Alexandria Journal of Medicine

Editorial Board

2012-06-01

Evaluation of the normal calcaneal angles in Egyptian population

Fahmy Anwar Shoukry, Yasser Khairi Aref, Asem Abd Elkawy Sabry — 2012-02-10

Abstract: Introduction: The calcaneus is the largest and strongest tarsal bone. It is the most commonly fractured tarsal bone and accounts for about 2% of all fractures. The importance of the calcaneal angles in assessing the fractures of calcaneus and planning treatment has been highlighted.Aim: The purpose of this study was to evaluate the normal calcaneal angles in the Egyptian populations who live in Alexandria and nearby governorates and compare their values to the published data.Methods: Lateral plain radiographs of 220 normal feet and ankles of 103 males and 97 females with age ranged from 20 to 40years, were studied retrospectively at El Hadra University Hospital, Alexandria, Arabrepublic of Egypt between June and December 2010. Three of the normal calcaneal angles (Böhler angle–Gissane’s angle–calcaneal compression angle) were measured and the mean and standard deviation of each angle were calculated. The relationships between each angle and age, sex, side of the body, occupation, weight, height, and residence of examined persons was tested and compared to previous researches and international figures.Results: The mean of Böhler angle in the Egyptian population was 30.14±4.182 ranged from 22° to 40°. The mean of Gissane’s angle was 122.92±6.952 ranged from 108° to 138°, while the mean of calcaneal compression angle was 31.03±3.82 ranged from 24° to 44°. The measured calcaneal angles are not significantly related to age, sex, and side of the body, residence and occupation of the examined persons except there is significant negative correlation between the Böhler angle and the age which not reported in the previous researches and studies.Conclusion: The study showed that difference in the mean of the calcaneal angles from other previous studies that reinforce the importance of establishing the normal range of the calcaneal angles in a given population.

Indicators of outcome after internal fixation of complex acetabular fractures

T.A. El-khadrawe, A.S. Hammad, A.E. Hassaan — 2012-01-24

Abstract: Introduction: Complex acetabular fractures are not uncommon injuries in Egypt. The aim of surgical treatment is to preserve hip mobility and to avoid post-traumatic arthritis.Aim: The aim of this study was to evaluate the clinical results of patients presented by displaced complex acetabular fractures and treated by open reduction and internal fixation. Factors affecting these results were to be determined.Methods: Displaced acetabular fractures involving the both columns were included. Initial assessment and treatment were directed towards the patient’s general condition. Posterior hip dislocation was reduced as fast as possible. Standard X-ray views and CT cuts were done for every patient. The definite surgery was done through an ilio-inguinal, a Kocher–Langenbeck or combined approaches. Postoperatively, the residual displacement was recorded together with the head roof relationship. Using Matta radiological and modified clinical grading, a correlation between radiological and clinical results was made. Factors affecting the outcome were defined.Results: The study involved 55 patients between May 2007 and December 2010. The mean follow-up period was 29.62±7.19months with a minimum of 12months and a maximum of 43months. Excellent to good results were achieved in 38 cases, 69.1%, while fair to poor results were obtained in 17 cases, 30.9%. Anatomical reduction and/or restoration of perfect head/roof congruency were strongly associated with better outcome. Beside this there was significant relation between good clinical outcome and the utilisation of the anterior approach. On the other hand bad outcome was associated with these factors: (1) associated pelvic ring injury, (2) fracture of the posterior wall, (3) articular surface comminution and (4) the presence of intra-articular fragments.Conclusion: Fracture personality and not the fracture type is the main determinant of its complexity. Surgical experience is required to achieve the best reduction while avoiding complications.

Challenge in diagnosis and treatment of colonic carcinoma emergencies

Alaa Hussein Abdel-Razek — 2012-01-25

Abstract: Introduction: Despite advances in perioperative care and operative techniques, urgent colorectal operations are still associated with higher mortality and morbidity than elective surgery.Aim: This study was to identify the challenge in diagnosis and treatment of emergencies caused by colon carcinoma; and to assess its outcome.Material and methods: This included 59 consecutive patients treated with emergency surgical intervention for colonic carcinoma; and other 59 patients of elective colonic surgery.Results: Morbidity rates were 27.1% versus 10.2% after emergency and elective surgery. Rates of 1-, 2- and 3-year survival were 64.4%, 57.6% and 47.5% respectively after emergency surgery; and 71.2%, 62.7% and 50.8% respectively after elective surgery.Conclusions: Challenge included presentation of undiagnosed patients with difficult or impossible colon preparation, colonoscopy, tissue biopsy or tumor staging; in addition to associated diseases and/or old age. Mortality and morbidity rates after emergency surgery were higher than elective surgery. Selection of the surgical procedure was guided by the tumor staging, co-morbidities and intraoperative assessment. Emergency resection, when possible, could approximate survival of elective resection. Total colectomy could obtain good outcome and survival when compared to other emergency procedures.

Evaluation of the results of operative treatment of hip dysplasia in children after the walking age

2012-02-27

Abstract: Background: Treatment of neglected developmental dysplasia of the hip (DDH) in children after the walking age has been a challenge to the orthopedic surgeons. It is usually surgical at this age group.Methods: The study included 35 patients (42 hips), they had been treated by different combinations of open reduction, femoral (shortening, derotation and varus) and pelvic (Salter or Dega) osteotomy. The age at the time of the operation ranged from 18 to 96months.Results: At the end of follow-up (a mean of 33.5months), the overall final clinical result was excellent in 13 (31%) patients, good in 24 (57%) patients, fair in four (9.5%) patients and poor in one (2.5%) patient satisfactory in 37 (88%) patients and unsatisfactory in five (12%) patients. The radiological end result was Class І (excellent) in 26 (62%) patients, Class II (good) in 11 (26%) patients, Class III (fair) in three (7%) patients and Class ІV (poor) in two (5%) patients. It was satisfactory in 37 (88%) patients and unsatisfactory in five (12%) patients.Conclusion: We concluded that operative treatment of neglected DDH after the walking age is a technically demanding procedure but when performed properly by an experienced surgeon it gives satisfactory results.

Juvenile idiopathic arthritis and the temporomandibular joint

2012-02-10

Abstract: Background: The temporomandibular joint (TMJ) is one of the most underdiagnosed and undertreated conditions of juvenile idiopathic arthritis (JIA) because its involvement is often asymptomatic and the joint is difficult to examine.Objectives: The aim of this study was to investigate clinical as well as magnetic resonance imaging findings of temporomandibular joint inflammation among juvenile idiopathic arthritis patients and to detect the correlation between them, moreover with different disease parameters.Methods: Forty patients with JIA and 10 apparently healthy control subjects underwent clinical and post contrast magnetic resonance imaging (MRI) examinations for TMJs. MRI findings were scored. Clinical and laboratory disease parameters were recorded.Results: The clinical symptoms and signs of TMJ arthritis were detected in 35% and 62.5% of JIA cases, respectively. While TMJ disease was observed in 80% of patients using contrast enhanced MRI. The mean total MRI score was significantly higher in patients with active disease compared to those without activity. Patients with systemic and polyarticular JIA showed significant increase in the mean of synovial enhancement, effusion and total MRI scores compared to those with the oligoarticular type. MRI abnormalities revealed significant association with clinical signs of TMJ examination but not with symptoms. Synovial enhancement score showed significant positive correlation with disease activity score and C-reactive protein as a marker of inflammation. A significant positive correlation was found between total MRI score and disease activity, functional and pain scores in patients with JIA.Conclusions: TMJ arthritis is common among patients with JIA, therefore; examination of the TMJ is mandatory during the follow up of patients. Clinical signs of TMJ arthritis can be used as filter for MRI examination TMJ is an important joint which may be considered during categorizing JIA patients in different subtypes.

Role of proton magnetic resonance spectroscopy in diagnosis of pilocytic astrocytoma in children

2012-01-24

Abstract: Background: Pilocytic astrocytomas are the second overall most common pediatric brain tumor. Magnetic resonance (MR) imaging is widely used in the diagnosis and follow up of pediatric patients with pilocytic astrocytomas because of its ability to provide anatomical detail. However conventional MR imaging does not provide information about tissue biochemistry.Aim of the work: To study the role of proton magnetic resonance spectroscopy in diagnosis of pilocytic astrocytoma in children.Subjects and methods: This study included seven pediatric patients with histopathologically proven pilocytic astrocytoma. All patients were subjected to full history taking and thorough clinical examination. Magnetic resonance (MR) imaging was performed at 1.5Tesla MR system using a standard head coil. Imaging included conventional MRI and proton magnetic resonance spectroscopy. Proton magnetic resonance spectroscopy was done using either single or multi-voxel technique. Surgical biopsy was then performed to all patients and correlation with histopathological data was done.Results: Out of the seven patients included in this study, six were females and one was male with mean age of 9.5years, the tumor was located in five of them in the posterior fossa, located in right thalamo-peduncular region in one patient and located in the hypothalamic–chiasmatic region in one patient.MR spectroscopic study showed the same findings in all the lesions including high Cho/NAA and Cho/Cr ratios (3.53±1.5) and (7.21±4.2), respectively, relative low concentration of creatine with increased NAA/Cr ratio (2.32±1.1). Lactate doublet was detected in all cases while no lipid peaks were detected.Conclusion: Based on the findings in this study we suggest that pilocytic astrocytoma has a specific spectroscopic metabolic profile which could be diagnostic for this type of tumor.

Intracerebral hemorrhage in children

Ihab Zidan, Amal Ghanem — 2012-04-03

Abstract: Introduction: Intracerebral hemorrhage (ICH) in children is relatively less common as compared to adults. It could be traumatic or spontaneous.Objective: There are limited studies about ICH in children. In this study, we analyze the etiology, clinical features, management options and outcome assessment in this population.Methods: All patients with intracerebral hemorrhage under 18years of age admitted to the neurosurgery department; Alexandria University Main Hospital and Medical Research Institute over a period of one year (June 2008–May 2009) were subjected to clinical examination, laboratory and radiological investigations and the cause of hemorrhage was determined.Results: Thirty patients with ICH were included in this study. Age of patients ranged from one month to 17.5years with a higher predilection in males. Presenting features were symptoms of raised intracranial pressure (60%), deterioration in sensorium (46%), limb weakness (36%) and seizures (30.0%). Trauma was the most common cause of ICH and was found in 13 patients (43%), followed by bleeding diathesis in nine patients (30%), arteriovenous malformation (AVM) in five patients (17%), intracranial tumor in two patients and an aneurysm in one patient. Treatment modalities consisted of: hematoma evacuation, excision of AVM, AVM emobilization, aneurysm clipping, tumor excision, and conservative management. Eleven patients were treated conservatively and 19 patients were treated surgically. The outcome showed: good recovery in 14(47%), fair recovery in seven (23%), poor recovery in seven (23%), and death in two patients (7%).Conclusions: Trauma is the leading cause of ICH in children. Bleeding diathesis and AVM come next. The initial neurological status of patients, the size, location and underlying pathophysiology of the hematoma are the most important determinants of patient outcome. Intracerebral hemorrhage due to bleeding diathesis was generally associated with a better outcome.

Development of a remediation program for Egyptian dyslexic children

2012-02-10

Abstract: Objectives: The present study was designed to formulate a remediation program for Arabic speaking children suffering from dyslexia based on improving phonological awareness using materials appropriate for Arabic culture.Methods: The study was carried out at the unit of Phoniatrics, Faculty of Medicine, Alexandria main university hospital. The subjects were divided into two groups. Group I: 30 dyslexic children of both sexes in the age range of 6½–10½years on which the proposed remediation programme was applied. Group II: 30 dyslexic children age and sex matched were included as a control group; they received no remediation programs during the time of conduction of the study. The formulated Arabic remediation program was based on improving the phonological awareness for dyslexic children, after the Phonological Awareness Training for Reading Program. Modifications and additions were made to suit the nature of the Arabic language, and face the differences between Arabic and English orthography. The program was divided into sound blending, sound segmenting, reading and spelling activities. The training program was applied twice weekly, with session duration lasting from 25 to 30min. Each session had about 2 or 3 children. The studied groups were subjected to protocol for evaluation of dyslexia before and after therapy to document to evaluate the improvement and the stability in the condition of these children.Results: The presented training program significantly improved reading, writing and phonological awareness of dyslexic cases.Conclusion: The present study highlighted the importance of phonological awareness skills as a prerequisite for emergence of literacy skills. The program was modified to suit Arabic speaking Egyptian children. The study found that the age of the child is the most important predictor factor, the younger the age of intervention the better the outcome of therapy program.

Validation of evidence-based clinical practice guideline: Nursing intervention for newly diagnosed pulmonary tuberculosis patients at community setting

Amel Ibrahim Ahmed, Sahar Mohamed Soliman, Lamiaa Amin Awad — 2012-02-10

Abstract: Background: Tuberculosis is a major contributor to disease burden in the developing countries. It is considered the second fatal disease all over the world and the third most important public health problem in Egypt. The direct causes of increasing the burden of tuberculosis are the inconsistent and fragmented health services. The nursing interventions of tuberculosis in community settings require a system of recommendations that ensure the consistency of care.Objective: The present study aimed at providing a valid evidence-based clinical guideline that assists nurses to intervene consistently to the newly diagnosed patient with pulmonary tuberculosis.Methods: The intended guideline was developed according to the criteria of the Scottish Intercollegiate Guidelines Network (SIGN) and the American Academy of Neurology. This guideline was developed based on the need for assessments of the intended users (nurses) and the end-point beneficiaries (newly diagnosed patients with pulmonary tuberculosis). The development process of the guideline consisted of seven main steps. The SIGN appraisal tools were used for the critical appraisal phase of the retrieved studies, and the “Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument”, that was used for appraising the internal validity of the developed guideline.Results: The developed guideline included thirty recommendations categorized into four main themes, which are assessment, nursing diagnosis, nursing care plan and implementation of care plan. The overall assessment of the guideline revealed that two-thirds of academic appraisers strongly recommended the guideline to be used in practice and most of practitioner nurses and practitioner physicians recommended the guideline to be in practice.Conclusion: The development of this guideline was based on the needs of the targeted users (nurses) and end-point beneficiaries (patients). It was strongly recommended by the appraisers to be used in the outpatients chest clinics. The study recommended that this developed guideline should be disseminated to the policy makers to be approved for application.

Knowledge and attitude of primary care doctors towards management of postmenopausal symptoms

2012-02-10

Abstract: Background: According to the current recommendations, women with post-menopausal symptoms should be managed. Knowledge and perception of primary care physicians towards management of postmenopausal symptoms are deficient.Aim: The aim of the present study was to explore knowledge and attitude of primary care doctors towards management of postmenopausal symptoms.Methods: This study is a cross-sectional survey that was conducted from October to December 2010 in the five health regions in Kuwait. Two centers were selected randomly from each health region. All physicians who were currently working in the selected centers were asked to participate in the study. Out of 209 physicians, 142 agreed to participate and completed a self-administered questionnaire.Results: The study revealed that 82.4% of physicians had moderate knowledge about treatment options for postmenopausal symptoms, 88.0% discussed postmenopausal symptoms with their patients, and 45.1% of them either described or referred their patients for hormonal replacement therapy (HRT). The correct answers regarding 10 statements related to the Women Health Initiative finding were ranging from 2.8% to 78.9% which indicated low level of knowledge. Regarding the effectiveness of hormonal replacement therapy in postmenopausal women, the majority of the physicians agreed correctly that HRT is effective in prevention of osteoporosis (87.3%), treatment of vasomotor symptoms (83.7%), and treatment of vulvo-vaginal symptoms (82.4%). There was a variation among physicians opinion about the effectiveness of certain treatment options for managing hot flushes in postmenopausal women.Conclusion: The results suggest that there is a lack of primary care physicians knowledge and confidence in recognizing signs and symptoms of menopause and in identifying and prescribing appropriate management.

Nalbuphine added to intrathecal morphine in total knee arthroplasty; effect on postoperative analgesic requirements and morphine related side effects

Moustafa Abdelaziz Moustafa, Rabab Saber Saleh — 2012-03-05

Abstract: Introduction: Intrathecal morphine is widely used for postoperative pain control in major orthopaedic surgery. However, its use is associated with frequent side effects.Aim of the work: Aim of the work was to investigate the effects of intrathecal coadministration of nalbuphine with intrathecal morphine on morphine related side effects and postoperative analgesic requirements.Methods: In this study, the intrathecal addition of 1mg nalbuphine hydrochloride to a combination of 3ml hyperbaric bupivacaine 0.5% and 0.2mg morphine sulfate was tried in patients undergoing total knee arthroplasty.Results: Patients who received intrathecal nalbuphine suffered significantly less than the control group from vomiting and pruritus meanwhile there was no effect on the postoperative analgesic requirements or the incidence of urinary retention. Intrathecal addition of nalbuphine to morphine decreased the opioid related side effects without affection of postoperative analgesia.Conclusions: The addition of nalbuphine to morphine intrathecally decreases the opioid related side effects without affection of postoperative analgesia. This combination can improve postoperative pain management in patients undergoing knee surgery under spinal anaesthesia.

Comparative study between the use of Macintosh Laryngoscope and Airtraq in patients with cervical spine immobilization

Marwa A. Tolon, Ola M. Zanaty, Wafaa Shafshak, Emad Eldin Arida — 2012-04-05

Abstract: Background: Airway management is a major responsibility for anesthetist. This study was carried out to evaluate and compare the efficacy of Airtraq (AL) and Macintosh Laryngoscopes (ML) in intubating patients with cervical spine immobilization using manual inline axial stabilization technique (MIAS).Methods: This randomized controlled study was carried out in Alexandria Main University Hospital on 40 adult ASA I and II patients after written informed consent and approval of the ethical committee, randomly categorized into two equal groups. All patients were subjected to same anesthetic protocol. Group I patients were intubated using AL and group II patients were intubated using ML. Hemodynamic measurements and oxygen saturation were recorded. Intubation criteria for both groups including (duration of intubation procedure, number of attempts, number of optimization maneuvers, Cormack and Lehane grade at laryngoscopy, Intubation Difficulty Scale score (IDS), rate of successful placement of endotracheal tube, neck mobility during laryngoscopy and intubation complications were recorded. Data statistically analyzed using SPSSR software using (t and χ2 tests) and P<0.05 considered significant.Results: There was statistically significant increase in both heart rate and mean arterial blood pressure values following intubation in ML group than AL, oxygen saturation showed no significant difference between the two groups. Duration of intubation was statistically significant longer in ML group and needed more optimization maneuvers than the AL group, while for the number of intubation attempts; there was no statistically significant difference between the two groups. Both the Cormack and Lehane grading and IDS score values have shown statistically significant higher values in ML group.Conclusion: The Airtraq Laryngoscope offers a new approach for the management of difficult airway like patients with potential cervical spine injury, it is fast, easy to use, gets an easy view of the larynx without moving the cervical spines or causing hemodynamic stimulation.