Tanta University, Faculty of Medicine

ORIGINAL ARTICLES
	Complete revascularization of patients with severe left ventricular dysfunction using mini extracorporeal circulation	p. 163
	Ibrahim M Yassin, Farouk M Oueida DOI:10.4103/tmj.tmj_7_18   Background and aim Mini extracorporeal circulation (MECC) when used as on-pump beating cardiac support during coronary artery bypass grafting can be a better alternative than the conventional cardiopulmonary bypass with aortic cross-clamping and cardioplegic arrest [(conventional cardiopulmonary bypass (cCPB)] in complete revascularization of patients with ejection fraction (EF) <30%. Patients and methods A retrospective study was conducted on consecutive 50 patients with chronic stable severely impaired EF (< 30%) who underwent isolated coronary artery bypass grafting surgery using MECC from January 2011 to June 2016 (group I), and they were compared with another 50 matched patients randomized to similar group connected to cCPB from January 2009 to June 2014 (group II). Emergency, unstable, combined surgery and end-stage renal disease patients on dialysis are excluded. Results There was no difference in CPB time, perioperative myocardial infarction (MI) or mortality between the two groups. Defibrillation was required in 10% in group I and in 82% in group II, with significantly lower cumulative energy of defibrillation (joules) (P<0.001). In group I, the requirement of inotropic support, incidence of atrial fibrillation (AF), the need for mechanical support, postoperative bleeding, the mean haematocrit value and the need for allogenic blood and products transfusion were significantly lower than in the group II (P<0.001), but the incidence of re-exploration was overall low (4% in group I) vs. 12% in group II), with a trend towards being significant (P=0.058). Postoperative creatine kinase MB isoenzyme and cardiac troponin I were significantly lower in group I (P<0.05) for 48 h. Lower postoperative creatinine (<0.01) was seen in group I. Duration of ventilation and length of ICU stay showed a trend towards being significant (P=0.053 and 0.057), but the total hospitalization time was significantly shorter in group I (P<0.05). Conclusion On-pump beating heart revascularization of low EF patients using MECC is a safe procedure with better outcome than cCPB in low EF patients. It is followed by a diminished release of ischaemia markers, better early and smooth postoperative course and lower total hospitalization time than after cCPB, and both result in a satisfactory clinical outcome.
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	The possible therapeutic role of mesenchymal stem cells in amiodarone-induced lung injury in adult male albino rats	p. 172
	Maram M.M Ghabrial, Maysa F.M Salem, Aml M.A.A El Ela, Safwat A.A El Deeb DOI:10.4103/tmj.tmj_4_18   Background and aim Lung injury and even pulmonary fibrosis represent a known adverse effect of amiodarone. No effective treatment was reported for pulmonary fibrosis except lung transplantation. Stem cell therapy holds a great promise for the repair of injured tissues. Mesenchymal stem cells (MSCs) have the potential to present a new trend of treatment. This work aimed to study the effect of bone marrow-MSCs on amiodarone-induced lung injury in albino rats by histological methods. Materials and methodsForty-two adult male albino rats were used. Seven rats were used as a source of bone marrow-MSCs. Thirty-five rats were divided into the following groups: negative control group included seven rats that received no treatment; vehicle control group included seven rats that received polysorbate 80; amiodarone group included 14 rats that received daily oral amiodarone for 6 weeks and were subdivided into two equal subgroups as subgroup 3a (amiodarone administrated) and subgroup 3b (kept for 4 weeks after amiodarone stoppage); and stem cell-treated group included seven rats that received stem cells after amiodarone stoppage. Lung specimens were examined histologically. Results Amiodarone group showed disrupted lung architecture, collapsed alveoli, and significant increase in the thickness of interalveolar septa. Bronchioles showed thickened smooth muscle layer and obliterated lumens. Highly significant increase in area percent of collagen fibers was observed. In stem cell group, there was improvement of these histological changes. Conclusion MSCs can improve the deleterious effects associated with amiodarone-induced lung injury.
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	Prognostic factors of patients requiring ventilatory support in the neuro-intensive care unit	p. 183
	Ahmed S Alkotami, Khaled H Rashed, Mohamed A Ragab, Hassan G Nassar DOI:10.4103/tmj.tmj_10_18   Background and aim Among ICU admitted patients, primary indication for mechanical ventilation is neurologic in 20%. This is much higher in a dedicated neuro-ICU. The purpose of this study was to assess the clinical predictors for outcome of patients requiring ventilatory support in the neuro-ICU.Patients and methods This was a prospective cohort study done at Neuropsychiatry Department and Center of Psychiatry, Neurology and Neurosurgery, Tanta University, from May 2016 to May 2017. All patients requiring ventilatory support after admission in our ICU, who were more than or equal to 18 years, and did not die before mechanical ventilation introduction were considered for the study. ResultsOf 63 patients, 30 (47.6%) died after mechanical ventilation introduction. Analysis of variables showed that all the following were significant predictors for mortality: old age, Acute Physiology and Chronic Health Evaluation-II score on admission, maximum Sequential Organ Failure Assessment score, National Institutes of Health Stroke Scale, Intracerebral Hemorrhage score on admission, ventilation strategy, main cause for ventilation, stroke type, and association of hypertension and cardiac diseases. Main cause of ventilation also significantly influenced modified Rankin scale among survivors. Conclusion Old age is associated with higher mortality, although mechanical ventilation can influence mortality among younger age groups. Early introduction of noninvasive positive pressure ventilation can improve in-hospital mortality. Outcome of ventilated patients is closely related to the main cause of ventilation, indicating mechanical ventilation is not essentially a therapeutic measure, however, a crucial supportive one. Application of Acute Physiology and Chronic Health Evaluation-II and Sequential Organ Failure Assessment scores and other prognostic and disability scores as National Institutes of Health Stroke Scale, Intracerebral Hemorrhage score and modified Rankin scale can monitor progression and significantly influence outcome of ventilated patients, especially when related to the main cause of ventilation.
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	A comparative study on the analgesic effect of tramadol or magnesium sulfate added to bupivacaine infiltration for postoperative pain management after lumbar disk surgeries	p. 203
	Soliman Ramadan Ahmed, Abd El-Raheem Mostafa Dowidar, Ashraf Al Sayed Al Zeftawy, Sameh Mohamed Fathy Ramadan SN, AD Mostafa, AA Al Sayed, SF Mohamed DOI:10.4103/tmj.tmj_57_17   Background Postoperative pain management aims to reduce patient discomfort and to allow early mobilization and recovery. Local anesthesia infiltration is a safe and effective anesthetic technique for many surgical procedures. Aim The aim of this study was to compare the effectiveness of local wound infiltration of bupivacaine plus tramadol and bupivacaine plus magnesium sulfate for postoperative analgesia after lumbar disk surgeries. Design A randomized double-blind study was conducted. SettingThe study was conducted at Tanta University Hospitals, Neurosurgical Department. Patients Sixty patients of either sex from 18 to 65 years old and undergoing elective lumbar disk surgery were included in the study. Patients and methods Patients were randomized preoperatively into three equal groups of 20 patients each. The patients of group I (bupivacaine group) received 20-ml solution containing bupivacaine 0.5% (10 ml), constituted with normal saline; the patients of group II (bupivacaine–magnesium group) received 20-ml solution, containing bupivacaine 0.5% (10 ml) with 500 mg of magnesium sulfate (5 ml) constituted with normal saline; and the patients of group III (bupivacaine–tramadol group) received 20-ml solution containing bupivacaine 0.5% (10 ml) with 2 mg/kg of tramadol constituted with normal saline. Postoperative pain as assessed using visual analog scale, and the time to first analgesic requirement and the total dose of rescue analgesia in the first 24 h postoperatively were also recorded. Results Wound infiltration with both tramadol and magnesium added to bupivacaine has provided a better pain control compared with bupivacaine alone. Visual analog scale values were significantly higher in group I than groups II and III at 4 h. First dose of supplemental analgesic was later in group III in comparison with groups II and I. Pethidine consumption was lowest in group III compared with the other two groups. Conclusion Local wound infiltration with a mixture of bupivacaine and tramadol after lumbar disk surgery produced an effective analgesia with reduced postoperative opioid requirements and minimal adverse effects compared with the other two groups.
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	Study of serum osteopontin levels in children with bronchial asthma in Egypt	p. 210
	Osama H Toema, Nabil M El-Esawy, Mohammed A Saad DOI:10.4103/tmj.tmj_47_17   Background Asthma is as an airway inflammation that results from interactions between various cells, cellular elements, and cytokines, which causes symptoms that include wheezing, breathlessness, and cough. Osteopontin (OPN) is a glycoprotein highly expressed in the bone and in a range of immune cells. It has chemotactic properties which promote cell recruitment to inflammatory sites and cytokine production. OPN affects IgE-mediated degranulation and migration of mast cells and other inflammatory cells taken together; these findings suggest a potential role for OPN in the regulatory pathway of asthma.Aim To measure the serum OPN level in asthmatic children to clarify its relation to bronchial asthma.Patients and methods The study was carried out on 60 asthmatic children aged 6–14 years. They were diagnosed and followed up in the Chest and Allergic Diseases Unit, Pediatric Department, Tanta University Hospital. Thirty asthmatic children were studied during acute exacerbation and 30 asthmatic children in clinically stable condition. Thirty healthy children were served as a control group. Pulmonary function tests and serum OPN level were done for patients and controls. Results The OPN levels were significantly higher in the asthma patients than controls. However, there was no statistically significant difference in OPN levels in asthma patients in stable conditions and those during exacerbations.Conclusion The present study has shown that asthma patients exhibit higher serum OPN levels than controls, suggesting a role for this protein in the pathogenesis of asthma that may help in the diagnosis of the disease.
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	Pattern of acute pediatric poisoning in Middle Delta Poison Control Centers	p. 215
	Fatma Gaber Ahmed Sobeeh, Nihal Salah El-Deen Abd El-Hay, Eman Ebrahim Draz, Khaled Mahmoud Saad DOI:10.4103/tmj.tmj_26_17   Background Pediatric poisoning is considered an important issue in many countries and accounts for a significant workload for emergency department consultations and hospital admissions. Thus, special epidemiological surveillance for each country is necessary to determine the problem according to which preventive measures can be taken. Aim The aim of this study was to determine the extent of acute pediatric poisoning in poison control centers located in Middle Delta as regards collected data. Patients and methods This retrospective study involved acutely poisoned pediatric patients aged less than or equal to 18 years old, who presented to poison control centers located in the Middle Delta in the 3 years period which extended from 1 January 2012 to 31 December 2014. The data had been collected from poison control centers located in the Middle Delta. The collected data included demographics, substance of exposure, manner of poisoning, data of clinical examination, data obtained from routine laboratory investigation, and patient's outcome. Results The findings of the study demonstrated that poisoning of children less than 6 years constituted the highest percentage. The majority of patients of acute poisoning were accidental. Accidental poisoning gradually decreases with increase in age. The most frequent poisoning caused by accidental manner was corrosives, while the most frequent poisoning in patients who attempt suicide was cholinesterase-inhibitor pesticides. Cholinesterase-inhibitor pesticides and corrosives constituted the highest percentage of poisoning. The most frequent manifestation was gastrointestinal manifestation and chest manifestation. Conclusion Poisoning of children constituted an important issue in Egypt. Poisoning of children less than 6 years constituted the highest percentage.
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	Programmed cell death 1 gene polymorphism association with activity and severity of systemic lupus erythematosus and rheumatoid arthritis in Egyptian patients	p. 225
	Wesam S Ibrahim, Salwa E Abdelghani DOI:10.4103/tmj.tmj_26_18   Background Programmed cell death 1 (PD-1) is an inhibitory regulator molecule of T cells and B cells. The PD-1 gene polymorphism was reported to be associated with autoimmune diseases like systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), with conflicting results in different studies. AimThe aim was to investigate the potential association of PD-1.3 (rs11568821) polymorphism with SLE and RA in Egyptian patients and its relationship to the disease activity and severity. Patients and methods A total of 88 Egyptian patients with RA and 95 Egyptian patients with SLE as well as 85 healthy Egyptian controls were included in this study. PD1.3G/A (rs11568821) polymorphism was performed by restriction fragment length polymorphism polymerase chain reaction (RFLP-PCR) technique. Results There was a significant difference in the distribution of A allele of PD-1.3 between RA, SLE, and control groups (38, 40, and 16%, respectively). Patients carrying A allele had high risk for RA and SLE in comparison with healthy control. Patients with RA with AA genotype had a significantly higher levels of C-reactive protein, erythrocyte sedimentation rate, anticyclic citrullinated peptide positivity, disease activity index 28, and modified Sharp score compared with those with GG and GA genotypes. Moreover, in SLE, AA genotype was significantly correlated with low C3 and C4, high proteinuria, positive anti-dsDNA antibody production, and damage index. Conclusion PD1.3G/A (rs11568821) polymorphism was associated with an increased risk of RA and SLE in Egyptian patients, so it could be a reasonable genetic risk factor for both diseases. Moreover, patients with RA and SLE who are homozygous for A allele are susceptible to have increased disease activity and severity.
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	Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections	p. 232
	Esraa H Abd-El Wahab, Sohair M Soliman, Sabry M Amen, Sameh R El-Shehdwy DOI:10.4103/tmj.tmj_34_17   Background Levobupivacaine showed a lower risk of cardiovascular and central nervous system toxicity than bupivacaine, which is the most popular local anesthetic agent in obstetric practice. The aim of this study was to investigate the clinical efficacy of levobupivacaine 0.5% compared with bupivacaine 0.5% for spinal anesthesia for cesarean sections. Aim The aim of this study was to compare the efficacy of levobupivacaine 0.5% versus bupivacaine 0.5% in spinal anesthesia for cesarean section. Patients and methods A total of 60 pregnant women in American Society of Anesthesiologists I–II group scheduled to have an elective cesarean operation were allocated into the study. Patients were randomly divided into two groups (30 patients in each group). Group I (bupivacaine group): in this group, patients received 2.5 ml bupivacaine 0.5%. Group II (levobupivacaine group): in this group, patients received 2.5 ml levobupivacaine 0.5%. Heart rate and mean arterial blood pressure were recorded intraoperatively. The onset time of sensory block and postoperative pain were assessed by visual analogue scale; time of postoperative first rescue of analgesia and duration of motor blockade were assessed by the Bromage score postoperatively. Results There was no significant difference between both groups as regards hemodynamics (heart rate and mean arterial pressure), two-segment regression of sensory block, time of first feeling of pain, total dose of consumption of analgesia, and visual analogue score. There was a significant decrease in the time to reach maximum sensory and motor block in group II compared with group I. Time of two-segment regression of motor block was significantly lower in group II than in group I.Conclusion Adequate surgical anesthesia can be achieved with both levobupivacaine and hyperbaric bupivacaine, as tested by the loss of pinprick sensation in both groups. Levobupivacaine given intrathecally can provide a safe and effective analgesic choice for parturients undergoing elective cesarean section, as the incidence of side effects with its use was significantly lower in comparison with hyperbaric bupivacaine.
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