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  Citation statistics : Table of Contents
   2013| October-December  | Volume 41 | Issue 4  
    Online since February 1, 2014

 
 
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ORIGINAL ARTICLES
A comparison of isosorbide mononitrate, misoprostol, and combination therapy for preinduction cervical ripening at term: a randomized controlled trial
Ahmed T Soliman
October-December 2013, 41(4):310-317
DOI:10.4103/1110-1415.126184  
Aim The purpose of this study was to compare the efficacy, safety, and acceptability of isosorbide mononitrate (IMN), misoprostol, and combination therapy for cervical ripening before induction of labor at term. Patients and methods A prospective, double-blind, placebo-controlled, randomized clinical trial was carried out on 196 term and post-term nulliparous women with unfavorable cervices who were assigned randomly to receive either 40 mg of IMN (n = 65), 50 ΅g of misoprostol (n = 65), or both of them (n = 66) in the posterior vaginal fornix. Changes in the Bishop score and cervical length, progress, and outcomes of labor and adverse effects were assessed. Results Combination therapy was more effective than IMN or misoprostol alone. Successful induction (vaginal delivery within 24 h of initiation of cervical ripening) was significantly higher in the misoprostol (60%) and the combination therapy (62.1%) groups compared with the IMN (27.7%) group (P < 0.0001). The mean duration (h) from treatment initiation to delivery was greater for IMN (26.7 ΁ 7.5) than for misoprostol (16.5 ΁ 6.7) and combination therapy (14.8 ΁ 6.2) groups (P < 0.0001). Oxytocin was needed more in the IMN group (93.8%) than in the misoprostol (21.5%) and combination therapy (25.8%) groups (P < 0.0001). IMN was safer and more acceptable than misoprostol and combination therapy. The cesarean rate was not significantly different among groups, but the major indications were different: dystocia (54.5%) in the IMN group versus a persistent nonreassuring fetal heart rate pattern (57.9%) in the misoprostol and (47.6%) the combination therapy groups (P = 0.01). Conclusion Combination therapy was more effective than either IMN or misoprostol alone for preinduction cervical ripening at term. However, IMN was safer, well tolerated, and more acceptable.
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Serum leptin and ghrelin concentrations in chronic hepatitis C genotype-4 patients with steatosis: their effect on the response to antiviral therapy
Mohamed S Abd El Gawad, Hazem Hakim, Mohamed M Elrakhawy, Emad I El Masry
October-December 2013, 41(4):327-335
DOI:10.4103/1110-1415.126198  
Background The precise pathogenic mechanisms of steatosis among patients with chronic hepatitis C (CHC) still remain largely unknown. Recent evidences identified various adipokines and gut hormones as relevant modulators of the pathophysiology of liver fibrosis and steatosis progression. We assessed whether pretreatment serum leptin and ghrelin concentrations differ in steatotic patients infected with hepatitis C virus (HCV) genotype-4 and whether these concentrations are associated with response to antiviral treatment. Participants and methods This study was conducted on 50 patients with CHC genotype-4 and steatosis and 25 age-matched healthy participants as a control group. Patients were treated with Peg-interferon and ribavirin for 48 weeks, independent of virologic response. Serum HCV-RNA concentrations were measured before the initiation of treatment and at weeks 12, 24, and 48 during the treatment. The genotype was determined using INNO-LIPA HCV assays, and serum leptin and ghrelin concentrations were measured using enzyme-linked immunosorbent assay. Biopsy specimens were scored according to the Ishak system, and steatosis was graded as mild, moderate, or severe. Results We found high insulin resistance and serum leptin concentrations and low plasma ghrelin concentrations at baseline in patients with CHC compared with the healthy controls (P = 0.000). Serum leptin levels tend to increase (P = 0.023), whereas plasma ghrelin levels tend to decrease (P = 0.004) as the grade of steatosis worsens. Plasma ghrelin at baseline showed significant negative correlations with insulin resistance and leptin. However, we did not find any correlations between leptin, ghrelin, insulin resistance, hepatic fibrosis, and hepatic steatosis with viral load. Sustained virological response (SVR) was achieved in 28 patients (56%) and was associated with a lower grade of liver steatosis (P = 0.013), milder fibrosis (P = 0.002), low value of insulin resistance (P = 0.001), lower leptin levels (P = 0.005), and higher ghrelin levels (P = 0.001), whereas patients who did not achieve SVR (nonresponder) had significantly higher leptin and lower ghrelin concentrations at baseline, with significant difference as the severity of steatosis worsened. Conclusion Increased serum leptin before treatment may predict non-SVR, whereas increased ghrelin may predict SVR. Ghrelin exerts antifibrotic effects on the liver and may represent a novel antifibrotic therapy.
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A new cutoff value for fecal calprotectin level in differentiating functional from organic causes of chronic diarrhea
Shahira El-Etreby, Hazam Hakim, Maha Ragab, Raghda Farag, Ehsan Rizk, Sahar Alsayed, Hanaa Abdeen
October-December 2013, 41(4):336-341
DOI:10.4103/1110-1415.126199  
Background The gold standard to establish inflammatory bowel disease diagnosis remains in the hands of endoscopists and pathologists. A challenge is thus to distinguish symptoms of inflammatory bowel disease from that of irritable bowel syndrome. Aim of this work The aim of this study was to evaluate the clinical usefulness of fecal calprotectin level as a noninvasive marker in order to distinguish patients with diarrhea in need of intensified follow-up from those who do not need further workup. Patients and methods From a total of 150 patients presented with chronic diarrhea with or without bleeding per-rectum in the outpatient clinic of Specialized Medical Hospital, only 60 were involved in this study. Stool analysis and culture were carried out. Measurement of fecal calprotectin was done using the ELISA kit. Inflammatory biomarkers, such as erythrocyte sedimentation rate and C-reactive protein and perinuclear anti-neutrophil cytoplasmic autoantibodies (P-ANCA) and cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA), were tested. Full colonoscopy with histopathological examination was performed. Results The frequencies of diseases on the basis of diagnostic colonoscopy and pathological examination were as follows: 19 patients with irritable bowel syndrome (31.67%), 41 patients with nonorganic gastrointestinal (GIT) disease versus organic GIT diseases (68.33%), 32 patients with ulcerative colitis (53.33%), two patients with Crohn's disease (3.33%), two patients with diverticulitis (3.33%), two patients with eosinophilic gastroenteritis (3.33%), and two patients with cancer colon (3.33%). There was a remarkable difference between organic GIT diseases versus nonorganic groups as regard fecal level of calprotectin (P < 0.001). Fecal calprotectin value of at least 350 μg/g with a receiver operating characteristic value of 0.931 [95% confidence interval (CI) 0.864-0.971] was diagnostic of ulcerative colitis with a sensitivity of 81.82% (95% CI 64.5-93), specificity of 85.19% (95% CI 66.3-95.8), positive predictive value of 86.32%, and negative predictive value of 80.39%. Conclusion Calprotectin, a fecal marker, is helpful as an adjunctive tool in overall evaluation of patients with nonspecific symptoms and as a diagnostic tool in those with inflammatory disease. It is less invasive than colonoscopy and can help to guide management in a more cost-effective manner.
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Urinary neutrophil gelatinase-associated lipocalin as a biomarker for the diagnosis of hepatorenal syndrome in cirrhotic patients
Hanan El-Bassat, Dina H Ziada, Atef Taha, Rasha Alm-Eldin
October-December 2013, 41(4):346-352
DOI:10.4103/1110-1415.126207  
Purpose The aim of the study was to assess the usefulness of urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a biomarker for hepatorenal syndrome (HRS) in patients with cirrhosis. Patients and methods Eighty-two cirrhotic patients were enrolled in this study. Urinary levels of NGAL were measured using enzyme-linked immunosorbent assay. Ten normal healthy individuals were enrolled as a control group. Group I included 15 cirrhotic patients with normal kidney function. Group II included 52 cirrhotic patients with acute impaired kidney function: 21 with prerenal azotemia, 22 with HRS, and nine with intrinsic acute kidney injury (iAKI). Group III included 15 cirrhotic patients with chronic impaired kidney function. Group IV included 10 healthy normal individuals as control. Results In HRS, uNGAL was significantly different from patients with either iAKI or prerenal azotemia. uNGAL levels in patients with prerenal azotemia were low and equivalent to levels in patients with normal kidney function and chronic kidney disease. uNGAL elevation was more prominent in type 1 than in type 2. Serum creatinine was significantly higher in patients with iAKI compared with those with normal kidney function and chronic kidney disease but was statistically similar to those with prerenal azotemia and HRS. Patients with HRS had a significantly higher level of serum creatinine than those with prerenal azotemia, but the level was similar to patients with iAKI. Fractional excretion of sodium was significantly higher in patients with iAKI than in patients with either HRS or prerenal azotemia. Conclusion uNGAL levels may be useful in the differential diagnosis of HRS from other causes of acute impairment of kidney function in cirrhosis.
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Evaluation of the immunoexpression of proinflammatory enzyme COX-2 and P53 gene in ulcerative colitis-associated dysplasia
Taher El-Demerdash, Dina H Ziada, Sahar El Yamany, Hussien Ghoraba, Eman Hasby, Nahla Khalaf
October-December 2013, 41(4):353-357
DOI:10.4103/1110-1415.126210  
Background and aim Ulcerative colitis (UC) patients are at increased risk for colorectal dysplasia and colorectal cancer. The aim of this study was to analyze the expression alteration of proinflammatory enzyme cyclooxygenase-2 (COX-2) and the tumor-suppressor gene P53 to clarify whether these alterations may play a role in the pathogenesis of dysplasia, which is a precancerous lesion. Patients and methods This study was conducted on 40 individuals who were divided into three groups: 15 UC patients without dysplasia, 15 UC patients with dysplasia, and 10 participants with normal colonoscopy and histopathology as a control group. Results There was a significant difference in the expression of Cox-2 and p53 in UC-related dysplasia compared with the UC group without dysplasia. There was a correlation between COX-2 and P53 expression and severity and duration of disease. Conclusion Addition of immunohistochemical analysis of Cox-2 enzyme and p53 gene to routine histologic assessment may improve the accuracy of early detection of dysplasia, which is a precancerous lesion, and thus decrease mortality from colorectal cancer.
  - 1,361 107
Cerebellar hematomas: management dilemmas
Ehab Ezzat El Gamal, Ashraf Mohamed Farid
October-December 2013, 41(4):358-363
DOI:10.4103/1110-1415.126212  
Objectives The aim of the study was to evaluate and investigate the best guidelines for conservative and surgical management of cerebellar hematomas of different etiologies. Patients and methods A prospective and retrospective study was conducted on 36 consecutive patients (20 male and 16 female) admitted to the Tanta Neurosurgical Department during the period from July 2007 to December 2012. We followed the fourth ventricular grading scale, hematoma size, and the Glasgow coma score in our decision-making on the basis of the clinical and neuroimaging studies. Surgical evacuation was performed on 20 of 36 patients. Cerebrospinal fluid diversion was performed on 10 patients (intraoperative external ventricular drainage, ventriculoperitoneal (VP) shunt, Endoscopic third Ventriculostomy (ETV)) either alone or as adjunctive to the surgical evacuation. Sixteen patients did not undergo surgical evacuation. Glasgow coma score was 12 or greater in 20 patients, 8-11 in 11 patients, and 7 or less in five patients. Results The degree of fourth ` ventricular compression was grade I in six patients, grade II in 19, and grade III in 11. Hydrocephalic changes were evident in 19 patients. Intraventricular hemorrhage was detected in computed tomography scans of 16 patients. Thirty-three patients had a history of hypertension, whereas the other three were suffering from bleeding tendencies due to hepatic diseases. Twenty-six patients had good outcome, whereas 10 died due to either recurrence after evacuation because of uncontrollable blood pressure or associated supratentorial hemorrhages or GCS of less than 7 on admission. Conclusion The surgical management of intracerebellar hematomas is still the main strategy; hence, we should correlate the hematoma size, fourth ventricular grade, medical condition of the patient, and initial clinical presentation in the decision-making.
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Prognosis of diastolic dysfunction: difference in renal function
El-Saied Shaeen
October-December 2013, 41(4):342-345
DOI:10.4103/1110-1415.126203  
Background Despite the common finding of diastolic dysfunction with preserved ejection fraction on routine echocardiography in elderly patients, it is unknown why some patients with isolated diastolic dysfunction are asymptomatic, whereas others develop diastolic heart failure (i.e. signs and symptoms of congestive heart failure). Aim The aim of the study is to investigate whether the intrinsic renal insufficiency turn diastolic dysfunction symptomatic. Patients and methods We reviewed 80 consecutive patients undergoing transthoracic echocardiography and divided them into two groups: group A, which included 40 patients with diastolic dysfunction without symptoms of heart failure, and group B, which included 40 patients with diastolic dysfunction and symptoms of heart failure. Patient's age, weight and cardiovascular risk factors (hypertension, diabetes and coronary artery disease) were recorded. We used Framingham criteria for congestive heart failure to determine the presence of diastolic heart failure from the symptoms developed, examination findings and radiological studies. Average creatinine clearance and estimated glomerular filtration rate were calculated for each group. Results There was difference neither in age or sex nor in the echocardiographic variables of diastolic function or left ventricular hypertrophy between groups. Multiple regression analysis showed that only lower levels of creatinine clearance (74 ± 46 vs. 44 ± 36 ml/min, P = significant) and lower estimated glomerular filtration rate (69 ± 28 vs. 44 ± 33 ml/min/m΂, P = significant) were associated with diastolic heart failure. There was no significant difference in the presence of hypertension, diabetes and coronary artery disease between two groups. Conclusion The results of this study support the hypothesis that patients with normal left ventricular ejection fractions but with diastolic dysfunction develop congestive heart failure because of underlying renal insufficiency. However, a larger prospective study is required to confirm this hypothesis.
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Evaluation of the role of multidetector computed tomography in biliary obstruction
Abdel Monem Nooman Darwish, Asem Ahmed El Fert, Amr Mohamed El Badry, Eman Moussa
October-December 2013, 41(4):318-326
DOI:10.4103/1110-1415.126194  
Objective The aim of the study was to evaluate the role of multidetector computed tomography (MDCT) cholangiography in detecting the cause and the level of biliary obstruction and also evaluating the global performance of combined axial, multiplanar reformatting (MPR), and minimum-intensity projection (MinIP) image reconstructions. Patients and methods Between January 2012 and August 2012, this study was performed on 30 patients with clinical and biochemical signs (increased serum levels of bilirubin and/or alkaline phosphatase) suggesting bile duct obstruction who referred to the CT unit in Tanta university hospital from the department of tropical medicine and infectious diseases. These patients were examined by 16-channel CT using a three-phase contrast protocol. The results obtained were compared with the results of histopathological and operative data in patients who underwent surgery. Results Our study showed that MDCT cholangiography was accurate in detecting the presence and the level of biliary obstruction in all 30 cases examined (100%), whereas it could define the cause of obstruction correctly in 93.3% of the cases. The overall performance of MPR and MinIP reconstruction in addition to conventional MDCT images showed a synergic effect to conventional axial CT images, showing an improvement in visualization in 83.3% and additional value in 30 and 16% of the cases, respectively. Conclusion MDCT cholangiography is a noninvasive and fast imaging tool in the assessment of patients with biliary obstruction. MPR and MinIP images provide an improvement of visualization of the biliary system and additional diagnostic value for differentiation of benign from malignant biliary obstruction. It represents a valuable supplement to conventional MDCT imaging of hepatopancreatic disorders.
  - 2,337 172
Long saphenous vein harvesting site infection after coronary artery bypass grafting
Khairy Gaballah, Mohamed Abo Elnor
October-December 2013, 41(4):306-309
DOI:10.4103/1110-1415.126180  
Introduction Coronary artery bypass grafting is a very common surgery with highly successful outcomes; however, wound complications from harvesting the long saphenous vein (LSV) can be a major source of postoperative morbidity. The aim of this study was to identify the incidence of LSV harvesting site infection in coronary artery bypass grafting and to detect the possible risk factors. Patients and methods Between September 2009 and December 2010, 100 patients who were diagnosed with coronary artery disease were included in our study and were admitted at Shebien El-Kom Teaching Hospital. All patients who developed major leg wound complication were assessed daily during the postoperative period using the ASEPSIS scoring system and 10 risk factors were analyzed and compared with the entire cohort of patients undergoing similar bypass procedure during the same time period. Results LSV harvesting site infections (ASEPSIS score >20) were identified in 12 patients (12%), including nine patients with mild infection (ASEPSIS score 21-30), two with moderate infection (ASEPSIS score 31-40), and one with severe infection (ASEPSIS score >40). Of the 10 variables evaluated using multivariate analysis, age, sex, obesity, smoking, diabetes, peripheral vascular disease, level of LSV harvesting, usage of intra-aortic balloon pump, Cardio-Pulmonary Bypass (CPB) time, and use of internal thoracic artery graft were identified as significant independent predictors of major leg wound complications (P < 0.05). Conclusion Identification of independent risk factors for infection is important to develop strategies that prevent infection and to allow for recognition of patients at high risk who may need more careful monitoring so as to prevent development of infection.
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REVIEW ARTICLE
Balloon dilatation sinuplasty: concept, procedure, and debate
Ahmed Elguindy
October-December 2013, 41(4):301-305
DOI:10.4103/1110-1415.126177  
Chronic rhinosinusitis affects millions of people every year. When medical treatment by antibiotics and steroids is not effective, then functional endoscopic sinus surgery is indicated. The aim of this article is to define the concept of balloon dilatation sinuplasty (BDS), to describe its technique and to review the current literature for the indications, contraindications, complications, outcomes and follow-ups of patients submitted to this procedure. The review showed that Balloon Dilatation Sinuplasty is a feasible, safe and effective procedure. It can be used an alternative in the treatment of CRS patients as a stand-alone medical procedure or as a hybrid surgical one with conventional instruments and/or with microdebriders
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