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   Table of Contents - Current issue
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January-March 2021
Volume 34 | Issue 1
Page Nos. 1-407

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DERMATOLOGY - REVIEW ARTICLE  

Effect of tramadol on the male reproductive system and sexual health Highly accessed article p. 1
Abdalla M Attia, Naglaa I Sarhan, Ola A Bakry, Hossam A Yassin, Nahla A Gamal
DOI:10.4103/mmj.mmj_694_16  
Objectives The aim of this study was to review the literature as regards the potential effects of chronic tramadol administration on the male reproductive system and sexual health in humans and experimental animals in vivo and in vitro in published studies. Materials and methods We searched electronic databases from 2006 to 2016, including PubMed MEDLINE, Medscape, EMBASE, EBCSO Academic Search Complete, Cochrane Systematic Reviews Database, and Google-Scholar. Study selection The articles that studied the effect of chronic tramadol administration on the male reproductive system and sexual health in both humans and laboratory animals were selected. The initial search selected articles that met the inclusion criteria. If the studies did not fulfill the inclusion criteria, they were excluded. Data extraction Study quality assessment included the following: whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Data synthesis Comparisons were made using a structured review with the results tabulated. Conclusion This review demonstrates a significant damage to testicular tissue with chronic tramadol administration. Tramadol was demonstrated to affect male reproductive hormones by decreasing serum testosterone and gonadotrophins and increasing estradiol and prolactin. As regards its effect on sexual function, it was demonstrated that it is neither more effective nor safer compared with other drugs used in the treatment of premature ejaculation. Moreover, it may be associated with erectile dysfunction.
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DERMATOLOGY - ORIGINAL ARTICLES Top

Effect of fetal sex on maternal total testosterone level Highly accessed article p. 9
Abdallah M Attia, Thoria A Omar, Mai A El-Melegy
DOI:10.4103/mmj.mmj_108_19  
Objective To study the effect of fetal sex on maternal serum total testosterone level and its application for fetal sex determination. Background Our study has been made to find a prenatal sex determination test that is rapid, accurate, and can be performed in early pregnancy. Patients and methods This study was done on 66 pregnant healthy women (aged 18–35 years) in their second trimester of pregnancy (13–26 gestational weeks) as a case group and another 20 healthy nonpregnant women, age-matched as a control group. Those cases with a history of drug intake, chronic diseases, and history of previous operations were excluded. Both groups were subjected to measurement of total testosterone levels. The pregnant women were rechecked after delivery to know the delivered baby's sex. After excluding five cases from the pregnant group, including three cases (abortion) and two cases (still birth) the final number of the case group was 61; after that the pregnant group was classified into two subgroups: pregnant with male (30) and pregnant with female (31). Results The maternal serum total testosterone level is significantly higher in the pregnant group compared with the nonpregnant control group. Regarding maternal testosterone in women carrying female fetus and others carrying male fetus, there was no statistically significant difference regarding the maternal total testosterone level between those who are pregnant in women compared with those who are carrying male fetus. Conclusion Maternal serum total testosterone level is not a good predictor of fetal sex.
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Evaluation of avanafil in the treatment of erectile dysfunction Highly accessed article p. 13
Abdalla M Attia, Sarah M.A. El-Soud
DOI:10.4103/mmj.mmj_115_19  
Objective To evaluate the post-marketing efficacy of avanafil 100 mg, safety, and the probable adverse events in the treatment of Egyptian men with erectile dysfunction (ED). Background ED is one of the most common sexual disorders due to organic, psychogenic, or mixed etiologies. Its prevalence ranges from 6 to 64% increasing with age. Avanafil is a highly selective and potent second-generation phosphodiesterase 5 inhibitor. Patients and methods This was a double-blind, placebo-controlled, crossover study including 26 patients with mild to severe ED using the International Index of Erectile Function-Erectile Function. Patients received avanafil 100 mg or placebo for 6 weeks each, with a 2-week washout period in between. It was taken 30 min precoital on-demand twice weekly. Follow-up was at the end of the third and sixth week. Results Avanafil 100 mg significantly increased the mean IEEF-EF score when compared with the baseline (P < 0.001) and when compared with the placebo (P = 0.005), while placebo was not significant (P > 0.05). On use of avanafil 100 mg, 45% of patients became normal (no ED, score >25) by the end of the sixth week; 40% showed different grades of improvement; and 15% showed no improvement. The onset of action of avanafil was within 30 min in 85% of responders. The reported adverse events were nasal congestion, headache, facial flushing, tingling of hands and/or feet, heartburn, and diarrhea. Conclusion Avanafil 100 mg has a rapid onset of action, is efficient, and a tolerable drug for the treatment of ED.
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Lipid profile in androgenetic alopecia p. 18
Ola A Bakry, Shimaa M El-Shafey, Amira M Amer
DOI:10.4103/mmj.mmj_125_19  
Objective The aim of this work is to evaluate lipid profile in patients with androgenetic alopecia and to correlate their levels with disease severity. Background Androgenetic alopecia (AGA) is the most common form of alopecia which is an androgen hormone-dependent process with continuous miniaturization of hair follicles in both genetically predisposed men and women. Lipids are a broad group of naturally occurring molecules. AGA has been found to be associated with coronary artery disease (CAD). The well-known risk factors of CAD are family history of CAD, hypertension, increased BMI, central obesity, hyperglycemia, and dyslipidemia. Patients and methods This case–control study was carried out on 30 men with early-onset AGA and 30 age-matched and sex-matched healthy subjects as the control group. All patients were subjected to full history taking, general examination, and laboratory investigations (fasting blood sugar and blood lipid profile). Results Our results showed no significant difference between cases and controls regarding age and sex. There were statistically significant differences regarding mean values of body weight, waist circumference, and BMI between cases and controls. There were statistically significant differences regarding mean values of fasting blood sugar, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol between cases and controls. Conclusion Patients with AGA appear to be at an increased risk of developing CAD and high blood lipids.
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Interleukin 17A gene polymorphism in alopecia areata p. 23
Iman A Seleit, Ola Ahmed B. Mohamed, Sally M El-Hefnawy, Samara M Azooz
DOI:10.4103/mmj.mmj_150_19  
Objective The aim of the current work was to investigate if interleukin 17A (IL-17A) G197A gene polymorphism confers susceptibility to alopecia areata (AA) in Egyptian patients. Background There is strong evidence for an autoimmune etiology of AA. IL-17A is a Th17 proinflammatory cytokine that has been linked to the pathogenesis of diverse autoimmune and inflammatory diseases. Patients and methods A total of 60 patients with AA were recruited, along with 40 healthy individuals who were matched for age and sex as a control group. IL-17A (G197A) gene polymorphism was investigated using restriction fragment length polymorphism PCR. Results Presence of A allele and AA genotype was significantly associated with AA cases compared with control group (P = 0.00 for both). A significant association was found between AA genotype and A allele and clinical data of the studied cases regarding disease severity, pattern of hair loss, nail changes, and course and response of disease to treatment (P = 0.00 for all). Conclusion IL-17A (G197A) gene polymorphism is associated with AA. Further large-scale studies are recommended to underscore and validate the current findings.
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Copy number variation of the NCF1 gene in patients of acne vulgaris p. 29
Mohammed A. M. Shoeb, Ola A Bakry, Shaimaa E Soliman, Lamiaa K Shehata
DOI:10.4103/mmj.mmj_153_19  
Objective The objective of this study was to evaluate the influence of neutrophil cytosolic factor 1 gene copy number variation (CNV) on acne vulgaris in a sample of Egyptian population to explore whether this CNV affects disease occurrence or increases its risk. Background Acne vulgaris is a common skin condition that affects the majority of the population during adolescence. Acne is characterized by a variable combination of comedones, pustules, inflammation, and scarring. Oxidative stress has been considered to play a role in acne. Neutrophil cytosolic factor 1 (NCF1) is a component of NADPH oxidase enzyme, which is responsible for the production of reactive oxygen species from phagocytes. It is reported that increased or decreased copy numbers of NCF1 gene affects many diseases such as rheumatoid arthritis and systemic lupus erythematosus. Patients and methods This study included 50 patients divided into two groups: 25 acne patients and 25 apparently healthy controls. Both groups were investigated for NCF1 CNV by quantitative real-time PCR. Results We found a statistically significant increased CNV of the NCF1 gene in the acne group compared with the control group (P = 0.028). Conclusion Our study suggests that an increased number of copies of the NCF1 gene may be a predisposing factor for acne vulgaris development. Moreover, decreased NCF1 copy numbers may be protective for acne.
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Fractional CO2 laser versus fractional CO2 laser with subcision in management of atrophic postacne scar p. 34
Magda M Haggag, Azza G Farag, Reem W Mousa
DOI:10.4103/mmj.mmj_160_19  
Objective To evaluate efficacy and safety of fractional CO2 laser treatment versus fractional CO2 with subcision in the management of atrophic postacne scars. Background Atrophic postacne scarring has always been a challenge to treat. Fractional CO2 resurfacing in combination with subcision is effective and well tolerated. Patients and methods This prospective study includes 50 patients with atrophic acne scars from Outpatient Clinic of Dermatology, Andrology and STDs Department. An informed consent was obtained. Patients from both sex at least 18 years with any types and any grade of atrophic postacne scars, and not receiving any treatment in the past 6 months for their scars were included. All patients were subjected to history taking, general examination, and qualitative grading of acne. Patients were divided into two groups: group A included 25 patients who were subjected to fractional CO2 laser, and group B included 25 patients who were subjected to subcision and fractional laser on the second day of subcision. Results Excellent satisfaction was 100% with grade 1 scar, and good satisfaction was more common with grade 2 scar (60%) in group A. There were highly statistically significant differences found between grade of scar and patient satisfaction in group A (P = 0.001). Excellent satisfaction was 90.91% with grade 1 scar, and good satisfaction was more common with grade 1 scar (57.14%) in group B. There were statistically significant differences found between grade of scar and patient satisfaction in group B (P = 0.028). Conclusion The combination of fractional carbon dioxide laser and subcision is safe and effective modality for the treatment of atrophic acne scars. Moreover, there were improvements in patient satisfaction, without considerable complication.
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Serum paraoxonase-1 levels as an indicator of oxidative stress in patients with vitiligo p. 40
Shawky M El-Farargy, Naglaa M Ghanayem, Eman K Farag
DOI:10.4103/mmj.mmj_163_19  
Objective To evaluate the use of serum paraoxonase-1 (PON1) activity as an indicator of oxidative stress in patients with active generalized vitiligo. Background Vitiligo is an acquired cutaneous disorder of pigmentation, characterized by destruction of melanocytes. One of the major hypotheses in the pathogenesis of vitiligo is the oxidative stress hypothesis. In patients with vitiligo, lower levels of PON1 prevent lipoprotein peroxidation and oxidation of low-density lipoprotein and cholesterol. Patients and methods A case–control study was conducted on 40 patients: 20 patients with recent active generalized vitiligo and 20 age-matched and sex-matched healthy volunteers served as controls. All the included patients underwent full history taking, full examination, routine laboratory investigations, and assessment of serum PON1. Results The serum PON1 level in patient group A (101.64 ± 25.48) was significantly lower than that in the control group B (181.88 ± 95.12) (P < 0.001). There was a significant negative correlation between serum PON1 level and vitiligo area severity index score (r = −0.780, P < 0.001). Conclusion Vitiligo is probably mediated through a process of oxidative stress and imbalance of oxidant–antioxidant system. Oxidative stress present in vitiligo disease can be determined by measurement of serum PON1 in these patients.
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Correlation between metabolic syndrome and benign prostatic hyperplasia Highly accessed article p. 43
Abd Allah M. Attia, Hossam A Yasien, Mohamed S.M. Elgharbawy, Haitham M AbdElaal
DOI:10.4103/mmj.mmj_166_19  
Objective To study the relation between metabolic syndrome (MetS) and benign prostatic hyperplasia (BPH). Background BPH is the most common urological condition among elderly males, with multiple etiopathogenesis. Patients and methods This prospective study was carried out on 90 male individuals aged 45–60 years classified into three groups: group 1 included 30 normal male individuals who had neither MetS nor BPH, group 2 included 30 patients with diagnosed BPH, and group 3 included 30 patients with diagnosed criteria of MetS. Results The study showed that compared with the control group, MetS group has significant higher manifestations of BPH with its different parameters, such as International Prostate Symptom Score (9.47 ± 5.68 vs. 2.87 ± 1.81, P > 0.001), prostate-specific antigen (3.06 ± 2.19 vs. 1.25 ± 0.82, P > 0.001), and prostatic weight (65.3 ± 30.7 vs. 28.7 ± 7.43 P > 0.001). Conclusion This study confirmed the frequent coexistence of MetS and BPH. This association seems to be a consequence of MetS-related changes in the sex hormone milieu and metabolic derangements.
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Sexual behavior after childbirth p. 47
Mohamed A Gaber, Hebatalla A Younes
DOI:10.4103/mmj.mmj_193_19  
Objective To study the prevalence of female sexual dysfunction after childbirth. Background Women's sexual activity changes at various stages of life and is affected by numerous factors; one of them includes childbirth and maternity. After childbirth, numerous physical, psychological, and sociocultural factors may affect the sexual activity of women and the quality of their lives. Patients and methods This cross-sectional study included 200 Egyptian postpartum women in the period from August 2018 till April 2019. The study was performed on postpartum women who attended the gynecology clinic, Shebin El Kom Teaching Hospital. Results The finding of the study indicated that all domains of Female Sexual Function Index (FSFI) were affected after labor, and the most affected was the sexual desire. The mean score before labor was 4.94 ± 0.84 and after labor was 3.40 ± 1.30, and the least prevalent was the dyspareunia; the mean score before labor was 4.16 ± 0.97 and after labor it was 4.89 ± 1.54. Conclusion Physical and emotional health problems are common after childbirth. In this article, we found that there were significantly lowered mean score values of all domains of FSFI, except pain (increased) and overall scale score decreased after labor. Decreased sexual desire is the most prevalent disorder of the sexual relationship in postpartum and the least prevalent was the dyspareunia.
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Evaluation of human papillomavirus in skin tags p. 52
Magda M Haggag, Azza G. A. Farag, Shymaa A El-Askary, Mai E. K. Ahmed
DOI:10.4103/mmj.mmj_200_19  
Background Skin tags (STs) are flesh-colored, pedunculated growths, with a smooth surface. The etiology of STs is still obscured. Human papillomavirus (HPV), a small DNA virus of papovavirus family, has been implicated in the causation of STs. Objective To detect the relationship between HPV skin infection and STs. Patients and methods Patients with STs (n = 80) and age-matched and sex-matched healthy controls (n = 40) were enrolled in this case–control study. From each patient, one skin biopsy was taken from STs lesions and another one from the perilesional skin (5 cm away from STs), and from each control, site-matched punch skin biopsy was taken. PCR was used to detect HPV DNA in every tested sample. Results HPV positivity showed a significant stepwise upregulation from normal skin (4, 10%), passing by STs perilesional (10, 12.5%) and ended by STs lesional (38, 47.5%) specimens (P < 0.001). Conclusion HPV has a role in the pathogenesis of STs. Therefore, using of antiviral or immunotherapy may help in STs management program.
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The value of calcium and high-sensitivity C-reactive protein serum levels in psoriatic patients p. 56
Mohamed A Basha, Wafaa A Shehata, Iman M Gayed, Shaimaa B El Hagary
DOI:10.4103/mmj.mmj_227_19  
Objective The aim was to evaluate the level of serum calcium and the serum level of high-sensitivity C-reactive protein (hsCRP) in patients with psoriasis. Background Psoriasis is a systemic chronic inflammatory disease of the skin with associated comorbidity. The most detrimental aspect of psoriasis is the concurrent physical comorbidities, such as cardiovascular disease, obesity, diabetes, metabolic syndrome, inflammatory bowel disease, and psoriatic arthritis that contribute to decreased longevity. Psoriasis is one of the skin diseases that have been found to show disturbance in systemic calcium metabolism. CRP is one of the acute-phase reactant proteins, and its blood level increases during inflammatory reactions. There is a link between the concentration of CRP and cardiovascular disease development in psoriatic patients. Patients and methods Psoriatic patients (n = 40) and age, sex-matched, and BMI-matched healthy controls (n = 40) were enrolled. Serum levels of hsCRP were measured by enzyme-linked immunosorbent assay, and assessment of serum calcium was done using enzymatic colorimetric technique. Results Serum calcium (P < 0.001) and serum hsCRP (P < 0.001) showed significant differences compared with controls. Conclusion Several biomarkers are altered in patients with psoriasis. In particular, decrease in serum calcium and increase in serum hsCRP could be of interest for further studies. A longitudinal observation study on levels of these biomarkers in response to treatment as well as a correlation of these markers with the development of concomitant diseases in patients with moderate-to-severe psoriasis should be initiated.
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Assessment of autologous platelet-rich plasma as a local therapy for female sexual dysfunction p. 61
Mohamed A Gaber, Shymaa A Shaltout
DOI:10.4103/mmj.mmj_228_19  
Objective To evaluate the role of localized injection of autologous platelet-rich plasma (PRP) in the treatment of female sexual dysfunction (FSD). Background FSD is defined as disorders of libido, arousal, orgasm, and sexual pain that lead to personal distress or interpersonal difficulties. Treatment of FSD is complicated by the lack of a single causative factor, limited proven treatment options, physician unfamiliarity with available treatments, overlap of different types of dysfunction, and limited availability of treatment. A safe nonsurgical, cost-effective procedure is the intravaginal and intraclitoral injection of PRP to treat this sexual dysfunction. Patients and methods This was a prospective study of 20 female individuals with FSD who underwent intravaginal and intraclitoral injection of PRP. Standardized female sexual function index was administrated before treatment and after treatment to measure the response of treatment. Results There were statistically high significant mean values of desire, arousal, lubrication, orgasm, and satisfaction after treatment (P < 0.001), which is highly significant. Conclusion PRP is an effective treatment of FSD. It is a minimally invasive procedure with very low side effects.
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Association between serum immunoglobulin E and soluble E-selectin, and atopic dermatitis p. 66
Shawky M El-Farrargy, Naglaa M Ghanayem, Shaimaa S.B. Sherief
DOI:10.4103/mmj.mmj_240_19  
Objective To study and evaluate the role of both serum immunoglobulin E (IgE) and soluble E-selectin in patients with atopic dermatitis (AD). Background AD is a chronic inflammatory skin disease that is characterized by intense itching and recurrent eczematous lesions. Although it most often starts in infancy. It is also highly prevalent in adults. Assessment of maintenance of AD could be related to serum IgE and soluble E-selectin. Treatment of AD remains a challenge. Patients and methods This case–control study was performed for 40 patients who were age-matched and sex-matched with 20 healthy control cases. The patient group was subdivided into two groups according to their severity. The sample comprised 28 men and 32 women. Their ages ranged between 3 and 28 years. Results There was significant statistical differences between the two studied patient groups and the control group regarding total IgE and E-selectin serum levels that were higher in the patient group than the control one. There was also significant statistical increase in the level of serum IgE and soluble E-selectin in severe AD patients compared with mild cases. Conclusion There was a positive association between serum IgE, soluble E-selectin, and AD in general and also with severity. So it may be used as a marker for AD.
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Helicobacter pylori infection in the palm and sole of psoriatic patients p. 71
Alaa H Marae, Wafaa A Shehata, Rania Azmy, Asmaa M Abousaeida
DOI:10.4103/mmj.mmj_246_19  
Objective To clarify the role of Helicobacter pylori infection in psoriatic patients with palm and sole affection Background Psoriasis is a chronic inflammatory disease that affects 2–3% of the population worldwide. H. pylori infection has been implicated in the pathogenesis of various skin diseases. Patients and methods This case–control study was conducted on 40 patients with psoriasis vulgaris and 40 age-matched and sex-matched healthy individuals. All patients were subjected to history taking and complete medical examination. Serum levels of anti-H. pylori immunoglobulin G were measured by enzyme-linked immunosorbent assay technique. Serum levels of anti-H. pylori immunoglobulin G were statistically analyzed in relation to psoriasis area and severity index score. Results H. pylori infection was more prevalent among patients who did not manifest palm and sole affection. However, 50% of palm-affected and sole-affected patients were positive for H. pylori infection (P = 0.02). Conclusion H. pylori may play a significant role in the development of palmoplantar psoriasis and may provide important clues to assist in the development of new therapeutic strategies for palmoplantar psoriatic patients through its eradication.
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Prevalence of female frigidity p. 76
Mohamed A Gaber, Doaa S Elsobky
DOI:10.4103/mmj.mmj_247_19  
Objectives To determine the prevalence of female frigidity among Egyptian females. Background Female frigidity or lack of sexual desire is the most prevalent sexual dysfunction in women across all ages. It was previously referred to as hypoactive sexual desire disorder and recently as female sexual interest and arousal disorder. Women with hypoactive sexual desire disorder may report little or no interest in sex, an inability to respond to sexual stimuli, or feeling numbness despite having a good relationship with her partner. Patients and methods This cross-sectional study was carried out in the period between June 2018 and July 2019. It was done at many sites providing services for women mainly in Alexandria and Menoufia, and also a web-based form was shared on social media groups and pages for women from Egypt. The patients were selected randomly. The study used the female sexual function index, and an Arabic translation was done with the questionnaire, and a section was added to collect data about the demographic characteristics of the participant. Results The study statistically showed that the prevalence of female frigidity among the study participants was 69.5%, the prevalence of female sexual dysfunction among the study group was 65.5%, and the prevailing sexual disorder among the study group was low sexual desire. Conclusion In this study, hypoactive sexual desire disorder was reported in 69.5% of women. There was a significant correlation between female sexual dysfunction and age, residency, and the duration of marriage.
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Platelet-rich plasma in facial rejuvenation p. 81
Mohamed A Shoieb, Mohamed A Gaber, Kholoud H Al Aasar
DOI:10.4103/mmj.mmj_261_19  
Objective This study aimed at evaluating the effect of using a combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) 3.5% using microneedling in facial skin rejuvenation and to estimate the visible skin improvement and patient satisfaction. Background PRP has attracted attention in the field of dermatology, specifically in the aesthetic field for skin rejuvenation. HA is involved in maintaining skin hydration. PRP along with HA offers a good combination for skin rejuvenation via microneedling for augmentation of collagen content, for increasing moisture, and for offering a rich source of growth factors. Materials and methods A total of 30 participants were enrolled in study and received facial treatments with PRP and HA through microneedling using dermapen every 2 weeks, and the results were evaluated through the assumed visual assessment scale. Results The results yielded statistically significant improvement concerning skin texture, dullness, acne, acne scars, wrinkles, wide pores, pallor, and firmness compared with baseline. Moreover, enrolled participants showed marked satisfaction with the results with minimal adverse effects. Conclusion PRP along with HA represents a potentially effective and safe material for skin rejuvenation through microneedling using dermapen.
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The psychosocial effect of androgenetic alopecia in males and females p. 87
Mohamed A Gaber, Hala E Doma
DOI:10.4103/mmj.mmj_268_19  
Objective The aim was to shed light on the psychosocial effect of androgenetic alopecia (AGA) in both males and females and its effect on quality of life of those patients. Background Hair loss can cause several psychological/psychiatric problems and lower self-confidence and sexual attractiveness, with impairment in school performance. Materials and methods A cross-sectional study was conducted that included 200 males and females diagnosed as having AGA. Results There were no significant differences between male and female, between urban and rural, between married patients and not married patients, and among nonworkers, manual workers, and professional workers regarding emotion, function, social, self-confidence, and total quality-of-life score. Moreover, there was a significant difference between married patients and not married patients regarding emotion score, with scores of 18.1 ± 1.54 and 15.97 ± 2.08, respectively (P < 0.001). There was a significant difference among nonworker, manual worker, and professional work regarding emotion score, where score 15.6 ± 1.21, 17.72 ± 1.42, and 18.22 ± 1.42, respectively (P = 0.005). There was a significant difference among nonworkers, manual worker, and professional work, regarding function score, with scores of 12.50 ± 1.51, 11.1 ± 1.77, and 10.65 ± 1.8, respectively. There was a positive significant correlation between age of studied patients and emotion score, and a negative significant correlation between age of studied patients and function score. On the contrary, there was a nonsignificant negative correlation between age of studied patients and social and total score and a nonsignificant positive correlation with self-confidence. Conclusion It was important to identify the psychological effect of AGA among the patients, as this was necessary to provide the psychological treatment with other line in these patients.
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INTERNAL MEDICINE - ORIGINAL ARTICLES Top

Autologous bone marrow transplantation for diffuse large B-cell lymphoma in Egypt: a two-center experience p. 93
Ghada H Akl, Sabry A Shoeib, Mohamed A Abdelhafez, Alaa E Abdelhamid, Ali S Ali, Essam A Abdelmohsen
DOI:10.4103/mmj.mmj_106_19  
Objective The aim of this work was to study the outcome of autologous bone marrow transplantation in diffuse large B-cell lymphoma (DLBCL) according to the experience of two centers, Naser Institute and Sheikh Zayed centers. Background Treatment for patients with DLBCL is based on the international prognostic index score and age. Autologous stem-cell transplantation (ASCT) is actually recommended in young patients who did not achieve complete remission after first-line chemotherapy. Patients and methods This retrospective case series study included the files of 191 patients who were diagnosed as having DLBCL according to the 2008 WHO classification of lymphoma in Naser Institute and Sheikh Zayed hematology units in the period from 2012 to 2018. The patients were classified into two groups. Group I: patients with DLBCL and received chemotherapy only, Group II: patients with DLBCL and received chemotherapy and then high-dose chemotherapy followed by ASCT (HDC). Results The data we had shown that there is no significant statistical difference between the studied groups as regards age and sex. The mean age was 40.34 years (±11.620) in patients with DLBCL and received chemotherapy only while in patients with DLBCL and received chemotherapy then HDC/ASCT was 42.66 years (±11.554). The 5-year overall survival in patients with chemotherapy only is not statistically significant compared with patients with chemotherapy and then HDC/ASCT (P = 0.202). Conclusion On the basis of our results, we can conclude that the outcome of HDC/ASCT in patients with DLBCL is nearly equal to the outcome of chemotherapy alone.
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Outcome of furosemide stress test in patients with oliguric acute kidney injury p. 98
Hassan A Attia, Mahmoud M Emara, Mohammed G Elnazer
DOI:10.4103/mmj.mmj_113_19  
Objective The aim of this study is to evaluate the outcome of furosemide stress test (FST) in patients with oliguric acute kidney injury (AKI) and its effect on increasing urine output compared with the effect of dialysis. Background AKI is a common complication of critical illness; 7–10% of ICU patients present with AKI during their ICU stay and about 45–60% of them are associated with high mortality while the early detection of adult patients with AKI may provide the opportunity to treat and prevent the extension to chronic kidney injury. Patients and methods A cohort study was conducted on two groups: one group included 40 cases who received FST following 80 mg furosemide intravenous shots upon inclusion in this study. The second group included 40 cases who did not respond to 80 mg furosemide intravenous shots and then received standard management by dialysis. Data were collected and tabulated. Results There is no significant difference between both groups of the study regarding: outcome (progression to grade III according to the Acute Kidney Injury Network III, length of stay in ICU, and mortality) and urine output. Conclusion FST does not have an additional privilege over standard management (by dialysis) in the treatment of AKI.
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Assessment of new hepatitis C virus therapy in patients with chronic kidney disease p. 103
Ahmed Ragheb, Mahmoud A Kora, Khaled M. A. El-Zorkany, Sarah E. H. El-Kabany
DOI:10.4103/mmj.mmj_159_19  
Objective To evaluate efficacy and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) and ribavirin (RBV) therapy in hepatitis C virus (HCV)-infected patients with chronic kidney disease (CKD). Background In the era of new direct-acting antiviral drugs for HCV, data about their efficacy and safety in different renal situations are still under evaluation especially in Egypt. Patients and methods Between June 2017 and August 2018, a prospective study at Damanhour Medical National Institute was designed to enroll 50 patients with chronic HCV and CKD grades 4, 5, and 5D. Patients were given OBV/PTV/r (25/150/100 mg) plus RBV (200 mg) once daily for 12 weeks. Sustained virologic response (SVR12) was the primary end point. Results All patients achieved SVR12 (100%). Hemoglobin levels were significantly reduced during treatment (P < 0.001), with partial improvement 12 weeks after treatment; however, they were significantly lower than the baseline levels (P < 0.001). Serum bilirubin and liver enzymes levels were significantly increased during treatment (P = 0.046 and 0.021, respectively). After 12 weeks, bilirubin levels were normalized, whereas liver enzymes were significantly reduced (P < 0.001). Following a nonsignificant deterioration in serum creatinine and estimated glomerular filtration rates during treatment, a significant improvement was achieved 12 weeks after treatment in nonhemodialysis patients (P = 0.010). No serious adverse events occurred. Only three patients discontinued treatment; however, they achieved SVR12. Conclusion This study concluded that the combination of OBV/PTV/r and RBV for 12 weeks is an effective and relatively safe option for patients with HCV and CKD grades 4, 5, and 5D, which was even associated with improved estimated glomerular filtration rates after treatment in nonhemodialysis patients.
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Genetic polymorphism of epidermal growth factor gene as a predictor of hepatocellular carcinoma in hepatitis C cirrhotic patients p. 112
Ibrahim Baghdadi, Khaled A Abu Ella, Ahmed Elsharawy, Elsayed Elshayb, Hala S El-Rebey, Mohamed M. M. Elhoseeny
DOI:10.4103/mmj.mmj_179_19  
Objectives To investigate the correlation between the epidermal growth factor (EGF) polymorphism and the risk of hepatocellular carcinoma (HCC) in hepatitis C viral (HCV)-related cirrhotic patients as well as its relation to EGF protein expression in HCC tissue. Background In Egypt, the incidence of HCC is ∼4.7% in chronic liver disease patients because of HCV infection. EGF plays an important role in hepatocyte regeneration and also plays a role in malignant transformation. A functional polymorphism in EGF was identified recently as the G/G genotype was associated with a higher risk of HCC and increased EGF expression in serum and liver tissue from HCC patients. Patients and methods This case–control study was carried out on 100 patients in the HCC clinic of the National Liver Institute, Menoufia University. Routine investigations and EGF genotyping were performed in 50 HCC patients (group I) subdivided into 25 patients with resectable HCC (subgroup IA) and 25 patients with advanced unrespectable HCC (subgroup IB). Twenty-five cirrhotic HCV patients did not have HCC (group II). There were a total of 25 healthy individuals (group III). Immunohistochemical detection of EGF was performed in HCC tissue biopsy from patients who underwent surgical resection. Results The GG genotype was associated with a significantly increased risk of HCC compared with the AG and AA genotypes (P = 0.031) in the cirrhotic group. The G allele led to a highly significant risk of HCC compared with allele A in recessive model GG versus AG + AA (P = 0.036) rather than in the dominant model GG + AG versus AA (P = 0.66). EGF expression in tumor tissue was statistically different only between GG and AG genotypes in the resectable HCC group (group IA) (P = 0.032). Conclusion The EGF gene polymorphism (GG genotype) led to a significant risk of HCC development in cirrhotic patients more than the AG and AA genotypes.
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Study of the relation between the colorectal neoplasm and visceral fat accumulation in postmenopausal women p. 118
Ehab A Abdel Atty, Elsayed I Elshayeb, Mohamed I Shaaban, Ahmed E Abd El-Alim, Mostafa M Arafa
DOI:10.4103/mmj.mmj_181_19  
Objective This study aimed to show the relation ship between colorectal carcinoma (CRC) and visceral adiposity in Egyptian postmenopausal women. Background Obesity is known to be an important risk factor for CRC, especially in women. The risk of CRC is greater with the visceral fat accumulation not total body fat content. Patients and methods This case–control study included 90 postmenopausal female patients: 45 women with CRC, 20 women with colorectal polyps, and 25 healthy women. Data were collected and statistically analyzed. CRC was diagnosed by colonoscopy and histopathology. Metabolic parameters were assessed according to the BMI and the waist to hip ratio. Results Visceral fat was significantly higher in patients with CRC and colorectal polyps compared with the control group. The prevalence of CRC increased with increasing visceral fat content. The study showed that 37 (82.2%) patients with CRC were obese [19 (42.2%) of these patients were overweight and 18 (40%) were obese class I and class II]. Also, 19 (95%) patients with colorectal polyps were obese [11 (55%) of these patients were overweight and eight (40%) patients were obese class I and class II]. Conclusion Visceral fat area is highly associated with CRC.
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Role of circulating micro-RNA-21 as a noninvasive biomarker for detection of colorectal cancer p. 124
Ehab A Abdel-Atti, El-Sayed I El-Shaib, Mohamed A Shehata, Ahmed A Sonbl, Mohamed H Badr, Mohamed H Gohar
DOI:10.4103/mmj.mmj_207_19  
Objective To assess serum micro-RNA-21 (miR-21) expression level as a stable blood-based biomarker for colorectal cancer (CRC). Background CRC represents the third most common tumor worldwide with male predominance, with significant morbidity and mortality despite the recent therapeutic improvements. Therefore, a noninvasive diagnostic marker with good sensitivity and specificity is very important, which leads to better clinical outcomes. MiR-21 is an oncogenic miRNA that modulates the expression of multiple cancer-related target genes. MiR-21 expression was upregulated in the serum and in the malignant tissues in relation to the normal tissues. Its elevated level is claimed to be associated with poor survival and poor response to treatment. Patients and methods This cross-sectional study was carried on 50 patients and measured their serum miR-21 (CYBR Green). The cases group comprised 20 consecutive patients with CRC proved by colonoscopy and histopathological biopsy examination, the second group comprised 20 patients with colorectal polyps with no malignant transformation proved by histopathological examination, and the third group included 10 patients with normal colonoscopy finding as the control group. The studied cases were attending the Endoscopy Unit Menoufia University Hospital and Nasser Institute. The three groups agreed to written consent to participate in this study after the approval of the local ethical committee. Results Serum miR-21 expression was significantly upregulated in the cases group of patients with CRC compared with the other groups, with P value less than 0.001, showing sensitivity of 85% and specificity of 83.3% at a cutoff point of −2.31. Conclusion Mi-RNA-21 shows upregulation in the serum in CRC cases, with statistically significant difference compared with the control group and the polyp group, showing promising results as a noninvasive biomarker of CRC.
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Effect of the mean platelet volume/platelet count ratio on arteriovenous fistula function in chronic hemodialysis patients p. 129
Hassan A Ahmed, Mahmoud M Emara, Heba E Kasem, Manar A. H. Tahoon
DOI:10.4103/mmj.mmj_230_19  
Objective The aim was to study the effect of increased mean platelet volume/platelet count (MPV/PL count) on arteriovenous fistula (AVF) function in chronic hemodialysis (HD) patients. Background Vascular access failure substantially contributes to morbidity and hospitalization in HD patients. Patients and methods A case–control study was conducted on 50 HD patients on regular HD for more than 6 months in Shebin El-Koom Teaching Hospital, Menoufia, Egypt. The patients were divided into two groups: 25 patients with functioning AVF as group 1 and 25 patients with nonfunctioning AVF as group 2. Patients were subjected to full history taking, clinical examination, laboratory workup, and radiology by Duplex ultrasound. Results There was no significant effect of age, sex, BMI, diabetes mellitus, hypertension, smoking, or type of anastomosis on AVF in HD patients. There was a significant effect of intradialysis hypotension on AVF in HD patients. There was a highly significant effect of fistula function on Kt/V in HD patients. There was a highly significant increase of MPV/PL count ratio in HD patients with failure of AVF. MPV/PL count at a cut-off level of 53.7 can accurately predict failure of AVF in the studied HD patients with 100% sensitivity and 84% specificity. Conclusion Assessment of MPV/PC ratio could adequately predict the failure of the function of AVF in the studied patients.
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Role of urinary neutrophil gelatinase-associated lipocalin in diabetic and nondiabetic patients with nephropathy p. 135
Sanaa S Gazareen, Mohamed A. E. R. Korani, Ahmed R Tawfeek, Thoria A Omar, Ghada I. E. A. Dwidar
DOI:10.4103/mmj.mmj_72_20  
Objective The aim was to study the role of neutrophil gelatinase-associated lipocalin (NGAL) in diabetic nephropathy patients with type 2 diabetes. Background Due to the high morbidity and mortality associated with diabetic nephropathy, it is important to establish a diagnosis and initiate therapy as soon as possible. Patients and methods This observational study was conducted on 88 subjects who were divided into four groups: Group 1 included 22 healthy individuals; group 2 included 22 type 2 diabetic patients with normoalbuminuria;, group 3 included 22 type 2 diabetic nephropathy patients; and group 4 included 22 nondiabetic patients with chronic kidney disease (CKD). All patients were admitted to the Internal Medicine Department at Menoufia University Hospital in the period from 20 December to 13 March 2019. Complete history, examination, and investigations urea, creatinine, fasting blood glucose, postprandial blood glucose, HbA1C, albumin/creatinine ratio, estimated glomerular filtration rate, and urinary NGAL were investigated for all subjects. Results Urea, creatinine and albumin/creatinine ratio were statistically significantly increased in diabetic nephropathy groups (145.30 ± 57.93), (3.95 ± 1.57), (201.27 ± 50.04) than in the diabetic group, while estimated glomerular filtration rate was significantly decreased among CKDs (23.64 ± 8.57) and diabetic nephropathy group (30.65 ± 14.34) than the diabetic (174.35 ± 86.13) and control groups (183.27 ± 44.17). Also, the level of NGAL was significantly increased in diabetic nephropathy groups (474.48 ± 308.22) and CKDs (367.37 ± 272.63) than diabetic groups (36.65 ± 28.30) and the control group (22.47 ± 21.16). Conclusion Diagnosis of diabetic nephropathy is based on the rise of creatinine and urea, and albumin/creatinine ratio with a decrease in estimated glomerular filtration rate. NGAL is a marker of CKD and any causes affecting the kidney. Cutoff point for NGAL was greater than 45 in patients with diabetes mellitus and greater than 30 in patients without diabetes, which were the best cutoff point for early detection of diabetic nephropathy.
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Vascular access in hemodialysis patients – Tanta University Hospital hemodialysis center's experience p. 141
Manal S Negm, Rasha Y Hagag, Shimaa H El-attar, Ghada M Alghazaly
DOI:10.4103/mmj.mmj_308_20  
Background A well-functioning vascular access is essential to provide efficient dialysis therapy. Morbidity related to vascular access is the leading cause of hospitalization in hemodialysis (HD) patients. Objectives To analyze the vascular access in maintenance HD patients and to assess its associated complications. Patients and methods A total of 101 patients on regular HD were included, and data were collected through a preformed questionnaire focusing on vascular access. Results Of the 101 patients studied, the vascular access at initiation of HD was temporary catheter in 95% and arteriovenous fistula (AVF) in 5% of the patients. Current vascular access was native AVF in 94%, temporary catheters in 1%, and permanent tunneled cuffed catheter in 5% of the patients. No arteriovenous graft was created. A tunneled catheter was inserted in the internal jugular vein in 99% of cases. A native AVF was created in 99% of the patients as the first permanent access. It was radioscephalic in 35%. The primary failure rate was 14%. The commonest complication with AVF was thrombosis (21%). Conclusion Temporary dialysis catheters were the most common initial vascular access. Native AVF was the most common vascular access. Thrombosis was the most common complication.
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TROPICAL - ORIGINAL ARTICLES Top

Assessment of serum magnesium level in patients with liver cirrhosis p. 148
Atef A Ali, Ayman A Elgamal, Ayman M Enab
DOI:10.4103/mmj.mmj_233_19  
Objective The aim was to assess serum magnesium level in patients with liver cirrhosis. Background Cirrhosis is a chronic disease of the liver in which diffuse destruction and regeneration of hepatic parenchymal cells and diffuse increase in connective tissue result in disorganization of the lobular architecture. Micronutrients play a significant role in liver diseases. Patients and methods A case–control study was conducted on 60 patients with liver cirrhosis who were classified into the following groups. Group I included 60 patients with liver cirrhosis. They were classified according to the Child-Pugh class into: group Ia which included 20 Child-Pugh A cirrhotic patients; group Ib included 20 Child-Pugh B cirrhotic patients; and group Ic included 20 Child-Pugh C cirrhotic patients. Group II included 20 healthy participants as a control group. Patients and controls were selected from the inpatient and outpatient clinic of the Hepatology Department Damanhur Fever Hospital and Tropical Department of Menoufia University. Routine investigations, magnesium, potassium, and sodium levels were investigated. Results Sodium, potassium, and magnesium levels were decreased than the normal range among cirrhotic patients and the lowest mean value was 122.950 ± 2.502, 4.165 ± 0.503, and 1.277 ± 0.202, respectively, among cirrhotic patients (Child class C). Conclusion Trace element abnormalities may reflect the condition of liver dysfunction. Liver dysfunction may alter the metabolism of trace elements. Does correction of these metabolic abnormalities of trace elements delay or prevent complication of cirrhosis should be evaluated in upcoming studies.
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Recent myocardial ischemia in patients presented with upper gastrointestinal bleeding with and without portal hypertension p. 154
Atef A Ali, Awni G Shalaby, Reham S El-Zaiat, Dina Y Abd Alshafy, Ayman A Sakr
DOI:10.4103/mmj.mmj_262_19  
Objective To assess the relationship between upper gastrointestinal bleeding (UGIB) in both cirrhotic and noncirrhotic groups and the development of acute myocardial infarction (AMI). Background UGIB can cause myocardial ischemia and necrosis. Both UGIB and liver cirrhosis have a higher mortality with the development of AMI, than either of them alone. Patients and methods A cross-sectional comparative study was done on 263 patients who presented with UGIB, and they were divided into four groups: GI (n = 118), cirrhotic patients; GII (n = 85), noncirrhotic patients; GIII (n = 30), cirrhotic patients with no history of UGIB; and GIV (n = 30), the control group. They were all subjected to history taking, examination, and investigations. Results Age was higher in GI than GII (P = 0.0001). Cardiac troponin I (cTn-I) was positive for MI in 18/118 (15.3%) in GI, 20/85 (23.5%) in GII, and 0% in GIII and GIV (P = 0.001). Mortality rate was 11/118 (9.3%) in GI and 4/85 (4.7%) in GII and 0% in GIII and GIV (P = 0.0001). Length of hospital stay (LOS) was higher in GI than GII. There was a positive correlation between Glasgow-Blatchford score and cTn-I elevation (R=+0.19, P = 0.003) (P = 0.0001). Odds ratio of smoking, viral hepatitis, and LOS in cTn-I-positive patients was 12.61, 14.49, and 2.76 times higher than troponin-negative patients, respectively (P = 0.0001). Conclusion Patients with cirrhosis when developing UGIB may be predisposed to AMI especially older ages, men, comorbid diseases, patients with increased LOS;in addition to more complications and higher mortality rate than non-cirrhotic patients.
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Response and safety of treatment of chronic hepatitis C by direct-acting antiviral drugs in patients with Child B-related cirrhosis p. 162
Hosam M Ibrahim, Mohamed R Moussa, Ayman A Sakr
DOI:10.4103/mmj.mmj_270_19  
Objectives To evaluate the response and safety of treatment of chronic hepatitis C virus (HCV) by direct-acting antiviral (DAAs) drugs in patients with Child B-related cirrhosis. Background Chronic HCV infection is considered to be one of the major public health diseases that affect most Egyptian population. The appearance of DAAs with its safety and high successful eradication rates has replaced the old treatment protocols, which used interferon. Patients and methods This was a cross-sectional study to collect data and outcome of chronic HCV-infected patients who were treated with DAAs. Treatment-naive patients without cirrhosis were treated without ribavirin, and those who had cirrhosis or were treatment experienced (interferon experienced or sofosbuvir experienced) received ribavirin. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored. Results SVR at 12 weeks was more seen in Child grade A patients (98.5%) when compared with Child grade B patients (86.7%) and non-SVR was more seen in Child grade B patients (13.1%) when compared with Child grade A patients (1.5%). Conclusion Treatment of chronic HCV-infected patients with DAA drugs in patients has proved to be safe and associated with a high SVR12 rate, in patients with different stages of fibrosis.
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CARDIOLOGY - ORIGINAL ARTICLES Top

Influence of risk factors on in-hospital outcomes in women presenting with acute coronary syndrome in a tertiary care center p. 170
Ahmed A Reda, Ahmed M El Kersh, Ghada A Kazamal, Amr I El-Sayed
DOI:10.4103/mmj.mmj_149_19  
Objective The aim of this study is to assess the influence of risk factors on in-hospital outcomes in women presenting with acute coronary syndrome. Background Cardiovascular disease is the cause of death in 55% of women compared with 43% of men. Acute coronary syndrome risk factors increase the likelihood of disease. Clinical research studies have demonstrated that effective risk factor reduction results in decreases in acute coronary syndrome morbidity and mortality. Patients and methods This is a cross-sectional study in which data were collected from September 2015 to September 2016. The study included 207 patients admitted in Cardiology Department, National Heart Institute, Egypt, chosen by simple random sample technique. A case record form was used that included modifiable and nonmodifiable risk factors, physical findings, investigations, diagnosis, interventional procedures, and in-hospital outcome. Results In this study, it was noticed that left ventricular (LV) dysfunction was the most frequent outcome: 13% for moderate reduction in LV function and 6% for severe reduction. Overall, 53.6% of those who developed mild to moderate LV dysfunction and 69.2% of those with severe LV dysfunction were diabetics. There was no statistically significant difference regarding death between ST-elevation myocardial infarction and non-ST-elevation myocardial infarction. There is a significant association between death and positive family history of ischemic heart disease (P = 0.05). Conclusion The results of this study have demonstrated that there was a significant association between death and positive family history of ischemic heart disease (P = 0.05).
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Ankle brachial index in patients with type II diabetes mellitus undergoing coronary angiography p. 174
Ahmed A Reda, Ahmed M El-Kersh, Eslam M El-Habashy
DOI:10.4103/mmj.mmj_242_19  
Objective The aim was to determine the relation between ankle-brachial index (ABI) with angiographic stenosis and major cardiovascular risk factors in type II diabetes mellitus (DM) patients. Background The role of DM in relation to coronary artery disease (CAD) was believed to be as important as CAD itself. Patients with DM were frequently combined with peripheral arterial disease. ABI is a noninvasive tool for identifying atherosclerosis, CAD. Patients and methods Patients under study were those admitted to Menoufia University Hospital and who had undergone coronary angiography. A total of 80 patients over 35 years of age with suspected CAD had been enrolled. All patients were subjected to ABI measurements and coronary angiography and risk factor. Patients had been divided into four groups according to ABI measurements and type II DM. Results ABI is a simple, inexpensive method for diagnosing patients with peripheral arterial disease. ABI is a sensitive, noninvasive predictor of CAD in diabetic patients. Conclusion ABI is a sensitive, noninvasive predictor of CAD in diabetic patients. It needs other markers for better specificity for predicting CAD.
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Assessment of coronary artery disease extension and severity in hepatitis C-infected patients p. 180
Mahmoud A Soliman, Ahmed M El Kersh, Niveen S Ibrahim, John R Nageh
DOI:10.4103/mmj.mmj_259_19  
Objectives To assess extension and severity of coronary artery disease (CAD) in patients with hepatitis C viral infection. Background Chronic HCV infection causes hepatic and systemic inflammation via increased levels of proatherogenic chemokines and cytokines Patients and methods This prospective cohort study was conducted on 200 stable patients scheduled for elective coronary angiography. All patients were evaluated by history taking and clinical, coronary angiography, and laboratory investigations, and the severity of the coronary lesions was estimated using the Gensini score. Results There were statistically significant differences between both groups regarding the presence of ischemic ST-T changes, where 38 patients of group A had those changes, whereas 67 patients of group B had them (P = 0.009). There was a statistically significant difference between both groups regarding ejection fraction% and segmental wall motion abnormalities. Overall, 78% of hepatitis C virus (HCV)-positive patients had significant CAD (group A) compared with 60% of patients with HCV negative (group B), with P = 0.006. Moreover, one-vessel affection was mainly among HCV-negative patients (55%) versus 34.6% in HCV-positive patients, with significant difference between both group (P = 0.003). Moreover, there was a statistically significant positive correlation between CAD severity according to Gensini score and HCV seropositivity (Gensini score in group A was 46.9 ± 53.7 vs. 17.9 ± 28.1 in group B; P < 0.001). Conclusion We have demonstrated an association between HCV infection and the severity of coronary atherosclerosis assessed with Gensini score, and the proposed mechanism was exaggerated inflammation in response to hepatitis virus infection.
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PEDIATRICS - ORIGINAL ARTICLES Top

Mean platelet volume as a prognostic factor in neonatal respiratory distress p. 187
Ghada M El Mashad, Hanan M El Saied, Ahmed G.S. Ali
DOI:10.4103/mmj.mmj_111_19  
Objective To evaluate mean platelet volume (MPV) as a prognostic factor in neonatal respiratory distress. Background Respiratory distress syndrome (RDS) is a major cause of morbidity and mortality in preterm infants. MPV is an indicator of platelet function. It may be considered a risk factor for the development of RDS. Patients and methods This was a case–control study conducted on 50 (21 males and 29 females) Egyptian preterm neonates. Of them, 25 were previously diagnosed as having RDS, as a patient group, and 25 were apparently healthy age-matched and sex-matched neonates as a control group. All of them were subjected to full history and physical examination. Blood samples were taken on first and third day. Blood for complete blood count was obtained by either venipuncture, arterial puncture, or through a central catheter. complete blood count included MPV, platelet count, and white blood cell count. Results MPV on the first day (fl) in the study group [10.8 (9.1, 11.2)] was significantly higher than controls [7.9 (7.6, 8.2)], with P value less than 0.001. MPV on third day (fl) in study group [11.5 (10.4, 12.2)] was significantly higher than controls [8.3 (8.1, 8.5)], with P value less than 0.001. However, platelet count on third day (×109/μl) in the study group [146 (103, 170)] was significantly lower than in controls [176 (150, 202)], with P = 0.032. Conclusion MPV is a simple and readily available biomarker, and it is indicated that platelet may have been involved in the physiopathologic process of RDS.
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Interleukin-6 gene -572G>C polymorphism in Egyptian children with idiopathic nephrotic syndrome p. 192
Ghada M El-Mashad, Essam Sh Khattab, Muhammad S El-Mekkawy, Nagwan Y Saleh, Wafaa N Abou El Yazed
DOI:10.4103/mmj.mmj_147_19  
Objective To evaluate the association of -572G > C polymorphism with idiopathic nephrotic syndrome (INS) in children. Background Interleukin 6 (IL-6) gene promoter polymorphisms, including -572G > C polymorphism, have been implicated in INS. Patients and methods A total of 55 Egyptian children with INS were recruited along with 51 healthy controls. Genotyping for IL-6 gene -572G > C polymorphism was performed by PCR followed by restriction fragment length polymorphism. Results GC genotype was more prevalent among patients compared with controls [40 vs. 7.8%, odds ratio (OR)=5.5, P = 0.002], but there was no significant difference between patients and controls regarding CC genotype (9.1 vs. 2%, OR = 5, P = 0.14). Under the dominant model, the pooled GC + CC was more prevalent among patients compared with controls (OR = 5.4, P < 0.001). The distribution of C allele was significantly higher among patients compared with controls (29.1 vs. 5.9%, OR = 5.3, P < 0.001). No significant difference was found between patients and controls regarding the prevalence of any of the alleles or genotypes under codominant, recessive, or dominant models. Conclusion IL-6 gene -572G > C polymorphism confers susceptibility to INS among children, but it has no influence on the response to steroids.
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Detection of thalassemia trait and iron-deficiency anemia among relatives of thalassemic patients – Menoufia Governorate p. 197
Seham M Ragab, Mohamed A Soliman, Sameh A Abd El Naby, Amr Mohammed R.I. Nassar
DOI:10.4103/mmj.mmj_175_19  
Objective To detect thalassemia trait and iron-deficiency anemia (IDA) among children relatives of thalassemic patients. Background Beta-thalassemia represents a major public health problem in Egypt. β-thalassemia trait (BTT) often shows microcytosis and an elevated level of hemoglobin A2. Despite the start of iron fortification, the prevalence of iron deficiency is still rather high in the Middle East countries. Patients and methods A cross-sectional study was conducted on 200 pediatric relatives of β-thalassemic pediatric patients attending the Hematology Unit of the Pediatric Department, Menoufia University Hospitals, during the period from October 2015 to April 2018. Full history, clinical examination, complete blood count, serum iron, serum ferritin, and total iron-binding capacity were investigated. Results Overall, 20.5% of patients had BTT and 12.5% had IDA. However, 66 (33%) of the studied children had microcytic hypochromic anemia. Pallor was found in 40.9% of total group, pica found in 19.7%, and easy fatigue in 25.8% of them. All IDA cases responded to oral iron therapy. Conclusion The frequency of BTT among pediatric close relatives of thalassemic patients is higher than in general population. IDA group had significantly higher Mentzer, Sirvastava, England and Fraser, Sirdah, Shine and Lal scores than BTT groups. BTT group had significantly higher red blood cells count, serum iron, serum ferritin, and hemoglobin A2 than IDA group. IDA group had significantly higher mean cell volume, mean cell hemoglobin, red cell distribution width, total iron-binding capacity, and hemoglobin A than BTT groups.
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Determine upper limit of normal range of antistreptolysin-O titer in normal school children from 5 to 15 years old p. 204
Ahmed A Khattab, Wael A Bahbah, Dalia H Abou-Elela, Tamer S Mohammed
DOI:10.4103/mmj.mmj_196_19  
Objective To determine upper limit of normal range of antistreptolysin-O (ASO) titer in normal school children from 5 to 15 years old in Menoufia Governorate. Background Although ASO titer has provided a useful guideline to physicians this has been shown to vary with age, geographical location, and site of infection. Patients and methods A cross-sectional study was carried out in Menoufia Governorate and the samples were collected from outpatient clinics of Menoufia university hospital other than infection (by advertising in the outpatient clinics for analysis streptococcus laboratory for free in children aged 5–15 years) in the period from July 2016 to May 2017. Two hundred children aged 5–15 years were participated in this study after consent from their parents. The children were categorized into two groups: group 1: include children aged 5–10 years and group 2: include children aged 11–15 years. Full history, routine, physical examination, and special investigations were taking. Results There was statistically significant difference between residence and social classes in the studied group. Also, there was statistically significant difference between age groups regarding ASO titer among rural patients. There was highly significant correlation between number of attacks of acute follicular tonsillitis with ASO titer level, age groups, and social classes. Conclusion The upper limit of normal ASO titer in normal Egyptian children is quite high, reaching up to 398.5 IU/ml. Therefore, an isolated high ASO titer is not sufficient to diagnose acute rheumatic fever. Basal levels of ASO titer increase with age but age does not affect the peak level during acute streptococcal infection. Additional studies will be required for establishment of standard values to avoid over diagnosis of acute rheumatic fever and complications of long-acting penicillin.
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Association between vitamin D deficiency and sepsis in pediatric ICU p. 210
Fady M El-Gendy, Ahmed A Khattab, Rehab G Naser, Aliaa A Abdel-Aziz
DOI:10.4103/mmj.mmj_210_19  
Objective To evaluate association between 25-hydroxyvitamin D [25(OH)D] and sepsis in pediatric ICU (PICU). Background Vitamin D is a fat-soluble steroid hormone that helps maintain proper calcium homeostasis and has a role in the function of the immune system. Data on the prevalence of vitamin D deficiency (VDD) in PICU in children with sepsis and its association with poor outcome were obtained. Patients and methods This study was carried out on 45 patients with sepsis admitted to the PICU, Pediatric Department, Menoufia University Hospital, and 45 controls, who attended the patient clinic and were found to be healthy. Demographic data, history, and general and local clinical examination were done. Investigations such as complete blood count and C-reactive protein were done. For measurement of vitamin D, fresh blood samples were taken within 24 h of admission, and level of vitamin D was measured by ELISA. VDD was defined as less than 10 ng/ml. Results Prevalence of VDD [25(OH)D level < 10 ng/ml] was higher among critically ill children with sepsis compared with health controls (33.3 vs. 11.1%; P = 0.02). 25(OH)D was strongly associated with pediatric index of mortality (P = 0.02), duration of mechanical ventilation (P = 0.003), length of PICU stay (P < 0.001), and mortality (P < 0.001). VDD was not associated with age, sex, residence, or admission season. Conclusion Lower 25(OH)D levels are associated with sepsis. There was a high prevalence of VDD in critically ill children with sepsis, and it was association with poor outcome.
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Study of short-term outcome of early and late cord clamping in full-term newborns p. 216
Maha A Tawfik, Dalia M Ellahony, Aymen M Abdel-Qader
DOI:10.4103/mmj.mmj_238_19  
Objective The aim was to assess short-term outcome of both early and late cord clamping in full-term newborns. Background Delaying clamping of the umbilical cord for at least 2 min after birth consistently improved both the short-term and long-term hematologic and iron status of full-term infants. Participants and methods This is a case–control study that was conducted on 100 Egyptian full-term neonates (47 males and 53 females), involving 50 newborns with early clamping of the cord less than or equal to 1 min as group I and 50 newborns with late clamping of the cord more than 1 min without milking of the cord, matched for age and sex, as group II. All of them were subjected to full history, physical examination, Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (APGAR) score, and blood samples taking at birth and after 24 h. Complete blood count including hemoglobin (Hb), packed cell volume, hematocrit, mean corpuscular volume, reticulocyte count, and total serum bilirubin (TBS) was done. Results Hb, hematocrit, packed cell volume, and TBS (P < 0.05) were significantly higher after 24 h of cord clamping in the delayed clamping group than early clamping. APGAR score had no significant difference. Conclusion In term infants, delayed umbilical cord clamping increases Hb levels at birth. There is a small increase in TBS, requiring follow-up after 24 h, in term infants undergoing delayed umbilical cord clamping.
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Value of plasma levels of cardiac myosin-binding protein C as a diagnostic and prognostic biomarker in heart failure p. 221
Ahmed A Khatab, Basim A El-Gazzar, Mohamed S Rizk, Mohamed G. F Abdel Ghani
DOI:10.4103/mmj.mmj_239_19  
Objective To study the value of measuring plasma levels of cardiac myosin-binding protein C (cMyBP-C) as a biomarker in the diagnosis and prognosis of heart failure (HF) in pediatric patients. Background Previous research studies have declared that cMyBP-C phosphorylation modulates cardiac contractility. It is a thick filament-associated protein which regulates actin–myosin interaction and thereby the systolic and diastolic function of the heart and regulates cardiac contractility. CMyBP-C has been reported in many studies as a specific early diagnostic biomarker of myocardial infarction. Patients and methods To reach the goal of this research, a case–control study was designed. The study sample included 35 Egyptian children from the hospitalized children at Menoufia University Hospital with HF as 'a patient group' and 30 apparently healthy children of similar age and sex matched as 'a control group.' Results We found a significant increase in cMyBP-C (P = 0.001) in the patients with HF. There was a statistically significant difference between cMyBP-C in the patients at admission and their ROSS classification, as higher level was noticed in class IV in relation to classes II and III (P = 0.001), and also higher in class III in relation to class II (P = 0.0.008). Conclusion Our study reveals that the plasma level of cMyBP-C is a significant biomarker, which can be used for diagnosis and prognosis of HF in pediatric patients.
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Effect of an early oral stimulation program on oral feeding in preterm neonates p. 226
Ghada M El Mashad, Hanan M El Saied, Nadia A Mekawy
DOI:10.4103/mmj.mmj_241_19  
Objective To evaluate the effect of prefeeding oral stimulation program on feeding performance, weight gain, and length of hospital stay of preterm infants in neonatal ICUs. Background Previous research has declared that poor oral-motor developments in premature infants are common. So, most of the preterm infants require individualized therapy. Early intervention of oral-motor management on feeding pattern improves the outcome. Patients and methods To reach the goal of this research, a case–control study was conducted. A total of 50 preterm infants were divided into two groups: (a) interventional group (25 preterm infants), which received prefeeding oral stimulation program by stimulation of the oral and perioral structures for 5 min for 10 days and was started immediately after delivery, and (b) control group (25 preterm infants), which did not receive stimulation. Postmenstrual age, total intake volume, body weight, the transition time from initiation of oral feeding to full oral feeding, and feeding efficiency were calculated. Results We found that the mean oral feeding duration was significantly lower among intervention group compared with control group (P = 0.04). The percentage of weight change was significantly higher among intervention group compared with control group (P = 0.03). Conclusion Our study reveals that early sensory oral-motor stimulation with nonnutritive sucking in preterm infants may be effective to expedite oral feeding and hospital discharge. A touch therapy program may confer a statistically significant weight gain for premature babies at much shorter intervals, which leads to a shorter hospital stay.
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Glutathione S-transferase (GSTM1 and GSTT1) polymorphisms' relationship between glycemic control of diabetic mothers and their infants p. 231
Soheir S Abou El-Ella, Naglaa F Barseem, Ragab M Dawood, Shimaa F.N. Dawoud
DOI:10.4103/mmj.mmj_258_19  
Objective To evaluate the glutathione S-transferase genetic variants (GSTM1 and GSTT1) in pregnant mothers with gestational diabetes mellitus (GDM) and the degree of glycemic control. Background Previous research has declared that GDM affects both the mother and the baby during pregnancy and in the long term. Patients and methods To reach the goal of this research, a case–control study was designed. A total of 80 pregnant women were divided into two groups: (a) patients group (40 patients had GDM during the third trimester of pregnancy) and (b) control group (40 apparently healthy pregnant women). All participants were subjected to detailed history taking, complete general examination of all body systems, laboratory investigations, and molecular genetic study. Results We found that there was a statistically significant difference in GSTT1-0 null genotype rates between mothers with GDM and controls (P = 0.04). However, there was no difference in the frequencies of GSTM1 null genotypes between mothers with GDM and controls (P = 0.112). GSTM1 was more prevalent in infants of diabetic mothers (IDM), with a significantly difference between IDM and controls regarding GSTM1 null genotypes (P = 0.04). This difference was positively associated with higher levels of respiratory rates above normal limits and low 1 min APGAR score. Conclusion Our study reveals that GSTM1-0 null genotype in IDM was positively correlated with the unfavorable presentation among affected newborns who are carriers of this polymorphism.
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Screening of β-thalassemia carriers in high school students in Shebin El-Kom, Menoufia Governorate p. 237
Seham M Ragb, Mohammed A Elrahim, Wafaa M.A. El Fotoh, Randa A.E. Ibrahim
DOI:10.4103/mmj.mmj_358_19  
Objective To identify the prevalence of β-thalassemia carriers among secondary school children for the prevention program of β-thalassemia and to update carrier rate data in Menoufia Governorate. Background β-thalassemia is the most prevalent hereditary disorder and is particularly prevalent among the Mediterranean people, and this geographical association is responsible for its naming. Patients and methods This study was conducted on 303 high school students aged 15–18 years from Shebin El-Kom, Menoufia Governorate, Egypt (62% women and 38% men). They were subjected to full history taking and clinical examination. Laboratory investigation included complete blood count, and serum ferritin level. High-performance liquid chromatography was done for samples with normal or high serum ferritin level. Results The overall prevalence of anemia among the studied students was 38%. Microcytic type was the most common and represented 57% of anemic students. Men have higher mean hemoglobin values than women in different age groups. Three (1%) students of the total studied students were diagnosed to have the β-thalassemia trait. Moreover, there was a significant difference in ferritin level between β-thalassemia carriers and students diagnosed with iron-deficiency anemia. The mean value of hemoglobin A2 in students with β-thalassemia trait was 5.56 ± 0.42%. Conclusion The prevalence of β-thalassemia carriers in high schools was about 1%. A full blood count with microcytosis, together with normal or high serum ferritin level, and hemoglobin A2 more than 3.5% were considered enough for the identification of β-thalassemia carriers in a screening process.
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Evaluation of oxidant–antioxidant balance and total antioxidant capacity in urinary tract infection in children p. 243
Fahima M Hassan, Basim A El-Gazzar, Mohamed G El-Helbawy, Manar H Elhabashy
DOI:10.4103/mmj.mmj_273_19  
Objective The aim was to detect serum levels of oxidative stress (OS) biomarkers [malondialdehyde (MDA) and total antioxidant capacity (TAC)] in children suffering from urinary tract infection (UTI). Background Reactive oxygen species (ROS) are normally produced in low levels during tissue metabolism and are necessary for several biological processes. However, higher levels of ROS might cause damage to cells. Cellular damage by ROS could be prevented by different types of either endogenous or exogenous antioxidant. UTI is the most common bacterial infection in children and a major cause of hospitalization resulting in bad affection of the pediatric kidney. Patients and methods This case–control study was conducted on 100 children (75 patients: 25 controls) from 3 to 15 years old. From 100 children, 59 were women while 41 were men. They were selected from the outpatient clinic of nephrology of Menoufia University Hospital and Outpatient Clinic of Shebin El-Kom Fever Hospital from January 2018 to January 2019. Oxidant–antioxidant balance biomarkers (MDA and TAC) were quantified in serum samples and urine culture was performed to identify the causative organism of UTI. Results There was significant increase in serum MDA while a decrease in TAC in UT-infected children. Escherichia coli was the most responsible microorganism for UTI in children. Conclusion UTI in children badly affect their health causing an increase in MDA and a decrease in TAC serum levels resulting in decreasing the protecting effects of antioxidants on the body of children.
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RADIOLOGY - ORIGINAL ARTICLES Top

Role of MRI in distinguishing intrahepatic cholangiocarcinoma from poorly differentiated hepatocellular carcinoma p. 248
Zenaib A Ali, Rehab M Habib, Walaa A. E. Sakr
DOI:10.4103/mmj.mmj_122_19  
Objectives To evaluate the role of MRI in the diagnosis of mass-forming intrahepatic cholangiocarcinoma (mICC), its enhancement pattern with contrast agent, and distinction from poorly differentiated hepatocellular carcinoma (pHCC). Background mICC is the second most common primary hepatobiliary tumor that is increasing in incidence. Imaging characteristics in mICC differ significantly, having overlapping imaging features with pHCC. Thus, it is important to differentiate mICC from pHCC. Patients and methods A retrospective MRI study was conducted on 15 patients with mICC and 15 patients with pHCC referred to MRI unit of the National Liver Institute, Menoufia University from June 2017 to January 2019. MRI were analyzed for tumor shape, intratumoral hemorrhage, fibrous capsule, T2 signal intensity, capsular retraction, intratumoral fat, biliary dilatation, vascular invasion, intraductal lesion, intrahepatic metastasis, restricted diffusion, and enhancement pattern after contrast injection. Associations between MRI features and tumor type were examined using the Fisher's exact and χ2 tests. Results Late enhancement was more common in mICC than pHCC (P < 0.001). T2 central hypointense area was more common in mICC versus HCC (P = 0.001). Capsular retraction was more common in mICC than HCC (P = 0.001). Biliary dilatation was more common in mICC than pHCC (P = 0.001). Fat component was more in pHCC than mICC (P = 0.01). Fibrous capsule was more common in pHCC than mICC (P = 0.002). Others parameters were not significant. Conclusion Biliary dilatation, central fibrosis, overlying capsular retraction, and late enhancement at 3 min with absence of fat and fibrous capsule appear to be the most important characteristics for mICC and help its differentiation from pHCC.
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The role of MRI in evaluation of cervical carcinoma p. 253
Hala H Mohamed, Safaa A Mohamed, Nehal A Ahmed
DOI:10.4103/mmj.mmj_169_19  
Objective To review the role of MRI in the diagnosis and staging of cervical carcinoma. Background It is widely accepted that MRI is the preferred imaging modality for detection of cervical carcinoma nowadays; different techniques are needed for early detection of the disease, its correct staging, and treatment. Patients and methods This case–control study included 62 patients divided into a case group of 32 patients diagnosed clinically or by transvaginal ultrasound with cervical cancer, confirmed by biopsy, and a control group of 30 patients who had pelvic MRI for other reasons. All patients were assessed by history and review of previous ultrasound reports and underwent pelvic MRI with diffusion-weighted MRI and dynamic contrast-enhanced MRI. Results This study revealed a statistically significant difference between the case and control groups regarding apparent diffusion coefficient (ADC) value (P < 0.001). There was no significant difference in ADC value between different subtypes of cervical cancer. The diagnostic accuracy of ADC in discrimination of patients and control in defining the best cutoff value of ADC (×10–3), which was 1.10, was 99.5%, with sensitivity of 96.6% and specificity of 96.9%. Conclusion Diffusion-weighted imaging is a potentially useful adjunct to conventional MRI in evaluating cervical carcinoma, thus improving overall diagnostic accuracy, tumor staging, prediction of response to therapy, and treatment follow-up. ADC values may vary not only with different imaging parameters but also with different types of MRI systems.
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Role of magnetic resonance imaging in diagnosis of pediatric bone tumors p. 259
Zynab A Ali, Rehab M Habib, Shrief R Abd Elkhalek
DOI:10.4103/mmj.mmj_212_19  
Objectives To evaluate the diagnostic effect of MRI in pediatric patients with suspected bone tumors and other bone pathologies. Background Bony lesions in pediatric age group is a frequent cause of pain and swelling. MRI is used to evaluate such patients, and information delivered by MRI is used to diagnose these lesions, whether benign or malignant. In addition, information delivered by MRI is used to guide biopsy procedure. Patients and methods This was a prospective study that included 50 patients. All were referred to the MRI unit in the diagnostic Radiology Department at Menoufia University Hospital from Menoufia University Hospital clinics and private clinics from June 2015 to November 2018. Results Our study revealed that MRI plays a sensitive diagnostic role in most cases not solved by plain radiography, for example, characterization of bony lesions like fatty content, cysts with and without fluid–fluid levels, and cartilaginous matrix, and also in aggressive bone lesions, MRI is used for locoregional staging and noninvasive evaluation of response to neoadjuvant treatment. Conclusion MRI is a sensitive and specific tool in primary detection and staging of pediatric bone tumors and tumor-like conditions. MRI helps guide biopsy from the soft tissue components and increases the chance of obtaining a definitive diagnostic result.
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Diffusion-weighted MRI after radiofrequency ablation for hepatocellular carcinoma p. 264
Mohamed R El-Kholy, Mohammed S Al Warraky, Shaimaa A Hassanien, Heba A El-Balshy
DOI:10.4103/mmj.mmj_236_19  
Objective This paper aims to evaluate the role of diffusion-weighted (DW) MRI in patients with hepatocellular carcinoma (HCC) treated by radiofrequency ablation (RFA). Background HCC is the most common primary cancer of the liver. RFA has become a widely used treatment for HCC, with some studies reporting significant long-term survival results. DW MRI had been investigated for assessment of treatment response to RFA. Patients and methods From October 2016 to May 2017, 30 patients with 30 lesions diagnosed as HCC had undergone DW MRI after RFA. The results were compared with the abdominal triphasic spiral computed tomography, which was used as the reference standard. Results The study included 30 patients with 30 HCC lesions. After RFA, there were 12 (40%) lesions with residual HCC activity and 18 (60%) adequately managed lesions. The mean apparent diffusion coefficient value in residual lesions was significantly lower than the mean apparent diffusion coefficient value in ablated lesions (P < 0.001). DW MRI had a sensitivity of 92%, a specificity of 100%, and an accuracy of 97%. Conclusion DW MRI was complementary for abdominal triphasic spiral computed tomography in the assessment of tumor response after RFA. Diffusion-weighted MRI is considered to be capable of evaluating the response to therapy of HCC.
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Early assessment of knee osteoarthritis using three-dimensional water-selective gradient-echo MRI technique p. 269
Mohamed A Maaly, Tarek F Abd Ella, Dalia W Elyamany
DOI:10.4103/mmj.mmj_257_19  
Objective The aim was to evaluate the role of three-dimensional water-selective gradient-echo MRI technique (WATS) in early assessment of knee osteoarthritis (OA). Background OA is a degenerative joint disease occurring in older adults. The 3D WATS is the best imaging technique currently available for the assessment of articular cartilage. Patients and methods A prospective study was conducted on 25 patients with suspected knee joint disorder who were enrolled from the Rheumatology and Orthopedic Departments in Mansoura University Hospitals and Outpatient Clinic in Menoufia University Hospital from February 2017 to February 2018. Complete history, clinical examination, and imaging analysis using a knee coil in a 1.5T MRI scanner were done. Results Women were more affected with OA (68%) than men (32%). Cartilage defects were the most common MRI finding (76%). Osteophyte formation is represented by 12 (48%) cases. There were six cases with normal cartilage appearance and 19 cases have different grades of cartilage defect. Grade II cartilage defect was the most common finding (eight cases, 32%); 12 (48%) cases presented with osteophyte; 11 (44%) cases had osteophytes greater than 5 mm and one (4%) case had osteophyte of less than 5 mm. Conclusion Three-dimensional Gradient echo imaging is considered the standard technique for morphologic evaluations of knee cartilage. The 3D-WATS are proved to be more helpful in accurate assessment of cartilage thickness and volume, showing morphological changes of cartilage surface and internal cartilage signal changes. The 3D-WATS sequences cannot replace routine 2D sequences because they do not allow accurate assessment of other important joint structures.
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Role of positron emission tomography/computed tomography for the staging of primary colorectal cancers p. 274
Waleed A Mousa, Mohamed M Houseni, Basma A Dessouky, Heba E Mostafa
DOI:10.4103/mmj.mmj_263_19  
Objective The aim of this paper was to evaluate the role of positron emission tomography (PET) combined with contrast-enhanced computed tomography (CECT) in staging patients with primary colorectal cancer (CRC). Background CRC is the second leading cause of cancer-related deaths and the fourth most common malignancy worldwide. Cross-sectional imaging studies such as CT and MRI have evolved as the best modalities for staging rectal cancer. PET combined with CT is widely used not only for preoperative staging, but also for assessing the outcomes of rectal carcinoma. Patients and methods This prospective study was carried out on 50 patients: 30 (60%) men and 20 (40%) women in the age range from 27 to 74 years, who were diagnosed or suspected to have cancer colon by other radiological imaging. Results Our results showed that PET-CT had equal sensitivity (95.4%) and specificity (82%), positive predictive value (PPV) (80.7%), negative predictive value (NPV) (95.8%), and accuracy (88%) for the detection of regional lymph node metastasis compared to CECT. But PET-CT and CECT had higher sensitivity and higher specificity, PPV, NPV, and accuracy more than PET for detection of metastatic lymph nodes and PET-CT had equal sensitivity (92.8%) and specificity (86.2%), PPV (72.2%), NPV (96.8%), and accuracy (88%) for detection of lung metastasis compared to PET. But PET-CT and PET had higher sensitivity and higher specificity, PPV, NPV, and accuracy more than CECT for detection of pulmonary deposits. Conclusion According to our results, fluorine-18 fluorodeoxyglucose PET/CT has contributed positively to the staging of primary CRC patients.
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NEUROPSYCHIATRY - ORIGINAL ARTICLES Top

Psychiatric comorbidity and quality of life in patients with dermatological diseases p. 281
Nabil R Mohamed, Afaf Z Rajab, Amr S Shalaby, Azza G Farg, Amira A El-Bakry
DOI:10.4103/mmj.mmj_155_19  
Objective The aim of the study was to compare the psychiatric comorbidities in patients with vitiligo with control group considering the burden in their life quality. Background Several studies reported high rates of depression and anxiety particularly for specific dermatological diseases such as vitiligo, affecting their life quality. Patients and methods A total of 30 patients with vitiligo as well as 30 participants as a control group were included. The study was conducted in Neuropsychiatry Department, Menoufia University. Arabic version of the Structured Clinical Interview for psychiatric Disorders 1 based on the Diagnostic and Statistical Manual of Mental Health Disorders, fourth ed., was used for psychiatric diagnosis. Dermatology life quality index was used to assess life quality in patients with vitiligo. Arabic version of the Holmes and Rahe Stress Scale was used to determine stressful life events that might increase risk for illnesses. Results A statistically significant difference between the patients with vitiligo and controls was found regarding psychiatric comorbidities (P < 0.001). Only seven (23.3%) patients of vitiligo group were free of psychiatric disorders. Overall, 23 patients of vitiligo group had psychiatric comorbidities versus control group (76.7 vs. 16.7%). Quality of life (QOL) affection was at moderate effect in 16.7%, very large effect in 30%, and extreme large effect in 10%. Conclusion Patients with vitiligo disease were associated with high rates of psychiatric comorbidity. A significant disruption was found in QOL. Screening may be helpful for early diagnosis, improving their QOL.
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Safety and efficacy of low-dose alteplase in the treatment of acute ischemic stroke in Egyptian patients p. 285
Wafik M El-Sheikh, Gelan M Salim, Khaled H Afifi, Basma G El-Shanawany
DOI:10.4103/mmj.mmj_269_19  
Objective To evaluate the safety and efficacy of low-dose alteplase (0.6 mg/kg) in the treatment of Egyptian patients with acute ischemic stroke (AIS). Background High cost and concerns associated with post-thrombolysis intracerebral hemorrhage are major obstacles that limit utilization of the standard-dose alteplase (0.9 mg/kg) in AIS in Egypt. Patients and methods This is a nonrandomized clinical trial conducted on 40 Egyptian patients with AIS who were eligible for intravenous alteplase. Patients were thrombolysed at a dose of 0.6 mg/kg. Primary outcomes were safety expressed in the proportion of patients who developed symptomatic intracranial hemorrhage according to European Cooperative Acute Stroke Study III definition and 3-month mortality and efficacy expressed in the proportion of patients with modified Rankin Scale of 0–1 (favorable outcome) at 3 months. Results The proportion of favorable outcome (efficacy analysis) was 37.5% (n = 15). No cases developed symptomatic intracranial hemorrhage in the studied sample with an overall mortality rate of 7.5% (n = 3) with one case recorded in hospital mortality (safety analysis). Conclusion Intravenous alteplase at 0.6 mg/kg within 4.5 h of stroke onset could be safe and effective in routine clinical practice as a substitute of the standard dose (0.9 mg/kg) especially in developing countries like Egypt.
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CLINICAL PATHOLOGY - ORIGINAL ARTICLES Top

Role of homeobox-A9 gene expression in patients with de novo acute myeloid leukemia p. 291
Samia H Kandel, Iman A Ahmedy, Safaa I Tayel, Azza R Mohamed
DOI:10.4103/mmj.mmj_165_19  
Objective To study the clinical significance and the prognostic value of homeobox-A9 (HOXA9) gene in patients with newly diagnosed acute myeloid leukemia (AML). Background HOX genes are transcription factors. In humans, the 39 HOX genes are organized into four genomic regions (the HOXA, B, C and D clusters), located on four chromosomes (chromosomes 7, 17, 12, and 2, respectively). They play important roles during embryogenesis. The characteristic expression of HOX genes can also be detected in different adult tissues. Patients and methods This prospective case–control study was conducted on 60 patients with newly diagnosed AML and 40 healthy patients serving as a control group. They underwent a full history, clinical examination, complete blood count, bone marrow examination, and quantification of HOXA9 in blood by quantitative real-time PCR assay. Results From the results of this study, we found that HOXA9 was higher in patients with AML than healthy controls (P < 0.001). The highest incidence was found in AML M7 and M5, in patients with AML with older age, with hepatomegaly and splenomegaly, in patients with AML with unfavorable cytogenetic criteria, and in patients with AML who did not achieve complete remission. Conclusion HOXA9 is higher in patients with AML than controls. High HOXA9 expression has a negative prognostic effect on patients with AML and poorer response to chemotherapy. Moreover, it represents an independent prognostic factor mediating chemotherapy.
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Nephroprotective effect of coadministration of curcumin and sildenafil in adenine-induced chronic renal failure in rats p. 297
Maha M El-Batsh, Rehab M Samaka, Emad Eldin M. Elhenawy, Abd Elrahman A. Yassin, Samar R Elnaggar
DOI:10.4103/mmj.mmj_167_19  
Background Chronic renal failure (CRF) is a major public health problem worldwide. The pathophysiological basis of the disease and its complication include inflammation and oxidative stress, which are similar in humans and animals. In this study, we seek to develop new therapeutic modalities for CRF. Objective This study aimed to investigate the nephroprotective effects of curcumin (CUR) and/or sildenafil in adenine (AD) model of CRF. Materials and methods Rats were divided into five groups as follows: control naive group, AD group received AD 200 mg/kg/day orally to induce CRF, CUR group received CUR 200 mg/kg/day in addition to AD, sildenafil group received sildenafil 0.5 mg/kg/day in addition to AD, and combination group received combination of CUR 200 mg/kg/day and sildenafil 0.5 mg/kg/day in addition to AD. After consecutive 28 days of treatment, body weight, kidney index, and Doppler on renal artery assessments were done for all groups. In addition, kidney function tests and markers of oxidative stress were evaluated. Histopathological assessment of renal tissues and immunohistochemical staining for tumor necrosis factor-α were performed. Results CUR, sildenafil, and their combination significantly decreased body weight loss and urine volume and improved renal hemodynamic changes caused by AD. In addition, they significantly improved kidney function tests and biomarkers of oxidative stress. A significant down-regulation of tumor necrosis factor-α immunohistochemical expression was noted. They also brought histopathological changes induced by AD toward normal. Conclusion CUR and sildenafil may play a role in renal protection in AD-induced nephrotoxicity. The combined treatment showed better nephroprotective effect than either treatment alone did.
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Genetic polymorphism of BCL11A (rs11886868) in Egyptian patients with β-thalassemia p. 305
Mohamed A Soliman, Rawhia H El-Edel, Amal H AbdElhameed, Seham M Ragab, Manal Monir Mansour, Mohamed A Helwa
DOI:10.4103/mmj.mmj_232_19  
Objectives To study the effect of BCL11A (rs11886868) gene polymorphism on clinical status of Egyptian patients with β-thalassemia. Background β-thalassemia is a genetic disorder that results from β-globin gene mutations leading to defective synthesis of adult hemoglobin (Hb A). Clinical consequences vary tremendously from nearly asymptomatic to severely anemic and transfusion-dependent patients. Phenotypic variations have been linked not only to the type of β-globin gene mutations and amount of synthesized Hb A but also to recently discovered genetic modifiers mapping outside the β-globin gene cluster including BCL11A gene polymorphism. These modifiers are associated with increased fetal hemoglobin (Hb F) levels. Patients and methods Blood samples were collected from 120 patients with β-thalassemia before transfusion of blood. Complete blood count, quantitative measurement of different Hb types by high-performance liquid chromatography, and analysis of single nucleotide polymorphism rs11886868 in the BCL11A gene by Taqman single nucleotide polymorphism genotyping assay and real-time PCR were done. Results The genotype distribution of BCL11A gene polymorphism showed low frequency of CC genotype (15%) among Egyptian patients with β-thalassemia. The CT genotype was 41.7% and TT genotype was 43.3%. There was a significant relation between BCL11A (rs11886868) genotypes and Hb F levels, with the highest Hb F levels were observed in the CC genotype followed by CT genotype, whereas Hb F levels were the lowest in TT genotype. Patients with CC genotype had mild disease phenotype owing to increased Hb F production. Hb F utilizes some of the free α-chain and ameliorates clinical presentation. Conclusion Screening of BCL11A gene variants may be used as a marker for severity risk in newly diagnosed patients with β-thalassemia and as a predictor of clinical outcome of this disorder.
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PATHOLOGY - ORIGINAL ARTICLES Top

Nucleocytoplasmic expression of autophagy-related protein 7 in psoriasis p. 310
Rehab M Samaka, Mohammed A Basha, Wafaa A Shehata, Ahmed E Tahoun
DOI:10.4103/mmj.mmj_176_19  
Objective The aim of this study was to evaluate the role of autophagy-related protein 7 (Atg7) in psoriasis. Background Despite psoriasis being a common skin disorder, the exact pathogenic mechanism of psoriasis is still not fully understood. Abnormal autophagy is now established to be associated with pathogenesis of some skin disorders. Atg7 plays a central role in the machinery of the autophagy. Materials and methods This prospective case-control study included 30 patients with chronic plaque psoriasis, either lesional or perilesional, and 20 age-matched and sex-matched apparently normal participants as a control group. All cases were immunohistochemically stained for Atg7 antibody. Results There was a significant difference among the three studied groups regarding epidermal topographic distribution of Atg7 (P < 0.001). Nucleocytoplasmic topographic localization was dominant in psoriatic skin, either lesional or perilesional, in comparison with 15.8% of normal skin. Regarding dermal Atg7 expression, there were significant differences between the studied three groups regarding all parameters of immunohistochemically of Atg7 such as status (P = 0.006), topography, percentage, and intensity (P < 0.001 for all). Conclusion Nucleocytoplasmic expression of Atg7 in psoriatic skin could be incriminated in pathogenesis of psoriasis.
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Does Beclin 1 have a role in basal cell carcinoma? p. 321
Rehab M Samaka, Alaa H Marey, Tarek M Rageh, Dania N Abo Elros
DOI:10.4103/mmj.mmj_252_19  
Objective To evaluate the role of Beclin 1 in basal cell carcinoma (BCC). Background BCC is the most common kind of skin cancer with increased incidence. Autophagy is considered an intracellular homeostatic pathway that is related to cancer and other diseases. Beclin 1 is a specific marker for autophagy. Patients and methods This An Ambidirectional Cohort Study was conducted on 77 cases with BCC and 20 age-matched and sex-matched apparently healthy participants. All sections were immunohistochemical stained for Beclin 1 antibody. Results Significant absolute Beclin 1 cytoplasmic localization in epidermis and dermis of control group was noted, whereas in BCC, most cases showed nucleocytoplasmic Beclin 1 expression in epithelial cells and surrounding stroma (P > 0.001 for both). High Beclin 1 H score and H score category of epithelium and stroma were significantly noted in BCC in comparison with control groups (P > 0.001 for both). There were significant associations between higher Beclin 1 stromal H score and noduloulcerative clinical presentation and adenoid variant of BCC (P = 0.001 and 0.02, respectively). Moreover, there was a positive correlation between Beclin 1 stromal H score and size of BCC. Conclusion Overexpression and nuclear localization of Beclin 1 could play a tumor-promoting role in pathogenesis of BCC.
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PHYSIOLOGY - ORIGINAL ARTICLE Top

COVID-19 – a descriptive study of demographic trends in Rajasthan, listed in top five affected states of India p. 328
Sudhir Bhandari, Ajit S Shaktawat, Raman Sharma, Sudhir Mehta, Bhoopendra Patel, Kapil Gupta, Sanjay K Singhal, Jitendra Gupta, Shivankan Kakkar, Kavita Yadav, Amit Tak, Amitabh Dube
DOI:10.4103/mmj.mmj_183_20  
Objective The aim was to investigate the epidemiological profile and disease trend of nCOVID-19 in Rajasthan, listed among the top five COVID-19-affected states in India. Background The pandemic of coronavirus disease (COVID-19) has created a huge burden on health care system, and every nation, including India, has been struggling to contain the spread of this virus through various measures, including nationwide lockdowns. Methods The present observational descriptive study was performed on available epidemiological data of the state of nCOVID-19, from March 2, 2020, to April 22, 2020, and highlights epidemiological profile and disease trend of nCOVID-19 in the state of Rajasthan. Results Rajasthan in India reported 1918 nCOVID-19 cases with 25 deaths as of April 22, 2020. The nCOVID-19 exhibited a sex bias with a preponderance for male patients (62.7%), with a male: female ratio of 1.68. Individuals in the age group of 16–30 years represented the highest percentage (34.7%) of nCOVID-19 cases. The recovery rate and death rate were 31.8 and 1.5%, respectively. Higher proportion of cases in Rajasthan belonged to districts located in eastern plains and arid western zones. Conclusion Implementation of lockdown, along with mandatory advisory on practices like social distancing, wearing of facial mask, and frequent hand washing in India, remains a crucial step in containment of this pandemic. Moreover, timely and adequate changes of guidelines as issued by Indian Council of Medical Research, India, have led to flattening of the epidemiological curve.
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PHARMACOLOGY - ORIGINAL ARTICLE Top

Possible protective effects of quercetin on doxorubicin-induced cardiotoxicity in rats p. 333
Fatma E. R. Hashish, Moshira M Abdel-Wahed, Mahmoud H El-Odemi, Sherin S El-Naidany, Maha M ElBatsh
DOI:10.4103/mmj.mmj_5_20  
Objective Our study aimed to investigate the possible protective effects of quercetin (QCT) on doxorubicin (DOX)-induced cardiotoxicity in rats. Background DOX is an antineoplastic drug that produces cardiotoxicity; it generates highly cytotoxic-free radicals that damage the cardiomyocytes. QCT is a plant flavonoid. QCT pretreatment reduces DOX-induced oxidative stress. Materials and methods Fifty-five adult rats were divided into four groups: group 1 (control) received saline (5 ml/kg) orally for 4 weeks; group 2 (DOX) received six doses of DOX intraperitoneally (2.5 mg/kg) on alternative days in the last 2 weeks; group 3 (QCT + DOX) received QCT orally (10 mg/kg once daily) for 4 weeks and DOX intraperitoneally (2.5 mg/kg) in the last 2 weeks as group 2, and group 4 (QCT) received QCT (10 mg/kg once daily) orally for 4 weeks. We measured the body weight, heart weight, and ECG parameters. Serum cardiac troponin-I (cTn-I), serum malondialdehyde (MDA), and total serum antioxidant capacity (TAC) have been estimated. In addition, histopathological changes of the rat heart were assessed. Results The DOX group showed significant ECG changes, significant increase in serum cTn-I (P < 0.001) and MDA (P < 0.001), significant decrease in TAC (P < 0.001), pathological picture of cardiomyopathy by hematoxylin and eosin staining, and high apoptotic index (P < 0.001) by caspase-3 stain compared with the control group. QCT pretreatment improved ECG changes, significantly decreased serum cTn-I (P < 0.001) and MDA (P < 0.001), significantly increased serum TAC (P < 0.001), and improved histopathological changes of the heart with significant lower apoptotic index (P < 0.001) compared with the DOX group. Conclusion QCT may be a promising cardioprotective agent against DOX-induced cardiotoxicity due to its inhibition of cardiac apoptosis and oxidative stress.
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PHYSICAL MEDICINE RHEUMATOLOGY AND REHABILITATION - ORIGINAL ARTICLES Top

Relation of serum tumor necrosis factor-α level with disease severity in spastic cerebral palsy p. 340
Samar G Soliman, Alaa A Labeeb, Heba A Esaily, Sameh A Abd El-Naby, Safa I Tayel, Eman A Abd Allah, Jehan D Fayed
DOI:10.4103/mmj.mmj_178_19  
Objective To detect the relation between serum tumor necrosis factor-α (sTNF-α) level and disease severity in children with lower limb spastic cerebral palsy (CP). Background Glial cells are activated following a primary insult to the immature brain, secreting chemical mediators such as tumor necrosis factor-α, leading to secondary white matter injury, causing CP. Patients and methods A randomized controlled clinical trial was conducted, including 80 ambulatory children with lower limb spastic CP and 80 healthy age-matched and sex-matched children as control group. At baseline, patients with CP were assessed using Modified Modified Ashworth Scale, bilateral adductor tone score, passive range of motion of lower limb joints, and outcome measures, such as Edinburgh Visual Gait Scale, Gross Motor Functional Measure-88, and Caregiver Priorities and Child Health Index of Life with Disabilities. Interventions were botulinum toxin-A injection, sTNF-α measurement, and rehabilitation. Follow-up after 2, 6, and 12 weeks had the same assessment as baseline, except for sTNF-α, and outcome measures were done at baseline and week 12. The control group had sTNF-α measured. Results Modified Modified Ashworth Scale, ankle dorsiflexion, popliteal angle, and outcome measures significantly improved after intervention (P > 0.001). Baseline sTNF-α was significantly higher in patients with CP (P > 0.001), positively correlated with CP severity (P = 0.01), and significantly improved after treatment (P > 0.001). Age and weight negatively correlated with baseline sTNF-α. Outcome measures significantly correlated with sTNF-α after intervention. Conclusion Baseline sTNF-α in spastic CP was higher than controls and positively correlated with disease severity. It significantly improved after rehabilitation and significantly correlated with improvement in all outcome measures.
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Study of musculoskeletal manifestations in patients with inflammatory bowel diseases p. 347
Samar G Soliman, Alaa A. E. Labeeb, Waleed A Mousa, Mohammed H Badr, Maha M. A. Salman
DOI:10.4103/mmj.mmj_183_19  
Objective The aim was to study the involvement of sacroiliac joints, lower limb joints, and enthesis and to detect osteoporosis in patients with inflammatory bowel disease (IBD), and then to correlate them with disease activity in patients with ulcerative colitis (UC). Background IBDs are systemic diseases that commonly display extraintestinal manifestations. Musculoskeletal involvement is one of the most common extraintestinal manifestations. Patients and methods This cross-sectional study included 50 patients with IBD who were evaluated for rheumatologic manifestations by clinical examination, laboratory, and radiologic studies such as musculoskeletal ultrasonography of lower limb entheses, digital radiographs of both sacroiliac and hip joints, and dual-energy X-ray absorptiometry scan for evaluation of osteoporosis. Results In this study, we found that most patients had tenderness rather than swelling of joints (knee tenderness in 66% and swelling in 34%). Bilateral sacroiliitis was present in 78% of patients. The proximal patellar entheses were the most inflamed site followed by Achilles tendon entheses. UC disease activity was significantly related to knee, ankle, and entheseal swelling and sacroiliac tenderness. There was a highly significant positive correlation between UC disease activity and fecal calprotectin level and a nonsignificant negative correlation with dual-energy X-ray absorptiometry scan T-score. Conclusion Musculoskeletal manifestations are common in patients with IBD and should be studied clinically and radiologically by expert rheumatologist for early detection and management.
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COMMUNITY MEDICINE - ORIGINAL ARTICLES Top

Epidemiology of Helicobacter pylori infection among children (6–12 years) in Menoufia Governorate p. 354
Sally A Mehesin, Safaa A Badr, Hewaida A El Shazli, Yasser A Ghoneim, Shaimaa S Soliman, Rabie E Al Bahnasy
DOI:10.4103/mmj.mmj_171_19  
Objective To study the prevalence of Helicobacter pylori infection and to assess potential risk factors and possible complications among children aged 6–12 years. Background H. pylori infection is said to be associated with growth delay in children, resistant iron-deficiency anemia, chronic antral gastritis that is related to duodenal ulcer, gastric ulcer, and probably gastric adenocarcinoma. Participants and methods A cross-sectional study included randomly selected 384 apparently healthy children from whom blood samples were collected after obtaining their parents' written consent. The study included 179 males and 205 females, and their age ranged from 6 to 12 years. Sociodemographic data and history of risk factors were obtained through a questionnaire. For every child, H. pylori antibody in serum was tested using H. pylori Antibody Rapid Test Cassette to detect the overexposure of H. pylori. Results Results of this study showed that prevalence of the overexposure to H. pylori was 45.1%. A significant association was found between each of previous usage of municipal tap water drinking, lack of personal hygiene, and contact with domestic animals and H. pylori infection, whereas there was no significant association between age, sex, or socioeconomic level and H. pylori infection. Conclusion In Menoufia Governorate, the seroprevalence of H. pylori was 45.1%. Tap water, lack of personal hygiene, and contact with domestic animal were major risk factors.
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Assessment of hygienic practices at the beginning of coronavirus disease-19 and after 3 months of its appearance in Egypt p. 360
Shaimaa Y Abd elRaouf, Shaimaa S Soliman, Nehad B Abd Elaty
DOI:10.4103/mmj.mmj_285_20  
Objective To assess the hygienic practices and preventive measures of individuals at the beginning of coronavirus disease-19 (COVID-19) pandemic and after 3 months of its appearance in Egypt. Background As there is still no definitive vaccine or treatment for COVID-19, personal hygienic practices and avoidance of exposure remain the gold standard for its prevention and control. Patients and methods A cross-sectional study included 391 participants who were asked to fill in a questionnaire to assess their hygienic practices and preventive measures of COVID-19 at the beginning and after 3 months of the pandemic in Egypt. The questionnaire consisted of 20 questions based on the WHO hygienic guidelines and was delivered through online Google form, and the higher the score, the better the practices. The validity and reliability of the questionnaire were shown to be satisfactory. Results The mean age of the studied group was 31.7 years (18–58 years), 72.4% were females, 81.8% were highly educated, 74.4% were living in urban areas, and 58.1% were married. The mean total score of the hygienic practices was significantly higher after 3 months of COVID-19 pandemic (49.1±7.82) than at the beginning (47.8±6.88), with P value less than 0.001. Participants who were aged more than 30 years (P=0.001), married (P=0.026), or currently working (P=0.001) maintained better practices than participants who were younger, single, or not working. Conclusion Most participants applied most of the hygienic practices to avoid COVID-19 infection. Some of the practices were improved after 3 months of COVID-19 appearance in Egypt.
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Physicians' awareness toward the diagnosis and treatment protocol for corona virus disease-19 p. 367
Manal A Al-Batanony, Hala M Gabr, Shaimaa S Soliman
DOI:10.4103/mmj.mmj_246_20  
Background The emergence of corona virus disease-19 (COVID-19) globally, coupled with its unknown etiology and its high transmission rate, has created an unprecedented state of emergency worldwide. Physicians' awareness about COVID-19 diagnosis and treatment protocols is essential in suppressing its pandemic status. Aim To assess the awareness of Egyptian physicians toward diagnosis and treatment protocol for COVID-19. Patients and methods An online cross-sectional survey was conducted from March 31 to April 20 2020 involving a total of 391 physicians across Egypt. Data were collected through a self-administered questionnaire about 'The Egyptian Diagnosis and Treatment Protocol for COVID-19' to assess their awareness toward the protocol, and the higher the score, the higher the awareness. Participants were classified according to their specialty into frontline specialties (chest, emergency/intensive care, anesthesia, and tropical medicine) and other nonfrontline specialties. Univariate and multivariate linear regression analyses were used to identify predictors of awareness score. Results The mean age of the participants was 40.72 ± 7.46 years. Overall, 58.1% were females, 77.2% were working in urban hospitals, and 32.7% of the physicians worked at both governmental and nongovernmental hospitals. The mean overall score was 18.33 ± 3.79. It was significantly higher among physicians of frontline specialties (20.88 ± 2.13) than other specialties (16.29 ± 3.59) (P < 0.001). Univariate and multivariate regression analyses revealed that male sex, working in urban health care settings, frontline specialties, working experience more than 5 years, medical doctorate degree, and working in a COVID-19 management place were significantly associated with higher awareness score. Conclusion Physicians with frontline specialties had knowledgeable awareness regarding the protocol. Continued professional education interventions and campaigns are advised for Egyptian physicians especially for those in nonfrontline specialties.
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FAMILY MEDICINE - ORIGINAL ARTICLE Top

Recurrent attacks of rheumatic fever among school-age children (6–12 years) p. 379
Hala M El-Moselhy Shaheen, Seham M Rgab, Noura A Khalel, Dina E. A. Saleh
DOI:10.4103/mmj.mmj_272_19  
Objective To assess factors related to recurrence of rheumatic fever attacks among school-age children (6–12 years) in El-Mahala El-Kobra City, Gharbiya Governorate. Background Recurrent episodes of acute rheumatic fever (ARF) can lead to rheumatic heart disease with considerable morbidity and mortality in children. Patients and methods A cross-sectional study was conducted in a center for follow-up of patients with rheumatic fever and rheumatic heart diseases in El-Mahala El-Kobra City, Gharbiya Governorate. There were 237 cases aged 6–12 years attending the selected center during the years of the study (first of November 2015 to end of October 2017). All cases that attended the center for follow-up (after either single attack or recurrent attacks of rheumatic fever) were recruited in the study. Participants were interviewed using a self-designed questionnaire filled by the researcher to assess socioeconomic characteristics and family and dietary history. Laboratory investigations included erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O titer, and hemoglobin percent, and also ECG and echocardiography were collected from patients' files. Conclusion There was a significant association between recurrence of rheumatic fever attacks and age of the patient, tonsillectomy, regimen of taking long-acting penicillin, and lack of adherence to treatment. Results The study revealed that among 237 studied rheumatic cases, 104 (43.9%) had recurrent attacks of ARF. The most significant factor associated with recurrent ARF was the age of the patient, negative history for tonsillectomy, a regimen of taking long-acting penicillin, and lack of adherence to its use.
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ONCOLOGY - ORIGINAL ARTICLE Top

Diagnostic and prognostic value of perforin-1 mRNA expression in acute myeloid leukemia p. 384
Eman S El Deen Arafat, Suzy F Gohar, Safa M Saber, Iman Fawzy, Eman M Abd El Gayed
DOI:10.4103/mmj.mmj_350_20  
Objective To study diagnostic value of perforin-1 gene mRNA expression and its relation to patients' outcomes in acute myeloid leukemia (AML). Background AML is a molecularly heterogeneous hematological malignancy with variable response to treatment and characterized by bone marrow and tissue infiltration with abnormally differentiated cells of hematopoietic origin. Perforin-1 is a glycoprotein responsible for pore formation in cell membranes of target cells. It has a role in immune regulation. Without perforin-1, cytotoxic T cells and natural killer cells show reduced or no cytolytic effect on target cells. Patients and methods Expression levels of perforin-1 mRNA were assessed by reverse transcriptase PCR and correlated with patients' features of response and survival. Results Patients with AML had significantly lower perforin expression compared with the control group (P < 0.001). Only seven patients, representing 11.7% of the studied patients had low perforin expression which was significantly related to poor disease cytogenetics and poor response (P = 0.018 and 0.043, respectively). However, logistic regression analysis revealed that older age and poor cytogenetics were considered as independent risk predictors for poor response in studied AML cases. At the end of follow-up period, 55% of patients were alive. The relation between perforin expression and overall survival revealed that there was no significant relation between perforin expression and overall survival in the studied patients (P = 0.09). Conclusion Lower perforin-1 mRNA expression was significantly associated with some poor prognostic features in patients with AML, such as unfavorable cytogenetics and poor response. It is also associated with shorter survival; however, this relation was not statistically significant.
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OPHTHALMOLOGY - ORIGINAL ARTICLE Top

Comparison of choroidal thickness before and after injection of ranibizumab in patients with diabetic macular edema p. 391
Moatz F Elsawy, Asmaa M Ibrahim, Lamiaa T. M. Kashkoush
DOI:10.4103/mmj.mmj_262_20  
Objective To compare choroidal thickness before and after injection of ranibizumab in patients with diabetic macular edema (DME) using enhanced depth optical coherence tomography (EDI-OCT). Background DME is one of the most common complications of diabetic retinopathy (DR) and the most common cause of visual impairment. Intravitreal injection of antivascular endothelial growth factor is currently the most commonly used procedure for the treatment of DME. Patients and methods A prospective clinical study was conducted on 30 eyes of 27 patients of DME who underwent intravitreal injection of ranibizumab. A complete history was taken from all cases, and a full ophthalmologic examination was done. Fluorescein angiography and EDI-OCT were performed before injection and also at 1 month after injection. The difference between preoperative and postoperative subfoveal choroidal thickness was calculated. Result The mean preoperative choroidal thickness measured subfoveally using EDI-OCT was 233.1 ± 20.22, whereas the mean of postoperative choroidal thickness after 1 month was 214.4 ± 19.61. The range of difference between preoperative and 1 month postoperative choroidal thickness using EDI-OCT was from 23 to 28 μm and the mean was 18.67 ± 8.99; the difference was calculated by subtracting the preoperative choroidal thickness from 1-month postoperative choroidal thickness. Conclusion There is a significant difference between the preoperative and 1-month postoperative choroidal thickness using EDI-OCT after injection of intravitreal ranibizumab in DME.
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INTERNAL MEDICINE - CASE REPORT Top

Role of adrenal venous sampling and radiological imaging in primary hyperaldosteronism: a case report p. 398
Mostafa N Mohrag
DOI:10.4103/mmj.mmj_260_20  
The authors present a case of a 63-year-old male patient who was evaluated for consistent hypokalemia and longstanding uncontrolled hypertension. Iatrogenic hypokalemia was excluded. The patient underwent a series of laboratory investigations which showed high levels of aldosterone and an increased aldosterone/renin ratio. A renal/adrenal ultrasound showed a mass in the right adrenal gland, which was presumed to be an adenoma. Adrenal venous sampling was conducted to establish the diagnosis and secretory ability of the mass, but the results showed a paradoxical low aldosterone secretion. The patient was further examined through MRI, which confirmed the adrenal mass, based on which he underwent laparoscopic adrenalectomy that resulted in the normalization of aldosterone, serum potassium, and blood pressure.
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PEDIATRICS - LETTER TO THE EDITOR Top

Assessment of health-related quality of life of hemodialysis patients in Benha City, Qalyubia Governorate p. 401
Mahmood D Al-Mendalawi
DOI:10.4103/mmj.mmj_123_19  
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COMMUNITY MEDICINE - LETTERS TO THE EDITOR Top

Role of government in minimizing the caseload and deaths attributed to noncommunicable diseases: World Health Organization p. 402
Saurabh Ram BihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/mmj.mmj_226_19  
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Addressing health sector discrimination: need of the hour p. 404
Saurabh Ram BihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/mmj.mmj_234_19  
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Strengthening the response of the health sector to improve the quality of life of women exposed to violence p. 406
Saurabh R Shrivastava, Prateek S Shrivastava
DOI:10.4103/mmj.mmj_266_19  
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