Al-Azhar Medical Faculty, Girls

Airway management in morbidly obese adolescents: a comparison between Bonfils fiberscope and fiberoptic bronchoscope assisted with direct laryngoscopy Mostafa M Sabra The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):1-6 Background and aim Pediatric patients presenting to bariatric surgery is increasing in percentage in the last years and has become a fast growing epidemic problem. The aim of this study was to evaluate the usefulness of Bonfils fiberscope (BF-L) and fiberoptic bronchoscope (FO-L), assisted by direct laryngoscopy for intubation in morbidly obese adolescents with predicted easy intubation using the El-Ganzouri risk index score. Patients and methods Thirty adolescent American Society of Anesthesiologist II–III patients, aged 12–19 years, scheduled for laparoscopic bariatric surgery were randomized into two equal groups for intubation, with assistance of regular Mackintosh laryngoscope in both groups, either group BF-L and group FO-L. The standard protocol for general anesthesia was used for both groups. The primary outcome measure was the visualization quality using the percentage of glottis opening score. The secondary outcome measures were: duration of intubation and number of intubation attempts. Results Percentage of glottis opening scores were significantly better in group BF-L, when compared with group FO-L (93±6.44%/83±8%, respectively, P=0.002). The intubation success rate was 100% in both groups, and the mean intubation time was significantly longer (16±4.67 s) in group FO-L compared with 11±3.50 s in group BF-L (P=0.02). As regards the number of attempts, all patients were successfully intubated on the first attempt in group BF-L, while intubation was successful in 14 patients in group FO-L and one patient on the second attempt, which was statistically insignificant (P<0.05). Conclusion Orotracheal intubation was performed more rapidly and easily with BF-L and FO-L, with superiority of BF-L than FO-L in patients with predicted easy intubation using the El-Ganzouri risk index score

Pulmonary fungal infection in patients with acute exacerbation of chronic obstructive pulmonary disease Eman M Mahmoud, Magd M. Galal El-Din, Manal R Hafez, Eman Sobh, Radwa S Ibrahim The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):7-13 Background Pulmonary fungal infection (PFI) is increasing among patients with chronic obstructive pulmonary disease (COPD). Survival depends on rapid diagnosis and early treatment. Aims To assess the prevalence of PFI in acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and to investigate the clinical, demographic, and radiological findings related to PFI in COPD patients. Patients and methods This observational cross-sectional study was conducted on 80 patients with AECOPD. High-resolution computed tomography, fiberoptic bronchoscopy with bronchoalveolar lavage, spirometry, sputum and bronchoalveolar lavage fungal culture and measurements of serum 1, 3 beta-D-glucan (BDG) were done for all patients. They were classified into possible PFI and probable PFI based on the Bulpa and colleagues criteria. Results Among the 80 studied patients, 19 patients had possible PFI, and 61 patients had probable PFI; of them 12 patients had positive BDG and 49 had negative BDG. The use of either systemic steroids and/or antibiotics in the last 3 months was higher in patients with probable PFI than those with possible PFI (P=0.003). The daily dose (mg/kg) and duration of systemic steroids were higher in patients with probable PFI (P=0.001). The use of inhaled corticosteroids (ICS), its dose, and its duration did not differ between both groups. Conclusion Probable PFI is prevalent among patients with AECOPD 61 (76.3%); of them 19.7% was invasive form. PFI in AECOPD is related to the use, dose, and duration of systemic steroids and antibiotic use in the last 3 months. Therefore, a lower dose or interrupted course of systemic steroid must be considered in COPD patients.

Methylenetetrahydrofolate reductase C677T gene polymorphism and diabetic nephropathy susceptibility in patients with type 2 diabetes mellitus Amena R Zidan, Hala M El Mougy, Hasnaa S Moustafa, Shahinaz El attar, Eman F Mohamed The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):14-22 Background Type 2 diabetes mellitus (T2DM) is becoming increasingly prevalent throughout the world. Diabetic nephropathy (DN) is one of the most serious microvascular complications of diabetes mellitus. The C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene has been reported to cause reduced MTHFR enzyme activity and impaired homocysteine metabolism, leading to hyperhomocysteinemia. Aim The aim of the study was to evaluate the role of MTHFR C677T gene polymorphism in the susceptibility to DN in type 2 diabetic patients. Patients and methods The study was conducted on 180 adult Egyptian participants (60 healthy controls, 60 patients with T2DM without nephropathy, and 60 patients with T2DM complicated with nephropathy). C677T genotypes were determined by PCR-RFLP analysis, and homocysteine levels were measured by enzyme-linked immunosorbent assay. Results The prevalence of polymorphic genotype of CT and TT and T allele was statistically significantly increased in diabetic patients than in controls (P<0.001). There was a statistically significant increase in polymorphic genotypes (CT and TT) and T allele in T2DM with nephropathy in comparison to T2DM without nephropathy group (P<0.001, 0.05, respectively). Serum homocysteine levels were significantly higher in patients with nephropathy than in patients without nephropathy or controls with P less than 0.001. The higher serum homocysteine level was observed with polymorphic genotypes TT and CT compared with CC genotypes (P<0.001). Conclusion The TT genotype and T allele of MTHFR C677T may represent a significant genetic molecular marker to predict the risk of DN in T2DM.

Association of platelet endothelial cell adhesion molecule-1 gene polymorphism (Leu125Val) with coronary artery disease in type II diabetics and nondiabetics Maha M.S El-Kishki, Amal M Abdelfattah Alramly, Mohamed O Taha, Rana A El Din Medhat The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):23-32 Background and objectives Platelet endothelial cell adhesion molecule-1 (PECAM-1) plays a key role in the transendothelial migration of circulating leukocytes (diapedesis) during vascular inflammation. Polymorphism (Leu125Val) of the PECAM-1 gene (373C/G) is functional. It was reported to be associated with high serum level of PECAM-1. We hypothesized that this genetic variation of the PECAM-1 gene could be associated with the development of atherosclerosis. Therefore we conducted a study to investigate the association between single-nucleotide polymorphism of the PECAM-1 gene, C+373G (Leu125Val) at exon 3, in Egyptian patients with coronary artery disease. Patients and methods Blood samples were withdrawn from 40 coronary artery disease patients and 20 age-matched and sex-matched controls. The single-nucleotide polymorphism of the PECAM-1 gene was analyzed by PCR-restriction fragment length polymorphism strategy. Results Genotype distributions between patient and control groups showed no significant statistical difference regarding the CC genotype, where 22.5% of patients and 35% of controls carried this genotype (P=0.470). As for the CG genotype, a statistically significant higher CG genotype distribution was found in patients, where 52.5% of patients and only 20% of controls carried this genotype (P=0.033). There was no statistically significant difference in GG distributions between patient and control groups, where 25% of patients and 45% of controls carried this genotype (P=0.202). No significant statistical difference was observed in allele frequency between the two groups, where 51.25% of patients and 55% of controls carry the G allele and 48.7% of patients and 45% of controls carry the C allele (P=0.846). Interpretation and conclusion We concluded that our study demonstrated a possible effect of PECAM-1 (Leu125Val) polymorphism on the development of atherosclerosis.

Prolotherapy for knee osteoarthritis Hesham El-Dosoky, Saad M El Zokm, El Sayed Abd El-Hamid, Yousra Abo State The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):33-43 Background and aim Osteoarthritis (OA) is the most common type of chronic arthritis and represents a major cause of pain and disability. Prolotherapy is an injection of hypertonic dextrose used for painful chronic musculoskeletal pain conditions, including knee OA. Patients and methods This study was done to evaluate the effect of prolotherapy in treatment of knee OA. It was carried out on 200 patients with mild to moderate knee OA. The patients were classified into two groups: group 1 (100 patients) was treated by prolotherapy at 1, 5, and 9 weeks with re-evaluation after 6 months, and group 2 (100 patients) was treated by NSAIDS and physiotherapy for 6 months and served as a control group. Results The 6-month post-treatment visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index showed significant difference in pain, stiffness, and functional disability (P=0.001 and 0.043; 0.032 and 0.027; and 0.007 and 0.015, respectively) in both groups when compared with the baseline. However, on comparing both groups after treatment, we noticed significant difference in pain and disability favoring group 1 (P=0.031 and 0.048, respectively), whereas stiffness did not show significant difference between them (P=0.83). By knee ultrasound, degree of synovitis showed significant difference in groups 1 and 2 when compared with the baseline (P=0.004 and 0.007, respectively), but other parameters showed no significant differences. However, when comparing both groups after treatment, we noticed significant difference in cartilage thickness favoring group 1 (P=0.01), whereas other parameters did not show significant difference between them, although the degree, signs, and symptoms of knee effusion were improved in favor of prolotherapy group. Conclusion Prolotherapy is a promising line for treatment of knee OA. Prolotherapy reduces pain and improves the functional status in patients with knee OA.

A comparative study between the effect of intrathecal hyperbaric bupivacaine with fentanyl and hyperbaric levobupivacaine with fentanyl for knee arthroscopy Ayman Esmail Hussien, Mohamed Adel Gawad Abdel Halim The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):44-49 Background The use of levobupivacaine as a pure S (−) enantiomer of bupivacaine was progressively increased due to lower cardiotoxicity and neurotoxicity and shorter motor block duration. The aim of this work was to compare the effectiveness of lower-dose local anesthetics’ use together with higher opioid dose to decrease the side effects of drugs. We compared sensorial, motor block levels and side effects of equal doses of hyperbaric bupivacaine and levobupivacaine with intrathecal fentanyl addition in knee arthroscopy. Patients and methods After hospital ethics committee approval and getting written informed consent from patients, 100 patients with American Society of Anesthesiologists grade I–II, aged 18–40 years were included in the study. They were randomized to either group A receiving 7.5 mg (1.5 ml) hyperbaric levobupivacaine with 25 μg (0.5 ml) fentanyl, or group B receiving 7.5 mg (1.5 ml) hyperbaric bupivacaine with 25 μg (0.5 ml) fentanyl. Results Hemodynamic parameters such as the 45th minute mean arterial pressure of group B was found to be lower (P<0.05). In group A, maximum sensorial block level and postoperative visual analog scale scores were higher (P<0.05). Onset of motor block time, time to maximum motor block, time to sensorial block, reversal of two dermatome and first analgesic need were similar in both groups. Conclusion Intrathecal hyperbaric levobupivacaine–fentanyl combination is a better and good alternative to bupivacaine–fentanyl combination in knee arthroscopy, as it maintains hemodynamic stability.

Challenges in the management of primary lower extremity varicose veins: what is the best treatment option? Ahmed Mousa, Mohamed El Azzazi, Bosat E Bosat The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):50-59 Background Varicose vein is considered as one of the commonly practiced venous problems for decades not only by vascular surgeons but also by general surgeons. Aim The purpose of the current study was to compare the results of management of lower limb superficial varicosities using conventional surgery versus endovenous laser ablation (EVLA) therapy. Patients and methods A retrospective study took place in the period of three years from January 2015 until December 2017. Patients were selected for having reflux of the great saphenous vein (GSV) with primary varicosities of the lower limb presenting to the vascular surgery clinic. Patients were divided into two groups: group I included those who were treated with GSV short stripping and saphenofemoral junction disconnection, whereas group II involved patients who underwent EVLA. Results The study included 80 patients. There were 50 females and 30 males, with a female to male ratio of 5 : 3. Patients’ age ranged from 22 to 44 years, with a median age of 34 years. There was a significantly higher initial technical success rate of 95% (n=38) in the group treated with EVLA versus 90% (n=36) in the group treated surgically (P=0 · 006). Operative outcome was statistically significantly higher in the group treated with EVLA compared with the surgically treated group (P=0.002). A significant difference between operative procedures versus operative outcome was seen (P=0.002). Recurrent varicosities were observed in 10% and 5% in group I and group II, respectively. Heat-induced deep vein thrombosis was reported in 2.5% of cases. Conclusion Treatment of superficial varicosities with EVLA had a lower incidence recurrence rate than traditional surgery in the short-term follow-up. Moreover, the minimally invasive EVLA therapy, especially, in female patients seems to be a highly effective and safe modality for treatment of primary GSV varicosities.

Diagnostic utility of flexible bronchoscopy in mediastinal and hilar lymphadenopathies Taghreed S Farag, Abeer S Farag The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):60-71 Background Mediastinal and/or hilar lymphadenopathy with or without parenchymal lesions are difficult in the diagnosis via noninvasive techniques. Objective To assess the role of flexible fiberoptic bronchoscopy (FOB), in particular, blind transbronchial needle aspiration (TBNA) in the diagnosis of mediastinal and/or hilar lymphadenopathies. Patients and methods A cross-sectional study was carried out on 42 out of 83 patients presented by chest radiography of hilar and/or mediastinal lymphadenopathies with or without parenchymal lesions. Contrast-enhanced computed tomography chest and FOB, TBNA, and bronchoalveolar lavage were done for all patients. Forceps biopsy and bronchial brushing were done for some patients with bronchoscopic airway abnormalities. Results A total of 52 patients underwent FOB procedures; among them 10 (19.2%) patients were excluded due to nonconclusive diagnosis for further evaluations; final histopathological and/or microbiological diagnosis was confirmed in 42 (80.8%) patients, and they were included in data analysis. Among them, 25 (59.5%) patients had malignant lymphadenopathies (five patients had small cell lung cancer, 18 patients had nonsmall cell lung cancer, and two patients had lymphoma) and 17 (40.5%) had benign lymphadenopathies (eight patients had sarcoidosis, three patients had tuberculosis, six patients had reactive lymphadenitis). The overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of TBNA in the diagnosis of intrathoracic lymphadenopathies were 75.00, 54.50, 60.00, 70.60, and 64.29%, respectively. Conclusion Bronchoscopy with TBNA has good sensitivity and negative predictive value with fair specificity and positive predictive value in the diagnosis of intrathoracic lymphadenopathies. TBNA is a safe, effective procedure and can be performed easily during routine diagnostic bronchoscopy, and minimize the requirement for mediastinoscopy and thoracotomy.

Dexmedetomidine and fentanyl combination versus dexmedetomidine and pethidine as sedatives during colonoscopy Ahmed M.M El-Garhy, Khaled S.S Makboul The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):72-78 Background and aim Endoscopy procedures are generally performed under sedation, which ranging from minimal sedation to deep sedation. Conscious sedation during colonoscopic procedures provides a high level of patient and physician satisfaction. An ideal sedative agent should allow rapid modification of the sedation level by modifying the dose and should not have any adverse effects. Because such an ideal sedative agent does not exist, the combination use of dexmedetomidine with opioids (fentanyl or pethidine) may have the advantages over the use of a single agent. The goal of this study was to assess the effect of dexmedetomidine in combination with fentanyl or pethidine as a sedative for outpatient colonoscopy on hemodynamics, level and onset of sedation, analgesia, and degree of satisfaction of the colonoscopist and patients. Patients and methods A total of 60 colonoscopy patients between 21 and 60 years of age were included in the study. The patients scheduled for elective outpatient colonoscopy (with conscious sedation) were randomized into two groups: group 1 ‘DF group’ (N=30): dexmedetomidine 1 μ/kg/h infusion by syringe pump along with 1 μ/kg fentanyl was administered before the start of colonoscopy as a single shot, and Group 2 ‘DP group’ (N=30): dexmedetomidine 1 μ/kg/h infusion by syringe pump along with 1 mg/kg pethidine was administered before the start of colonoscopy as a single shot. The assessment includes heart rate (HR, beats/min), mean arterial blood pressure (MAP, mmHg), oxygen saturation at baseline and every 5 min, onset and level of sedation by Ramsay Sedation Score (RSS) after administration of the drugs, Numeric Pain Rating Scale at the end of colonoscopy, and the degree of satisfaction of the patients and the colonoscopist. Results The average value of the 6 h measurements in fentanyl group was 75.6±0.91 beats/min; whereas in pethidine group was 92.2±0.67 beats/min, with highly significant statistical difference (P<0.001), whereas there were nonsignificant differences regarding MAP and oxygen saturation. There was a highly significant decrease in the onset of sedation and increase in RSS and Numeric Pain Rating Scale in fentanyl group compared with pethidine group (P<0.01 for all). Moreover, there were nonsignificant differences regarding the degree of satisfaction for the colonoscopist and the patient (P>0.05). Multiple regression analysis shows that the increase in baseline HR had an independent effect on increasing onset of sedation (P<0.0001). Moreover, the fentanyl usage and the decrease in baseline HR had an independent effect on increasing RSS (P<0.01). Conclusion Patients who underwent colonoscopy and received dexmedetomidine-fentanyl regimen showed better hemodynamics (decreased HR, normal MAP, and oxygen saturation measurements), along with rapid onset of sedation and satisfied RSS compared with patients who received dexmedetomidine–pethidine regimen. In contrast, pethidine group showed better analgesia than fentanyl group. Both groups showed comparable satisfaction results in the colonoscopist and patients.

Comparative study the levels of plasma transforming growth factor-β1, serum crp, fecal lactoferrin, and fecal calprotectin as biomarkers for disease activity in Egyptian patients with ulcerative colitis Arafat Kassem, Hosam A.S Shabana, Mabrouk M Aboelenin The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(1):79-90 Aim This study aimed to analyze the utility of transforming growth factor-β1 (TGF-β1), C-reactive protein (CRP), fecal lactoferrin (LF), fecal calprotectin, and the Mayo score for severity of ulcerative colitis (UC) in monitoring disease activity in Egyptian patients with UC. Patients and methods This study was carried out on 130 patients with UC and scored according to the Mayo score for severity of UC. Patients and controls were exposed to fecal and blood samples to assess TGF-β1, CRP, fecal LF, and fecal calprotectin. Results The values of TGF-β1, CRP, fecal LF, and fecal calprotectin in UC patients (n=130) compared with controls (n=30) were as follows: TGF-β1: 489.32±315.68 versus 5.93±1.81 pg/ml, CRP: 15.97±9.13 versus 3.17±0.95 mg/l, fecal LF: 497.06±448.95 versus 7.01±4.00 μg/g, fecal calprotectin: 809.70±554.36 versus 36.33±15.51 µg/g (for all P<0.001). The parameters of Mayo Score that determine the severity of ulcerative colitis correlated significantly with TGF-β1 (Spearman’s rank correlation coefficient r=0.925), CRP (r=0.957), LF (r=0.932), and calprotectin (r=0.953). TGF-β1, CRP, fecal LF, and calprotectin levels were significantly lower in UC patients with inactive disease (TGF-β1: 46.4±37.1 pg/ml; CRP: 4.8±1.3; LF: 28.6±28.3 μg/g; calprotectin: 71.7±24.2 µg/g; P<0.001 for both LF and calprotectin, but P>0.05 for both TGF-β1, and CRP) compared with patients with mild (TGF-β1: 343.4±110.7 pg/ml; CRP: 9.8±2.1; LF: 177.8±66.8 μg/g; calprotectin: 459.0±206.7 µg/g; P<0.001), moderate (TGF-β1: 640.6±141.0 pg/ml; CRP: 18.6±3.5; LF: 561.0±181.9 μg/g; calprotectin: 1080.8±224.1 µg/g; P<0.001), and high active disease (TGF-β1: 814.5±132.9 pg/ml; CRP: 27.1±3.0; LF: 1048.3±296.8 μg/g; and calprotectin: 1421.7±95.5 µg/g; P<0.001). The overall accuracy for the detection of histopathologic active disease was 87.7% for TGF-β1, 89.2% for the Mayo score for severity of UC, 84.6% for CRP, 90% for fecal LF, and 91.5 for fecal calprotectin. Conclusion Fecal LF, fecal calprotectin and TGF-β1, and CRP correlated significantly with the Mayo score for UC and histopathology. Furthermore, calprotectin and LF are appropriate markers that can distinguish endoscopic and histopathologic inactive from active disease. Also, TGF-β1 and CRP were used as suitable markers to differentiate mild from moderate and the moderate from high active disease. Thus, these four biomarkers may be used for surveillance of UC activity.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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6948891480

alsfakia@gmail.com