Comparison of measurements of the axial length of the eye using partial coherence interferometry and applanation ultrasound Fatma A Atwa, Hayam S Kamel, Rehab M Kamel, Amany R Ibrahim The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):293-296 Introduction Accurate biometry is an essential component of cataract surgery. Preoperative measurement of axial eye length (AEL), rather than the corneal curvature, is the most critical factor for accurate calculation of the intraocular lens (IOL) power [1]. Aim The aim of this study was to compare axial eye length (AEL) measured by applanation ultrasound (U/S) biometry versus that measured by partial coherence interferometry in eyes with clear crystalline lenses and eyes with cataract. Patients and methods A prospective, nonrandomized study included 60 eyes which were divided into two groups. Group I: 30 eyes with clear crystalline lenses. Group II: 30 eyes with cataractous lenses. Each group is further subdivided into three groups: group a with short AEL (<22.00 mm), group b with average AEL (22.00–25.00 mm), and group c with long AEL (>25 mm). Complete ophthalmological examination was performed for every patient. AEL was assessed by applanation A-scan U/S and optical biometry using partial coherence interferometry. Results A total of 60 eyes were included in the study. In group I (clear crystalline lens group), the mean AEL by applantion U/S biometry was 24.23±3.73 mm which is shorter than the mean AEL measured by optical biometry which is 24.48±3.66 mm and the difference is statistically highly significant (P=0.002). In group II (cataractous lens group), the mean AEL by applantion U/S biometry was 24.27±3.57 mm which is shorter than the mean AEL measured by optical biometry which is 24.46±3.43 mm and the difference between the two measurements was statistically nonsignificant (P=0.077). Conclusion Optical biometry provides longer mean measurements than applanation U/S biometry in eyes with cataract or clear lens, which is represented by a negative difference of 0.05 mm in AEL measurements. These results suggest that applanation A-Scan U/S biometry underestimates AEL.

Critical view of safety and Rouviere’s sulcus: extrahepatic biliary landmarks as a guide to safe laparoscopic cholecystectomy Ayman M Elwan The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):297-301 Introduction Bile duct injury is a serious complication of cholecystectomy. To fulfill the criteria for a critical view of safety requires Calot’s triangle to be cleared free of fat and fibrous tissue. Rouviere’s sulcus is a 2–5-cm sulcus running to the right of the liver hilum anterior to the caudate lobe. Aim Our aim is to study critical view of safety and Rouviere’s sulcus as extrahepatic landmarks and their benefits in avoiding common bile duct injury. Patients and methods From January 2015 to December 2018 (35 months), in New Damietta University Hospital, 300 patients with calculous cholecystitis undergoing laparoscopic cholecystectomy were included in this study. Results Rouviere’s sulcus was present in 293 (97.7%) patients: open type was found in 175 (58.3%) patients, whereas closed type was found in 118 (39.3%) of patients. The sulcus was not present in seven (2.3%) of patients. A critical view of safety was inspected in all patients (100%). There was conversion to open cholecystectomy in two (0.7%) patients owing to severe adhesions which cannot be dissected laparoscopically. No mortality was recorded in the follow-up period. Conclusion Rouviere’s sulcus and critical view of safety technique are very helpful extrahepatic landmarks to avoid common bile duct injury and perform safe laparoscopic cholecystectomy.

Walking epidural with low-dose levobupivacaine with fentanyl versus patient-controlled analgesia with fentanyl during painless labor Ahmed M Abd-Elgaleel, Osama I AbdallahBadr, Hanan A Rezq The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):302-307 Introduction Adequate pain relief is essential for patient healthcare, as it decreases hormonal stress response and hazards of postoperative analgesic drug effect, provides early ambulation and better wound healing, and is highly economical. Aim The aim of this study as a primary outcome is to compare and evaluate the efficacy and duration of analgesia between walking epidural analgesia using low-dose levobupivacaine with fentanyl versus intravenous patient-controlled analgesia (IV-PCA) with fentanyl during labor, and also, maternal satisfaction by visual analogue pain scale, whereas the secondary outcomes are maternal hemodynamic stability, obstetric outcomes, postoperative complications, and neonatal outcomes in terms of APGAR score and arterial blood gases. Patients and methods Eighty full-term primigravida patients, with American Society of Anesthesiologist status I and II scheduled for elective spontaneous vaginal delivery and requested analgesia, were divided into two groups: group I (n=40) was the epidural levobupivacaine with fentanyl (ELF) group, which received levobupivacaine 0.0625% with fentanyl 1 mcg/ml, 15 ml as initiation injection, followed by top-up doses of 5 ml in epidural catheter every 1 h or on patient’s request, whereas group II (n=40) was the IV-PCA group, which received 1 mcg/kg fentanyl intravenous as bolus dose, and then fentanyl 20 mcg increment (2 ml) with lockout interval of 5 min and at basal rate of 2 ml/h. Results On comparing ELF with IV-PCA groups, obstetric patient’s satisfaction was significantly more in ELF group (P<0.001), cervical dilatation was significantly rapid in ELF group (P=0.028), and also the duration to vaginal delivery was significantly lower in ELF group (P=0.037), whereas the results were insignificant for spontaneous vaginal delivery (P=0.728), instrumental vaginal delivery (P=0.526), and occasionally cesarean section (P>0.05). Maternal visual analogue pain scale was significantly less in ELF group from the fourth hour (P<0.001). Postoperative complications were insignificantly different between both the groups (P>0.05). Conclusion Epidural analgesia using low-concentration levobupivacaine 0.0625% with fentanyl 1 mcg/ml during early labor provided better analgesia and resulted in short duration for vaginal delivery than systemic analgesia. Patient-controlled analgesia is a good technique for the patients during labor if they refuse epidural analgesia or patients have any other contraindication to epidural analgesia.

Association of interleukin-4 gene polymorphism and rheumatoid arthritis in Egyptian patients Seham M.S El Nakeeb, Reem M Ahmed, Alzahraa A Elsied, Mohsen M Ali Elsied The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):308-316 Introduction Rheumatoid arthritis (RA) is a progressive disease characterized by chronic joint inflammation and subsequent structural damage. Interleukin (IL)-4-590 promoter polymorphism (rs2243250), a C-to-T base substitution, has been suggested to be associated with RA and has become of great interest to be investigated. Aim The aim of this study was to find the relationship between IL-4-590 promoter polymorphism and RA in Egyptians, and also to study the relationship of this gene with clinical and laboratory features of the disease. Patients and methods This study was carried on 180 subjects divided into two groups. The first group included 120 patients with RA and the second group were 60 apparently healthy individuals as controls. Genomic DNA was extracted from blood leukocytes of both groups and genotyped by PCR for amplification of IL-4 gene followed by restriction fragment length polymorphism. Results IL-4-590 (TT) genotype was significantly more frequent in patients with RA than controls (10 vs. 1.70%, P=0.027, odd ratio (OR)=7.543 and Confidence interval (CI)=0.947–60.049). IL-4-590 (CT) genotype showed no significant difference between patients with RA and controls (31.70 vs. 25%, P=0.195 OR=1.592 and CI=0.786–3.228), whereas IL-4-590 (CC) genotype was significantly less frequent in patients with RA than controls (58.30 vs. 73.30%, P=0.048). Regarding the distribution of different alleles, the frequency of T allele was significantly more in patients with RA than controls (P<0.01). In patients with RA, there were significant differences in some clinical and laboratory parameters of RA disease between different IL-4-590 genotypes (e.g. number of tender and swollen joints, duration of morning stiffness, disease activity score 28, serum rheumatoid factor, serum C-reactive protein, and serum anticyclic citrullinated peptide levels), all were higher in TT genotype, which means patients with RA with TT genotype may have more aggressive course of the disease. Conclusion The T allele and the TT genotype at position −590 of IL-4 gene may be related to development of RA in Egyptians and may be associated with the disease activity.

Evaluation of right heart function in heart failure patients using strain imaging and three-dimensional echocardiography Amal M Hamdy, Layla A Mohamed, Nadia A Agiba, Gehan E Youssof The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):317-323 Introduction Right heart function is an important predictor of morbidity and mortality in patients with cardiovascular diseases having left ventricular (LV) systolic dysfunction. Aim Assessment of right ventricular (RV) and right atrial (RA) functions in heart failure patients using strain imaging and three-dimensional echocardiography. Patients and methods This study included 60 patients (group I) having LV systolic dysfunction with LV ejection fraction less than or equal to 40% in addition to 20 healthy participants (group II) as a control group. LV measures included 2D and 3D-LV ejection fraction, LV-Tei index, and 2D and 3D-LV global longitudinal strain. RV measures included RV dimensions, RV fractional area change, RV-Tei index, 2D-RV global longitudinal strain, 3D-RV ejection fraction, 3D-average longitudinal strain for both interventricular septum, and RV free wall (3D-RVLS-sept and 3D-RVLS-FW, respectively). RA measures included RA dimensions, RA passive, active and total emptying volumes and fractions, peak RA longitudinal, and contractile strain. Parameters of LV, RV, and RA functions were compared between groups I and II. Results RV and RA dimensions and volumes, and LV-Tei and RV-Tei indexes were significantly higher in group I compared with group II. All other parameters of LV, RV, and RA function except RA-active emptying volumes were significantly lower in group I compared with group II. Cutoff values for parameters of RV and RA function showed good sensitivity and specificity to discriminate group I from group II. Cutoff points were 19.9% for 2D-RV global longitudinal strain, 46.4% for 3D-RV ejection fraction, 11.7% for 3D-RVLS-sept, 18.6% for 3D-RVLS-FW, 29.2% for peak RA longitudinal, and 17.1% for peak RA contractile strain. Sensitivity ranged from 78.3 to 96.7% and specificity ranged from 85 to 100% with a P value of less than 0.001. Conclusion RV and RA functions are impaired in heart failure patients with LV systolic dysfunction. Both 3D and strain imaging are good echo modalities in the evaluation of right heart function.

Validity of chest ultrasound in the diagnosis of acute chest disorders in children Ahmed E Kabil, Ahmed I Aboseif, Sherif M Kamal, Ehab I Sorour, Abd El Salam R Mohammed The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):324-329 Introduction Chest ultrasonography (US) is a promising tool in the evaluation of chest diseases as it is fast, user-friendly, noninvasive, easily reproducible, portable, widely available, inexpensive, and involves no ionizing radiation. Aim To assess the role of chest US in the diagnosis of acute chest disorders in children comparing it with conventional chest radiographs (CXR). Patients and methods This was a prospective, observational study, conducted at the Pediatric and Chest Departments of Al-Hussein and Sayed Galal, Al-Azhar University Hospitals, Cairo. Children aged from 1 month to 12 years, suffering from acute respiratory distress were included in this study. Full history taking, clinical examination, CXR, and chest US were performed for each patient. Computed tomography chest was performed in some cases where there was a doubt in diagnosis (e.g. lung abscess, mediastinal mass, and small pneumothorax). The main outcome was the correspondence between chest US findings and the patients’ final diagnosis based on history, clinical examination, laboratory results, and radiological finding. Results A total of 100 patients were included, 66 men and 34 women. Thirty patients had uncomplicated pneumonia, 17 patients had pneumonia complicated with effusion, 13 patients had nonpneumonic effusion, 12 patients had pneumothorax, four patients had lung collapse, 19 patients had acute bronchiolitis, three patients had lung abscess, and two cases had mediastinal masses. Chest US was true positive for the diagnosis in 83% of cases compared with 77% by the CXR (the conventional imaging technique). Conclusion The chest US is a valid, simple, safe, available, inexpensive method, and comparable to CXR for the diagnosis of acute chest disorders in children. Recommendation This study recommends administration of chest US as a diagnostic tool in the management of acute chest disorders in children.

The role of dexmedetomidine infusion on intraoperative desflurane and fentanyl requirement in spine surgery: a double-blinded, randomized, controlled trial Ruqaya M Elsayed, Amira A Shabaan The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):330-335 Introduction Dexmedetomidine is a potent selective agonist of α2 adrenoceptor having sedative, amnestic, sympatholytic, and pain-relieving properties without producing significant respiratory depression and promotes hemodynamic stability when used as an adjuvant during general anesthesia. Aim The objective of this study was to evaluate the effect of dexmedetomidine infusion on desflurane consumption, intraoperative fentanyl requirement, and hemodynamic changes. Patients and methods Sixty patients of American Society of Anesthesiologists I and II enlisted for elective spine surgery were randomly classified into two groups: group D dexmedetomidine group received preoperative intravenous dexmedetomidine 0.5 μg/kg over 10 min followed by 0.25 μg/kg/h (1 ml, 100 μg diluted with normal saline in 20 ml syringe) intraoperative infusion till the end of surgery and group P, the placebo group received a similar volume of normal saline. Desflurane consumption and intraoperative fentanyl requirement were recorded as well as intraoperative hemodynamic changes. Results Desflurane consumption and intraoperative fentanyl requirement were significantly lower in group D (P<0.001) as well as there was a significant decrease in heart rate and mean arterial blood pressure (P<0.05) in D group Conclusion Dexmedetomidine infusion resulted in significant reduction of desflurane consumption and intraoperative fentanyl requirement with significant decrease in heart rate and mean arterial blood pressure.

Revisional and conversional operations after bariatric surgery Radwa Attia, Kamal Abo Sonna, Hoda Abd Elazim The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):336-342 Introduction Bariatric/metabolic surgery is currently the only effective long-term treatment for morbid obesity and obesity-related diseases such as diabetes, heart disease, hypertension, obstructive sleep apnea, and dyslipidemia. With the increasing number of bariatric procedures being performed annually, it is expected that the incidence of revisions will increase. The overall incidence of surgical revision after a primary bariatric operation is 5–50%. Redo (revisional) surgery can be quite complex and technically challenging and may offer the patient a wide variety of solutions for treatment of weight reduction and complications after primary operations. Aim This study aimed to evaluate the initial experience of redo operations after bariatric surgery. Patients and methods A total of 20 patients were included in this study who underwent redo operations after bariatric surgery. Their BMI ranged from 25 to 50 kg/m2. They were managed from June 2016 to June 2018 at Al Zahraa University Hospital. The indications, surgical outcomes, and efficacy of the redo surgeries were analyzed. Result A total of 20 patients underwent redo operations. The primary bariatric procedures included vertical band gastroplasty in seven patients, Scopinaro operation in six patients, laparoscopic adjustable gastric banding in four patients, and sleeve gastrectomy in three patients. The indications for redo surgery included poor weight loss, weight regain, and malnutrition in cases of Scopinaro operation. The weight loss results varied depending on the indication for redo surgery. Postoperative complications revealed one case (5%) developed leak and required reoperation. However, no bleeding cases, no died cases, or other complications were observed during postoperative follow-up period. Conclusion Redo operation after bariatric surgery can be successfully performed via open or laparoscopic approach with acceptable risk. Deliberate selection for the proper revisional or conversion procedure can efficiently manage undesirable results from the primary surgery.

Effect of fentanyl, dexmedetomidine, and esmolol on pressor response during laparoscopic cholecystectomy Mofeed Abdalla The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):343-350 Introduction Laparoscopic surgery has many beneficial effects but the creation of pneumoperitoneum (PNP) may be associated with significant hemodynamic changes. Aim of the work Primary outcome: to compare opioids and nonopioids in controlling pressor response during laparoscopy. Secondary outcome: to compare the efficacy of dexmedetomidine (Dex) and esmolol in the same situation. Patients and methods Ninety patients undergoing laparoscopic cholecystectomy were randomly divided into three equal groups; group F: received fentanyl 1 μg/kg 10 min before induction and then 0.4 μg/kg/h throughout the PNP, group D: received Dex 1 μg/kg 10 min before induction and then 0.5 μg/kg/h throughout the PNP, group E: received esmolol 1 mg/kg 10 min before induction and then 0.5 mg/kg/h throughout the PNP. Hemodynamics mainly mean heart rate (MHR) and mean arterial pressure (MAP) were recorded at a specific time. Postoperative visual analog scale, time to first request of postoperative analgesia, number of patients who required postoperative analgesia, and postoperative analgesic consumption were recorded. Perioperative sedation score and blood glucose and postoperative complications, for example, bradycardia, hypotension, nausea, and vomiting were recorded. Time of discharge from the postanesthesia care unit (PACU) and hospital stay time were recorded. Results Group D showed better hemodynamic (MHR, MAP) stability and pain control than group E and much better than group F. Sedation score was higher in group D than other two groups after infusion of test drug only. The incidence of nausea and vomiting were higher in group F than group E and nausea was higher in group D than group E. Ondanosterone use was higher group F than other two groups. PACU stay time was longer in group D than other two groups. Conclusion Nonopioids (Dex and esmolol) were superior to fentanyl for attenuation of pressor response to intubation and PNP. Apart from nausea and longer PACU stay, Dex was superior to esmolol in controlling hemodynamics with better pain control.

Effect of nonpharmacological methods on incidence of postspinal hypotension during cesarean delivery: a comparative study Ahmed M.M El-Garhy, Eldesoky M.I Nouh The Scientific Journal of Al-Azhar Medical Faculty, Girls 2019 3(2):351-357 Introduction Hypotension is caused by upward spread of anesthetic into the subarachnoid space; this results in venous pooling in the capacitance vessels of the lower limbs as a result of block of sympathetic tone and unopposed activity of parasympathetic tone. It also may be caused by aorto-caval syndrome and is accompanied by bradycardia, nausea, and vomiting. Hypotension may have deleterious effects on mother and fetus and may result in uteroplacental hypoperfusion, as placental perfusion is pressure dependent, and lack of autoregulation of placental blood vessels, if persisted, may threaten the life of the fetus. Aim The primary aim of the work is to compare incidence of intraoperative hypotension between the three groups. The secondary outcome is to assess Appearance, Pulse, Grimace, Activity, Respiration (Apgar) score, vasopressor consumption, and occurrence of complications (nausea, vomiting, and bradycardia). Patients and methods A total of 150 patients undergoing cesarean delivery under spinal anesthesia were included. Patients were divided into three equal groups, using simple randomization method, with 50 patients each: group S, in which the patient will sit for 1 min after induction of spinal anesthesia and then will lie down; group E, in which patient’s legs will be elevated to 30° from the horizontal plane; and group C in which the patient will lie down immediately after induction of spinal anesthesia as a control group. Then, heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure were measured every 2 min until delivery of fetus and then every 5 min until the end of surgery. Sensory level was assessed before start of surgery, subsequently after lying down, and every 1 min using hot and cold test until it reaches T6 sensory level. Fetal well-being was assessed by Appearance, Pulse, Grimace, Activity, Respiration (Apgar) score measured by a pediatrician blinded to the study protocol at 1 and 5 min after delivery. Incidence of hypotension is defined as ‘at least one episode of decrease in systolic blood pressure to less than 90 mmHg or decrease in systolic pressure more than 20% from the baseline till the end of surgery’. It was treated immediately by 200 ml intravenous bolus fluids and injection of 5 mg ephedrine intravenous bolus every 2 min until elevation of blood pressure, and the total of ephedrine consumption was calculated. Duration of surgery and intraoperative complications was recorded as bradycardia, defined by heart rate below 60 beats/min, which was treated by 0.5 mg atropine sulfate, and nausea and vomiting, which were treated by ondansetron intravenous 4 mg after correction of hypotension. Results A total of 150 cesarean delivery patients between 22 and 34 years of age were included in the study. Regarding basic clinical and demographic data, it was found that the median age of all cesarean delivery patients was 30 years. The median BMI of all cesarean delivery patients was 32.5. Regarding the surgery duration, the median surgery duration of all cesarean delivery patients was 40 min. Regarding level of sensory block, most patients had sensory block at T6 (70%), and 30% at T4 in groups C, E, and S, correspondingly. Regarding primary outcome (incidence of hypotension mean arterial blood pressuer (MAP)<70 mmHg), there was a highly significant increase in incidence of hypotension in group C compared with other groups of patients, with highly significant statistical difference (P=0.0092). The incidence of hypotension in group C was 70%, in group E was 50%, whereas in group S was 40% (P=0.0092). Regarding secondary outcomes (ephedrine consumption, Apgar scores, and complications), there was a highly significant increase in ephedrine consumption in group C compared with other groups (P=0.000002). The median value of ephedrine consumption in group C was 7.5 mg, in group E was 2.5 mg, whereas no ephedrine was consumed in group S (P=0.000002). Moreover, there was a nonsignificant difference regarding Apgar score at 1 min (P>0.05). There was a highly significant increase in Apgar score at 5 min in group S compared with other groups (P=0.0047). There was a highly significant increase in bradycardia in group C compared with the other groups (P=0.0015). There was a highly significant increase in nausea in group C compared with the other groups (P=0.0008). There was a highly significant increase in vomiting in group C compared with the other groups (P=0.0008). Conclusion Incidence of hypotension in patients undergoing cesarean delivery under spinal anesthesia markedly decreased in patients who sat for 1 min after induction of spinal anesthesia and then lied down (group S) compared with patients who lied down immediately after induction of spinal anesthesia.