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Table of Contents
October-December 2020
Volume 33 | Issue 4
Page Nos. 1115-1423
Online since Thursday, December 24, 2020
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INTERNAL MEDICINE - REVIEW ARTICLE
Immunological perspectives to understand the difference between children and adults in COVID-19
p. 1115
Mohamed A Sakr
DOI
:10.4103/mmj.mmj_198_20
Objective
The aim was to review and summarize potential explanation for the difference between children and adults in susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which could help in suggestion of targets for future therapies.
Materials and methods
Systematic online search was applied using PubMed, Medscape, Science Direct, and WHO EMF databases with no date restrictions. English-language reports of the possible causes in the difference of immune response to SARS-CoV-2 infection in children from adults were included. Articles not reporting on the immune response to SARS-CoV-2 infection in children and adults were not included. Data were extracted on immunological mechanisms and other causes of health outcomes in Coronavirus Disease 2019 (COVID-19). Comparisons were made through a structured review, with the results tabulated. There were five studies about the role of angiotensin-converting enzyme 2 receptors, five studies about the role of the adaptive immune response, two studies about the role of telomere length, one study about the role of viral interference, two studies about the role of natural antibodies, and seven studies about other reasons for the difference between children and adults in susceptibility to SARS-CoV-2.
Findings
The most possible reasons for the difference between children and adults in susceptibility to COVID-19 include the expression and maturity of angiotensin-converting enzyme 2 receptors, the adaptive immune response to SARS-CoV-2 infection is qualitatively different in children from adults, shortened telomere length in adult leukocytes compared to children, viral interference with other viral infection in the respiratory tract, and more natural antibodies and lactoferrin with immunomodulatory characteristics in children.
Conclusion
Combination of some possibilities rather than one cause may explain the difference in pediatric and adult COVID-19 incidence, clinical presentation, and severity. More clinical trials on lactoferrin efficacy against SARS-CoV-2 infections should be done.
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OPHTHALMOLOGY - ORIGINAL ARTICLES
Efficacy of intravitreal injection of aflibercept in the treatment of neovascular age-related macular degeneration
p. 1123
Hoda M. K El Sobky, Ahmed I Basiony, Basant M. M. Doma
DOI
:10.4103/mmj.mmj_321_19
Objectives
To evaluate the visual and anatomical outcomes following intravitreal injection of aflibercept in patients with neovascular age-related macular degeneration (AMD).
Background
Neovascular AMD is considered a principal cause of visual impairment worldwide. It is associated with choroidal neovascularization, which causes exudation that affects vision. Early clinical trials showed that intravitreal injection of anti-vascular endothelial growth factor agents is associated with significant improvement of visual outcomes in the majority of eyes. Aflibercept is an anti-vascular endothelial growth factor agent that recently gained approval for treating neovascular AMD.
Patients and methods
This prospective study conducted at Menoufia University Hospitals, included 60 eyes of 46 patients with treatment–naïve neovascular AMD. The patients received 3monthly aflibercept intravitreal injections. The best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure were measured at diagnosis and after each injection. Also, the patients were asked to fill the 25-item National Eye Institute Visual Function Questionnaire at baseline and at the end of the study.
Results
The mean BCVA improved from 0.061 (decimal fraction) to 0.081 after the third injection (
P
< 0.001). The mean CMT significantly decreased from 484.07 μm at baseline to 331.1 μm after the third injection (
P
< 0.001). No significant changes in intraocular pressure were observed during the study. There was a significant improvement in total score and some subscale scores of the 25-item National Eye Institute Visual Function Questionnaire.
Conclusion
Intravitreal aflibercept in neovascular AMD is associated with increased BCVA and reduced CMT. In addition, intravitreal aflibercept possibly has a benefit of improving the quality of vision-related functions.
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Nepafenac and bromfenac versus a placebo in minimizing the incidence of pseudophakic cystoid macular edema after phacoemulsification
p. 1131
Hoda M. K. ElSobky, Hanan A. E Ahmed Madi, Mohammed S. A. Aziz
DOI
:10.4103/mmj.mmj_27_20
Objectives
This study aims to evaluate the effect of two types of topical NSAIDs, nepafenac and bromfenac, in comparison with a placebo on macular edema after phacoemulsification.
Background
Cystoid macular edema (CME) is the commonest cause of visual decline after phacoemulsification.
Design
A prospective comparative randomized Open-label clinical trial was performed.
Patients and methods
A total of 75 patients with senile cataract were included in the present study. Of them, 19 patients were assigned to receive nepafenac 0.3% eye drops, 19 received bromfenac 0.09% eye drops, and 37 received a placebo. The primary outcome measure included the change in the mean spectral-domain optical coherence tomography central subfield thickness at 1 day, 1 week, 1, 2 and 3 months after surgery. The secondary outcome measures included the total macular volume at 1 day, 1 week, 1, 2, 3 months postoperatively; the percentage of eyes in each group that developed CME; and the corrected visual acuity on 6 and 12 weeks after surgery.
Results
For all retinal thickness measurements, a significant increase in all three groups had been detected, starting from the first week postoperatively. Compared with the control regimen, add-on bromfenac or nepafenac resulted in statistically significant minimization of the changes in the following parameters: change in the macular volume and the central subfield thickness.
Conclusion
Topical NSAIDs therapy 2 days before surgery has an additive effect in minimizing the risk of pseudophakic CME. Bromfenac has statistically surpassed nepafenac in minimizing the incidence of CME after uneventful phacoemulsification.
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Choroidal thickness prognostic indicator for visual improvement in central retinal vein occlusion
p. 1139
Hoda M. K. EI-Sobky, Marwa A Zaky, Mohamed F Elhamadan
DOI
:10.4103/mmj.mmj_28_20
Objective
The aim was to study the relationship between baseline choroidal thickness and functional improvement in central retinal vein occlusion (CRVO) patients receiving antivascular endothelial growth factor (VEGF) therapy.
Background
CRVO is one of the most common vascular diseases of the retina that seriously affect visual acuity.
Design
Prospective study.
Patients and methods
Forty eyes of 40 patients with CRVO were included. All patients received anti-VEGF treatment (Ranibizumab) three injections 1 month apart. Enhanced depth imaging optical coherence tomography was used to evaluate choroidal thickness and macular thickness at baseline and after treatment. Also, best-corrected visual acuity was documented before and after treatment as a sign of functional improvement.
Results
Forty eyes of 40 patients with CRVO were included. Patients were classified into two groups according to their improvement in visual acuity: the responder group in whom visual acuity gain greater than or equal to two lines and the nonresponder group in whom visual acuity gain less than two lines. Baseline choroidal thickness in CRVO eyes (259 ± 37.9 μm) was thicker than in their fellow eye (202.5 ± 21.8 μm) (
P
= 0.001). Mean choroidal thickness at baseline for functional responders (259.2 ± 37.9 μm) was greater than that of nonresponders (224.9 ± 33.6 μm) (
P
= 0.005). On multivariate analysis a thicker baseline choroidal thickness (<237 μm) was found to be a positive indicator for visual improvement (odds ratio = 2.45;
P
= 0.025), Also, age (<60 years old) was a positive indicator for visual improvement (odds ratio = 2.39;
P
= 0.036).
Conclusion
Initial choroidal thickness and the age of patients can be used as a prognostic indicator for functional improvement in CRVO patients receiving anti-VEGF treatment.
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Treat-and-extend vs pro re nata regimens of aflibercept in diabetic macular edema
p. 1144
Abd E Elsebaey, Asmaa M. A. Ibrahim, Eman A Elshaarawy
DOI
:10.4103/mmj.mmj_42_20
Objective
The aim of the present study was to compare between two regimens of intravitreal injection of aflibercept in diabetic macular edema (DME): treat-and-extend (T and E) vs pro re nata (PRN).
Background
T and E and PRN (as needed) regimens of intravitreal antivascular endothelial growth factor treatment have been found to reduce the injection burden on patients and improve the cost-effectiveness of the treatment of macular edema.
Patients and methods
This prospective randomized comparative study was conducted on patients with DME, who were randomly divided into two groups. Eyes in group I were treated with T and E regimen of intravitreal injection of aflibercept and eyes in group II were treated with PRN regimen of intravitreal injection of aflibercept.
Results
The mean baseline best-corrected visual acuity (BCVA) was 0.833 ± 0.159 logarithm of the minimum angle of resolution (logMAR) units in patients with T and E protocol and 0.880 ± 0.077 logMAR units in patients with PRN protocol; after the loading dose, the BCVA was improved to 0.673 ± 0.103 logMAR units in patients with T and E protocol and 0.700 ± 0.093 logMAR units in patients with PRN protocol; and after resolving edema, the BCVA was 0.353 ± 0.106 logMAR units in patients with T and E protocol and 0.407 ± 0.096 logMAR units in patients with PRN protocol, with no statistically significant differences between the groups. However, there was a highly statistically significant difference between the groups regarding number of injections (
P
= 0.005).
Conclusion
Overall, an individualized T and E regimen has the potential to reduce clinic burden and improve patient compliance, while still maintaining effectiveness and providing well-tolerated treatment for DME.
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Characteristics of posterior corneal astigmatism in different stages of keratoconus
p. 1150
Abd E. E. Sarhan, Marwa A Zaky, Gehad A. F. Sakr
DOI
:10.4103/mmj.mmj_44_20
Objective
The aim was to evaluate the magnitudes and axis orientation of anterior corneal astigmatism (ACA) and posterior corneal astigmatism (PCA) and the correlation between ACA and PCA in the different stages of keratoconus (KC).
Background
PCA is an essential factor to be considered for accurate measurement of intraocular lens (IOL) power used in the treatment of cataract with KC.
Patients and methods
A retrospective case series study was conducted between August 2017 and July 2018 on a sample of 94 eyes with KC. Participants were divided into four subgroups according to Amsler–Krumeich classification. Pentacam was used to measure the magnitude and axis orientation of ACA and PCA. A correlation between ACA and PCA in the different stages of KC was also done.
Results
The means of anterior and PCA were 3.5 ± 3.02 diopters (D) and 0.72 ± 0.53 D, respectively. With-the-rule astigmatism was the dominant type of astigmatism orientation at both anterior (80.9%) and posterior (87.2%) corneal surfaces, some were oblique, and there were no cases with against-the-rule astigmatism orientation. There was a strong correlation (
P
< 0.001) between ACA and PCA in the different stages of KC, and the correlation was lower in eyes with grade 2 (
P
= 0.002) and grade 3 (
P
= 0.01) KC.
Conclusion
The prevalence rates of with-the-rule orientation of the ACA and PCA were higher than those for oblique orientation, and there were no cases with against-the-rule astigmatism orientation. The corneal astigmatism values at the two surfaces were significantly associated with the severity of KC, and the ACA and PCA values were strongly correlated.
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Ultrasound biomicroscopy role in assessing subscleral trabeculectomy operation
p. 1155
Mahmoud E Abd Elkhaleq, Hatem G Marey, Asmaa M Ibrahim
DOI
:10.4103/mmj.mmj_52_20
Objective
This study aimed to evaluate the role of ultrasound biomicroscopy (UBM) in assessing uneventful trabeculectomy parameters.
Background
The recent development of the UBM device has made it possible to observe the detailed structure of the anterior segment of the eye with a noninvasive procedure.
Patients and methods
In this prospective cohort study, an analysis of UBM scanning of 30 glaucomatous eyes of 30 patients, any age, both sexes, after 1 month from uneventful subscleral trabeculectomy operation was done.
Results
There was a negative significant correlation between bleb size (
r
= 0.905,
P
< 0.001) and intraocular pressure (IOP). There was an insignificant correlation at anterior chamber depth and IOP (
P
= 0.193). There was a positive significant correlation at bleb reflectivity and IOP (
r
= 0.836,
P
< 0.001). Multiple regression analysis showed that both bleb size and reflectivity affect IOP, but anterior chamber depth does not.
Conclusion
UBM is a good predictor of the anatomical patency of surgically created passage in post-trabeculectomy patients and well correlated with IOP.
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Assessment of epithelial changes by anterior segment optical coherent topography after photorefractive keratectomy
p. 1160
Abdel R El-Sebaey, Asmaa M Ibrahim, Amina F Radwan
DOI
:10.4103/mmj.mmj_56_20
Objective
The aim of the study was to evaluate corneal epithelial changes after photorefractive keratectomy (PRK) by anterior segment optical coherence tomography (AS-OCT) and correlate these with ablation depth (AD) and refractive outcome.
Background
Evaluation of corneal epithelial changes profile after PRK is essential for understanding postoperative wound healing and clinical outcomes.
Patients and methods
This a prospective nonrandomized clinical study in 100 eyes of 50 patients treated with PRK for myopia, astigmatism, or compound myopic astigmatism. Epithelial thickness maps were obtained by AS-OCT preoperatively and at 2 and 3 months postoperatively. Correlation between epithelial changes and the amount of AD and spherical equivalent were analyzed.
Results
Compared with the preoperative value the central 1 mm and paracentral (superior, inferior, temporal, nasal) 1: 3 mm zone epithelium was 5.71 ± 2.221 and (6.23 ± 2.176, 6.31 ± 2.553, 8.35 ± 2.436, 6.06 ± 2.000 μm) thicker, respectively, at 3 months postoperatively (
P
< 0.01). Epithelial thickness reached approximately the preoperative thickness 2 months later with the central 1 mm and paracentral (Superior, inferior, temporal, nasal) epithelium being 0.06 ± 0.180 and (0.35 ± 1.021, 0.19 ± 0.790, 0.63 ± 1.496, 0.38 ± 1.362) μm, respectively. The spherical equivalent changed from −6.25 to −0.625 D preoperatively to −1.5–0.0 D at 2 months postoperatively and remained stable at 3 months. There was a significant correlation between epithelial thickness and AD.
Conclusion
The epithelial thickness was assessed by AS-OCT. Epithelial thickness reached approximately the preoperative thickness at 2 months after PRK but there was statistically significant increase up to 3 months. There was statistically significant positive correlation between AD and epithelial thickening. These changes do not affect refraction.
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Riboflavin and fluorescein stain before argon laser in the treatment of resistant corneal ulcer
p. 1167
Fareed M Wagdy, Abdel Rahman E. Sarahan, Ghada M Atta, Mohamed S Abdel Aziz
DOI
:10.4103/mmj.mmj_57_20
Objective
To evaluate the effectiveness and safety of argon laser in resistant corneal ulcers with the aid of fluorescein stain or riboflavin.
Background
The use of argon laser irradiation of refractory keratitis has proved beneficial in the treatment of these particular corneal ulcers as an adjunctive treatment.
Patients and methods
In all, 40 cases were divided into two groups. The first group included 20 patients stained with fluorescein sodium 0.25% before argon laser and the second group included 20 patients stained with riboflavin 0.1% before argon laser. Before laser treatment, a drop of benoxinate hydrochloride 0.4% and a single drop of fluorescein sodium 0.25% were instilled in the first group and riboflavin 0.1% in the second group. Argon laser irradiation of the affected cornea was performed using argon frequency doubled yttrium aluminum garnet laser, spot size of 500 μm, pulse duration of 0.2 s, and power of 900 mW. All cases were followed up within 4 months in four visits.
Results
A total of 17 cases healed within 4 months in the riboflavin 0.1% stained group, while only 16 cases healed within 4 months in the fluorescein sodium 0.25% stained group.
Conclusion
Argon laser treatment seems to be an effective adjuvant method for dealing with resistant corneal ulcers. The use of fluorescein sodium 0.25% stain or riboflavin 0.1% solution enhances visualization as well as uptake of laser shots. The difference in the healing rate between both the groups, although statistically significant, carries no clinical significance due to the small sample size.
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Transepithelial photorefractive keratectomy for myopic astigmatism in comparison with conventional photorefractive keratectomy
p. 1171
Amin F Ellakwa, Mohamed S Abd El-Aziz, Heba S Shetaih
DOI
:10.4103/mmj.mmj_66_20
Objectives
To compare the outcomes of transepithelial photorefractive keratectomy (Trans-PRK) with those of conventional photorefractive keratectomy (PRK) with respect to the postoperative pain, healing time, visual acuity recovery, and haze.
Background
PRK was the first of a kind of corrective eye surgery to use a laser rather than a blade to remove corneal tissue. Trans-PRK, where both the epithelium and stroma are removed in a single step, is a relatively new procedure of laser refractive error correction.
Patients and methods
A prospective comparative nonrandomized study was conducted, where patients with low to moderate myopia with or without astigmatism were assigned to the Trans-PRK group or the PRK group. In the Trans-PRK group, eyes were treated using the Amaris excimer laser. Outcome measures included postoperative pain using a pain questionnaire, epithelial healing time, uncorrected visual acuity, and corneal haze, which were compared between the study groups.
Results
The mean subjective postoperative pain score (2, indicating hurts little more) at 48 h was 2.26 in Trans-PRK group (97 eyes) and 2.38 in PRK group (97 eyes) (
P
= 0.369). The mean ± SD time to complete epithelial healing was 2.25 ± 0.6 days and 3.43 ± 0.8 days, respectively (
P
< 0.001). At 1 week, first month, and third month, the uncorrected visual acuity postoperatively was statistically significantly better in Trans-PRK; however, corrected visual acuity or manifest refraction between the groups was not significant. Haze was significantly less in Trans-PRK group (
P
= 0.007).
Conclusion
Trans-PRK may offer an effective and easier platform than conventional PRK in the treatment of mild and moderate myopia, and patients have better visual outcome, faster healing time, and less postoperative haze.
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Evaluation of the diagnostic value of visual electrophysiological examination in childhood nystagmus
p. 1178
Noha K Gaber, Azza A Shehab, Hesham M El Mazar, Hoda M El Sobky, Asmaa M Ibrahim
DOI
:10.4103/mmj.mmj_94_20
Objectives
To evaluate the use of electroretinography (ERG) and recording of visual-evoked potentials (VEP) as diagnostic tools in children with early-onset nystagmus to clarify the need to include them as a basic step in the evaluation of cases of early-onset nystagmus, especially with normal ocular examination.
Background
Nystagmus in children can be caused by many causes, starting from idiopathic motor nystagmus compatible with relatively good vision, ending with ocular abnormalities that impair vision or other neurologic abnormalities that may be life threatening. Knowledge of the exact diagnosis is essential in the rehabilitation of a visually impaired child.
Patients and methods
In 32 children with early-onset nystagmus, ERG was recorded under light sedation, and VEP were simultaneously recorded to flash stimulus in all patients.
Results
The study comprised 64 eyes of 32 patients, with their age ranging from 3 months to 7 years. Indications for referral included children with early-onset nystagmus. Children with obvious cause for nystagmus were excluded from the study. Overall, 37.5% of children had been diagnosed as having retinal dysfunction, including cone dystrophy (6.3%) and cone/rod dystrophy (31.2%). Neurological nystagmus was recognized in 34.3% of children. Ocular albinism was diagnosed in 6.3% of cases. One (3.1%) case was diagnosed as optic nerve hypoplasia. Six (18.8%) cases were diagnosed as idiopathic nystagmus.
Conclusion
This study clarified the need to investigate children with nystagmus by ERG and suggested that the ERG was useful where the diagnosis was uncertain, particularly at an early age with no obvious cause on ocular examination. VEP are complementary to ERG and can be tested simultaneously. Visual electrophysiological examination of children with early-onset nystagmus can establish or exclude retinal and postretinal pathway dysfunction, thus assisting in its classification and subsequent rehabilitation.
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Eccentric viewing training for low-vision rehabilitation in patients with central scotoma
p. 1186
Adel G Zaky, Boshra El Bayoumi, Esraa S Elghoubashy, Abdelrahman E Sarhan, Marwa A Zaky
DOI
:10.4103/mmj.mmj_116_20
Objective
The aim was to evaluate the value of subjective eccentric viewing (EV) training in vision rehabilitation in patients with central scotoma.
Background
EV, also known as eccentric fixation, involves identifying a functioning area of the retina that has reasonable sensitivity, and is as close to the fovea as possible, and to learn to use it effectively, which is known as preferred retinal locus.
Materials and Methods
The direction of EV was monitored in 33 low-vision patients with bilateral central scotomas, the preferred retinal locus was identified, and the preserved visual field was found. The patients were divided randomly into two groups regarding their use of optical low-vision devices with EV training. After 2 months of training, changes in near and far best-corrected visual acuity (BCVA) and reading speed were evaluated.
Results
After 2 months of EV training, near BCVA and mean reading speed significantly improved. Regarding the use of low-vision devices, the group that used low-vision devices with EV training showed significant improvement in the near and far BCVA than the group that did not use low-vision device.
Conclusion
EV training can be used as a very effective method for low-vision rehabilitation in patients presented with central scotomas, and it can give very good results using simple and inexpensive equipment.
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High-order aberration changes after corneal collagen cross-linking for keratoconus
p. 1195
Hany A Khairy, Ahmed I Basiony, Mahmoud A. E. R. M. Ibrahim
DOI
:10.4103/mmj.mmj_118_20
Objective
The aim was to determine the changes in the ocular high-order aberrations (HOAs) after corneal cross-linking (CXL) in patients with keratoconus and its correlation with the changes in visual acuity (VA).
Background
HOAs are among the important refractive and visual quality properties of the human ocular system, and the decreased levels of some visual features such as contrast sensitivity have been partially attributed to these parameters. Evaluation of long-term changes of HOAs after CXL is useful in understanding the efficacy of CXL on improving optical, refractive, and VA.
Patients and methods
All patients were subjected to preoperative and postoperative assessment for best-corrected VA, anterior segment examination (cornea, iris, and lens), posterior segment examination (vitreous and retina), corneal topography, and HOA using Oculus Pentacam II.
Results
Regarding coma and trefoil aberrations, there was a statistically insignificant difference preoperatively and postoperatively in both eyes, as
P
value was more than 0.05. The total HOAs were statistically significant preoperatively and postoperatively, as
P
value was less than 0.05.
Conclusion
Total HOAs and keratometric readings significantly decreased after CXL. Ocular aberrations play a key role in influencing retinal image quality. Correcting HOAs in patients with keratoconus is likely to improve the quality of vision significantly.
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Evaluation of corneal haze after transepithelial photorefractive keratectomy
p. 1201
Amin F Ellakwa, Nermeen M Badawy, Islam F. F. Mohamad
DOI
:10.4103/mmj.mmj_121_20
Background
Transepithelial photorefractive keratectomy (t-PRK) has been associated with diminished wound healing response, hence less refractive regression and haze, compared with other techniques of epithelial removal in PRK.
Objectives
To evaluate the corneal haze after t-PRK.
Patients and methods
This prospective highly selectional observational study involved 100 eyes of patients with simple myopia and mixed myopia with astigmatism who underwent t-PRK to correct their vision. Both males and females were included who were age and sex matched.
Results
The results showed improvement of visual haze along the follow-up period. Comparison of visual haze between follow-up period 1 week after t-PRK and the end of the follow-up period (6 months) revealed the following: after 1 week, mean ± SD visual haze was 1.22 ± 1.19, which decreased to 0.8 ± 1.05 after 1 month, decreased to 0.325 ± 0.605 after 3 months, and then decreased to 0.12 ± 0.356 after 6 months. The results showed a statistically highly significant difference (
P
< 0.001). Preoperative visual acuity, refractive error, ablation depth, and residual stromal tissue showed a significant correlation with corneal haze postoperatively.
Conclusion
Preoperative visual acuity, refractive error, ablation depth, and residual stroma can induce corneal haze postoperatively, but most of the corneal hazes disappear with time. However, some need surgical interference.
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Bilateral lateral rectus recession versus three-muscle surgery in management of exotropia
p. 1207
Hany A Khairy, Ghada Z Rajab, Tarek M. O. Abd El Hares
DOI
:10.4103/mmj.mmj_215_20
Objectives
To compare the efficacy of bilateral lateral rectus recession (BLR) surgery versus BLR plus one medial rectus resection surgery in the management of exotropia (XT).
Background
The exact nature of this surgery remains debatable, with some surgeons preferring the BLR procedure and others the unilateral recession resection procedure.
Patients and methods
A total of 40 patients with XT were classified into two equal groups according to the type of surgical technique used: group 1 included 20 patients who underwent BLR surgery, and group 2 included 20 patients who underwent BLR plus one medial rectus resection surgery in the management of XT.
Results
The outcome of surgery after the end of the follow-up period (6 months) was recorded as follows: 14 (70%) patients and 11 (55%) patients were corrected in groups 1 and 2, respectively; one (5%) patient and eight (40%) patients were overcorrected in groups 1 and 2, respectively; and five (25%) patients and one (5%) patient were undercorrected in groups 1 and 2, respectively. There was a statistically highly significant difference between groups 1 and 2 (
P
< 0.001). The overall success of strabismus surgery was 70% in group 1, being lower than group 2 (80%).
Conclusion
The study indicates that both two-muscle and three-muscle surgeries effectively treat different degrees of XT, with a low rate of induced lateral incomitance; however, the three-muscle techniques showed more successful treatment than the two-muscle techniques.
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The effect of changes in intraocular pressure on choroidal thickness by optical coherence tomography
p. 1213
Mostafa K Nassar, Asmaa M Ibrahim, Shymaa F Saad
DOI
:10.4103/mmj.mmj_161_20
Objective
The aim was to compare the choroid thickness (CT) in eyes with newly discovered glaucoma with the eyes of healthy controls.
Background
Glaucoma is characterized by progressive damage to retinal ganglion cells, leading to optic nerve head morphological changes, thinning of the retinal nerve fiber layer (RNFL), and loss of visual field.
Materials and methods
A total of 100 patients (100 eyes) with newly discovered glaucoma and 50 age-matched normal participants underwent macular CT scanning using enhanced-depth imaging-optical coherence tomography (EDI-OCT). The average subfoveal choroid thickness (SFCT) of the glaucoma eyes was compared with that of normal eyes.
Results
The CT, RNFL, and intraocular pressure (IOP) were found to have significant changes between glaucomatous and normal eyes. The mean CT under the fovea (SFCT) was 277.3 ± 37.78 μm in the glaucomatous eyes, which was found to be thicker than in normal eyes (259.8 ± 24.92 μm) (
P
< 0.05). Mean RNFL was thinner in glaucomatous eyes (91.39 ± 12.47) than in normal eyes (110.9 ± 7.40) (
P
< 0.05). Mean IOP was 26.16 ± 3.0 in glaucomatous eyes and 19.50 ± 2.59 in normal eyes. The correlation between IOP and both RNFL and CT was not significant, with
P
= 0.825 and 0.230, respectively.
Conclusion
The CT is higher in patients with glaucoma than in normal group based on EDI-OCT measurements.
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Evaluation of corneal endothelial changes after posterior capsule rupture during phacoemulsification using specular microscope
p. 1218
Hoda El Sobky, Marwa Zaky, Hebatallh M. T. Nada
DOI
:10.4103/mmj.mmj_168_20
Background
Phacoemulsification cataract surgery is now the technique of choice for routine cataract extraction. However, posterior capsule rupture (PCR) during phacoemulsification cataract surgery remains an important complication because it may lead to poor visual outcome.
Objective
The aim of this study was to evaluate the effect of PCR during cataract extraction by phacoemulsification on the corneal endothelium using a specular microscope.
Patients and methods
A total of 50 patients with age range between 45 and 65 years were enrolled in this study during a period of 1 year. Anterior chamber depth measurement was done
.
Preoperatively, anterior chamber depth (mm) was recorded using intraocular lens master. Central corneal thickness (CCT) and the endothelial cell counts were measured using a noncontact specular microscope preoperatively and postoperatively.
Results
We compared the preoperative details and contrasted the 1- and 3-month postoperative outcomes, including best -corrected visual acuity, endothelial cell loss, CCT, coefficient of variation, and hexagonality. We found that the majority of our patients (92%) experienced improved best-corrected visual acuity at 3 months after phacoemulsification. Our patients had an increased CCT 1 month postoperatively, with a significant rise from baseline. When polymegathism was evaluated, we observed that coefficient of variation increased significantly from baseline, and declined slightly by 3 months postoperatively. Regarding cell count density, we observed a significant decrease of cell density following the operation after 1 month and a much more decrease after 3 months.
Conclusion
We concluded that PCR during phacoemulsification resulted in significant corneal endothelial damage; however, it provided better visual acuity. For better outcomes, early recognition of PCR is advised, besides immediate proper management to minimize the endothelial damage.
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Optical coherence tomography in dry eye after laser
in-situ
keratomileusis with omega-3 supplementation
p. 1226
Mostafa K Nassar, Marwa A Zaky, Amany M. E. Mohamed
DOI
:10.4103/mmj.mmj_185_20
Background
Dry eye is the most common complication after laser in-situ keratomileusis (LASIK). Anterior segment optical coherence tomography (AS-OCT) is a noninvasive and quick clinical tool for the evaluation of a tear film. Oral omega-3 supplementation has been shown to improve nerve regeneration after injury to the cornea.
Aim
The aim of this work was to evaluate tear menisci parameters by AS-OCT in diagnosis of dry eye after LASIK procedure and evaluation of the role of oral omega-3 supplementation in the management of dry eye after LASIK.
Patients and methods
A prospective randomized study was performed on 50 participants who underwent LASIK procedure. These participants were further divided in two groups: the first group included 25 cases supplemented with omega-3 fatty acids, and the second group included 25 cases without omega-3 supplementation. The mean age of the studied patients with omega-3 administration was 33.2 ± 10.49 years, with a range from 19 to 45 years. Cases with any inflammatory pathology of the lid were excluded from the study.
Results
Upper tear meniscus height, upper tear meniscus depth, and upper tear meniscus area were statistically lower than lower tear meniscus height, lower tear meniscus depth, and lower tear meniscus area preoperatively and 1 day, 1 week, and 1 month postoperatively among the studied patients. Upper and lower tear menisci parameters were statistically higher inomega-3-treated group than control group preoperatively and at 1 day, 1 week, and 1 month postoperatively.
Conclusion
AS-OCT is considered a noninvasive approach to produce a tear meniscus image and a potential tool to diagnose dry eye after LASIK.
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Macular thickness changes after neodymium: yttrium–aluminum–garnet laser capsulotomy in diabetic patients
p. 1231
Faried M Wagdy, Samar M Abdel Elsadek, Adel G Zaky
DOI
:10.4103/mmj.mmj_192_20
Objective
The aim was to evaluate the changes in macular thickness (MT) post-neodymium: yttrium–aluminum–garnet (ND: YAG) laser capsulotomy in diabetic patients.
Background
ND:YAG laser capsulotomy has been found to be safe, effective, and easily applied in a short time at an outpatient clinic. However, events such as cystoid macular edema, retinal detachment, and rise in intraocular pressure tend to occur after ND: YAG laser capsulotomy.
Patients and methods
This prospective case series study included 100 eyes of 100 diabetic patients diagnosed as posterior capsule opacification (PCO), following uncomplicated cataract surgery. All patients were examined beforehand ND: YAG laser capsulotomy and on the first, third, and sixth month post-ND: YAG laser capsulotomy for intraocular pressure, MT, and best-corrected visual acuity. Patients were divided into two groups according to the presence or absence of diabetic retinopathy and maculopathy: group A included diabetic patients with no diabetic retinopathy and maculopathy and group B included diabetic patients with diabetic retinopathy and maculopathy.
Results
Group A involving diabetic patients with no diabetic retinopathy and maculopathy suffering from PCO had increased MT at the first, third, and sixth month after laser capsulotomy (
P
< 0.001). Group B involving diabetic patients with diabetic retinopathy and maculopathy suffering from PCO had increased MT at the first, third, and sixth month after laser capsulotomy (
P
< 0.001). The two groups showed a statistically significant increase in MT. There was statistically significant increase in MT during the follow-up period in both groups (
P
< 0.001).
Conclusion
An increase in MT can be detected after ND: YAG laser capsulotomy in diabetic patients especially diabetic patients with diabetic retinopathy and maculopathy.
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A comparative randomized study to evaluate the effect of azithromycin 1.5% eyedrops versus moxifloxacin 0.5% eyedrops on bacterial conjunctivitis
p. 1237
Hesham M. F El Maraz, Sameh S Mandour, Soha S. F Abd-El Maksoud
DOI
:10.4103/mmj.mmj_202_20
Objective
To evaluate the effect of azithromycin 1.5% eyedrops versus moxifloxacin 0.5% eyedrops on bacterial conjunctivitis.
Background
Purulent bacterial conjunctivitis affects all ages, with high frequency in newborns and children. This study evaluates the effect of azithromycin 1.5% eyedrops with moxifloxacin 0.5% eyedrops in treatment of bacterial conjunctivitis.
Patients and methods
A prospective comparative randomized controlled clinical trial was conducted that included 100 participants with purulent bacterial conjunctivitis at Menoufia outpatient clinic. Patients received either azithromycin 1.5% eyedrops twice daily for 7 days or moxifloxacin 0.5% eyedrops three times per day for 7 days. The primary variable was clinical cure at days 3 and 7 on the worst eye. The cure was defined as absence of purulent discharge and bulbar conjunctivitis.
Results
Overall, 88% of patients in the azithromycin group and 90% in the moxifloxacin group were clinically cured at D7. Clinical cure with azithromycin was not inferior to moxifloxacin at day 7, and discharge was absent in 92% of patients treated with azithromycin and 94% with moxifloxacin. Azithromycin and moxifloxacin were well tolerated.
Conclusion
Azithromycin 1.5% for 7 days was as effective as moxifloxacin for 7 days. Furthermore, patients on azithromycin presented clinical cure on day 3 as patients on moxifloxacin.
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Retinopathy of prematurity in preterm children
p. 1246
Hany A Khairy, Marwa A Zaky, Samah A Ibrahem Tolan
DOI
:10.4103/mmj.mmj_207_20
Objectives
The aim of this work was to screen the incidence of retinopathy of prematurity (ROP) in preterm children.
Background
Screening of ROP in preterm infants is important to detect early stages and observation till complete retinal vascularization. Cases with late stages need early treatment to prevent retinal detachment and blindness.
Patients and methods
This study was conducted on 30 extremely preterm infants born at less than 32 weeks of gestational age and admitted to neonatal incubators unit from March 2019 to December 2019 at Menoufia University Hospital and Al Quds Hospital in Al Mahla Al Qubra, Egypt.
Results
A total of 30 were included in the study. Males constituted 14 of the candidates, with ROP present in eight (44.4%), and females represented 16 candidates, with ROP present in 10 (55.6%). The mean hemoglobin levels during the first week of life were significantly lower in infants who developed ROP that warranted treatment.
Conclusion
ROP screening is essential to decrease blindness and long-term visual morbidity in preterm infants. The guidelines of management should be updated for practicing ophthalmologists.
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Systemic anticoagulant in management of central retinal vein occlusion
p. 1252
Hesham M Elmazar, Asmaa M Ibrahim, Mohamed A Abd EL-Hafez, Aya E El-Absawy
DOI
:10.4103/mmj.mmj_253_20
Background
Central retinal vein occlusion (CRVO) is one of the commonest retinal vascular diseases.
Objective
The aim was to compare between intravitreal injection of antivascular endothelial growth factors and combined intravitreal injection of antivasular endothelial growth factors with systemic anticoagulant drugs in treatment of CRVO.
Patients and methods
This study included 30 patients with CRVO who were divided into two groups. The first group was treated by intravitreal injection? of anti-Vascular endothelial growth factor (VEGF) (Ranibizumab) using three injections, 1 month apart. The second group was treated the same protocol of injection of the first group and systemic anticoagulant drugs, low-molecular-weight heparin. Optical coherence tomography was used to evaluate central macular thickness (CMT) at baseline and after treatment. Best-corrected visual acuity (BCVA) was documented before and after treatment.
Results
This study included 30 patients with CRVO. The first group treated by anti-VEGF (Ranibizumab) injection only improved in CMT from 702.9 ± 191.6 mm to 448.9 ± 178.0 mm (
P
= 0.001). BCVA also improved from 0.05 ± 0.01 to 0.11 ± 0.06 (
P
= 0.006). The second group treated by anti-VEGF (Ranibizumab) injection and systemic anticoagulant also improved in CMT from 814.4 ± 200.9 mm to 397.5 ± 166 mm (
P
= 0.001) and improved in BCVA from 0.06 ± 0.04 (range: 0.05–1.0) to 0.01 ± 0.11 (
P
= 0.002).
Conclusion
Systemic anticoagulant appears to be useful in the management of retinal vein occlusion regarding improvement in CMT and BCVA, but there is no difference regarding improvement between it and intravitreal injection of anti-VEGF (Ranibizumab).
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OBSTETRICS & GYNECOLOGY - ORIGINAL ARTICLES
Role of CA-125 and ultrasound in early prediction of outcome of threatened miscarriage
p. 1258
Mohamed E Anter, Ayman A Shabana, Hamed E Ellakwa, Haitham A Hamza, Marwa M Omar
DOI
:10.4103/mmj.mmj_23_20
Objective
The aim was to study the role of serum cancer antigen 125 (CA-125) and ultrasound in early prediction of outcome of threatened miscarriage.
Background
Threatened abortion is a clinically descriptive term applied to women who are less than 24 weeks of gestation having vaginal spotting or bleeding, closed cervical, and possibly mild uterine cramps.
Patients and methods
A prospective case–control study was conducted on 80 pregnant women at 6–12 weeks attending the Department of Obstetrics and Gynecology of El-Menoufia University Hospital Mit-Ghamer General Hospital during the period from January 2017 to February 2018. A total of 40 women had symptoms of threatened miscarriage and 40 had apparently healthy pregnancy as controls. Serum CA-125 was assayed by Cobas410 full auto motion method, and they were followed up till 20 weeks of gestational age.
Results
A total of 80 pregnant women were recruited in the study and were divided into two groups: group I (40 with threatened miscarriage) and group II (40 controls). Serum CA-125 was significant higher in group I, and it was significantly higher in women who developed miscarriage than those who continued their pregnancy till 20 weeks. Using receiver operating characteristic curve analysis, optimal cutoff criteria of CA-125 of greater than 30.3 IU/ml for prediction of occurrence of miscarriage in patients with threatened miscarriage would be established with sensitivity of 100% and specificity 98.6%.
Conclusion
Maternal serum CA-125, as well as ultrasound seems to be a promising biomarker for the early prediction of pregnancy outcome in threatened miscarriage.
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Predicting factors of success in induction of labor after 37 weeks
p. 1264
Ibrahim A Seif-Elnasr, Thoraya A Omar, Ahmed N Abd-Elhamid, Dalia S Mohamed
DOI
:10.4103/mmj.mmj_41_20
Objectives
To compare transvaginal measurement of cervical length and insulin-like growth factor-binding protein-1 (IGFBP-1) in the prediction of successful induction of labor.
Background
The successful induction of labor aims to achieve vaginal delivery when the continuation of pregnancy presents a threat to the life or well-being of the mother and fetus. The process of induction should only be considered when vaginal delivery is felt to be the appropriate route of delivery.
Patients and methods
A total of 140 women, 37–42 weeks in pregnancy, underwent induction of labor. Before induction, detection of IGFBP-1 in cervical secretions by the Actim partus test was done, then a digital examination of the cervix was performed, and the Bishop score was noted. Cervical length was measured by transvaginal ultrasound.
Results
The mean cervical length in patients delivered vaginally was 24.89 ± 5.48 mm whereas the mean cervical length in patients delivered by cesarean section was 26.79 ± 3.06 mm. IGFBP-1 is positive by Actim partus test in 94% in patients delivered vaginally, whereas IGFBP-1 is positive by Actim partus test in 39.5% in patients delivered by cesarean section.
Conclusion
There was a statistically significant positive correlation between detection of IGFBP-1 in cervical secretions and successful induction of labor.
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Effect of tranexamic acid in reducing blood loss during and after cesarean delivery
p. 1270
Zakaria F Sanad, Hamed E Ellakwa, Alaa M Gomaa, Haitham A Hamza, Haitham H Elsalamony
DOI
:10.4103/mmj.mmj_129_20
Objective
The aim was to evaluate the effect of tranexamic acid (TA) in reducing blood loss during and after elective cesarean delivery (CS).
Background
Postpartum hemorrhage is an obstetrical emergency that can follow delivery. It is a major cause of maternal sickness and maternal death.
Patients and methods
In all, 74 full-term pregnant primigravida with singleton pregnancy aged between 20 and 35 years, scheduled for elective CS were enrolled at a prospective study. The patients were divided into two groups. Group I: patients received a bolus injection of 1 g of intravenous TA diluted in 20 ml of 5% dextrose solution slowly over 5 min at 10 min before skin incision. Oxytocin 10 units in 500 ml normal saline (9% saline) intravenous drip (8 ml/min) were administrated after fetal delivery. Group II: no TA was given; oxytocin was administered as in group I. Preoperatively, complete blood picture and coagulation profile were done.
Result
Hemoglobin and hematocrit levels decreased significantly in group II than in group I (
P
= 0.007; 0.005) consecutively. On comparing the two studied groups, there was a significant decrease in the amount of blood loss in group I than in group II (
P
= 0.001). More cases in group II than in the TA group required further ecbolic treatment during the postoperative period (
P
= 0.018).
Conclusion
A safe dose of TA plays an effective role in reducing blood loss during lower segment CS without causing complications
.
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Study of placental laterality with uterine artery Doppler in the prediction of preeclampsia
p. 1276
Nasser K Abd El-Aal, Osama A El Kelany, Hesham S Mahmoud, Heba F Salama, Ahmed E Nasser
DOI
:10.4103/mmj.mmj_133_20
Objective
To demonst rate if placental laterality combined with uterine artery Doppler can be used as a predictor for the development of preeclampsia.
Background
The uteroplacental blood flow may be deficient in cases with lateral placenta, and this may facilitate development of preeclampsia. Placenta is considered lateral when 75% or more of the placental mass is located at one side of the midline of uterine cavity. Uterine artery Doppler was done to all cases to find out high resistance index and abnormal protodiastolic notch in Doppler waveform.
Patients and methods
Ultrasonography was done for all participants at 18–22 weeks of pregnancy to determine the placenta location. Uterine artery Doppler was done for all cases at 18–24 weeks of gestation to find out the presence of protodiastolic notch and high resistance index.
Results
Of 73 cases with lateral placenta and high uterine artery resistance index, 56 (76.7%) cases developed preeclampsia (
P
= 0.026). Moreover, among 77 cases with lateral and presented protodiastolic notch, 57 (74%) cases developed preeclampsia (
P
= 0.050).
Conclusion
The risk of developing preeclampsia is significantly increased when lateral placentas are associated with uterine artery Doppler abnormality.
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Oral versus topical antifungal treatment for recurrent vulvovaginal candidiasis
p. 1281
Mohamed kandil, Tarek M Sayyed, Lamiaa A. A. Omran, Abd Elhamid E. Shaheen
DOI
:10.4103/mmj.mmj_141_20
Objective
To evaluate the effect of using oral versus topical antimycotic preparations in treatment of recurrent vulvovaginal candidiasis.
Background
Vaginal candidiasis is a common disease in women during their lifetime. Although several antifungal drugs are routinely used for treatment, recurrent vaginal candidiasis is a challenge for patients and gynecologists.
Patients and methods
This was a randomized control trial that included 88 cases complaining of recurrent vaginal candidiasis, with occurrence ranging from 4 to 8 episodes/year, with confirmed clinical and mycological diagnosis of vaginal candidiasis. Patients were divided into two groups by randomized number sequence: group A received oral fluconazole and group B received local clotrimazole vaginal tablets. This trial was conducted at the Department of Obstetrics and Gynecology, Zawyet Aal-Naoora Hospital, in Menoufia from March 2017 to June 2018.
Results
This study revealed a total clinical cure rate of 81% for fluconazole group and 76.1% for clotrimazole group. Total mycological cure rate was 80.5% for group A and 77.3% for group B. There was no statistically significant difference regarding clinical or mycological cure rates in all visits between the two groups. The most frequent adverse effect in group A was nausea and for group B was vaginal burning sensation.
Conclusion
Response to treatment of recurrent vulvovaginal candidiasis was similar among fluconazole and long-term use of clotrimazole vaginal tablets.
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Angle of progression in women undergoing trial of labor after cesarean section in predicting mode of delivery
p. 1286
Nehad M Hossny, Ayman A Shabana, Saly S Abd-Elbaset, Amira A Fathey
DOI
:10.4103/mmj.mmj_203_20
Objective
To assess the ability of ultrasonic measurement of angle of progression (AOP) in predicting mode of delivery in women undergoing vaginal birth after cesarean section (CS).
Background
The intrapartum ultrasound measurement of AOP is reliable regardless of the fetal head station assessed manually or the clinician's level of ultrasound experience.
Patients and methods
A prospective observational study was conducted from March 2019 to January 2020 at Menoufia University Hospital, including 100 patients with a history of previous one CS in spontaneous labor. Patients were followed up, and AOP was measured in them using transperineal ultrasound. Patients were divided into two groups according to mode of delivery as follows: group 1, delivered by CS, and group 2, delivered by normal vaginal delivery (NVD).
Results
The mean AOP was decreased in CS group (98.20 ± 15.83) than NVD group (112.21 ± 12.66). Additionally, at cutoff point of AOP less than 95 (86°), area under curve was 0.511 (95% confidence interval: 0.264–0.758;
P
= 0.024), with sensitivity of 71.4%, specificity of 85.5%, and accuracy 81.5%. However, at cutoff point of AOP more than 95 (113°), area under curve was 0.545 (95% confidence interval: 0.412–0.679;
P
= 0.016), with sensitivity of 85.7%, specificity of 69.4%, and accuracy 93.25%.
Conclusions
The AOP was significantly decreased in CS group than NVD group. The results prove a vital role for using this angle as a simple and accurate landmark to evaluate station of fetal head and provide a useful predictor for mode of delivery, particularly in patients with planned vaginal birth after cesarean delivery (VBAC).
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Hypothyroidism among menorrhagic women attending Munshaat Sultan Family Health Center, Menoufia University, Egypt
p. 1293
Taghreed M Farahat, Hala M Shaheen, Fatma A El Esrigy, Marwa M Mohasseb, Mohammed A Emara
DOI
:10.4103/mmj.mmj_654_17
Objective
The aim of this study was to assess the frequency of hypothyroidism among menorrhagic women attending Munshaat Sultan Family Health Center.
Background
Menorrhagia is a very common complaint among women. The prevalence of menorrhagia is estimated at 11–13% in women in the childbearing period and increases with age. Hypothyroidism is considered a correctable cause of menorrhagia. All women with unexplained menorrhagia should be tested for thyrotrophin-releasing hormone.
Patients and methods
A cross-sectional study was conducted on 250 menorrhagic women, who were recruited from Munshaat Sultan Family Health Center, Menoufia District, Menoufia Governorate, Egypt, during the period from the first of January to the end of December 2016. The studied participants were evaluated through comprehensive medical history, clinical examination, laboratory investigation (serum free thyroxine and thyroid-stimulating hormone), and radiological (local vaginal and thyroid ultrasound) investigations.
Results
The study revealed that the frequency of hypothyroidism among the studied menorrhagic women was ~17%, subclinical hypothyroidism represented ~83%, and overt hypothyroidism represented ~17%. There was statistically significant difference between menorrhagic women experiencing hypothyroidism and those who did not regarding duration of menorrhagia in days, number of sanitary pads used daily, gush of blood during menses, staining of clothes, need for double protection, impairment of daily activities, presence of blood clots, and the amount of blood loss during menses (
P
< 0.001).
Conclusion
Hypothyroidism is a frequent abnormality in menorrhagic women that needs to be highlighted as a correctable cause of menorrhagia.
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Intradermal sterile water injection versus intramuscular pethidine injection for pain relief in first stage of labor
p. 1298
Ahmed N Abd Elhamid, Tarek M Sayyed, Haitham A Aboali, Dina A. A Abd Alsalam
DOI
:10.4103/mmj.mmj_211_20
Objectives
To compare the effectiveness and safety of intradermal sterile water injection versus pethidine to decrease labor pain.
Background
In this study, we tried to clarify the possible role of sterile water injection as alternative to pethidine for relieving labor pain.
Patients and methods
A randomized controlled clinical trial was carried out on 78 parturient women in active phase of first stage of labor. Patients were randomly assigned to either one of two groups: group A (intradermal sterile water injection group) received four intradermal injections of 0.5-ml sterile water in the lumbosacral region, and group B (pethidine group) received 1 mg/kg intramuscular pethidine. The primary outcome of this study included the effect of two techniques in reliving labor pain according to visual analog scale. The secondary outcome included labor duration and delivery mode.
Results
Intradermal sterile water injection had significantly higher pain scores immediately before injection (
P
= 0.04), significantly lower pain scores at 60 min after injection (
P
= 0.009), and nonsignificantly lower pain scores at 30 min (
P
= 0.07) and 90 min (
P
= 0.12) after injection. Sterile water injection had significantly lower maternal vomiting (
P
< 0.001) and drowsiness (
P
< 0.001). There was a nonsignificant difference in neonatal Apgar score after 1 min (
P
= 0.07) and significantly higher Apgar score after 5 min in group A (
P
= 0.001). There was significant shortness of duration of labor in pethidine group (
P
= 0.042). There was no significant difference regarding mode of delivery (
P
= 0.455).
Conclusion
Sterile water injection is considered to be effective, safe, inexpensive, and acceptable method for decreasing labor pain.
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GENERAL SURGERY - ORIGINAL ARTICLES
Correlation of inferior vena cava diameter and collapsibility index with central venous pressure in shocked patients
p. 1304
Moharam A. E. S. Mohammed, Mahmoud G. E. D. Hagag, Waleed A. E. F. Mousa, Mahmoud T. A. H. Toulan
DOI
:10.4103/mmj.mmj_65_20
Objective
The aim was to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in shocked patients in the emergency room.
Background
Assessment of intravascular volume is important in shocked patients. It can be measured through many techniques, among those include CVP, collapsibility index, and diameter of IVC.
Patients and methods
This was a prospective and cross-sectional study and included 100 patients treated at the Emergency Department of Menoufia University Hospital. They were selected according to certain inclusion and exclusion criteria with already inserted central venous catheter and were measured for CVP, and concomitantly the IVC diameter was measured with ultrasound using M-mode to measure the expiratory and inspiratory diameter and collapsibility index of the IVC, and then the patients were divided into three groups according to the CVP, with CVP less than 10, CVP 10–15 and CVP more than 15.
Results
Among the 100 patients enrolled, the median age was 56.01 ± 20.92 years. The correlation of the CVP measurement with the ultrasound IVC caval index was
r
= −0.911 (
P
< 0.001), with the expiratory IVC diameter was
r
= 0.703 (
P
< 0.001), and with the inspiratory IVC diameter was
r
= 0.875 (
P
< 0.001). The sensitivity and specificity of the caval index showed that the cutoff points were 50, 40, and 20 at CVP levels 10, 10–15, and 15 cm H
2
O, respectively.
Conclusion
This study found that in shocked patients there is a good correlation between CVP and collapsibility index, as well as with inspiratory and expiratory diameter of IVC.
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Early outcome of darn repair versus Lichtenstein mesh hernioplasty for open primary uncomplicated inguinal hernia
p. 1309
Mohamed L Ahmed, Mohamed A. E. El-Balshy, Ahmed M. E. S. A. Badawy
DOI
:10.4103/mmj.mmj_101_20
Objective
To evaluate the early outcome of mesh hernioplasty versus darn repair for the treatment of primary uncomplicated inguinal hernia.
Background
The definitive treatment of inguinal hernia is surgery. The gold standard for open inguinal hernia repair is Lichtenstein tension-free mesh repair, but after a long period of using this technique, complications were noted such as chronic postoperative pain, cost-effectiveness, and infection. So, the present study evaluated the darn repair compared with Lichtenstein repair for inguinal hernia treatment.
Patients and methods
Between October 2018 and December 2019, this prospective case-controlled study was done on 60 patients presenting with uncomplicated inguinal hernia. The 60 patients were randomly divided into two groups. Group A consisted of 30 patients who underwent darning repair, and group B conducted of 30 patients who underwent Lichtenstein repair.
Results
The operative time in group A (64.5 ± 6.4 min) was significantly longer than in group B (47.9 ± 6.05 min) (
P
< 0.001). Recurrence occurred in two cases in group A compared with one case only in group B. Chronic pain was evaluated by visual analog scale. It was highly significant in group B compared with group A (
P
< 0.001). There were insignificant differences between the two groups regarding the other postoperative complications.
Conclusion
The darning technique could be an effective and safe procedure for the treatment of primary inguinal hernia.
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Complications of the peroneal artery perforator propeller flap in soft tissue coverage of leg defects
p. 1315
Tarek F. A. Keshk, Ahmed A Taalab, Mahmoud A Abdelaty
DOI
:10.4103/mmj.mmj_114_20
Objectives
To highlight the complications of peroneal artery perforator propeller flaps in coverage of leg defects and how to avoid and manage.
Background
Complex soft tissue defects of the leg represent a difficult reconstructive problem. The lateral aspect of the leg, which is perfused by a number of perforators from the peroneal artery, is one of the most suitable areas for harvesting perforator flaps.
Patients and methods
This descriptive study included 31 patients presented by soft tissue loss of leg from January 2018 to January 2020. All patients were examined for the site, the size, and the extent of the defect. Floor of the defect was examined for exposed bone, fractures, or exposed tendons. The flaps were evaluated regarding achieving the preoperative goal for coverage of the soft tissue defects, limb function, and patient satisfaction.
Results
Of 31 cases, 18 healed uneventfully, and 13 cases were complicated. Five patients had partial loss of the distal end of the flap. There was a complete flap loss in two patients. Three cases had wound infection with partial dehiscence. Two cases had partial loss of the skin graft on the donor site. One case had hematoma collection under the skin graft.
Conclusion
Peroneal artery perforator propeller flaps provide durable coverage for complex leg defects. Complications are avoidable and easy to manage.
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Different treatment modalities in traumatic splenic injuries
p. 1322
Ahmed S El Gammal, Ahmed M Abo Ghida, Ahmed M Nabil
DOI
:10.4103/mmj.mmj_126_20
Objective
To evaluate surgical and nonoperative splenic conservation modalities in traumatic splenic injuries.
Background
Splenic injury is common, affecting up to 32% of patients with blunt abdominal trauma. Nonoperative management (NOM) of hemodynamically stable patients with blunt splenic injury has become the standard of care in pediatric and adult populations. Successful outcome following NOM is reported as up to 97% of patients regardless of the grade of splenic injury.
Patients and methods
This was a prospective study including 150 patients) 88 patients and the other one contained 62 patients (at Menoufia University Hospital, General Surgery Department, and Itay El Baroud General Hospital, General Surgery Department, during December 2018 to October 2019. Patients were divided into two groups: group I included patients who were hemodynamically stable, without signs of peritonitis, and group II included patients who were hemodynamically unstable and were managed operatively according to grade of injury by splenectomy, partial splenectomy, and selenography of a tear. Full history taking, clinical examination, complete blood count, and ultrasound sonographic examination were done.
Results
In the current study, the first group consists of 88 patients and only 22 needed blood transfusion, but in the second group, all patients needed blood transfusion. Moreover, in the first group, the minimum hospital stay was 5 days, the maximum was 9 days, and the mean were 6.40 ± 1.35, whereas in the second group, the minimum of hospital stay was 5 days, and the maximum was 7 days, with mean of 6.0 ± 0.79.
Conclusion
NOM for blunt splenic trauma in hemodynamically stable patients is safe, effective, and associated with low morbidity and no mortality. However, NOM should be practiced in hospitals where an efficient ICU is available.
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Imbrication versus no reinforcement during laparoscopic sleeve gastrectomy
p. 1328
Hatem M Sultan, Abd-Elgalil M El-Balshy, Osama M. M. Moustafa
DOI
:10.4103/mmj.mmj_152_20
Background
Laparoscopic sleeve gastrectomy (LSG) is a common procedure in recent years for treatment of morbid obesity. However, leak and bleeding are its main challenging complications. Despite numerous studies regarding such complications, there is still no conclusion on reinforcement of staple line in this procedure. The purpose of our study was to compare staple line imbrication versus no reinforcement.
Objectives
To determine the effects of reinforcement of staple line by imbrication using continuous seromuscular invagination using absorbable suture on bleeding, leakage, length of hospital stay, readmission, reoperation rates, and stricture rates.
Patients and methods
In our pilot study, 60 patients experiencing morbid obesity with BMI above 35 kg/m
2
were prepared for LSG. The patients were enrolled randomly into two equal groups comparing the effect of staple line reinforcement by imbrication whole staple line by seromuscular invagination using absorbable suture (group A) versus no reinforcement (group B). The study was conducted in Menoufia University in the period between October 2017 and June 2019.
Results
Hemorrhage and leak did not occur in group A but occurred in two (6.7%) patients and one (3.3%) patient, respectively, in group B, but stricture occurred in two (6.7%) patients in group A and no patients in group B.
Conclusion
This pilot study has shown that reinforcement by staple line imbrication as a step in LSG is safe, technically easy, of low cost, and can reduce the incidence of postoperative complications, as bleeding and leakage, although it significantly prolongs the operative time and may lead to increase in the rate of stricture.
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Role of interleukin-6, interleukin-8, and β-2 microglobulin in assessment of severity of pancreatitis
p. 1335
Ahmed S El-Gamal, Nahla F Osman, Yahia M AlKhateap, Ahmed M Maarek
DOI
:10.4103/mmj.mmj_166_20
Objective
The aim was to evaluate the role of interleukin-6 (IL-6), IL-8, and β-2 microglobulin (B2M) in assessment of severity of pancreatitis.
Background
Acute pancreatitis is a potentially lethal disease, especially in its severe form, which accounts for ~20% of cases in patients hospitalized with acute pancreatitis.
Patients and methods
This prospective comparative study was conducted on 80 patients with acute pancreatitis who were divided into two groups: mild/moderate acute pancreatitis (MAP) group and severe acute pancreatitis (SAP group). All patients were subjected to full history taking; clinical examination; and laboratory investigation, which included complete blood count, renal function tests, prothrombin time, partial thromboplastin time, international normalized ratio, liver function tests, serum electrolytes, serum albumin, serum amylase and lipase, and pancreatic markers.
Results
The authors found a highly significant increase in total leukocyte count in SAP group when compared with MAP group (
P
< 0.001); a highly significant decrease in serum albumin in SAP group when compared with MAP group (
P
< 0.001); a highly significant increase in baseline IL-6, IL-8, and B2M in SAP group when compared with MAP group (
P
< 0.001); a significant increase in third day IL-6, IL-8, and B2M in SAP group when compared with MAP group (
P
< 0.001); and a highly significant increase in complications and mortality rate, in SAP group when compared with MAP group (
P
< 0.001).
Conclusion
Inflammatory markers, particularly ILs, are important tools in the prediction and follow-up of patients with AP.
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PLASTIC SURGERY - ORIGINAL ARTICLES
Hypothenar Island flap: a safe and excellent choice for little finger defects
p. 1341
Tarek F Keshk, Sherief M El Kashty, Ahmed M Harfoush
DOI
:10.4103/mmj.mmj_110_20
Objective
The aim was to evaluate the functional and cosmetic results of hypothenar island flap for the reconstruction of little finger defects and to assess them by follow-up.
Background
Reconstruction of soft-tissue defects of little finger of the hand needs a single-stage procedure that can provide well-vascularized coverage at the earliest stage to give the best functional result.
Patients and methods
This follow-up study that included 19 patients (13 men and six women) was carried out in the Plastic and Reconstructive Surgery Departments of Menoufia University and Helmia Military Hospital from October 2017 to October 2019, with assessment by a follow-up period of 12 months and physiotherapy. All the patients studied had the hypothenar island flap for coverage of the defects. The defects were due to postblunt trauma in three cases, post-burn in three cases, and post-sharp trauma in 13 cases. The largest flap was 20 × 15 mm
2
. The donor site was directly closed in all cases.
Results
The overall results were satisfactory regarding the function and appearance without major complications according to patient and doctor satisfaction. Regarding flap course and survival, 14 (73.7%) flaps passed uneventfully, five (26.3%) flaps suffered from venous congestion, five congested flaps survived without total loss and only partial loss and thus we had 19 (100%) survived flaps.
Conclusion
Hypothenar island flap is a reliable and versatile source for coverage of soft-tissue defects of little finger of the hand.
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Complicated facial filler management by facelift
p. 1347
Mohamed A El-Nahas, Fouad M Ghareeb
DOI
:10.4103/mmj.mmj_142_20
Objective
The aim was to study and evaluate the role of facelift technique in the management of complications of permanent facial filler.
Background
Facial filler complications vary from skin discoloration in the form of hyperemia, hyperpigmentation, or nodule, which may be due to accumulated filler or granulomatous reaction. Complicated patients show symptoms of abnormal skin texture and facial deformities. Treatment of these conditions in the form of drainage, excision, or intralesional laser is usually unsatisfactory.
Patients and methods
The idea of this method is to expose and radically resect all nodules with draining any fluid filler which is present in the subcutaneous layer of the face. This is achieved by facelift exposure, and after proper wash of the field, the facial skin is re-draped.
Results
A total of seven patients with complicated filler have been treated by this technique. The operation is more difficult than ordinary facelift owing to difficult dissection in the presence of fibrosis, nodules, and scars. Moreover, the postoperative bleeding and edema are more than those seen in ordinary facelift. There were two (28%) cases of hematomas, which required evacuation in office. Paresis of the left frontal branch occurred in one (14%) patient and improved after 7 months (
P
= 0.013). However, there was marked improvement in the facial contour and skin quality.
Conclusion
The use of the facelift technique as a surgical tool to treat major complications of multiple fillers in the face has proved to be a very satisfactory method, despite being more difficult than the ordinary facelift surgery in facial rejuvenation.
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UROLOGY - ORIGINAL ARTICLES
Predictive factors of renal and ureteric stone disintegration by the extracorporeal shock wave lithotripsy
p. 1352
Fatma A Elserfy, Tarek M Abd-AlBaky, Eid A El Sherif, Mohamed G Elmarakbey
DOI
:10.4103/mmj.mmj_122_20
Objective
The objective of this work was to evaluate possible predictive variables for the outcome of shock wave lithotripsy of renal and ureteric stones.
Background
Nephrolithiasis is a common disease affecting the population with a peak incidence at around the third to fourth decade of life. The prevalence of stone disease is increasing with increasing annual expenditure. Extracorporeal shock wave lithotripsy (ESWL) is the preferred treatment for renal and several ureteral calculi owing to its noninvasive characteristic and its favorable clinical outcome.
Patients and methods
This study was carried out on 100 patients who are supposed to be treated with ESWL and diagnosed with renal or ureteric stone. All cases were evaluated before, during, and after the procedure as follows: full medical history, clinical examination, laboratory investigations, and radiological investigations.
Results
A total of 91 of the studied patients were males. Age of the studied patients ranged from 24 to 58 years, with a mean of 38.72 years. There is a significant relation between need for second session and presence of tenderness, hypertension and stone site, international normalized ratio, operation duration, complaint duration, stone size, and Hounsfield unit. Presence of renal stone significantly protects from that risk. There are significant relations between postoperative complications and smoking, BMI, urine analysis, hypertension, and past history of stone. There are significant relations between postoperative complications and need for second session, serum creatinine, operation duration, and stone size.
Conclusion
ESWL is an effective and reasonable initial therapy in the management of ureteral stones 2 cm or less at all levels of the ureter.
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Holmium laser vs cold knife – direct vision internal urethrotomy in management of bulbar urethral stricture
p. 1358
Mohamed S Elgharbawy, Ayman F Adli, Mohamed M Abdallaha, Fatma A Elserafy
DOI
:10.4103/mmj.mmj_113_20
Objectives
The aim was to compare the safety and efficacy of using Holmium: YAG laser vs the cold knife in the treatment of short-segment bulbar urethral stricture.
Background
Male urethral stricture is a common condition in urological practice. Cold knife urethrotomy is the most appealing therapeutic method among urologists, as it is an easy and minimally invasive endoscopic procedure.
Patients and methods
This is a randomized prospective study that was done on 60 patients divided into two groups: group A included 30 patients subjected to cold knife urethrotomy (direct VIU), and group B included 30 patients subjected to HO: YAG laser urethrotomy (laser VIU).
Results
After 6 months, the success rate was 77.8% with less than 1-cm stricture length of direct VIU cases vs 78.3% with less than 1-cm stricture length of laser VIU cases. On the contrary, it was 41.7% with stricture greater than 1 cm of direct VIU cases vs 42.9% with more than 1 cm stricture length of laser VIU cases. After 12 months, we had the same results obtained at 6 months.
Conclusion
Laser VIU by using Ho: YAG laser can be used as a method of treatment of this disorder. It is an effective, low-invasive technique, with results are comparable to those of cold knife (direct VIU).
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Use of local anesthetic cream to the skin during extracorporeal shock wave lithotripsy
p. 1362
Atef A Badawy, Abd-Elalim M Eldoray, Mohamed A Elshazly, Emad Abd-Elhady Abu-Zekry
DOI
:10.4103/mmj.mmj_108_20
Objectives
To assess the efficacy of local anesthetic cream compared with nalufin for pain control during extracorporeal shock wave lithotripsy (SWL).
Background
Local anesthetic is a method of pain control for various procedures.
Patients and methods
This is a prospective randomized study of patients diagnosed with renal or ureteric stones and should receive SWL as treatment. A total of 80 patients were divided into two groups, with 40 patients each: eutectic mixture of local anesthetics (EMLA) group (group A) received EMLA cream and received nalufin intravenous injection on demand if pain was intolerable, and nalufin group (group B) received nalufin intravenous injection before SWL. Data were coded and entered to the International Business Machines Company for Statistical Package for Social Science, version 23.
Results
Group A tolerated more intense pain (
P
= 0.027), group B received more doses of nalufin (
P
= 0.000), patients of group B expressed more intense feeling of pain by face scale (
P
= 0.011), numerical pain score was more for the group B (
P
= 0.004), group A patients were more satisfied (
P
= 0.030), group A had less time in the hospital stay (
P
= 0.000), and group B experienced more percentage of complications (
P
= 0.000).
Conclusion
Using EMLA during SWL was successful for pain control and patient comfort and significantly reduced use of nalufin and reduced complications and hospital stay.
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OTORHINOLARYNGOLOGY - ORIGINAL ARTICLE
Correlation between nasopharyngeal bacteria in the Eustachian tube area and that in middle ear effusion
p. 1367
Ayman A Abdel-Fattah, Yaser A Khalil, Mohamed A Fathallah
DOI
:10.4103/1110-2098.304504
Background
Otitis media with effusion is a pathological condition characterized by the accumulation of nonpurulent fluid within the middle ear cleft with an intact tympanic membrane.
Materials and Methods
This study included 40 patients with otitis media with effusion. After obtaining consent from all patients, they were subjected to detailed history, full clinical examination, especially ear examination, audiological assessment, radiological assessment, swab from nasopharynx at the Eustachian tube areas for bacteriological examination, and samples from middle ear fluid in both ears for bacteriological examination.
Results
There was a highly significant relation between right ear sample and nasopharyngeal swap in the right tubal area in the study group (
P
< 0.01). Moreover, there was a highly significant relation between left ear sample and nasopharyngeal swap in the left tubal area in the study group (
P
< 0.01).
Conclusion
There was a highly significant relation between bacteria in middle ear fluid (if present) and that in the corresponding tubal area in the nasopharynx.
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ONCOLOGY - ORIGINAL ARTICLES
Diagnostic and prognostic value of P53 and the human programmed cell death 4 genes in colorectal cancer
p. 1372
Dalia H Abou-Elela, Waleed M. F. Abd-El azem, Tamer F Abdel-Aziz, Enas A Elkhouly, Suzy F Gohar
DOI
:10.4103/mmj.mmj_77_20
Objective
The aim was to study the human programmed cell death 4 (PDCD4) and p53 as diagnostic and prognostic markers in patients with colorectal cancer (CRC).
Background
CRC is one of the most common cancers. Novel molecules and pathways continue to emerge in the search for improved therapeutic strategies.
Patients and methods
A total of 120 patients diagnosed with CRC were included and classified based on stage to group 1 (early-stage patients) and group 2 (advanced-stage patients). Moreover, 60 patients diagnosed with benign colorectal polyps were included as a control group (group 3). P53 and PDCD4 antigen levels were measured at presentation, and their relations to patient demographics and clinical features were estimated.
Results
For PDCD4, area under the curve was 0.889 at cutoff more than 3 ng/ml, with a diagnostic sensitivity of 85.0% and specificity 93.33%, whereas for P53, area under the curve was 1.000 at cutoff greater than 295 pg/ml, with a sensitivity and specificity of 100%. PDCD4 was significantly elevated in group 1 patients compared with group 2 (mean ± SD: 6.9 ± 3.4 vs 1.6 ± 1), with
P
value less than 0.001. PDCD4 levels were significantly related to tumor grade in groups 1 and 2 (
P
= 0.041 and 0.011, respectively). P53 levels were higher among patients in group 1 than group 2 (mean ± SD: 2422 ± 692.5 vs 2392.7 ± 680.3, respectively). P53 levels had statistically significant relation with tumor grade in group 2 patients (
P
= 0.004).
Conclusion
Both P53 and PDCD4 had diagnostic value. Elevated PDCD4 levels had a positive prognostic value, whereas elevated P53 levels had a negative prognostic value.
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Value of l-alanyl-l-glutamine parenteral formula in patients with head and neck cancer receiving radiotherapy
p. 1379
Mohamed A Shehata, Eman A Tawfeek, Enas A Elkhouly, Shaimaa S Soliman, Mohammed A Shalaby, Suzy F Gohar
DOI
:10.4103/mmj.mmj_209_20
Objective
The aim was to determine the effect of administration of parenteral l-alanyl-l-glutamine-containing formula on occurrence of treatment-related malnutrition and acute radiotherapy (RT)-related toxicities in patients with head and neck cancer.
Background
Studies have shown that glutamine-containing nutritional therapy can improve the nutritional status of adult patients with cancer.
Patients and methods
A total of 40 patients with head and neck carcinoma were randomized to receive either parenteral l-alanyl-l-glutamine-containing formula (0.4 mg/kg) during the first 2 weeks of RT (with or without chemotherapy) or placebo. Nutritional assessment was done for all patients at diagnosis and on weekly basis till end of treatment using subjective global assessment tool and anthropometric measures. Treatment-related toxicity was reported and graded. Quality of life (QoL) was assessed using Functional Assessment of Cancer Therapy for patients with head and neck cancer.
Results
There was a significant difference between the studied groups regarding subjective global assessment tool score from third week till 7th week (P = 0.019, 0.005, <0.001, <0.001, and 0.021, respectively). Low BMI was more frequent in group 2 patients. Conversely, severe weight loss was significantly different between both groups starting from third week (
P
= 0.020, 0.010, 0.004, 0.031, and 0.044). There was higher frequency and severity of acute RT toxicities in group 2 patients. There was a significant difference between the two groups regarding QoL as well (
P
= 0.005).
Conclusion
l-alanyl-l-glutamine nutritional supplement resulted not only in better nutritional status but also in improved treatment tolerance and QoL.
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CARDIOTHORACIC SURGERY -ORIGINAL ARTICLE
Levosimendan vs intra-aortic balloon pump in low ejection fraction coronary artery bypass grafting patients
p. 1388
Amr M Allama, Ahmed L Dokhan, Ahmed H Onsi, Mohamed G Hagag
DOI
:10.4103/mmj.mmj_84_20
Background
Coronary artery bypass grafting (CABG) surgery in poor left ventricular function patients is still risky with much postoperative comorbidity that mandates trials to find the best management protocol to cure those patients safely. The authors aimed at evaluating the postoperative outcome of preoperative prophylactic use of levosimendan vs intra-aortic balloon pump (IABP) in those patients.
Patients and methods
In all, 90 patients presented with coronary insufficiency with an ejection fraction of less than 35% and underwent CABG. They were divided into three groups: group A (30 patients) who did not receive preoperative prophylactic support with neither IABP nor levosimendan; in group B (30 patients) IABP was inserted with induction of anesthesia; and in group C (30 patients) levosimendan was administered intravenously through the central line after induction of anesthesia. The authors followed postoperative hemodynamics and morbidities during hospital stay till discharge.
Results
Group C had significantly lesser ICU stay than other groups. Groups B and C had significantly lower needs of postoperative inotropic supports than group A. However, mortality and other major morbidities were similar among the three groups.
Conclusion
Patients with prophylactic preoperative support with IABP or levosimendan had the same postoperative outcome as patients without preoperative support in a situation of CABG with low ejection fraction. However, this prophylactic use add a value of lower needs of postoperative inotropes and moreover levosimendan is associated with lesser ICU stay.
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NEUROSURGERY - ORIGINAL ARTICLES
Comparative study of posterior cervical laminectomy vs facet fixation without laminectomy for the treatment of cervical spondylotic myelopathy
p. 1393
Ahmed F Elmahdy, Esam-Eldin Gaber, Adel Hanafy, Ahmed Azab, Ahmed Gabry, Hany Elkholy
DOI
:10.4103/mmj.mmj_86_20
Objective
The aim was to compare facet fixation operation as the sole management of cervical spondylotic myelopathy (CSM) vs posterior cervical laminectomy without facet fixation.
Background
CSM is a chronic spinal cord dysfunction in the cervical region due to cervical spondylosis, which is an age-related degenerative disorder of the cervical spine components. It is caused by a combination of static and dynamic degenerative factors in the adult population of more than 50 years. Surgical decompression of the spinal canal is the primary treatment of choice, which can be done directly by eliminating the static factors as in posterior cervical laminectomy or indirectly by eliminating the dynamic factors as in facet fixation leading to regression of the spondylotic process.
Patients and methods
This comparative prospective study involved 40 patients with CSM, who were randomly distributed into two equal groups. The patients were followed up for 6 months.
Results
Among the 40 patients, two groups were described. Group 1 included 20 patients who underwent posterior cervical laminectomy without fixation. Group 2 included 20 patients who underwent facet fixation without laminectomy. Postoperative neurological recovery rate at the end of the follow-up period was satisfactory (excellent and good) in 55% in group 1 and 70% in group 2.
Conclusion
Both facet fixation and posterior cervical laminectomy techniques are simple, safe, and effective procedures in achieving relief and improvement in patients with multilevel CSM. Facet fixation provided better postoperative Nurick's grades, Modified Japanese Orthopedic Association scores, and better postoperative neurological recovery rate (NRR) without significant complications while postoperative instability and kyphosis remains the main drawback of posterior cervical laminectomy.
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Managing atlantoaxial instability by posterior fusion using C1 lateral mass and C2 pedicle screws
p. 1399
Mohamed A Elnagar, Adel M Hanafy, Basim M Ayoub, Haitham E El-Kader, Ahmed F Sheha, Ahmed G Elnaggar
DOI
:10.4103/mmj.mmj_98_20
Objective
The aim was to evaluate the posterior atlantoaxial fixation using C1 lateral mass and C2 pedicle by a polyaxial screw in atlantoaxial instability correction.
Background
The craniocervical junction refers to the transitional zone between the cranial base and the upper cervical spine. Owing to the complexity of this area, almost all stabilization techniques are traditionally limited. However, C1 lateral mass – C2 pedicle screw fixation is gaining popularity in handling the atlantoaxial instability.
Patients and methods
This study included patients with craniocervical instability admitted to the Departments of Neurosurgery at Menoufia University and Nasser Institute during the period from May 2016 to April 2018 (almost 2 years) with a follow-up period up to 6 months. Participants were treated during the study period by C1 lateral mass and C2 pedicle screws.
Results
A total of nine cases were included, comprising 67% males and 33% females. Quadriparesis was the common presentation in 45% of patients, followed by those with neck pain or paresthesia. The mean operative time was ∼160 min. Of nine patients, three experienced mild complications, without mortality or morbidity, such as numbness, dural tear, and wound infection.
Conclusion
C1 lateral mass and C2 pedicle screw procedure is safe and provides reasonably efficient results for correcting atlantoaxial instability cases, with minimal adverse effects.
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Endovascular management of ruptured cerebral arteriovenous malformations in pediatric patients
p. 1405
Mohamed S.M. Elsanafiry, Esam E. G. Saleh, Magdy A. E. A. El-Mahalawy, Hosam Eldin A. Habib, Mohamed A Eltabl
DOI
:10.4103/mmj.mmj_112_20
Objective
To evaluate the efficacy, safety, and outcome of endovascular therapy (EVT) of ruptured cerebral arteriovenous malformation (c-AVM) in pediatric patients.
Background
Children with c-AVM have a higher annual risk of hemorrhage than adults (2–4 vs. 1–3% per year). Hemorrhage is fatal in ~25% of these children. Complete obliteration is most commonly achieved by multimodal therapy, which includes microsurgery, EVT, and stereotactic radiosurgery or a combination of two or more of these techniques.
Patients and methods
A prospective study included 18 patients (eight male and 10 female), with a mean age of 10.7 years (4–17 years). All had supratentorial c-AVMs, and none had a family history. According to the Spetzler–Martin grading system, two patients had grade I AVMs, six patients had grade II AVMs, eight patients had grade III AVMs, and two patients had grade IV AVMs. EVT was selected as the primary modality of treatment.
Results
A total of 10 patients had complete obliteration of the nidus, four patients had near-total obliteration, and four patients had incomplete obliteration requiring further treatment. After EVT, 10 patients had grade 0 in the Modified Rankin Scale, four patients had grade I, two patients had grade II, one patient had grade III, and one patient had grade IV.
Conclusion
In this article, EVT was an effective and safe technique for the treatment of c-AVMs showing a high cure rate as a single treatment modality or as a preprocedural technique facilitating other forms of treatment and improving the outcome of the cases.
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FAMILY MEDICINE - ORIGINAL ARTICLE
Anxiety, depression, and commitment to infection control measures among Egyptians during COVID-19 pandemic
p. 1410
Safa H AlKalasha, Zeinab A Kasemy
DOI
:10.4103/mmj.mmj_245_20
Objective
The aim was to evaluate anxiety and depression among Egyptians during coronavirus disease 2019 (COVID-19) pandemic, its associated factors, and public commitment to infection control measures.
Background
COVID-19 pandemic may be stressful for people. Fear and anxiety regarding a new disease can be overwhelming.
Participants and methods
A prospective study was conducted on 1080 Egyptians using four questionnaires: first, sociodemographic data and hearing about COVID-19; second, generalized anxiety disorders questionnaire; third, patient health questionnaire; and fourth, commitment to infection control measures during this epidemic. These questionnaires were applied twice, with 2 months apart, from March to May 2020.
Results
Participants' age ranged from 15 to 50 (29.98 ± 7.95) years, with female sex predominance. Approximately 98.9% of the participants had heard about COVID-19 and 83.3% of them followed up the daily report of new cases and deaths. Prevalence of anxiety was 61.7%, whereas depression was 54.1%, and mixed depression-anxiety represented 33.3% of the participants. Anxiety and depression were significantly higher among participants who are highly educated, working, of lower socioeconomic status, and of urban residency. Moderate to severe anxiety toward COVID-19 declined with time from 24.4 to 18.6%, whereas severity of depression was increased among participants from 29.4 to 44.1% with time (
P
< 0.001). Commitment to infection control measures declined with time (
P
< 0.001).
Conclusion
Anxiety and depression were higher among public during COVID-19 pandemic. Female sex, being married, urban residency, and following up daily report about cases and deaths of COVID-19 were the likelihood associated factors. With time, anxiety and fear owing to pandemic may be reduced as well as people's commitment to infection control measures, whereas depression may increase among public owing to longevity of pandemic and its social and financial consequences.
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PEDIATRIC SURGERY - CASE REPORTS
Delayed presentation of the duodenal web with malrotation
p. 1418
Aditya P Singh, Dinesh K Barolia, Vinita Chaturvedi, Gurudatt Raipuria, Chetan Sharma
DOI
:10.4103/mmj.mmj_272_18
Duodenal web presents usually during the neonatal period with frank features of upper intestinal obstruction. Duodenal webs are rare congenital anomalies that are among the causes of duodenal obstructions. However, on rare occasions, duodenal web might present during late infancy or early childhood in an unusual pattern. The association of duodenal web with malrotation is also unusual. We are presenting here a case of duodenal web in fourth part with malrotation in a 14-month-old male child. The baby had been experiencing intermittent episodes of subacute intestinal obstruction for the past 8 months.
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Missed duodenal web in a patient of malrotation of the gut – a rare case
p. 1421
LD Agrawal, Dileep Garg, Sapna Singh, Hema Mitra
DOI
:10.4103/mmj.mmj_390_18
'Always look for duodenal obstruction in a case of malrotation', this dictum has to be followed. The duodenum is the most common site for congenital intestinal obstruction. The duodenal web with a central hole can present without any overt signs of obstruction at a later age. Here, we report a case of duodenal obstruction presented with complain of vomiting. The patient was operated previously for malrotation of the gut at the age of 1.5 years. At surgery we found a duodenal web with central perforation. Web was excised, and the patient was discharged uneventfully.
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© Menoufia Medical Journal | Published by
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Online since 31 Jan, 2014