Al-Azhar Assiut Medical Journal

Comparative study of the pattern of tuberculosis in Suez and Damietta Chest Hospitals in the period 2007–2016 Fares Mohammed Oaf, Ezzat Atwa Risk, Abd El Monem El-Shabrawi Metwally, Kamel Abd-Elghafar Elghonemy, Mokhles Abdel Fadil Zineldin, Abdel-Fatah Ahmed Abdel-Khalek Al-Azhar Assiut Medical Journal 2018 16(4):319-326 Background Tuberculosis (TB) is an infectious disease affecting the world population for thousands of years. Aim The aim was to study and compare the pattern of TB in Suez and Damietta Chest Hospitals through the period from 2007 to 2016. Patients and methods This is a retrospective study that was carried out at Damietta and Suez Chest Hospitals and dispensaries and included all cases of TB from January 2007 to December 2016. Data were collected from TB registration units. Direct observed therapies strategy in chest hospitals and dispensaries started since January 1999. Results A total of 1208 (62.3%) cases were men and 732 (37.7%) were women. The highest rate of infection was reported in age group of 20–29 years (45.7%); the lowest affected age group was that greater than 60 years (5.1%). Type of TB was pulmonary in 76.1% and extrapulmonary in 23.9%. The main presenting symptom was cough presented in 50.8%, hemoptysis in 20.3%, chest pain in 14.7%, and fever in 14.2%. The sputum smear was positive in 89.3% and negative in 10.7%; and there was significant increase of positive smear in Damietta when compared with Suez Governorates (92.1 vs. 86.2%, respectively). The most common extrapulmonary lesion was pleural effusion (40.5%); then lymph node (19.4%) and the least was cold abscess (2.6%). Diabetes was reported in 11.5% and prolonged corticosteroid therapy in 6.5%. The condition at discharge was improvement in 85.5%, failure in 6.6%, relapse in 4.8%, and death in 3.1%. Both groups were comparable as regards the studied variables. Conclusion There was progressive decrease of total TB cases in both Damietta and Suez Governorate from 2007 to 2016 and both governorates were comparable.

Magnesium sulfate, dexmedetomidine, and lignocaine in attenuating hypertension during laparoscopic cholecystectomy: a comparative study Ismail M.A Ahmed, Hesham S Abdelraouf Al-Azhar Assiut Medical Journal 2018 16(4):327-332 Background Pneumoperitoneum during laparoscopic surgery is associated with significant hemodynamic changes represented by increasing heart rate, vascular resistance, and blood pressure. This study aimed to compare the safety of each of magnesium sulfate, dexmedetomidine, and lignocaine on hemodynamic responses during pneumoperitoneum. Patients and methods In all, 120 patients were enrolled in the study. They were electively planned for laparoscopic cholecystectomy. Their ages were in the range of 21–60 years. Men were 38.3% and women 61.67%. American Society of Anesthesiologists I: 74.17% and II: 25.83%. The patients were randomly allocated into four groups: each of 30 patients. Group M administered magnesium sulfate preoperatively as loading followed by infusion 50 mg/kg/h, group D received dexmedetomidine preoperatively as loading followed by infusion 0.5 µg/kg/h, group L was given lignocaine preoperatively as loading followed by infusion 1 mg/kg/h, and group C received normal saline. Results A significant difference was noticed as regards heart rate changes and mean arterial blood pressure increase between the groups of magnesium sulfate, dexmedetomidine, lignocaine, and the control group at the time of drug administration, after intubation, throughout pneumoperitoneum at 5 min intervals, postpneumoperitoneum, and in the postoperative period after 10 min (P<0.001). Conclusion Magnesium sulfate and dexmedetomidine infusions have comparable effects. Lignocaine was less effective in the attenuation of the hypertensive response of pneumoperitoneum and reducing the dose requirements of opioids during laparoscopic cholecystectomy.

Immediate and short-term outcome of septoplasty with nasal packing with reference to the effect of arterial blood gases' concentrations Mohamed A Fatahalla, Ashraf A Wahba, Mahmoud M Elsayed Al-Azhar Assiut Medical Journal 2018 16(4):333-342 Objectives To evaluate the outcome of septoplasty and the effect of bilateral anterior nasal packing (NP) on surgical outcome and postoperative (PO) arterial blood gas levels. Patients and methods A total of 90 patients underwent septoplasty: group I included patients who received PO bilateral anterior NP at the end of surgery for 48 h and group II included patients free of NP. Patients were evaluated clinically using the Nasal Obstruction and Septoplasty Effectiveness scale and underwent septoplasty using Cottle’s technique. Arterial blood samples were obtained preoperatively and before NP removal for estimation of arterial blood pH, bicarbonate (HCO3−), partial pressure of O2 (PaO2) and CO2 (PaCO2), and O2 saturation (SaO2) levels. Pain severity was assessed using numeric rating scale at 6 h, D-1, and D-2 PO, and during the first 48 h PO, nasal bleeding in group II was estimated. After NP removal, pack removal-associated pain and amount of bleeding were determined. Results Operations were conducted uneventfully with nonsignificant difference between groups. At 48 h PO, mean PaO2, PaCO2, and SaO2 levels were significantly lower in all patients than preoperative levels, with significantly lower SaO2 and PaCO2 levels in patients of group I than group II. Numeric rating scale pain scores in both groups showed progressive significant decrease till 48 h PO, with significantly lower scores in group II. Removal of NP resulted in pain scored by more than or equal to 4 in 30 patients and induced minimal bleeding, which was significantly lower than bleeding occurred in patients of group II throughout the 48 h PO. All patients enjoyed significant reduction of Nasal Obstruction and Septoplasty Effectiveness score, with nonsignificant difference between both groups. Conclusion NP after septoplasty reduced amount of PO bleeding, but pain associated with NP presence and removal-induced deleterious effect on patients’ satisfaction with deleterious effect on arterial blood O2 and CO2 levels but with nonsignificant effect on arterial blood pH or HCO3 concentration.

Sensory and motor effects of dexmedetomidine as an adjuvant to bupivacaine for brachial plexus block Yousry Kandil Al-Azhar Assiut Medical Journal 2018 16(4):343-348 Background Dexmedetomidine is a highly selective (eight time more selective than clonidine), specific, and potent α2-adrenergic agonist having analgesic, sedative, antihypertensive, and anesthetic sparing effects when used in systemic routes. Patients and methods Forty patients of both sexes, aged between 25 and 70 years; American Society of Anesthesiologists I–II, who were submitted to elective upper limb surgery by supraclavicular brachial plexus block were included in the present study. They were selected during the period from March 2016 to June 2017. The patients were divided randomly by sealed envelopes into two equal groups (n=20). Group I: 20 patients received 30 ml bupivacaine 0.25%. Group II: 20 patients received 30 ml bupivacaine 0.25% plus 100 μg dexmedetomidine. Results The duration was reported in group II 13.13±1.10 and 16.50±1.63 min for the onset of sensory and motor blocks, respectively, and in group I 14.90±1.18 and 18.63±1.12 min for the onset of sensory and motor blocks, respectively. There was significant decrease of median pain score in group II when compared with group I at 4, 8, 12, 16, 20, and 24 h postoperatively. Conclusion Dexmedetomidine had significantly better postoperative analgesic effects, longer duration of sensory and motor blockade, and earlier onset of action. However, it had unwanted side effects in the form of transient bradycardia and hypotension.

Using two scores for the prediction of mortality in pediatric intensive care units Ashraf Abdelkader, Mohamed M Shaaban, Mahmoud Zahran Al-Azhar Assiut Medical Journal 2018 16(4):349-355 Background Pediatric intensive care unit (PICU) has a specific location for the management of seriously ill children. Aim of the work The purpose of the study was to compare two models [Pediatric Risk of Mortality III (PRISM III) and the Pediatric Index of Mortality 3 (PIM3) scores] for the prediction of mortality in PICU in KSA. Patients and methods A prospective, cohort study was conducted and two mortality scores, PRISM III and PIM3, were applied on 68 children admitted to the PICU at As-Salama Hospital, Al Khobar, KSA over a period of 1 year from January till December 2016. Results The mean age was 7.6±5.3 years with more men than women and the mean length of hospital stay was 9.8±7.0 days. The overall expected mortality using the PRISM III score was 6.7% whereas that by PIM3 was 7.4% and the observed mortality was 17.6%. Both tests underpredicted mortality at all probability levels. However, the degree of underprediction was less when the predicted mortality was more than 25%. Both tests showed excellent discrimination with a value of 0.94 (95% confidence interval, 0.86–1.0) with 94.1% sensitivity and 72.0% specificity; and of 0.93 (95% confidence interval, 0.87–0.99) with 82.4% sensitivity and 84.0% specificity, respectively. The Hosmer and Lemeshow goodness-of-fit test showed good calibration for PRISM III score (χ2=4.57, P=0.148) but poor calibration for PIM3 score (χ2=8.66, P=0.01). Conclusion Both PRISM III and PIM3 scores underpredicted mortality at all probability levels. They offered good discrimination; however, the performance of the scoring system in the PICU patients was poor. PRISM III score showed good calibration while PIM3 score showed poor calibration.

Cerebral microembolization in patients with prosthetic valve and anticoagulation assessment using transcranial Doppler ultrasonography Mohamed A Zaki, Mohamed EL Sayed Moussa Al-Azhar Assiut Medical Journal 2018 16(4):356-359 Background Transcranial Doppler detection of microemboli is widely described, and thromboembolism is a major cause of morbidity in patients with prosthetic heart valves. They require lifelong anticoagulation to minimize thrombotic complications. This study was undertaken to assess the clinical relevance of microembolic signals (MESs) and their relation to anticoagulation. Patients and methods Thirty patients with single mitral mechanical prosthetic valve were included. All of them were selected with low intensity of international normalization ratio (INR). After 2-week interval, INR intensities were stabilized to the recommended levels. Transcranial Doppler monitoring for MES detection was done to the same patients, before and after the stabilization of INR intensities. Results Microemboli were detected in 86.7% of patients before and after the INR level adjustment, with mean number of 57.63±13.12 before adjust. The numbers were significantly lowered after the adjustment of INR, as the emboli number became 24.1±9.12. Conclusion Compared with previously thought findings, the study results were different, as there was a significant effect of the anticoagulation on the number of MESs detected in patients with mechanical valve replacement, but without effect in MES incidence, denoting that, there were a variety of MESs rather than thrombotic. Further assessment by MES differentiation to define solid ones will be indicated.

The role of human umbilical cord blood stem cells in modifying the effect of experimentally induced myocardial infarction in male albino rats Mohammed S Tawfeeq, Salah M Ibrahim, Somia H Abd Allah, Randa S Gomaa, Alaa E Salama, Reham M WahidEldin Al-Azhar Assiut Medical Journal 2018 16(4):360-370 Background Ischemic heart diseases are considered as the first cause of death around the world. Mesenchymal stem cells are considered to be a novel therapy that can achieve real success in myocardial infarction (MI). Objective Evaluating the homing capability of human umbilical cord blood stem cells (HUCBSCs) in the injured myocardium and its role in the development of MI in adult male rats. Materials and methods Fifty adult male albino rats were divided into five groups (n=10): control, MI, MI pretreated with HUCBSCs, MI posttreated with HUCBSCs within 24 h, and MI posttreated with HUCBSCs within 1 week. Serum cardiac troponin I and creatine kinase-myoglobin binding levels were evaluated to assess MI induction. Gene expression of human β actin gene was assessed to evaluate HUCBSCs homing and rat caspase-3 gene was assessed to evaluate apoptosis. Myocardial histopathological examination was done to assess fibrosis. Echocardiographic left ventricular dimensions and function and mean arterial blood pressure were assessed. Results β actin gene expression was higher in all HUCBSCs injected groups compared with normal and MI groups. Administration of HUCBSCs decreased caspase-3 gene expression and fibrosis and improved cardiac function and mean arterial blood pressure in all HUCBSCs injected groups compared with the MI group and these effects were more in pretreated group than both posttreated groups. Expression of rat caspase-3 gene, histopathological assessment, and echocardiography results showed more improvement in posttreated within 24 h group than posttreated within 1-week group. Conclusion HUCBSCs have high homing capability in injured myocardium and they could be used as a preventive therapy in case of ischemia to protect the heart from implications of MI. Moreover, it could be an effective therapy especially if administered within 24 h after MI. Further studies are recommended to highlight the preventive role of HUCBSCs and its clinical application especially in cases of unstable angina.

The effect of 'cytochrome P-450 2C9' and 'vitamin K epoxide reductase complex 1' genetic polymorphism upon oral anticoagulation requirements Hossam Y.K Mohammed, Yousry Z Al-Zohairy, Mahmoud Abd El-Latif Hashish Al-Azhar Assiut Medical Journal 2018 16(4):371-376 Background Polymorphisms in the gene encoding the cytochrome P-450 2C9 enzyme (CYP2C9) are known to contribute to variability in sensitivity to Marevan. CYP2C9 is the enzyme primarily responsible for the metabolic clearance of s-enantiomer of Marevan. The vitamin K epoxide reductase complex 1 (VKORC1) is the target of coumarin anticoagulants, and its common genetic variants result in altered sensitivity to Marevan. VKORC1 polymorphisms are associated with a need for lower doses of Marevan during long-term therapy. Aim of work This study aimed to assess the allelic frequencies and to investigate the relationship between ‘CYP2C9’ and ‘VKORC1’ genotype and vitamin K antagonist anticoagulation. Patients and methods This study was conducted on 40 patients. There were 24 females and 16 males, with a male to female ratio of 2 : 3. Their ages ranged from 28 to 72 years. All the studied patients were laboratory investigated with international normalized ratio, complete blood count, and detection of VKORC1 and CYP2C9 by PCR reverse hybridization method using PGX thrombo strip assay (Vienna Lab.). Results Regarding the distribution of patients according to frequency of deep venous thrombosis (DVT) attacks, 16 (40%) patients showed single attack of DVT and 24 (60%) patients showed recurrent attacks. Patients with single attack of DVT comprised 12 (75%) females and four (25%) males, with male to female ratio of 1 : 3. As for the patients with recurrent attacks of DVT, there were 13 (54.2%) female and 11(45.8%) male patients, with a male to female ratio of 1 : 1.2. Conclusion Detection of genetic polymorphisms in CYP2C9 and VKORC1 genes before onset of warfarin therapy greatly influenced response to warfarin and shortened the time required to reach target international normalized ratio, and hence reduced the risk of recurrence of DVT.

Comparative study between cervical polyetheretherketone cages and dynamic cervical implant postanterior cervical discectomy Mostafa G Eldin, Mohammed S Mohammed Al-Azhar Assiut Medical Journal 2018 16(4):377-385 Objective This is a prospective comparative study between polyetheretherketone (PEEK) cages and dynamic cervical implants (DCI) to evaluate the safety, the effectiveness, and the clinical outcome with radiological outcome for patients with single-level degenerated cervical disc disease treated by anterior cervical discectomy. Patients and methods We studied 30 patients with single-level cervical disc disease. Preoperative evaluation included plain cervical radiography including dynamic views. MRI was carried out to confirm the clinical diagnosis. Results Our study showed that the procedures of two groups were safe and easy without major complications and do not show significant differences between DCI and anterior cervical discectomy and fusion (ACDF) with PEEK cages in terms of improvement in clinical symptoms, blood loss, or operation time; however, DCI was associated with better postoperative neck disability index scores and also resulted in better overall cervical range of motion and segmental range of motion at the treated level than ACDF with PEEK cage. ACDF with PEEK cage is still the gold standard technique for treatment of cervical degenerative disc disease. It improves patient activity and provides a stable segment. However, it fails to restore normal cervical biomechanics and does not prevent adjacent segment disease. Conclusion DCI is considered as a new strategy and an intermediate stage between ACDF and total disc replacement.

Infraclavicular brachial plexus block using nalbuphine versus midazolam as adjuvants to bupivacaine in upper limb surgery Mohamed Abdel Gawad Abdel Halim Al-Azhar Assiut Medical Journal 2018 16(4):386-391 Background Brachial plexus block is a regional anesthesia technique for different surgeries in the upper limb. It is useful as a sole regional anesthesia technique or combined with general anesthesia. The adjuvants to local anesthetics may be improving the quality and duration of analgesia of the brachial plexus block. Objective To evaluate the efficacy of nalbuphine and midazolam as adjuvants to bupivacaine in the infraclavicular brachial plexus block. Patients and methods The study was carried out on 70 patients of the American Society of Anesthesiologist, physical status I, II of both sexes, 20–60 years old and scheduled to forearm and hand surgeries. The patients were classified into three equal groups. Group B: using 20 ml of bupivacaine (3 mg/kg) with 1 ml of saline. Group M: using 20 ml of bupivacaine (3 mg/kg) with midazolam 5 mg (1 ml). Group N: using 20 ml of bupivacaine (3 mg/kg) with nalbuphine 1 ml (10 mg). Results The onset time of sensory and motor blocks were significantly shorter in the adjuvant groups N and M compared with group B. There was a significant increase in the duration of postoperative analgesia in group N compared with groups M and B. Conclusion The addition of nalbuphine and midazolam to bupivacaine in the infraclavicular brachial block improves the speed of sensory and motor onset, the quality of anesthesia, and decreases the analgesic requirements during the first 24 h postoperatively without obvious side effects. The addition of nalbuphine to bupivacaine was superior in delaying the postoperative analgesia requirement.