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   Table of Contents - Current issue
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October-December 2017
Volume 15 | Issue 4
Page Nos. 163-227

Online since Thursday, July 19, 2018

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ORIGINAL ARTICLES  

Interictal ceramide kinase in migraine Highly accessed article p. 163
Manal H Maabady, Ghada S Abdelazim, Asmaa El Madbouly
DOI:10.4103/AZMJ.AZMJ_28_17  
Introduction Migraine is a common neurologic disorder. It is still controversial whether migraine is a primarily vascular disorder or caused by neuronal dysfunction, but it is likely that both have a significant role to play. Objective The objective of this study was to evaluate serum levels of interictal ceramide kinase in patients with migraine. Patients and methods A total of 35 patients with migraine, including 12 patients with migraine with aura and 23 patients with migraine without aura, and 16 apparently healthy, age-matched and sex-matched individuals were included in this study. Patients underwent full history taking, including type of headache, frequency of headache attacks per month, and assessment of migraine-related disability by the Migraine Disability Assessment Scale. Serum ceramide kinase level was evaluated for both patients (during pain-free period) and control participants using quantitative sandwich enzyme-linked immunosorbent assay. Results The patients with migraine had significantly higher serum levels of ceramide kinase than the control group, and these levels were significantly correlated with the frequency of the attacks and with scores of Migraine Disability Assessment Scale. Conclusion The results suggested that migraine is associated with alteration in sphingolipid metabolism and that might be because of increased levels of ceramide kinase.
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Seroma formation after modified radical mastectomy p. 168
Mahmoud AboAmra
DOI:10.4103/AZMJ.AZMJ_31_17  
Background Modified radical mastectomy remains the most commonly performed surgery for breast cancer. Aim of the work The aim of this study was to evaluate the effect of different methods (conventional scalpel, electrocautery, and harmonic scalpel) of breast dissection during mastectomy on seroma formation. Patient and methods This study was conducted in Al-Azhar University Hospital in Assiut from April 2013 to April 2016, on 110 female patients aged from 25 to 70 years; all patients were having stage II breast cancer, according to the Manchester and International Union against Cancer (TNM). Modified radical mastectomy was done after complete preoperative assessment. Result One-hundred and ten female patients have stage II breast cancer aged from 25 to 70 years. During the modified radical mastectomy, in this study, the breast dissection was done by electrocautery in 42 patients, using conventional scalpel in another 42 patients and using harmonic scalpel in the remaining 26 patients. At the end of this study, there were 15 cases (out of 110 patients) of postmastectomy seroma detected postoperatively, only one case in the conventional scalpel group, 14 cases in the electrocautery group and no case in the harmonic scalpel group. The wound drains were removed in all cases on day 7postoperatively. In all patients of this study, a pressure garment was used postoperatively. Conclusion The use of harmonic scalpel in breast dissection is better than electrocautery use as regards postmastectomy seroma formation. If harmonic scalpel is not available, it is better to use the conventional scalpel.
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Evaluation of acute physiology and chronic health evaluation IV score and sequential organ failure assessment score in predicting outcome of patients in respiratory intensive care unit p. 172
Ahmad A Naglh, Moustafa Zedan, Mahmoud Arafa, Mohammad Alzeftawy
DOI:10.4103/AZMJ.AZMJ_25_17  
Background Scoring systems in ICU allow assessment of severity of the disease and provide an estimate of in-hospital mortality. And they quantify the severity of illness for hospital and health care system administration. Objective The objective of this study was to detect the ability of acute physiology and chronic health evaluation (APACHE) IV score and sequential organ failure assessment (SOFA) score in predicting outcome of patients in respiratory intensive care unit (RICU). Patients and methods A prospective observational cohort study was performed at the RICU of Bab El-Sha’eria and Al-Hussein Al-Azhar University hospitals. The study includes all critically ill patients admitted to the RICU between November 2014 and November 2016. Data were collected from 100 patients (42 female and 58 male) consecutively admitted to the RICU (aged ≥18 years and ICU stay of ≤24 h). Mean of APACHE IV score, length of stay, and predicted mortality rate were calculated during the first 24 h. Mean of SOFA score and length of stay were calculated during the admission. Data were analyzed with SPSS versus version 15. Results In 100 patients, the observed mortality rate was 49%. The mean age in survived patients was 57.216±12.588 years and in nonsurvived patients was 62.694±10.304 years. APACHE IV score more than 81 was kept as cutoff point, with sensitivity of 81.6% and specificity of 80.4% with area under receiver operating characteristic curve of 0.841. SOFA score more than 7 was kept as cutoff point, with sensitivity of 95.9% and specificity of 100% with area under receiver operating characteristic curve of 0.997. Conclusion The mortality prediction by APACHE IV and SOFA scoring systems performs acceptably in our patients, and they can be used as performance assessment tools in our RICUs. Both scores showed good discrimination between survived and nonsurvived patients, with SOFA score being more accurate in predicting mortality than APACHE IV.
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Breast cancer prognostication with neutrophil–lymphocyte ratio and platelet–lymphocyte ratio p. 179
Taha Bahgat
DOI:10.4103/AZMJ.AZMJ_45_16  
Introduction Peripheral blood-derived inflammation-based markers such as neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) have been recently evaluated as prognostic markers in solid tumors. Although evidence to support these markers as prognostic factors is documented in gastrointestinal cancers, little is known of their impact on breast cancer (BC). Patients and methods A total of 100 patients presented with resectable early-stage BC treated with neoadjuvant chemotherapy. Tumor characteristics included tumor size, number of positive lymph nodes, estrogen and progesterone receptors, tumor grade, lympho-vascular invasion, and human epidermal growth factor receptor 2 (HER2) status. Sample of peripheral blood was analyzed and NLR and PLR were calculated. Results Forty-two (42%) patients were judged as having low NLR and 58 (58%) as high NLR. Low NLR was significantly correlated with younger age (P=0.028), premenopausal status (P=0.032), pathological complete response result (P<0.001), and triple-negative BC phenotype (P<0.001). The low-PLR group had significantly more patients older than 52 years old (P=0.001) and postmenopausal patients (P=0.001) than the high-PLR group. The low-PLR group also had a higher pathological complete response rate (P=0.024). The low-PLR group was found to have significantly longer Defensive Functioning Scale (P=0.001) than the high-PLR group. Univariate analysis showed that lymph node metastasis (P=0.040) and a high PLR (P=0.010) were unfavorable prognostic factors. Moreover, multivariate analysis also revealed that lymph node metastasis (P=0.030) and a high PLR (P=0.010) were independent, unfavorable prognostic factors in BC. Conclusion Both NLR and PLR are independently associated with an increased risk of Defensive Functioning Scale in BC.
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Effect of new direct-acting antiviral drugs on insulin resistance and glycemic control after treatment of chronic hepatitis C virus infection in type 2 diabetic patients p. 187
Alaa E.M Hashim, Hanaa T Kandeel, Olfat M Hendy, Khaled El-Mola, Fathyia M El-Raey, Mohamed S.M Attia
DOI:10.4103/AZMJ.AZMJ_7_18  
Background Hepatitis C virus (HCV) infection is associated with diabetes and may worsen glycemic control in patients with diabetes. The benefits of eradicating HCV infection with direct-acting antiviral (DAAs) may go well beyond avoiding the damage caused by chronic liver inflammation, to include declines in glycated hemoglobin percent and other metabolic parameters. The present study was designed to evaluate the effect of new DAAs drugs, used for treatment of HCV, on insulin resistance and glycemic control at the end of treatment and 3 months after end of treatment of HCV infection in patient with type 2 diabetic mellitus (T2DM) in Damietta Governorate. Patients and methods This study included 75 T2DM patients with chronic HCV infection. Patients were divided according to level of glycosylated hemoglobin percent into three groups. All patients received DAAs and were monitored by A1C%, homeostasis model assessment-insulin resistance, and fasting blood sugar before, at the end of treatment, and 12 week after the end of treatment. Patients were allocated into two groups: the first group included 57 (76%) patients with improved glycemic control (IGC) and the second group included 18 (24%) patients with nonimproved glycemic control (NIGC). Results In IGC group, 45 (78.9%) patients needed to decrease the dose of antidiabetic treatment. There were no significant differences between IGC and NIGC groups regarding sex and liver condition. The percentage of patients with old age, those with positive family history of T2DM, and those with long duration of T2DM were significantly higher in NIGC group compared with IGC. Conclusion Diabetic patients receiving DAAs should be closely monitored during reduction of antidiabetic drugs, especially regarding insulin and sulfonylurea, to avoid hypoglycemic events. Improvement of glycemic control with DAAs is seen more in younger patients without family history of T2DM and short duration of diabetes mellitus.
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Lichtenstein procedure versus darn repair in primary inguinal hernia surgery p. 196
Ahmed A.M Khyrallh
DOI:10.4103/AZMJ.AZMJ_59_17  
Introduction With the advent of newer methods for inguinal hernia repair like laparoscopy and mesh, older techniques like darn repair have gone into the background. However, in developing countries like Egypt where cost-effectiveness is of prime concern, darn repair still enjoys a good reputation and popularity for the repair of inguinal hernia. This study was carried out to compare darn repair with Lichtenstein repair regarding early outcome. Patients and methods A total of 100 male patients aged from 20 to 60 years old who presented with primary inguinal hernia were operated upon with Lichtenstein or darn repair as elective procedure from January 2013 to October 2016. They were subjected to this prospective randomized-controlled trial. The primary endpoint was to compare the early outcome of these two procedures. Results The need for analgesia and hospital stay was higher in patients who had Lichtenstein repair. Hematoma occurred in one (1%) patient and seroma occurred in four (4%) patients in both groups. The prevalence of wound infections as superficial and deep infections in groups A and B was 4 and 4%, respectively, which were resolved through conservative management. Complications of recurrence in group A were 2% as compared with group B, which had a recurrence of 4%. This difference was not significant. Conclusion Both darn repair and Lichtenstein repair resulted in rapid recovery and low recurrence rates; however, the advantage of the darn repair lies in the fact that it does not require mesh, so it is much cost effective.
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Dermoscopy versus skin biopsy in diagnosis of suspicious skin lesions p. 203
Hassan Ibrahim, Moustafa El-Taieb, Ahmed Ahmed, Radia Hamada, Essam Nada
DOI:10.4103/AZMJ.AZMJ_67_17  
Background Dermoscopy is a simple and inexpensive diagnostic technique that permits the visualization of morphologic features that are not visible to the naked eye, forming a link between clinical dermatology and microscopic dermatopathology. For many years, skin biopsy was considered the only definite diagnostic tool that confirms or excludes the clinical diagnosis. Skin biopsies are invasive and have many adverse effects and precautions. Objective To evaluate the accuracy of dermoscope in diagnosis of skin tumors and its correlation with clinical and pathological diagnosis. Patients and methods Thirty-four patients who attended Dermatology Clinic at Qena University Hospital from January 2013 to December 2014 were recruited in a nonrandomized prospective study. The inclusion criteria were reported through the following: full history taking, such as (a) name, age, sex, duration of the lesion, onset, progress, and symptoms; (b) previous history of similar lesions or skin cancer; (c) family history of similar lesion or skin cancer; and (d) any recognized changes in the lesion in the past year such as change in size, consistency, hair growth, or bleeding; dermatologic examination, such as (I) type, site, size, shape, color, surface, and border of lesion have been also detected and reported by using of the three-point checklist as a method for differentiation between benign and suspicious lesions and (II) any specific manifestations as tenderness, bleeding, and recurrence have been detected; (III) digital photography has been performed using digital camera (Sony cyber-shot 16.1 mega pixels); dermoscopic findings by using dermoscope (HEINE BETA DELTA 20), and histopathological examination. Results There was an excellent diagnostic reliability of dermoscopy compared with skin biopsy with interrater κ value of 0.859 (confidence interval: 0.734–0.984, P<0.001). The overall agreement between dermoscopical and histopathological diagnosis was recorded in 27/33 (81.8%) cases. The ability of dermoscopy to differentiate lesion categories was investigated. Nine of the 10 neoplastic lesions and 22 of the 23 non-neoplastic lesions were identified by dermoscopy [χ2(1)=24.2, P<0.001] with sensitivity and specificity rates of 90 and 95.7%, respectively, and positive and negative predictive values of 90 and 95.7%, respectively. Regarding differentiation benign from malignant skin lesions, dermoscopy identified 25 of the 26 benign lesions and identified all malignant skin lesions [χ2(1)=27.8, P<0.001]. The specificity and sensitivity were 96.2 and 100%, respectively, and the positive and negative predictive values were 100 and 87.5%, respectively. Conclusion There was a good agreement between the dermoscopy and clinical diagnosis and also a good agreement between the dermoscopy and pathological diagnosis. So dermoscopy can be introduced as a routine diagnostic tool in dermatological examination and will be of a great aid in the accurate diagnosis of suspicious skin lesions before invasive skin biopsy. However, further studies with large sample size are needed later on.
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Ileopexy in open reduction of ileocolic intussusception in pediatrics: its role on recurrence p. 210
Ibrahim Mahmoud Elsayaad, Mohammed Shahin, Ahmed Fekry El-Deek
DOI:10.4103/AZMJ.AZMJ_5_18  
Background Intussusception is the main reason of intestinal obstruction in pediatrics. Hydrostatic reduction (HR) is the cornerstone in its treatment. However, surgical treatment is indicated in case of failure of HR. Fixation of terminal ileum (ileopexy) has been used to reduce or even prevent recurrence of intussusception, but its outcome has not been well studied. Aim The aim was to investigate the effect of fixation of terminal ileum on recurrence rate after surgical reduction of intussusception in pediatric age group. Patients and methods A total of 80 children scheduled for surgical reduction of intussusception were included and randomly assigned to fixation of terminal ileum (group A; n=40) or no fixation (group B; n=40). All were assessed clinically, and laboratory investigations were done. Patient’s demographics and surgical outcome were documented and compared between both groups. Results Both groups were comparable regarding demographic data, clinical presentation, duration of symptoms before admission, surgical indication, and duration of hospital stay. In addition, the recurrence rate was nonsignificantly reduced in group A when compared with group B (5.0 vs. 15.0%, respectively). In addition, HR was successful in one and failed in the other recurrent case in group A (50.0% of success) compared with only one (16.7%) of six in group B. Conclusion Fixation of terminal ileum during surgical reduction of intussusception is safe, feasible, and simple technique. It results in reduction of the recurrence rate. However, the difference was statistically nonsignificant.
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Attenuation of cardiovascular responses to tracheal extubation with labetalol p. 216
Mokhtar M Younes, Ali A Mahareak, Eman A Salem, Tawfeek Nooreldin
DOI:10.4103/AZMJ.AZMJ_14_18  
Background Stress response to tracheal extubation causes autonomic or endocrine disturbances such as hypertension, tachycardia, and arrhythmias that may be potentially dangerous in patients with cardiovascular disease. It is better to avoid the occurrence of stress response by preemptive therapy. Various pharmacological methods are used to suppress this response, but none of them is 100% effective. So, it is desirable to use a drug with rapidly recognizable and easily treatable adverse effects. Aim The aim of this study was to compare the effects of labetalol, fentanyl, and lidocaine in suppressing hemodynamic stress response to tracheal extubation. Patients and methods This prospective, randomized, controlled, double-blinded study was conducted in multicenter Fakhry Hospital, Al Hussain University hospital and Al Zahra University hospital on 80 patients classified as American Society of Anesthesiologists physical status I or II who were undergoing elective general surgery under general anesthesia between January 2017 and June 2017. These 80 patients were randomized through computer-generated and sealed opaque envelope method into four equal groups, each of them with 20 patients. All patients received a standardized anesthetic protocol. Fifteen minutes before extubation, patients received either labetalol 0.25 mg/kg or fentanyl 2.0 µg/kg or lidocaine 2% 1.5 mg/kg or isotonic saline. All patients were extubated by anesthesiologists who were blinded to the studied drugs, and all were continuously monitored for 20 min after extubation. The primary outcome was hemodynamic changes, heart rate (HR) and mean arterial blood pressure (MAP), which were recorded before and after extubation. The secondary outcomes were respiratory rate and oxygen saturation (SpO2), which were recorded after extubation on room air, and the degree of sedation after extubation, as assessed by Ramsay sedation score. Results The results of our study reveal that HR and MAP were comparable in all the groups until 10 min before extubation. Later, there was an increase in HR and MAP in lidocaine and saline groups. There was statistically significant decrease in HR and MAP in labetalol and fentanyl groups at 5 min before extubation, at extubation, and 5 and 10 min after extubation, in comparison with lidocaine and saline groups. Moreover, there was a statistically significant decrease in HR and MAP in labetalol group at 5 min before extubation, at extubation, and 5 and 10 min after extubation, in comparison with fentanyl group. Conclusion We conclude that both labetalol and fentanyl effectively blunt hemodynamic response to tracheal extubation in patients undergoing elective surgeries under general anesthesia and can be safely used. Labetalol at dose of 0.25 mg/kg is a better agent than fentanyl (2.0 µg/kg) and lidocaine (1.5 mg/kg) in attenuating the sympathetic response to tracheal extubation. However, patients in the fentanyl group showed greater degree of sedation without any deleterious effects.
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Evaluation of serum periostin level in atopic dermatitis patients p. 223
Afaf H Ghanem, Fathia M Khattab, Amal Zidan
DOI:10.4103/AZMJ.AZMJ_3_18  
Background Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease. Periostin is an intrinsic mediator induced by T helper-2 cytokines. It has been reported to play a critical role in the pathogenesis of AD. Objective The objective of this study was to estimate the serum periostin level in AD patients and to determine its correlation with the severity and chronicity of the disease. Patients and methods This study included 36 AD patients and 36 healthy controls, matched for age and sex. Three millimeters of venous blood was collected from each patient. Serum periostin level was determined by enzyme-linked immunosorbent assay. We determined the correlation between serum periostin level, duration of disease, severity, type of atopy, and SCORAD score. Results There were highly significant differences between patients and controls as regards serum periostin level (P<0.001). There were significant differences between severe AD patients in serum periostin level, with an increased level among those with severe degree (P<0.001). There were significant differences in serum periostin level among the widespread type (P=0.03). Furthermore, there were significant positive correlations between periostin level and both duration and SCORAD score of the patient group. Conclusion Serum periostin level may correlate with disease severity and chronicity in patients with AD.
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