional study which was conducted in Shibin El-Kom city including all doctors and nurses at teaching hospitals in Shibin El-Kom and Shibin El-Kom primary healthcare center (PHCC). The total number of doctors were 961 and nurses were 685. Socioeconomic Scale and Patient Health Questionnaire 9 were collected. Results The prevalence of depressive symptoms among all participants of the PHCC (71.4%) was higher than tertiary healthcare hospital (THCH) (59%). The prevalence of depressive symptoms among the doctors of the PHCC (73.8%) was higher than THCH (58.8%), and the prevalence among nurses of the PHCC (68.6%) was higher than THCH (45.4%). Conclusion The prevalence of depressive symptoms was high among healthcare providers; to face this problem, there should be programs aiming at improving the mental health of healthcare provider's. Such programs should focus on the optimal financial, social, practical, and healthy lifestyle needed for better human health.
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ERRATUM Top

Erratum: Study of prognostic and predictive factors in locally advanced breast cancer in Egypt p. 716

DOI:10.4103/1110-2098.239774  
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