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   Table of Contents - Current issue
Coverpage
January-March 2018
Volume 46 | Issue 1
Page Nos. 1-82

Online since Thursday, July 26, 2018

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ORIGINAL ARTICLES  

Efficacy of caudal levopubivacaine versus bupivacaine in children undergoing lower abdominal surgery: a prospective randomized controlled study Highly accessed article p. 1
Mohammed S El-Sharkawy, Abd El-Raheem M Dowidar, Sabry M Amen, Rehab S El-Kalla
DOI:10.4103/tmj.tmj_58_17  
Background Postoperative pain in pediatrics causes psychological and physiological problems; thus, preemptive analgesia is important, even in newborns. Caudal block is a useful adjuvant with general anesthesia and for postoperative analgesia for infraumbilical operations. Levobupivacaine is less cardiotoxic, less neurotoxic, and an equally potent local anesthetic compared with its racemate. Aim Our aim is to compare the efficacy of caudally administered isobaric levobupivacaine 0.25% versus isobaric bupivacaine 0.25% in children undergoing lower abdominal surgery. Patients and methods This study was carried out on 60 children, 1–10 years, American Society of Anesthesiologists I–II, scheduled for elective lower abdominal surgery. Patients were randomized into two equal groups (30 patients in each group): group I: bupivacaine group: patients received 1 ml/kg bupivacaine 0.25%. Group II: levobupivacaine group: patients received 1 ml/kg levobupivacaine 0.25%. The onset time of sensory block, heart rate, mean arterial blood pressure, and respiratory rate were recorded intraoperatively. Postoperative pain was assessed using the Children’s and Infant’s Postoperative Pain Scale; time of postoperative first rescue of analgesia and duration of motor blockade were determined by the Bromage score postoperatively. Results There was no significant difference between both groups in the onset time of sensory block, hemodynamics (heart rate and mean arterial pressure), and respiratory rate. Children’s and Infant’s Postoperative Pain Scale was significantly lower in group I at 120 and 180 min postoperatively. The Bromage score was significantly lower in group ІІ at 15, 30, and 60 min postoperatively. Time till administration of first-rescue analgesia was significantly shorter in group II than group I. Conclusion Using similar doses, bupivacaine produced a higher incidence of residual motor block and longer analgesic block than levobupivacaine. Thus, levobupivacaine is more suitable for short operations and could make it preferable for day case surgery. However, bupivacaine is still more suitable for prolonged operations.
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Study of platelet indices in cirrhotic patients with spontaneous bacterial peritonitis p. 8
Rania M Elkafoury, Abdelrahman A Kobtan, Taher E Attia, Amal H Abdelhamed
DOI:10.4103/tmj.tmj_63_17  
Background Ascites are a pathological collection of fluid within the peritoneal cavity and the most common complication of liver cirrhosis. Spontaneous bacterial peritonitis (SBP) is an infection that develops in cirrhotic ascitic patients. Platelets release prothrombotic and proinflammatory agents and participate in the induction and advancement of vascular and inflammatory disorders. Aim The aim of this study was to evaluate platelet indices as noninvasive predictors for the diagnosis of SBP in cirrhotic patients. Patients and methods Patients were divided into the following groups: group I included 52 cirrhotic ascitic patients with SBP; group II included 34 cirrhotic ascitic patients without SBP; group III (the control group) included 20 healthy individuals. A complete blood count analysis was carried out using the Erma PCE-210 hematology analyzer. Platelet count, mean platelet volume (MPV), and platelet distribution width (PDW) of all the participating patients were determined. Results In this study, there were differences in MPV and PDW between the three groups. MPV showed a significant increase in SBP in comparison with ascitic patients and control participants (11.39±1.08, 10.39±1.32, and 9.47±1.29 fl, respectively), with a P value of less than 0.001. Similarly, the PDW was greater in SBP patients compared with those in groups II and III, but with no significant difference (14.14±2.01, 13.96±3.58, and 12.90±3.13, respectively). Conclusion MPV measurement is an inexpensive, fast, and easy to use test that can predict the development of SBP in cirrhotic ascitic patients.
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Surface linear versus submucosal cauterization using radiofrequency for the management of inferior turbinate hypertrophy p. 16
Shimaa G El-Gamalah, Abo-Baker S Behery, Mohamed H Hamad, Yasser I Aglan
DOI:10.4103/tmj.tmj_67_17  
Background and aim Inferior turbinate hypertrophy is one of the major causes of nasal obstruction. Radiofrequency thermal ablation (RFTA) is a technique in which high-frequency current passes quickly through the target tissue to cause a reduction in tissue amount through ablation by heat. In RFTA application, initially, a coagulation necrosis is formed in the tissue, then, tissue ablation is occurred through recovery. The aim of this work was to evaluate and compare the effectiveness of surface linear versus submucosal cauterization by using radiofrequency in the management of hypertrophied inferior turbinates. Patients and methods Patients who had bilateral nasal obstruction caused by only inferior turbinate hypertrophy underwent surgical treatment by surface linear cauterization for right hypertrophied inferior turbinate and submucosal cauterization for left hypertrophied inferior turbinate using radiofrequency with 0° telescope under general anesthesia. Information was collected regarding nasal obstruction, crust formation, adhesions and patient satisfaction. The data were recorded at 1 week, 1, 3, and 6 months postoperatively based on a 10-point visual analogue scale. Results Regarding nasal obstruction, significant difference was found between both techniques only at 1 week after intervention in favor of surface group. Regarding crustation, significant difference was observed between both techniques at 1 week, 1, and 3 months. Regarding satisfaction, significant difference was seen between both techniques at 1 week, 1, and 3 months. Regarding adhesion, significant difference was seen between both techniques only at 1 week. Conclusion Surface linear method may lead to crust formation and more adhesions.
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The value of adding ketamine to lidocaine and bupivacaine mixture in ultrasonic-guided spermatic cord block in scrotal surgery: a randomized double-blind prospective study p. 23
Mostafa M Shaheen, Nadia H Fattouh, Ayman A Yousef, Ahmed A Shama
DOI:10.4103/tmj.tmj_39_17  
Background Spermatic cord block for scrotal surgery avoids the potential risks of neuraxial and general anesthesia and provides long-lasting postoperative analgesia. Aim The aim of this study is to evaluate the value of adding ketamine to lidocaine-bupivacaine mixture for ultrasonic-guided spermatic cord block for patients undergoing scrotal surgery. Patients and methods This study was carried out in Tanta University Hospitals on 50 patients with ASA physical status I and II, age older than or equal to 18 years, who were scheduled for elective scrotal surgery. Patients were randomly allocated into two equal groups using sealed envelopes: 25 patients received ultrasound-guided spermatic cord block by a mixture of lidocaine 5 ml (2%), plain bupivacaine 5 ml (0.5%), and 1-ml normal saline (group 1), and 25 patients received ultrasound-guided spermatic cord block by a mixture of lidocaine 5 ml (2%), plain bupivacaine 5 ml (0.5%), and ketamine (0.5 mg/kg) (group 2). Results There was no significant difference between the demographic data, patient characteristics, heart rate, mean arterial blood pressure, and oxygen saturation in the studied groups. There was significantly rapid onset and prolonged duration of blockade in group 2 and significant increase in visual analog scale score in group 1 at 6 h postoperatively, whereas a significant increase occurred in group 2 at 12 h, postoperatively. There was significant increase in group 1 regarding the amount of rescue analgesia. Conclusion In ultrasound-guided spermatic cord block in scrotal surgery, addition of (0.5 mg/kg) ketamine to lidocaine–bupivacaine mixture improves onset of the block, prolongs postoperative analgesia, and reduces the consumption of postoperative rescue analgesics.
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Assessment of aggressive behavior among preparatory school children in Tanta City p. 29
Abd El-Rahman A Assaf, Mohamed A Abd El-Hay, Mai A Eissa, Shereen D Abohammar
DOI:10.4103/tmj.tmj_1_18  
Background and aim School violence and aggression have become an increasing concern to public health professionals, clinicians, policy makers, educators, and the general public. It is a multidimensional problem with biological, psychological, social, and environmental roots. The purpose of this study was to assess the prevalence of aggressive behavior and to explore the associated psychosocial risk factors among preparatory school children. Patients and methods A multistage stratified sample of 380 students of both sexes, 12–15 years old, was collected from the preparatory schools at Tanta City through the academic year 2016–2017. Aggressive behavior was assessed by Modified Overt Aggression Scale. Arabic version of Kiddie Schedule for Affective Disorders and Schizophrenia − Present and Lifetime Version was applied to assess current and past episodes of psychopathology in children and adolescents who had high scores of aggression. Results Overall, 23.7% of the studied sample had aggression, and it was distributed as follows: 0.8% of the sample scored high on aggression scale, 5.5% moderate, 7.4% mild, and 10% minimal. Risk factors of aggressive behavior included male sex; second child of the family; smoking; drug addiction; watching action movies; history of physical abuse; no hobbies or playing sports; widowed or divorced parent; poor relationships with parents, friends, and teachers; living in extended families; family history of psychiatric illness; low socioeconomic class; a drug-addict family member; physical abuse in the family; unfavorable school atmosphere; and history of dropping class. Overall, 8.9% of aggressive students had attention-deficit hyperactivity disorder, 6.7% had conduct disorder, 6.7% had depression, 3.3% had oppositional defiant disorder, and 1.1% had substance use disorder. Conclusion School aggression and violence is a frequent and a multifaceted problem among the school adolescents.
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Histological and immunohistochemical study of the effect of tramadol on the seminiferous tubules of adult albino rat and the effect of its withdrawal p. 38
Amira Ali Abou Elnaga, Amira Adly Kassab, Gehan Mohamed Soliman, Awatif Omar El Shal
DOI:10.4103/tmj.tmj_85_17  
Background Tramadol is a centrally acting opioid analgesic drug that is widely used in the treatment of pain. It is currently the most prescribed opioid in the world, so its abuse, dependence, toxicity, and tramadol-related deaths have increased. Aim This study aimed to evaluate the histological effect of tramadol on the seminiferous tubules of testis of adult albino rat and assess the effect of its withdrawal. Materials and methods A total of 52 adult male albino rats were used and divided into two main groups: the first served as control, and the second was treated with tramadol and subdivided into four subgroups. The first and third subgroups received tramadol once daily by gastric tube in a dosage of 40 mg/kg for 4 and 6 weeks, respectively, whereas the second and the fourth (recovery subgroups) received tramadol in a dosage of 40 mg/kg once daily for 4 and 6 weeks, respectively, and then kept without treatment for another 4 weeks. Specimens from the testes were processed for light and electron microscopic examination. Immunohistochemical study was carried out. Morphometric study was also done, and statistical results were analysis. Results Specimens from tramadol-treated animals showed obvious structural changes. Some spermatogenic cells appeared disorganized with wide intercellular spaces. Many spermatogonia showed vacuolated cytoplasm and deeply stained nuclei. Ultrastructurally, Sertoli cells showed cytoplasmic vacuoles. Some primary spermatocytes appeared with concentric lamellar formations. The immunohistochemical study showed a highly significant decrease in Bcl-2 immunoreaction. In contrast, minimal changes were observed in the recovery groups, with a nonsignificant change in the immunoreaction. Conclusion Tramadol-induced histological and immunohistochemical effects on the seminiferous tubules of rat testis, so its abuse should be avoided except with medical prescription.
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Comparative study between combined spinal-epidural anesthesia versus femoral/sciatic nerve block under ultrasound and nerve stimulator guidance for both-bone leg fractures p. 54
Hamed Abd El-Aziz El-Badawy, Abd Al-Maksoad Aymen Yousef, Gamal Muhamad El-Mawy, El-Saied Hanan El-Kalawy
DOI:10.4103/tmj.tmj_46_17  
Background General anesthesia has a lot of complications, so alternative procedures like combined spinal-epidural anesthesia (CSEA) are better but with their adverse effects on cardiovascular and pulmonary functions. New era tend toward ultrasound (US) guidance and nerve stimulator for nerve block to ensure better effects without any complications. Aim The aim of this study was to compare CSEA versus femoral/sciatic nerve block (FSNB) by US guidance and nerve stimulator as anesthetic technique for patients with both-bone leg (BBL) fractures. Patients and methods Ninety adult patients, ASA I–II, scheduled for fracture BBL were included in the study. Patients were randomized into two equal groups. Group I CSEA received intrathecal 5 mg of hyperbaric bupivacaine 0.5+15% μg fentanyl, and then 7 ml of epidural (0.375% of plain bupivacaine+fentanyl 2 μg/ml) was injected as a loading dose. Finally, an additional epidural of 4 ml of 2% lidocaine was given if the desired sensory level was not reached till after 20 min or the operation lasted more than 80 min. Group II underwent FSNB by using US guidance and nerve stimulator. We first blocked the sciatic nerve by injection of 15 ml of 0.25% bupivacaine and 10 ml of 1% lidocaine. Then femoral nerve block was done by injection of 20 ml of bupivacaine 0.25% and 10 ml of 1% lidocaine. Results There was no significant difference between both groups in demographic data and failure rate. The onset of sensory and motor block was shorter in CSEA group, but the duration of sensory and motor block was prolonged in FSNB group. First dose of analgesia required was earlier in CSEA group. Heart rate and mean arterial blood pressure showed significant decrease in CSEA group at 5, 15, and 30 min intraoperatively. Visual analogue pain scale was higher and need for rescue analgesia was earlier in CSEA group. Conclusion FSNB by US guidance nerve stimulation technique provides better block characteristics, longer duration of analgesic, better intraoperative hemodynamics, and decreased the need for postoperative rescue analgesia in comparison with CSEA in patients with BBL fractures.
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Immunohistochemical expression of human β-defensin-2 in verruca vulgaris p. 61
Amany M Abdel-Latif, Abeer Abd El-Hakam Hodeib, Safinaz H El-Shorbagy, Shimaa A.W Shaheen
DOI:10.4103/tmj.tmj_53_17  
Background Verruca vulgaris is the commonest viral cutaneous infection that is caused by human papilloma virus. There are more than 150 genotypically different types of human papilloma virus. Types 1, 2, 4, 27, and 57 were found with verruca vulgaris. Human β-defensins (hBDs), a family of small antimicrobial peptides, are important effector molecules of innate immunity, possessing antimicrobial, anti-inflammatory, and immunomodulatory activities. Aim The aim of this work was to investigate the immunohistochemical expression of hBD-2 in verruca vulgaris lesion in a trial to elucidate its possible role in the pathogenesis of the disease. Patients and methods This study included 15 lesional skin specimens of 15 patients with typical clinically and histopathologically diagnosed verruca vulgaris (group I). Seven specimens of nonlesional normal skin of contralateral sides of seven of these patients (group II) in addition to other seven normal skin specimens from seven healthy subjects of matched age and sex (group III) served as controls. All specimens were studied histopathologically using hematoxylin and eosin stain and immunohistochemically for detection of hBD-2 expression. Results All lesional skin specimens (group I) showed positive expression of hBD-2. Twelve (80%) specimens showed positive expression in all epidermal layers [immunoreactivity (IR) 3]. Two (13.3%) specimens showed positive expression in the stratum corneum only (IR 1), and one (6.7%) specimen showed positive expression in the stratum corneum and stratum granulosum (IR 2). Groups II and III showed no expression of hBD-2 (IR 0). There was highly significant difference between patients and controls (P<0.001). Conclusion There was positive immunohistochemical expression of hBD-2 in lesional skin specimens taken from patients with verruca vulgaris, whereas there was no expression in normal skin specimens taken from the patients and the volunteers. This may indicate a possible role of hBD-2 in the pathogenesis of verruca vulgaris and also in the immunity against it.
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CD4 and CD25 cells in children under the age of 5 diagnosed with type І diabetes mellitus p. 67
Muhammad I.M El-Masry, Ekhlas H El-Sheikh, Ahmed A.E.-B Abo El Ezz, Hossam A.E.-M Hodeib
DOI:10.4103/tmj.tmj_31_17  
Background and aim Type І diabetes mellitus (T1DM) is a T-cell-mediated, chronic disease characterized by a deficiency or absence of insulin, when the body’s own immune system attacks the β cells in the islets of Langerhans of the pancreas. The increased incidence of T1DM in children under the age of 5 years and the aggressive process of β-cell destruction in this age group indicate the need to assess the immune system. CD4+CD25+high regulatory T cells (Tregs) appear to be critical in regulating immune responses to self-antigens. The aim of this study is to evaluate CD4+CD25+ Tregs frequency in the peripheral blood of children diagnosed with T1DM under the age of 5 in comparison with those diagnosed at a later age and healthy controls. Patients and methods The present study was carried out on 80 children who were classified into three groups: group I included 20 children with newly diagnosed T1DM under the age of 5; group II included 20 children with newly diagnosed T1DM older than 5 years of age; group III included 40 apparently healthy children as a reference group divided into age-dependent groups. The history of all children included in the study was recorded. Clinical examination and laboratory investigations included fasting and postprandial serum glucose, renal and liver function tests, complete blood count, glycated hemoglobin, and fasting C-peptide. Flow cytometric analysis was carried out for peripheral blood lymphocytes using monoclonal antibodies against CD4 [fluorescein isothiocyanate (FITC) labeled] and CD25 [phycoerythrin (PE) labeled]. Results We found that both patient groups had highly significantly lower mean percentage of CD4+CD25+high Tregs in comparison with the control groups. Also, a highly significantly lower mean% CD4+CD25+high Tregs in patients younger than 5 years of age in comparison with patients older than 5 years of age was found. Also, diabetic children younger than 5 years of age had a highly significantly lower fasting C-peptide than diabetic children older than 5 years of age. Conclusion This study highlights the distinctiveness of diabetes in children under age of five who had a low secretion of C-peptide which reflect a more destructive lesion of β-cells with consequent lower absolute cell mass in this age group and very low CD4+CD25high T-regs that evince the pathogenesis of autoimmunity. Understanding the differences in the immune system activity in young diabetic children may pave the way toward identification of children at risk of T1DM and enable the use of novel forms of intervention.
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A comparative study between combined spinal anesthesia with bilateral thoracic paravertebral block and general anesthesia in laparoscopic cholecystectomy p. 77
Eman H Abd El-Wahab Abu Shanab, Mohamad G Ayaad, Ahmed A El-Dabe, Sanaa M El-Nomany
DOI:10.4103/tmj.tmj_27_17  
Background Paravertebral block is a common regional anesthetic technique such as intraoperative anesthesia and perioperative analgesia used in multiple surgical procedures. Many studies have demonstrated that laparoscopic cholecystectomy (LC) with the patient under spinal anesthesia (SA) was feasible and safe and was associated with stable hemodynamics and better postoperative pain control. Aim The aim is to compare the anesthetic effect of combined SA with bilateral thoracic paravertebral block and general anesthesia in LC. Patients and methods Sixty patients undergoing LC were randomized into two groups: group I receiving general anesthesia and group II receiving SA with bilateral thoracic paravertebral block at the level of T7 with a catheter on the right side, and then injecting 10 ml plain bupivacaine 0.5% on the left side through the epidural needle without catheter as a single shot. Patients were still in the sitting position, and then SA was performed using a 25 G spinal needle at L2–L3 intervertebral space. 2 ml=10 mg of hyperbaric bupivacaine hydrochloride (0.5%) was injected intrathecally. Results Intraoperatively, there was significant increase in stress response including mean arterial blood pressure and heart rate in group I than in group II at 30 min and at the end of operation. Significant decrease in intraoperative opioid requirement as fentanyl in group II than in group I was observed. The time of first analgesic requirement within 8 h in the postoperative period if the Visual Analogue Scale more than 3 was significantly increased in group II than in group I. As regards intraoperative end tidal CO2, oxygen saturation, operative time, nausea, vomiting, headache and patient satisfaction, there was insignificant difference between the two groups. Conclusion LC can be performed under SA and bilateral thoracic paravertebral block at low pressure pneumoperitoneum, providing hemodynamic stability and with no respiratory complications.
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