Objective This study was carried out to assess the role of the endoscope in septal surgery by comparing conventional and endoscopic-aided septal surgeries regarding the operative blood loss, the operative duration, operative complications and assessment of the airway postoperatively through an endoscope using subjective and objective criteria. Background A deviated septum is one of the most common causes of nasal block. It also causes contact headache, epistaxis, infection of paranasal sinuses and middle-ear diseases due to eustachian tube blockage. Materials and methods This randomized prospective study was conducted among 60 patients with a symptomatic deviated nasal septum. All of the patients underwent nasal examination by anterior rhinoscopy and nasal endoscopy. Patients were divided randomly into two groups, A and B, with 30 cases in each group. Group A underwent endoscopic-aided septal surgery and group B underwent conventional septal surgery. The two groups were compared for the operative duration, the blood loss, postoperative assessment of the nasal airway endoscopically and complications either intraoperatively or postoperatively. Results There were statistically significant differences between both groups regarding the operative duration, the blood loss, postoperative persistent posterior deviations, persistent spurs and persistant contact with turbinates in favour of endoscopic-aided septal surgery, wherein P values were 0.001, 0.001, 0,038, 0.020 and 0.011 consecutively. Conclusion Endoscopic-aided septal surgery is superior to conventional septal surgery in terms of less time consumption, less blood loss, correction of posterior deviations and spurs, less dissection and less intra- and postoperative complications, and it is also a valuable teaching tool.

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Objectives We examined the efficacy of dexamethasone as an adjuvant to low volumes of local anaesthetics in an ultrasound-guided supraclavicular brachial plexus block (SBPB). Background SBPB is an effective nerve block for use during upper limb surgery as an alternative to general anaesthesia. In addition, this block has a beneficial postoperative analgesic effect for these surgeries. Materials and methods We compared three groups of patients; each group included 30 patients scheduled for forearm and hand orthopaedic surgeries and anaesthetized by SBPB. Group A was anaesthetized by an injection of 15 ml of bupivacaine 0.5% mixed with 8 mg (2 ml) dexamethasone, group B was anaesthetized by an injection of 20 ml of bupivacaine 0.5% mixed with 8 mg (2 ml) dexamethasone and group C was anaesthetized by an injection of 20 ml of bupivacaine 0.5% mixed with 2 ml normal saline. All groups were assessed for efficacy of the block by assessment of the onset and duration of sensory and motor block and assessment of the quality and duration of postoperative analgesia. All groups were assessed for the incidence of complications. Results The addition of dexamethasone to low volumes of bupivacaine in SBPB significantly hastened the onset and prolonged the duration of sensory and motor block. Dexamethasone yielded better quality of postoperative analgesia with lower levels of the visual analogue scale; also, it led to a statistically significantly longer duration of postoperative analgesia with lower analgesic consumption, and these effects were more prominent in group B with a slightly higher volume of bupivacaine. There were very few incidences of complications among the three groups. Conclusion The addition of dexamethasone to low volumes of bupivacaine in ultrasound-guided SBPB significantly decreased the onset time and prolonged the duration of sensory and motor blockade; also, it prolonged the duration and improved the quality of postoperative analgesia, with very few incidences of complications.

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Objectives This study focused on the management of patients with phalangeal fractures by a mini external fixator from April 2010 to October 2014. All procedures were performed under regional anesthesia. There were 10 open and 10 closed fractures and 15 comminuted and five oblique fractures. Background These fractures can be treated conservatively or operatively depending on the nature of injuries, fracture pattern, and fracture stability. Materials and methods In this study, fractures were managed by a mini external fixator; 80% were managed on the same day of injury. The mean time of removal of the fixator was 18.4 days and the mean follow-up was 2.5 years. Complications occurred in nine fractures; 95% of fractures healed and just one case of nonunion was present. There was no need for removal of the fixator in the other complication. Results It is obvious that patients with closed fractures show better results than those with open fractures; our result was markedly better in extra-articular fractures than intra-articular fractures. All patients above 60 years old had poor resulrs and the unstisfactory results (poor and fair) were increased when the time of application of fixator increase. In all cases, patients' satisfaction was high. Conclusion External fixation proved to be a suitable and alternative technique for stabilization of comminuted, oblique, and open fractures.

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Objective The aim of the study was to evaluate the clinical and functional outcome of internal fixation of distal femoral fractures with a condylar buttress plate versus a distal femoral locked plate. Background Distal femoral fractures are serious injuries that are difficult to treat and carry an unpredictable prognosis requiring special preoperative planning and close follow-up. Surgical treatment has become the standard treatment after considerable improvement in surgical techniques and the implants used, which avoid the complications of conservative treatment. Patients and methods We conducted a randomized prospective study including 30 patients (17 men and 13 women) with distal femoral fractures who were treated by means of open reduction, internal fixation (ORIF), using a distal femoral locked plate in 15 patients and a condylar buttress plate in 15 patients. Fractures were of types A, B, and C according to the AO/ASIF classification. Patients were followed up for 6 months. The exclusion criteria included open fractures, periprosthetic fractures, and old nonunited fractures. The clinical and functional outcomes were classified according to the functional evaluation scoring system described by Sanders and colleagues . Results The functional outcome was excellent in 33.3 versus 20%, good in 46.7 versus 26.7%, fair in 13.3 versus 20%, and poor in 6.7 versus 33.3% of patients treated with the distal femoral locked plate and the condylar buttress plate, respectively. The range of motion was significantly superior in patients treated with the distal femoral locked plate. Complications were significantly fewer with the distal femoral locked plate than with the condylar buttress plate with respect to infection, varus deformity, nonunion, and implant failure. Conclusion The distal femoral locked plate fixation provided better functional outcome and achieved better degree of knee flexion compared with the condylar buttress plate in the treatment of distal femoral fractures in the same fracture pattern.

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Objective The aim of the study was to review the different options for voice rehabilitation to improve the quality of life of laryngectomized patients after total laryngectomy. Data source Data for the study were collected from previous investigations and reviews as well as from medical websites (PubMed, Medscape, MD Consult) and scientific journals. Study selection Studies were selected for evaluating new advancements in voice rehabilitation after total laryngectomy. Data extraction In this review data from published studies were manually extracted and summarized. Data summary Total laryngectomy is potentially a debilitative surgery resulting in compromise of some of the most basic functions of life, including speech and swallowing. At present, there are several options available for these patients: esophageal speech, artificial larynx, and tracheoesophageal speech. The choice of speech rehabilitation varies from patient to patient, but tracheoesophageal voice has become the preferred method. Results No single method is considered the best for all patients, but tracheoesophageal puncture has become the preferred method in the past decade. Conclusion Voice rehabilitation is one of the most important determinants of the quality of life after total laryngectomy. Recent advances in prosthetic voice devices have made them the gold standard for voice rehabilitation. Thus, voice rehabilitation is preferred and used more often than other methods (esophageal speech and artificial larynx). There is ongoing research to find solutions to the most common complications of tracheoesophageal puncture.

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Objective This study was designed to evaluate the length of the first and second stages of labor in nulliparous obese Egyptian women and compare them with those in women with normal BMI. Background Maternal obesity is now the most common risk factor for maternal mortality in developed countries and is also associated with a wide spectrum of adverse pregnancy outcomes. The duration of first stage of labor, the rate of cesarean delivery, and inadequate progress of cervical dilatation during labor were found to be higher in women with BMI more than 30 compared with women of average weight. Participants and methods Nulliparous women of more than 37 gestational weeks who were in labor were included in this study. First-visit BMI was used to categorize weight as normal (≤24) or obese (≥30). Over 12 months (study period), we observed 603 deliveries; 239 were nulliparous and 211 were term singleton. Eighty women met the inclusion criteria: 40 women with normal BMI constituting the control group and 40 obese women who constituted the study group. Results The duration of first stage of labor was significantly longer in obese women compared with normal weight women (19.76 ± 0.77 vs. 16.87 ± 0.66 h; P < 0.001), whereas the duration of the second stage of labor showed no significant difference between obese and normal weight women (61.0 ± 34.8 vs. 60.9 ± 34.3 min; P = 0.990). When adjusted for age, hypertension, and induction, the likelihood of completing stages I and II was significantly lower among obese nulliparous than among those with BMI 24 or less. Conclusion About half of nulliparous women in our population are obese and the duration of stage I is significantly longer among them, whereas the second stage of labor may be independent of maternal BMI. The second stage in the nulliparous parturient woman does not appear to be longer or more likely to end in cesarean delivery on the basis of prepregnancy BMI

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Objective This study aimed to evaluate the prevalence and difficulties during surgery of tympanostomy tube (TT) insertion, complications after surgery, and modalities for management. Background In view of the high incidence of otitis media with effusion in children and the fact that TT is one of its major treatments, we decided to conduct the present observational study. Patients and methods This study included 220 patients with persistent otitis media with effusion after failed medical treatment for 3 months. All patients underwent TT insertion either unilateral or bilateral in 378 operated ears. Results There were 198 problems detected in 378 operated ears. The difficulties during insertion of TT were observed in 82 ears. The most common was the thick mucoid discharge (P = 0.10), followed by the narrow external auditory canals (P = 0.005). Early complications were observed in 42 ears. The most common was early otorrhea (P = 0.03), followed by early extrusion (P < 0.001). Late complications were detected in 74 ears - for example, plugged tubes (P = 0.77) and recurrence of effusion (P = 0.01). Conclusion TT insertion is a temporary procedure performed until the Eustachian tube function returns to its normal function; however, this procedure has many problems during and after insertion. Difficulties of insertion and late side effects are common problems that can be anticipated in nearly one-fifth of the cases. Therefore, ORL surgeons must be aware of the type of difficulty and its management before performing the surgery.

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Objective The aim of this study was to evaluate the results of Muller's muscle-conjunctival resection in the treatment of mild-to-moderate ptosis with fair-to-good levator function. Background Muller's muscle-conjunctival resection, which was originally described by Fasanella and Servat and later modified by Putterman and Urist, has traditionally been performed for correction of mild-to-moderate upper eyelid ptosis, resulting in improved eyelid height. Patients and methods A prospective nonrandomized study was conducted on patients attending the Outpatient Clinic of Ophthalmology Department in Menoufia University Hospital during the period of study from May 2013 to October 2014. This study was conducted on 20 eyes of 20 patients with mild-to-moderate ptosis with fair-to-good levator function. Muller's muscle-conjunctival resection was performed for all cases, and the patients were followed up for 6 months. Results Success of the operation was determined by means of postoperative eyelid elevation. Patients were divided into three categories: (a) successful (eyelid elevated to cover 2 mm of the cornea or within 0.5 mm of this level), which included 12 eyelids (60%); (b) accepted (within 1 mm of normal eyelid level, which covers 2 mm of the cornea), which included eight eyelids (40%); and (c) failed (uncorrected 0%). Conclusion Muller's muscle-conjunctival resection surgery has high success rate in treating mild-to-moderate ptosis with fair-to-good levator function. It also has few and mild complications, with the advantage of good cosmetic results due to avoidance of cutaneous scar, and results in good eyelid contour.

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Objective The aim of this work is to compare the different modalities in the management of functional ovarian cysts. Background A functional ovarian cyst is a growth on an ovary that develops during a woman's ovulation cycle. Women who develop a functional ovarian cyst generally remain asymptomatic and only learn of its presence during their annual female examination. Most functional ovarian cysts are small and benign, require no treatment, and dissolve on their own. If the cyst is small to moderate in size and causes no symptoms, a watchful approach will usually be adopted. Materials and methods This study included 80 patients with functional ovarian cysts: 40 patients followed up by transvaginal ultrasound only (expectant group) and 40 patients who received combined oral contraceptive pills (oral contraceptive group) and followed up by transvaginal ultrasound for 3 months. Persistent functional ovarian cysts will be managed by transvaginal ultrasound-guided needle cyst aspiration and then followed up by transvaginal ultrasound for 3 months. Results There was no statistically significances between different modalities of management as regards short-term expectant management (31\40) and combined oral contraceptive management (34\40) for functional ovarian cysts. Persistent functional ovarian cysts were managed by transvaginal-guided ultrasound needle aspiration, which showed a high recurrence rate in both groups, 5\9 and 3\6, respectively, after short-term follow-up. Conclusion The results of the study suggest that optimal management for functional ovarian cysts in reproductive age is expectant management.

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Purpose The aim of this work was to study the risk factors, clinical results, particularly the functional outcome, and radiological results for intraoperative periprosthetic fractures (PPFs) around hip arthroplasties through a retrospective analysis. Materials and methods We conducted a retrospective study based on hospital records. Patients with intraoperative PPFs around hip arthroplasties who underwent follow-up for at least 9 months were enrolled in the study. For each patient, preoperative and intraoperative risk factors were analyzed; the functional outcome in terms of the Harris hip score was compared before fracture and at the last follow-up. Results Fifteen cases were enrolled in this study. Six male and nine female patients were included with a mean ± SD age of 57.2 ± 8.5 years. A mean follow-up of 15.2 months was achieved. The average Harris hip score at the last follow-up was 85.7 points. All cases obtained primary bony union. The mean time from surgery to bony union was 8.3 months, ranging 3-12 months. Conclusion Female patients are at a higher risk of intraoperative PPF; in addition, significant femoral deformity and osteopenia are estimated risk factors. Cortical perforations and bone defects along with previously existing osteotomies are the other risk factors. Revision surgeries, cementless components, straight long stem, and vigorous manipulation of the femur are the surgery-related risk factors detected. Component stability is the most important factor for intraoperative decision-making. Extended trochanteric osteotomy is a safe and useful procedure, especially when using long straight stems. In addition, the use of supplementary cerclage fixation of fracture fragments for Vancouver B fractures yields better results.

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Objective The aim of this study is to determine the differences between silicone oils 1000, 2000, and 5000 cs in retinal reattachment, visual acuity, and complications. Background Each of the silicone oils 1000, 2000, and 5000 cs has its own advantages and complications. Patients and methods This study included 42 eyes that were subjected to vitreoretinal surgeries with a silicone oil injection. Patients were divided into three groups: group A included 14 eyes injected with silicone oil 1000 cs, group B included 14 eyes injected with silicone oil 2000 cs, and group C included 14 eyes injected with silicone oil 5000 cs; injections were administered through the pars plana approach. Results Silicone oil 5000 cs showed the best visual outcome and resulted in more complications (except emulsification as it emulsified less). Silicone oil 1000 cs showed the less visual outcome and fewer complications. Silicone oil 2000 cs showed good visual outcome and resulted in many complications that were intermediate between the other two viscosities. Conclusion Silicone oil 5000 cs is considered the most successful retinal tamponade. However, low-viscosity silicone oils are preferred sometimes because surgical injection and removal from the vitreous cavity are easier, and fewer complications are caused by these oils, such as cataract and increased intraocular pressure.

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Objective This study aimed to correlate lower uterine segment (LUS) thickness measured by both transvaginal (TVS) and transabdominal ultrasonography (TAS) after completion of 36 weeks of pregnancy with that measured manually using a caliper at the time of cesarean delivery and to determine minimum LUS thickness indicative of its integrity in women who have undergone a previous cesarean section. Background Ultrasound is used to evaluate the LUS, especially if there is a previous scar, and it is more beneficial to predict the possibility of the occurrence of any complications during labor either by repeated cesarean section or by vaginal delivery. Patients and methods Pregnant women admitted to our university hospital at 36-40 weeks' gestation planning for elective cesarean delivery were included in this study. The patients were subdivided into two groups. Group I (study group) included 50 pregnant patients, ±36-40 weeks, with a history of one previous lower segment cesarean section. Group II (control group) included 50 pregnant patients, ±36-40 weeks, with no history of a previous cesarean section. This group was subdivided into two subgroups: IIA included 25 patients in whom elective cesarean section delivery was planned during the period of study because of obstetric indications and IIB included 25 patients with low-risk pregnancies who had vaginal delivery. All patients were examined by both TAS and TVS to evaluate the thickness of the LUS and the thickness was remeasured using a vernier caliper intraoperatively among those who delivered by an elective cesarean section. Results Evaluation of the LUS by TVS and TAS and comparison of the results of both with the results obtained by actual measurement intraoperatively indicated that TVS was more reliable and accurate. Conclusion Evaluation of LUS scar by TVS is superior compared with TAS.

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Objective The aim of this study was to evaluate the outcome of uterine balloon tamponade using a condom-catheter in the management of primary postpartum hemorrhage (PPH). Background Guidelines for the management of postpartum hemorrhage involve a stepwise approach including the exclusion of retained products and genital tract trauma. Uterine atony, which is the most common cause, is dealt with uterine rubbing and various uterotonic agents. Among the new modalities introduced to arrest the bleeding is the uterine tamponade using various balloons and catheters. The condom catheter uses a sterile rubber catheter fitted with a condom that can be used for uterine tamponade. Materials and methods This prospective observational study included 50 women with PPH unresponsive to uterotonics and bimanual compression, and was conducted at the Department of Obstetrics and Gynecology, Menoufia University Hospital, Egypt. About 28 patients suffered from atonic postpartum hemorrhage, whereas 22 patients suffered from PPH due to placenta previa. Clinical assessment, laboratory investigations, and intrauterine condom catheter were applied to all patients. The primary outcome was the success of the balloon to stop bleeding; however, maternal complications were assessed as the secondary outcome. Results The condom catheter was successful in controlling PPH in all cases of atonic PPH (28/28; 100%): 18 after vaginal delivery and 10 after cesarean section. It successfully controlled PPH due to placental site bleeding in 20 cases (90%) and failed to control PPH in two cases (10%), which were managed by cesarean hysterectomy. There was (P<0.001) a significant statistical difference between vaginal and abdominal balloon insertion regarding postinsertion complications. Conclusion The condom catheter controls PPH effectively. It is a simple, inexpensive, and safe method of conserving the reproductive capacity along with saving the life of women with primary PPH.

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Objective The aim of this study was to identify the incidence, risk factors and the clinical relevance of incidental parathyroid excision during total and subtotal thyroidectomy in thyroid diseases. Background Postoperative hypocalcaemia is observed in total thyroidectomy patients and it is the most common complication. It is usually transient, and the incidence of permanent hyperparathyroidism is 3% or less. Despite being self-limiting in most patients, symptomatic hypocalcaemia is of particular concern because of a delay in its manifestation and the consequent need for prolonged patient hospitalization or readmission. Patients and methods In this randomized prospective study, we surveyed 30 patients who were admitted in the General Surgery Department, Menoufia University Hospital, during the period from November 2012 to March 2014 with benign thyroid diseases such as simple multinodular goiter, secondary toxic goiter, diffuse toxic goiter relapsing after full medical treatment, selected cases of thyroiditis (Hashimoto's thyroiditis) and thyroid cancer. Results We found two cases with temporary hypocalcaemia with multinodular goiter and medullary carcinoma. The typical signs and symptoms associated with hypocalcaemia are neuromuscular irritability, including perioral or acral paresthesia, muscle cramps that may progress to carpopedal spasm, laryngospasm, bronchospasm or even tetany. Treatment is based on the severity of symptoms. In severe cases (calcium levels less than 7.5% or severe symptoms), intravenous calcium salts are administered using one ampoule of calcium gluconate in 1 l of 5% dextrose at an initial infusion rate of 100 ml/h. With frequent monitoring of the serum calcium level (usually every 1-2 h), the infusion rate is titrated to keep the serum calcium level in the low normal range. Conclusion Incidental parathyroid excision during thyroid resection is not uncommon, and it occurred in 16.4% of the cases in this series. Total thyroidectomy, extra thyroid extension of the tumour, and thyroiditis were found to be the risk factors for incidental parathyroid excision.

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Objective A study evaluating the outcomes of different surgical modalities for management of the postburn elbow contracture. Background The incidence of the postburn contracture is unkown, but it is inversely propotional to the standards of the initial management. Methods This is a prospective study included 20 patients suffering from different degrees and forms of postburn elbow contracture. All patients had scar contracture release and then were managed according to the forms of the contractures and the availability of adjacent healthy unscarred tissues. Results Different techniques had been used in this study, seven cases had skin graft representing 35% of all cases, there was partial loss in one case and one case had recontracture later on. Five cases representing 25% of cases had z-plasty flap, only one case had tip necrosis. Two cases had five z-plasty technique representing 10% of cases and there was no complications including infection, dehiscence, hematoma, tip necrosis or recontracture. Three cases representing 15% of cases had reversed lateral arm flap and there was no complications. Three cases representing 15% of cases had proximally based lateral forearm flap and also there was no complications. Conclusion Flaps are better for resurfacing the defects after post-burn contractures release. Flaps do not need rigorous post-operative physiotherapy or splintage, no recurrence of contracture and grow with age especially in children.

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Objective To compare between laparoscopic and open liver resection for liver tumors. Background Laparoscopic surgery has become a standard in many elective procedures, but it is still gaining popularity in liver surgery. The safety of laparoscopic liver resection is still under study. Materials and methods This study was prospectively conducted from October 2012 to December 2014 on 30 patients presenting with hepatic tumors (benign and malignant) to the outpatient clinic of both Menoufia University Hospitals and El-Salam Oncology Center. Patients were divided randomly into two groups: group A, which includes 15 patients operated upon by laparoscopic technique; and group B, which includes 15 patients operated upon by open technique. Results Operating time was significantly longer in the laparoscopy group: it was 131.54 ± 15.61 versus 118.04 ± 19.41 min. Blood loss was highly significant in laparoscopic resections. Mean hospital stay was highly significant shortly after laparoscopy 6.20 ± 1.10 versus 8.81 ± 1.50 days. Patients who underwent laparoscopic procedure resumed oral intake earlier than the open group. The overall complication rate was significantly lower in the laparoscopic group than the open group. Conclusion Laparoscopic liver resection improved surgical and postsurgical outcome for open liver resection regarding less operative blood loss, postoperative pain, postoperative complications, and hospital stay.

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Objectives The aim of the present study was to detect histopathological and immunohistochemical changes in the heart of albino rats after low-voltage electrocution in an attempt to confirm the diagnosis of electrocution as a proximate cause of death. Background Electrical injuries are often dramatic accidents and are potentially fatal. Many victims of electric shock die before help arrives and survivors may suffer severe injuries. Forensic pathologists have made several attempts to find an effective means to establish the cause of death by electrocution. Familiarity with both the incidence of the problem and the mechanism of injuries may lead to a more skillful means of diagnosing this type of death. Materials and methods Twenty-six adult male albino rats were divided randomly into two main groups: control group (I) and experimental group (II). The control group (I) included 10 rats that were killed by cervical dislocation without any application of electrical current. The experimental group (II) included 16 rats that were electrocuted until death by a 220 V alternating current with the points of electrical contact placed on the skin of the left forelimb and the skin of the right hind limb. Sections from the hearts of both groups were fixed in formalin and routinely processed. Caspase-3 expression was evaluated in both groups by immunohistochemistry. Results Areas of interstitial hemorrhage, necrotic, and fragmented cardiomyocytes, square or rounded nuclei, myocardial waviness, and contraction bands were the prominent histopathological findings in the heart specimens of the rats of the electrocuted group (II) in comparison with the control group (I). Also, they showed a positive immune reaction for caspase-3 when compared with the control group. Conclusion This study concluded that the histopathological changes and immunohistochemical findings, besides the circumstantial evidence and external marks that may be found at autopsy, may provide a basis for the diagnosis of deaths caused by electrocution in suspected cases associated with limited external findings. Thus, it is advisable to use these techniques routinely in examinations and for the diagnosis of all deaths suspected to have been caused by electrocution.

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Objectives The aim of this study was to investigate the diagnostic and predictive value of plasma brain natriuretic peptide (BNP) levels in detecting diastolic dysfunction in β-thalassemic patients in comparison with conventional and new Doppler echocardiography indices. Background β-Thalassemia major is a unique disease characterized by early diastolic dysfunction related exclusively to iron myocardial deposition. BNP is a sensitive biomarker for the detection of asymptomatic left ventricular (LV) dysfunction and has important diagnostic and prognostic implications. Materials and methods This study enrolled 25 b-thalassemic major patients with normal systolic function and 10 age-matched and sex-matched individuals. All participants were studied thoroughly by tissue Doppler echocardiography and blood samples were taken for determination of BNP, ferritin, total iron, and complete blood count. Patients were divided into two groups according to the E mitral/E mitral annulus ratio (E/E') at cutoff point 8. Results BNP levels were higher in thalassemic patients compared with the control group. BNP and serum ferritin levels showed a statistically significant increase in group I (E/E' >8) in comparison with group II (E/E' <8). There was a statistically significant positive correlation between BNP and serum ferritin. Using receiver operating characteristic analysis, BNP at a cut point of 28.5 pg/ml was highly accurate (area under curve = 0.86, P = 0.003) in ruling out diastolic dysfunction (E/E' <8), with a sensitivity 88.9% and a specificity of 81.2%. Conclusion BNP level is significantly increased in LV diastolic dysfunction and has a predictive value in detecting latent LV diastolic dysfunction in β-thalassemia major.

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Objectives The study was designed to evaluate the effect of steroid therapy on renal functions in children with immune thrombocytopenia (ITP). Background ITP is usually a benign self-limiting condition. The most appropriate initial therapy for children with ITP remains controversial. When therapy is indicated, the primary method of treatment is steroid therapy. Materials and methods The study was conducted on 33 children newly diagnosed with ITP (19 male; 14 female). The patients were classified into two main groups: group I included patients who needed corticosteroid therapy (18 patients) and group II included patients who did not need corticosteroid therapy (15 patients). Fifteen healthy age-matched and sex-matched children were included in the study as controls. All individuals were subjected to history taking, thorough clinical examination, anthropometric measurements, complete blood count, complete urine analysis, and renal function tests [blood urea, serum creatinine concentrations, and estimated glomerular filtration rate (eGFR)]. Blood samples were taken before any treatment and after an accumulative dose of 350 mg/m ² steroid therapy for group I. Results The study revealed that ITP children who received steroids had significant increase in serum creatinine and significant decrease in eGFR without difference in blood urea, compared with those who did not receive steroids and with controls. The same was true in paired analysis on comparing ITP patients after steroid therapy with their investigations before steroid therapy. Conclusion Patients with ITP under short course of corticosteroid therapy are at risk for impaired renal functions in the form of increased serum creatinine concentration and decreased eGFR.

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Objective The aim of this study is to evaluate the application and clinical outcomes (oncological and cosmetic) following oncoplastic conservative surgery using bilateral reduction mammoplasty in conjunction with breast conservation therapy for esthetic purposes. Background Breast cancer is the most common malignancy in women worldwide. Until recently, breast surgery could provide only two options for early-stage breast cancer: either modified radical mastectomy or segmental excision, followed by radiation, but the latter causes breast deformities. Reduction mammoplasty is used as a conservative breast surgery with excision of a large volume of tissue without compromising the cosmetic outcome. Patients and methods We studied 17 patients with breast cancer, aged 30-65 years (mean 48.4 years). Patients had been operated on by the reduction mammoplasty technique at Menoufia University Hospital in 2012 and later. Patients were followed up at regular intervals 2 years or more after the operation had been carried out. Results Reduction mammoplasty is a good technique for conservative breast cancer surgery at its early stage, with fewer complications and better cosmetic results. All specimens showed free resection margins with an average size of 2.4 cm. No recurrence was detected. Postoperative complications were encountered in seven patients in the form of wound infection, seroma, partial skin slough, and asymmetry. Long-term follow-up results are awaited to support the more widespread use of this surgical technique in the definitive treatment of early-stage breast cancer. Conclusion Oncoplastic breast surgery is now being used widely as a better substitute for the management of early-stage primary breast cancer with proved safety and efficacy.

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Objectives To study the role of pelvic and para-aortic lymphadenectomy in ovarian carcinoma, especially in the early stages in which conventional imaging such as computed tomography and MRI reveal that pelvic and para-aortic lymph nodes were negative. Background Pelvic and aortic nodes are common sites of metastasis from gynecologic malignancies, and there is no question that the evaluation of the lymph node status provides important prognostic information. Materials and methods Between October 2012 and October 2014, 18 patients who were previously untreated and had biopsy-proven ovarian carcinoma were operated upon in the Department of General Surgery, Menoufia University Hospital. The surgical procedure consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and or omentectomy, in addition to systematic pelvic and para-aortic lymphadenectomy. Results Positive nodes were found in eight patients (44.4%): four pelvic, one aortic, and three both pelvic and aortic metastases. The median number of positive nodes was five pelvic (range 1-12) and four aortic (range 1-6) nodes. The most frequently involved node group with ovarian carcinoma was the obturator group. Conclusion These data may be useful for tailoring lymphadenectomy in relation to the preferred sites of retroperitoneal lymph node metastasis and the median number of nodes resected from each group, and it confirms that systematic pelvic and aortic lymphadenectomy is a feasible procedure and can be performed with acceptable morbidity and no mortality. However, to provide solid evidence that this procedure has a therapeutic benefit, randomized controlled studies are needed.

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Objective This study aimed to determine the advantage of a combination of transdermal nitroglycerine and neostigmine in intravenous regional anesthesia (IVRA). Background The aim of this study was to evaluate the effect of transdermal nitroglycerine, neostigmine, or both when added to lidocaine compared with lidocaine alone in the IVRA technique. Patients and methods Eighty patients (ASA grade I and II, aged 18-60 years) of both sexes were enrolled. The patients were divided randomly into groups as follows: group 1: the neostigmine group: a dose of 2.5 mg/kg lidocaine 0.5% (0.5 ml/kg) with the addition of 0.5 mg neostigmine was administered (n = 20). Group 2: nitroglycerine group: a dose of 2.5 mg/kg lidocaine 0.5% (0.5 ml/kg) with the addition of 5 mg of transdermal nitroglycerine (a nitroglycerine patch was applied 2 h before the start of IVRA) was administered (n = 20). Group 3: nitroglycerine-neostigmine group: a dose of 2.5 mg/kg lidocaine 0.5% (0.5 ml/kg) with the addition of 5 mg of transdermal nitroglycerine (a nitroglycerine patch was applied 2 h before the start of IVRA) and 0.5 mg neostigmine was administered (n = 20). Group 4: lidocaine only (control group): participants received IVRA with 2 ml saline added to lidocaine (0.5 ml/kg) (n = 20). Exclusion criteria Patients with ischemic heart disease, heart block, second or third degree, severe sinoatrial block, serious adverse drug reaction to lidocaine or amide local anesthetics, concurrent treatment with quinidine, flecainide, disopyramide, procainamide, Adams-Stokes syndrome, Wolff-Parkinson-White syndrome, allergic reactions to organic nitrates, allergy to nitroglycerin, allergy to the adhesive patches, hypersensitivity to neostigmine, myasthenia graves, a history of reaction to bromides, peritonitis, mechanical gastrointestinal, or urinary tract obstruction were excluded. Results Sensory and motor block onset times were shorter in the neostigmine-nitroglycerine group compared with all the other groups (P < 0.05). Sensory block recovery time was significantly prolonged and the quality of anesthesia was better in the neostigmine-nitroglycerine group compared with all the other groups (P < 0.05). Conclusion We found that the addition of 0.5 mg neostigmine to a dose of 2.5 mg/kg of 0.5% lidocaine for IVRA with a 5 mg transdermal nitroglycerine patch improved the operating conditions and the quality of anesthesia and prolonged postoperative relief, with no adverse effects.

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Objectives The aim of this study was to compare between traditional abdominoplasty and current techniques of abdominoplasty, follow complications associated with the new techniques of abdominoplasty, etiology and management, and minimize the amount of invasive surgery while maximizing the esthetic surgical results and patient benefits. Patients and methods A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were studied in the period from October 2010 to October 2014 at the Plastic Surgery Department, Menofia University Hospitals. The patients were divided into three groups to compare between traditional abdominoplasty, lipoabdominoplasty with limited dissection superior to the umbilicus and lipoabdominoplasty with limited dissection superior to the umbilicus, preservation of scarpas fascia, and lowering incision line. Results A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were included in this study. The study was carried out on the basis of inclusion and exclusion criteria, and the choice of participants for each group was carried out randomly. There was a statistically significant difference between different groups in age, blood transfusion, and occurrence of complications (P < 0.05). Conclusion We recommend following the new technique of abdominoplasty, which includes lipoabdominoplasty, limited dissection superior to the umbilicus with preservation of scarp's fascia; it was found that fewer complications developed with the use of our new technique for lipoabdominoplasty compared with the use of the traditional technique, and there were greater patient benefits than observed previously.

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Objective The aim of the study was to conduct a meta-analysis of published, full-length, randomized controlled trials (RCTs) evaluating the effect of prophylactic glyceryl trinitrate (GTN) on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (PEP) and the prevention of hyperamylasemia. Data sources Literature searches were conducted using PubMed, EMBASE, The Cochrane Library, and Web of Knowledge databases (up to May 2014) using keywords 'post-ERCP', 'pancreatitis', 'ERCP', 'post endoscopic retrograde cholangiopancreatography pancreatitis', 'GTN', 'glyceryl trinitrate', and 'nitroglycerin', and were limited to RCTs. No language restriction was imposed. Study selection The following selection criteria were applied: (i) study design - RCTs; (ii) study population - patients undergoing endoscopic retrograde cholangiopancreatography (ERCP); (iii) intervention - prophylactic administration of GTN; (iv) comparison intervention - control or no treatment; and (v) outcome measures - the overall incidence of PEP, the incidence of moderate to severe PEP, the incidence of hyperamylasemia, and the incidence of adverse effect with prophylactic use of GTN. Data extraction Data from eligible studies were extracted independently by using standard forms. Details of the studies included name of the first author, year of publication, country, setting, sample size, interventions, dosage, follow-up, routes of drug administration, inclusion and exclusion criteria of each study, definition, incidence of PEP (including overall and moderate to severe pancreatitis, respectively) and hyperamylasemia. Data synthesis All statistical analyses were performed using Comprehensive Meta-analysis Version 2. All outcomes were expressed as odds ratio (OR) with 95% confidence interval (CI). Findings Eleven randomized controlled trials (RCTs) involving 2395 patients were included. Eleven RCTs compared GTN with placebo for PEP prevention. Meta-analysis showed that the overall incidence of PEP was significantly reduced by GTN treatment (OR 0.65, 95% CI 0.483-0.784). Nevertheless, GTN administration did not decrease the incidence of moderate to severe PEP (OR 0.687, 95% CI 0.407-1.16). Subgroup analyses revealed that GTN administered sublingually was more effective than transdermal and topical administration in reducing the incidence of PEP. In addition, the incidence of hyperamylasemia was significantly reduced by GTN treatment (OR 0.483, 95% CI 0.289-0.809).

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Objective The aim of this study was to evaluate the feasibility, safety, and outcome of one-stage posterior sagittal anorectoplasty in cases of rectovestibular fistula. Background Rectovestibular fistula is the most common type of anorectal malformation in the female population. The standard treatment for rectovestibular fistula is the staged approach. In recent times, posterior sagittal anorectoplasty has revolutionized the management of anorectal malformation (ARMs). Materials and methods This study was conducted on 24 female patients with rectovestibular fistula who were divided into two groups: Group 1: This group comprised patients who underwent primary repair without colostomy (14 cases) prospectively. Group 2: This group comprised patients who underwent multistage repair (10 cases) retrospectively (the last 10 cases were operated upon in our hospital). Results A total of 24 patients were included in our study. All patients were more than 1 month old. Intraoperative complications included opening the posterior wall of the vagina (n = 2). Postoperative complications included the following: anal excoriations in seven patients in group 1 only; superficial wound inflammation in four patients in group 1 but only in one patient in group 2; partial dehiscence of the perineal skin in three patients in group 1 but only in one patient in group 2; anal stenosis in one patient in each group; and mucosal prolapse in one patient in group 1 only. Conclusion Primary repair of rectovestibular fistula is technically feasible and safe. It avoids the risk of complications related to colostomy and the risks of multiple anesthesia, and reduces the economic and psychological burden on the family.

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Objectives The aim of this study was to assess the ocular manifestations of diabetes and follow-up the results of treatment. Background Diabetes mellitus is a major cause of blindness in the USA and the leading cause of new blindness in working-aged Americans. Diabetic retinopathy alone accounts for at least 12% of new cases of blindness each year in the USA. Individuals with diabetes are at 25 times greater risk for blindness compared with the general population. The estimated annual incidence of new cases of proliferative diabetic retinopathy and diabetic macular edema are 65 000 and 75 000, respectively. Over a lifetime, 70% of patients with insulin-dependent diabetes mellitus develop proliferative diabetic retinopathy and 40% of patients develop macular edema. Both complications, if untreated, frequently lead to serious visual loss and disability. Patients and methods A total of 200 eyes of 100 diabetic patients (58 male and 42 female patients) were included in the study. Of them, 15 patients had type I (insulin-dependent) diabetes mellitus and 85 patients had type II (noninsulin-dependent) diabetes mellitus. The mean duration of diabetes in the groups was 11.78 ± 5.28 years, with a maximum of 22 years. Complete ophthalmic examination was performed for all patients. Informed consent was obtained from all participants, to ensure voluntary participation in the study. Results The patients were divided into two groups: Group 1 represented diabetic patients with different stages of diabetic retinopathy and other eye manifestations. It comprised 152 eyes of 76 diabetic patients with established diagnosis of diabetes mellitus. Group 2 represented diabetic patients with normal fundus and comprised 48 eyes of 24 diabetic patients with established diagnosis of diabetes mellitus. Conclusion Diabetic retinopathy is one of the most common causes of visual loss in adults; therefore, the earlier the diagnosis, the better the management.

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Objectives The aim of the study was to evaluate the role of optical coherence tomography (OCT) in optic disc analysis in glaucoma patients. Background Forty patients underwent full ophthalmic examination, including a review of medical history, best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, dilated fundoscopic examination, automated perimetry, and OCT at 1 month and after 6 months. Patients and methods Stratus OCT was used for ocular imaging in patients with dilated pupils. All patients had optic nerve head and retinal nerve fiber layer thickness (RNFL) measured during the two visits. Quality assessment of stratus OCT scans was evaluated by an experienced examiner masked to the patient's other test results. Good-quality scans had to have focused images from the ocular fundus, adequate signal strength (>6 for RNFL and macula scans), and the presence of a centered circular ring around the optic disc (for RNFL scans). Results There was a statistically significant difference between patients at 1 month and after 6 months as regards OCT (RNFL), especially with regard to the inferior quadrant, with the P value of the RNFL inferior quadrant, which was the most affected after 6 months, at 0.03 and the P value of the rim area being highly significant at 0.001. Conclusion An OCT would be significantly informative early in the disease course to diagnose a preperimetric glaucoma, to confirm on a visual field, and to follow up longitudinal glaucoma progression.

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Objective The aim of this study was to evaluate the postoperative outcome and the recurrence rate after primary pterygium excision using preoperative subpterygial bevacizumab injection at the time of surgical removal as against 2 weeks before surgery. Background Recurrence after pterygium excision represents a challenge for ophthalmologists and is considered to be the most common postoperative complication. Several techniques have evolved in a trial to overcome the high rate of postoperative recurrence. However, none proved to be totally effective. Patients and methods Forty eyes with primary pterygium were divided into two groups. Group A eyes (included 20 eyes) were operated upon with pterygium excision after subpterygial injection of bevacizumab. Group B eyes (included 20 eyes) were operated upon with pterygium excision 2 weeks after subpterygial injection of bevacizumab. Pterygium regrowth over the cornea for 1 mm or more was considered as a recurrence. Results The follow-up period was 6 months. In group A, recurrence was reported in two (10%) eyes, whereas in group B, recurrence was reported in one (5%) eye. No serious postoperative complications were reported. There was no statistically significant difference between the two groups regarding the recurrence rate and the complication rate. Conclusion Both techniques used in the current study proved to be effective in reducing the recurrence rate after excision of the primary nasal pterygium with minimal postoperative complications. Injection of bevacizumab 2 weeks before had a better effect on decreasing the pterygium vascularity, which minimized bleeding during operation in addition to decreasing the recurrence rate, according to this study.

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Objectives The aim of this work was to study the role of fundus fluorescein angiography and spectral domain optical coherence tomography (SDOCT) in the diagnosis of wet age-related macular degeneration (AMD). Background AMD is the leading cause of severe visual impairment in elderly people. Various imaging methods are available for the diagnosis and the classification of AMD. Fluorescein angiography (FA) is the gold standard for the differential diagnosis of neovascular AMD and determination of lesion characteristics. SDOCT is used for the diagnosis and the follow-up of patients with neovascular AMD undergoing antivascular endothelial growth factor therapy, by providing high-resolution cross-sectional images of retinal pathology. Participants and methods This study included 30 patients divided into three groups: group Me, patients with dry AMD; group II, patients with wet AMD divided into classic choroidal neovascularization (CNV) and occult CNV; group III, patients with geographic atrophy. All participants underwent a full ophthalmologic evaluation, including dilated fundus examination by binocular indirect ophthalmoscope. Slit-lamp biomicroscopy was performed using the Goldman three mirror lens and Volk 78 lens; also, the best-corrected visual acuity was measured with the Landolt chart and converted to the logarithm of the minimum angle of resolution (logMAR) units, and fundus fluorescein angiography and then optical coherence tomography (OCT) were performed. Results Using SDOCT imaging to delineate the lesion morphology, early AMD was detected by the presence of a normal foveal contour and minimal alteration in the macular area, classic CNV by the presence of a well-defined lesion with steep margins and a crater like configuration, and occult CNV by the presence of an ill-defined, flat lesion with a convex surface. FA-OCT overlay images provided a significant correlation between FA patterns and OCT features such as retinal pigment epithelium (RPE) complex changes. The sensitivity of cases with dry AMD in FA to cases with undulation in OCT was 100%, the specificity was 92%, the accuracy was 93%, the positive predictive value (PPV) was 75%, and the negative predictive value (NPV) was 100%. The sensitivity of cases with wet AMD in FA to cases with thickening in OCT was 96%, the specificity was 20%, the accuracy was 83%, the PPV was 86%, and the NPV was 50%. The sensitivity of cases with geographic atrophy of AMD in FA to cases with thinning in OCT was 100%, the specificity was 97%, the accuracy was 97%, the PPV was 50%, and the NPV was 100%. Conclusion SDOCT is highly sensitive for identifying AMD, CNV, and CNV activity, but cannot fully replace FA in the diagnosis of AMD.

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Background Pterygium is a common condition. Many theories have been proposed for its pathogenesis, but excessive sun exposure is the most accepted. Studies show that immunostaining of vascular endothelial growth factor is more intensive in pterygial than in normal conjunctival sections. Objectives The aim of the study was to conduct a trial evaluating the role of antivascular endothelial growth factor in the management of pterygium. Materials and methods Fifty eyes with primary pterygium were included in a nonrandomized trial to evaluate the effect of subconjunctival bevacizumab before excision using the bare sclera technique. None of the eyes had any history of previous ocular disease or surgery. Eyes were examined at presentation, 3 weeks after injection, and 3 and 6 months postoperatively. Examinations included best-corrected visual acuity (BCVA), slit-lamp, and fundus examinations. Pterygium was assessed with regard to site, vascularity, horizontal length, and recurrence after 3 and 6 months. Recurrence was defined as any fibrovascular growth over the cornea 1 mm beyond the limbus. Results There were statistically significant results regarding age, sex, and occupation; 72% were male; the average age was 43.00 ± 13.47 years; 80% worked outdoors. The pterygia resolved with a postoperative recurrence rate of 36% after 6 months. After injection, there was no statistically significant difference regarding improvement in visual acuity. There was significant improvement in ocular irritation, inflammation (82.14%), and horizontal length. Preinjection length average was 2.99 ± 1.08 mm and postinjection length average was 1.78 ± 0.99 mm. Vascularity improved in all cases by one grade after injection. Before injection, 14 cases (28%) were grade I, 22 cases (44%) were grade II, and 14 cases (28%) were grade III. Three weeks after injection, 36 cases (72%) were grade I and 14 cases (28%) were grade II. Conclusion Subconjunctival bevacizumab is well tolerated without local or systemic side effects. The main effect was reduction of inflammation and vascularity of the pterygium with no effect on recurrence.

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Background Enhanced recovery after surgery or fast-track surgery is a set of protocols aimed to reduce the physiological burden of surgery, thus improving outcomes. Fast-track surgery aims to use evidence-based practice to reduce complications, improve postoperative quality of life, and decrease hospital length of stay. Aims The aim of the study was to investigate the effect of applying enhanced recovery after surgery (ERAS) protocols on patients undergoing different abdominal operations. Settings and design The study was a prospective observational study that was conducted on 25 patients of ASA grades I-III, aged between 15 and 65 years, with different abdominal pathologies who were to undergo elective operations between August 2013 and May 2014. Materials and methods Patients were subjected to ERAS protocols. All patients were monitored in the hospital as needed until the patient fulfilled the discharge criteria (adequate oral intake; pain well controlled with oral analgesics; ability to void without difficulty; able to ambulate independently or at baseline levels; the patient believing he is ready for discharge and able to look after himself at home). Statistical analysis was performed using SPSS. Descriptive statistics were expressed as mean ± SD unless otherwise stated. Results The ERAS program has been proven to be safe, not only in reducing postoperative hospital stay and morbidity but also in improving patient convalescence. Conclusion The ERAS program had a significant role in reducing the duration of hospital stay as well as morbidity in patients undergoing major abdominal surgery.

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Objective The main aim of this study was to evaluate the efficacy of progesterone supplementation, cervical cerclage, or a combination of both in the prevention of preterm labor (PTL) and their impact on the perinatal outcome. Background PTL is defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix before term gestation (between 20 and 37 weeks). Preterm delivery occurs in 5-13% of pregnancies before 37 weeks' gestation. Patients and methods The present study was designed as a randomized clinical trial. Only 147 women who fulfilled our inclusion criteria (singleton pregnancy and a history of spontaneous PTL, twin or triplet gestations, sonographic cervical length <25 mm in mid trimester, and gestational age at the first antenatal visit of 12-16 weeks) were assigned randomly to the study. Forty-nine women received vaginal progesterone, 49 women were subjected to cervical cerclage, and 48 women received vaginal progesterone and cerclage. The primary outcome parameter was spontaneous delivery at less than 37 weeks' gestation. The secondary outcome parameter was spontaneous delivery at 34 or less weeks' gestation. The neonatal morbidity parameters were birth weight, Apgar score, and neonatal intensive care unit admission. Results The primary and secondary outcome parameters were significantly improved in the combination group (P = 0.005 and 0.008, respectively); also, the neonatal morbidity parameters (birth weight, Apgar score, and neonatal intensive care unit admission) were significantly improved in the combination group (P = 0.047, 0.003, and 0.002, respectively). Conclusion The combination of vaginal progesterone and cerclage was found to be significantly more effective in preventing PTL and in improving the perinatal outcomes in the high-risk groups.

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