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   Table of Contents - Current issue
Coverpage
January-April 2018
Volume 3 | Issue 1
Page Nos. 1-66

Online since Monday, January 7, 2019

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REVIEW ARTICLES  

Adaptive support ventilation versus synchronized intermittent mandatory ventilation in patients with chronic obstructive pulmonary disease p. 1
Olfat M.N. A-N El-Shenawy, Mohamed M. A-H Metwally, Alaa E.T.H Abdel-Mabboud, Alaa S Abdel Ghany
DOI:10.4103/JCMRP.JCMRP_11_18  
Adaptive support ventilation (ASV) is a fully automated closed-loop ventilation mode that can act as pressure support (PS) and pressure-controlled ventilation. The aim of this study was to evaluate the benefits of using ASV in the initiation, maintenance, and weaning phases of the mechanical ventilation in comparison with synchronized intermittent mandatory ventilation (SIMV)+PS mode in patients with chronic obstructive pulmonary disease (COPD). Sixty patients with COPD requiring mechanical ventilation were recruited in this study. Among them, 37 patients were treated by SIMV+PS, whereas 23 patients were assigned for ASV. After resolution of the cause of acute respiratory failure, assessment of readiness for weaning was done. Patients were followed after 30, 60 min, and 24 h. Ventilator and hospital outcomes were recorded. Compared with SIMV+PS, ASV provided shorter weaning time (27.3 ± 12.3 vs. 62 ± 14.1 h). Moreover, there was a shorter hospital stay of 14.83 ± 6.14 for ASV group compared with 22.14 ± 17.39 days for SIMV+PS, with similar weaning failure rates, death rate, and intubation period in both groups. This study proved that ASV mode was successful as a mode of initiation, maintenance, and weaning in acute exacerbation of patients with COPD requiring mechanical ventilation with a shorter weaning time and shorter hospital stay compared with SIMV+PS mode.
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Acute-on-chronic liver failure: a clinically important new syndrome p. 6
Mohammed A Medhat, Abdel G.A. Soliman, Hanan M Nafeh, Francois Durand
DOI:10.4103/JCMRP.JCMRP_13_18  
Acute-on-chronic liver failure is a new syndrome characterized by multiple organ (s) failure and high short-term mortality. This review article focuses on the definitions, diagnosis, and different treatment options for this syndrome. Patient education, anticipation, early identification of the acute insult, and early detection of chronic liver disease would be immensely helpful to prevent the disease.
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Clinical audit for insertion and removal of Cu T380a intrauterine device in a Secondary Care Center in Upper Egypt p. 22
Momen A. M Kamel, Ali M. M El Saman, Mahmoud A.M Abd El Aleem, Hend S. Abd El Sabour Morsy
DOI:10.4103/JCMRP.JCMRP_50_18  
Clinical audit comes under the clinical governance umbrella and forms part of the system for improving the standard of clinical practice. Many organizations worldwide have published standards for intrauterine device (IUD) use and removal. There is no audit that has been published about using IUD in Egypt; therefore, our objective was to audit the current IUD insertion and removal, identifying the gap between the current practice and ideal practice and setting recommendations to fill the gap to improve client satisfaction and minimize complications and to reaudit the magnitude of improvement. A total of 500 IUD insertion/removal clients (350 cases for preaudit and 150 cases for postaudit) were included in the study. There were statistically significant improvement in several preinsertion, insertion, postinsertion, preremoval, and removal steps of IUD in postauditing in comparison to preauditing, but there are no statistically significant differences in the frequency of all postremoval steps of IUD in postauditing in comparison to preauditing. The present audit identified a gap in a number of items that were partially improved in the reaudit phase and this indicates the value of audit in IUD insertions and removal steps.
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ORIGINAL ARTICLES Top

Treatment of third-degree marasmus among children admitted to Assiut University Children Hospital: a clinical audit p. 26
Faida M Moustafa, Manal M Darwish, Osama M El-Asheer, Ebtesam A. A. Tayia
DOI:10.4103/JCMRP.JCMRP_37_17  
Introduction Optimal infant and young child feeding can be achieved easily by encouraging mothers to breastfeed exclusively for the first 6 months and to introduce nutritionally adequate, safe, age-appropriate, and responsive complementary feeding starting at 6 months. Patients and methods The present study aimed to assess the degree of adherence of medical physicians to protocols for treatment of severe marasmus among children attending Assiut University Children Hospital during the period from 1 January to 30 June 2015 according to WHO guidelines (2003), which is locally approved and documented by nutrition unit of Assiut University Children Hospital as a reference standard. The study included 31 patients with third-degree marasmus whose age ranged from 6 to 36 months. Results and conclusion Data about mid-upper arm circumference, Z-score, stabilization, transitional, and rehabilitation phases were not fully fulfilled. Regarding the assessment of conscious level, dehydration, hypothermia, hypoglycemia, severe anemia, shock, and types of complications, most items were fulfilled well.
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The role of lung ultrasound in differentiating lung congestion and lung infection in pediatric cardiac patients p. 30
Mahmoud Kamal Moustafa, Maha Mohammad Sayed Ahmed El Kholy, Gamal Ali Abdelaal Askar, Duaa Mohammad Raafat, Amal Mahmoud El Sisi
DOI:10.4103/JCMRP.JCMRP_39_17  
Background Lung sonography in emergency situations has become one of the most appropriate studies. This technique allows us to diagnose the major causes of acute respiratory distress at the bedside without major interventions. It is an easy and costless approach to diagnose many lung diseases. Patients and methods This work is a cross-sectional, prospective, and descriptive study that included cardiac patients admitted to the pediatric cardiology ward through a period of 6 months. They had their data completely revised and their treatment recorded and diagnosis traced with a direct question: is it congestion or infection. A lung ultrasound (LUS) was done to assure the diagnosis. Also, chest radiography and echocardiography correlation were assessed. Results A total of 60 patients were enrolled over a period of 6 months (58% were males), with a mean age ± SD of 17.33 ± 30.91 months. The B-profile was found in 27 patients; A-profile was found in 35 patients; AB-profile was found in six cases and hypoechoic areas were found in nine cases. LUS appeared to be normal in three cases. Conclusion LUS shows high reliability and accuracy in the diagnosis of pneumonia, pulmonary congestion, pulmonary edema, air trapping, and the possibility of a follow-up until complete resolution of many lung diseases, without exposure to harmful radiation.
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Could metformin be used as a treatment for preeclampsia: A pilot study p. 37
Hany Abdel-Aleem, Ayman H Shamash, Hanan G Abd El-Azeem, Alaa M Makhlouf, Omar M Shaaban
DOI:10.4103/JCMRP.JCMRP_45_17  
Objective To test the effect of metformin on serum level of antiangiogenic factors, soluble endoglin (sEng) and soluble fms-like tyrosine kinase-1 (sFLT-1), in patients with preeclampsia (PE). Patients and methods A controlled before and after prospective study was conducted on 40 patients with nonsevere PE conducted in a tertiary hospital setting. At admission, clinical and laboratory investigations had been done. Metformin tablets (500 mg three times daily) with meals were given from the time of study admission till delivery or termination of pregnancy. Serum level of sEng and sFLT-1 were measured before and 1 week after metformin treatment. Outcome of delivery had been obtained. Results One week after metformin treatment, there was a statistically significant reduction in maternal sEng and sFLT-1, with a mean difference of −448.86 ± 238.48 and −397.72 ± 125.52 pg/ml, respectively. In addition, there were significant reductions in both systolic blood pressure from 147 ± 12.4 to 131 ± 10.6 mmHg and diastolic blood pressure from 92 ± 7 to 85 ± 8.2 mmHg 1 week after metformin use. Five (12.5%) cases progressed to severe PE. Conclusion Metformin use for 1 week reduces the antiangiogenic biomarkers sEng and sFLT-1, and it could have a role in the treatment of PE.
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Hemodynamic stability of ketamine/propofol admixture ketofol in patients undergoing endoscopic retrograde cholangiopancreatography p. 43
Mohamed A Baker, Nagwa M Ibrahim, Mo'men M Makkey
DOI:10.4103/JCMRP.JCMRP_66_17  
Background and aim Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure for diagnosis of many gastrointestinal tract disorders. Propofol is a commonly used agent, but we decrease its adverse effects by adding ketamine. We aimed in this study to compare propofol versus propofol–ketamine regarding hemodynamic stability, recovery, and complications in ERCP. Patients and methods A total of 90 American Society of Anesthesiology status II–III patients aged 18–60 years who underwent ERCP were randomly allocated by sealed envelope assignment into two groups of 45 patients each: group P received intravenous 2 mg/kg propofol and group KF received intravenous propofol–ketamine 3:1 mixture (%1 15 ml propofol + 1 ml 50 mg/ml ketamine + 4 ml saline in a 20 ml syringe, which resulted in 0.25 mg/ml ketamine and 0.75 mg/ml propofol) until Ramsay sedation scale increased to 3–4. For each patient, the following data were collected: heart rate, mean arterial blood pressure, oxygen saturation, procedure time, total drug dosage, recovery score, and patients' and the doctor's satisfaction score (clinical trial NCT02618668). Results The total dosage of propofol consumed was significantly higher in group P compared with group KF (283.78 ± 144.23 and 110.94 ± 51.75 mg, respectively). Recovery time was slightly longer in group P compared with group KF (20.67 ± 5.29 and 19.44 ± 4.16 min, respectively). There was a significance difference in patient satisfaction scores between group KF (1.16 ± 0.64) and group P (1.82 ± 0.83). There was a significance difference in surgeon satisfaction scores between group KF (1.11 ± 0.49) and group P (2.13 ± 0.97). Conclusion Propofol ketamine combination (ketofol) is associated with greater satisfaction scores and a shorter recovery than propofol and without important adverse effects in ERCP interventions.
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The effects of addition of dexamethasone to bupivacaine during ultrasound-guided femoral nerve block for postoperative analgesia in patients undergoing total knee replacement surgery p. 47
Kawthar H Mohammed, Waleed S Hasan, Sherif M Bekhet
DOI:10.4103/JCMRP.JCMRP_74_17  
Introduction The goal of knee replacement is to relieve pain, improve quality of life, and maintain or improve knee function. The procedure is performed on people of all ages. However, a significant number of patients experience persistent pain and functional limitations following knee replacement, with ~20% of patients reporting unfavorable pain outcomes. Materials and methods Our study was done after obtaining Assiut University Hospital Ethical Committee approval and informed written consent from the patients who were admitted to the Department of Orthopedics in Assiut University Hospital and were planned for total knee replacement surgery in the period from December 2015 until July 2017. Our study included 60 patients aged between 18 and 80 years. Patients were randomized into two groups: group B (30 ml of 0.25% bupivacaine) and group BD (28 ml of 0.25% bupivacaine + 2 ml dexamethasone 8 mg). Results The current study showed that preemptive addition of 8 mg dexamethasone to 30 ml bupivacaine 0.25% for femoral nerve block guided with ultrasound for total knee replacement surgery on side of operation resulted in a reduction of visual analog scale pain score over the postoperative 24 h prolonged the duration of the block, required longer time till first analgesic, and led to more patient satisfaction and less incidence of nausea and vomiting. As seen in our results that the visual analog scale was significantly low starting from 4 h (1 ± 0 vs. 1.13 ± 0.35; P < 0.001), 8 h (1.07 ± 0.25 vs. 1.67 ± 0.71; P < 0.001), 12 h (1.23 ± 0.43 vs. 1.97 ± 0.67; P = 0.789), 16 h (1.67 ± 0.71 vs. 2.37 ± 0.67; P = 0.563), 20 h (1.9 ± 0.76 vs. 2.87 ± 0.82; P = 0.774), and 24 h (2.03 ± 0.76 vs. 2.97 ± 0.61; P = 0.052). Conclusion Our study results demonstrate that the addition of dexamethasone to bupivacaine suggestively prolongs its analgesic effect postoperatively. These results are consistent with the trend of previous studies using dexamethasone as an additive to local anesthetic in peripheral nerve blocking.
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Urodynamic changes in women with pelvic organ prolapse p. 52
Omar A Sayed, Ahmed S Elazab, Medhat A Abdallah, Mohamed I Taha
DOI:10.4103/JCMRP.JCMRP_2_18  
Aim To study the prevalence of urodynamic changes associated with female having pelvic organ prolapse (POP) and to correlate these changes with symptoms. Patients and methods A cross-sectional hospital-based study was performed on 29 women with POP seeking care at a Female Urology Clinic, Urology Department, Assiut University Hospital, Assiut, Egypt. A questionnaire was administered to gather information about symptoms. Urine analysis, abdominal ultrasound, and urodynamic study were done. Results Overactive bladder was more common in cystocele. Hydronephrosis was present in 24.1% of POP cases; all of them were fourth degree. As the degree of POP increases, overactive bladder decreases and infravesical obstruction is more likely. Conclusion Urodynamic and clinical findings are common among women with POP.
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Outcome of percutaneous nephrolithotomy for renal stones in Assiut Urology and Nephrology Hospital p. 58
Mohamed Gadelmoula, Ehab A Desouki, Atef Abdellatif, Mohamed Shalaby
DOI:10.4103/JCMRP.JCMRP_7_18  
Context Percutaneous nephrolithotomy (PCNL) has become the standard treatment for renal stones not amenable to extracorporeal shock wave lithotripsy in many countries. Aims The current study aims to evaluate the outcome of PCNL, in terms of efficacy and success rate, in the management of renal stones in our hospital. Settings and design This is a descriptive case-series study. Patients and methods A total of 230 patients, 173 men and 57 women underwent PCNL in our hospital between September 2013 and September 2015. The following clinical parameters were reported; stone site, size, serum creatinine, operative time, site of calyceal puncture, number of tracts, decrease in hemoglobin level, length of hospital stay, stone-free rate (SFR), and complications. Statistical analysis used Intercooled STATA, version 9.2 was used. χ-Test or Fisher's exact test was used for comparison of the categorical data and Mann–Whitney U-test used to compare the noncategorical data. Results The median age was 38 years (range: 3–75 years). The mean operative time was 110 ± 30 min, and hospital stay ranged from 2 to 8 days. The primary SFR was 70.9% after the first session of PCNL but the overall clearance was 87.7%. It was found that stone location, access puncture, access number, and operative time were statistically significant factors affecting SFR. The overall complications were 13%. Conclusion PCNL is considered a standard treatment for large renal stones. Stones distribution, access puncture, number of access, and operative time significantly affect the SFR. The usage of flexible nephroscope and a second-look nephroscopy improved the outcome.
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CASE REPORT Top

Clinical audit on pediatric hypovolemic shock p. 63
Amal A Soliman, Ismail L Mohamad, Asmaa S Mohammed
DOI:10.4103/JCMRP.JCMRP_77_17  
Though often considered a benign disease, acute gastroenteritis remains a major cause of pediatric morbidity and mortality around the world and the main cause of pediatric hypovolemic shock. Fifty patients with hypovolemic shock due to gastroenteritis were included. Clinical management of these cases was compared with the guidelines. Weight was monitored only at the time of admission for most of cases, but according to the guidelines weight should be monitored daily during fluid intake. We need to stick with the international guidelines as the reference standard to avoid the use of unnecessary lines of management and to decrease mortality rate from pediatric hypovolemic shock due to gastroenteritis
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