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   Table of Contents - Current issue
Coverpage
July-September 2017
Volume 15 | Issue 3
Page Nos. 127-162

Online since Thursday, February 22, 2018

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ORIGINAL ARTICLES  

Comparative study of midazolam, dexmedetomidine, and ketamine as an adjuvant to lidocaine in intravenous regional anesthesia for forearm and hand surgeries Highly accessed article p. 127
Alaa E Mahmoud, Abdelwahab A Saleh, Ali A Mahareak, Ali A Alkumity
DOI:10.4103/AZMJ.AZMJ_32_17  
Background Intravenous regional anesthesia (IVRA) is an ideal method of providing anesthesia for minor surgical procedures to the extremities performed on an ambulatory basis. This study aimed to study the effects of adding midazolam, dexmedetomidine, or ketamine as an adjuvant to lidocaine in IVRA during forearm and hand surgeries and examine their benefits and complications. Patients and methods A total of 120 patients were included, aged 40–60 years (American Society of Anesthesiologists physical status I–II), undergoing hand and forearm, from April 2015 to August 2016. Patients were randomly divided into four equal groups. Lidocaine-only group (LL group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg). Lidocaine plus midazolam group (LM group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus midazolam 50 µg/kg added as an adjuvant. Lidocaine plus dexmedetomidine group (LD group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus dexmedetomidine 1 µg/kg added as an adjuvant. Lidocaine plus ketamine group (LK group) received IVRA using 40 ml of lidocaine 0.5% (3 mg/kg) plus ketamine 0.5 mg/kg added as an adjuvant. The time of onset, duration, and quality of analgesia; levels of sensory and motor block; heart rate; mean arterial blood pressure; and visual analog score were recorded. Adverse effects of hematoma, injection pain, skin erythema, sedation, and hallucinations were recorded. Results The onset time of sensory and motor blocks was significantly shorter in the adjuvant groups LM, LD, LK in comparison with the control group LL. The grade of sensory and motor blocks was significantly better in groups LM, LD, and LK in comparison with the LL group. The onset time of tourniquet pain was significantly shorter in the control group LL in comparison with adjuvant groups LM, LD, and LK. There was a significant increase in fentanyl requirements in the control LL group compared with adjuvant LM, LD, and LK groups. The duration of postoperative analgesia was significantly prolonged in adjuvant groups LM, LD, and LK compared with the control LL group. Hematoma, injection pain, cutaneous erythema, and hallucination were reported as postoperative complications. Conclusion The addition of midazolam, dexmedetomidine, or ketamine to lidocaine for IVRA improved the quality of intraoperative and postoperative analgesia with minimal adverse effects and higher patients and surgeon satisfaction.
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Evaluation of serum ferritin level in patients with fever of unknown origin p. 135
Raed Hamed Mansour, Shaban Salah Abd El-moneum, Tarek Aly Hassan, Ahmed Abdelalim Abuo Elhassan, Mohamed Hasan Elnadry, Wlid Mohamed Elbakrawy
DOI:10.4103/AZMJ.AZMJ_56_16  
Background Diagnosis of the cause of fever of unknown origin (FUO) is a great challenge. Serum ferritin may be a useful index for differentiating between infectious and noninfectious causes of FUO (malignant disease or collagen disease). In this respect, serum ferritin has the advantage of decreasing the number of unnecessary tests and helping to exclude infectious disease. Objective This study aimed to evaluate serum ferritin levels among patients suffering from FUO. Methods A comparison was made between infectious, noninfectious, and undiagnosed cases of FUO as regards serum ferritin level using an in-vitro enzyme-linked immunosorbent assay. Results The most common causes of FUO were infectious diseases (120/300, 40%), followed by noninfectious diseases such as malignant (61/300, 20.4%) and autoimmune causes (49/300, 16.3%). Undiagnosed cases constituted 70/300 (23.3%). The mean serum ferritin level in the infectious group, noninfectious group, and undiagnosed group was 99.25±49.58, 1098.94±284.54, and 112.40±183.23, respectively, with highly significant difference between infectious and noninfectious causes of FUO (P<0.001). However, there were no significant differences between infectious and undiagnosed causes of FUO. The optimal cutoff point was 559.0; the area under the curve was 0.79, with highly significant difference (P<0.001) at 95% confidence interval of 0.71–0.88. Conclusion High serum ferritin level (>559 ng/ml) helps in differentiation between infectious and noninfectious causes of FUO. In undiagnosed cases of FUO we must direct our thinking to infectious diseases.
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Value of automatic tube compensation in weaning of mechanically ventilated patients in medical ICU p. 142
Mohamed Abouzeid, Ahmed E Kabil, Ahmed Al-Ashkar, Hafez Abdel-Hafez
DOI:10.4103/AZMJ.AZMJ_29_17  
Background Automatic tube compensation (ATC) has been recently introduced to compensate for artificial airway resistance that may be beneficial during spontaneous breathing trials. It has been used as a mode of mechanical ventilation in some newer mechanical ventilators and as an add-on feature for the existing ventilation modes in some other ventilators. Objective To assess the expected value of ATC in the weaning process. Patients and methods A prospective randomized controlled study was conducted at the Medical ICU of Al-Hussein University Hospital, Cairo. Sixty mechanically ventilated patients were included during the period from September 2016 to June 2017. The patients were randomly divided into three groups: 20 patients were weaned by pressure support ventilation (PSV) plus ATC, 20 patients were weaned by PSV alone and 20 patients were weaned by ATC alone. The primary outcome measure was comparison between different groups in weaning outcomes and duration of weaning. Results There was no significant difference between the three groups as regards demographic data, cause of admission or baseline characters at the start of randomization. The weaning duration of PSV+ATC group was significantly lower than the other groups. The duration of weaning in the ATC group was lower than that in the PSV group. There was a higher trend towards successful extubation in PSV+ATC group than other groups but without statistically significant difference. Mortality and morbidity were lower in PSV+ATC group than other groups and were lower in the ATC group than the PSV group but without statistically significant difference. Conclusion In medical ICU patients, the weaning process can be successfully performed by ATC as an add-on feature to the existing modes or as a separate mode. Duration of weaning, total duration of mechanical ventilation and duration of ICU stay were significantly lower with ATC.
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Prevalence of migraine, its effect, and some comorbid psychiatric disorders among female medical students at Al-Azhar University in Cairo p. 148
Eman Saif, Reda El-Belbasy, Zeinab El-Sayed Hammour, Mahasen Mohamed
DOI:10.4103/AZMJ.AZMJ_47_17  
Background The study on the importance of being mentally, socially, and physically healthy as a medical student is a deficient area in the scientific research in developing countries. Migraine has a negative effect on the general health as well as educational performance. Medical students, especially females, may be at a higher risk to manifest migraine associated with anxiety and/or depression. Aims The aims of this study were to determine the prevalence of migraine headache, to investigate its effect, and to assess some comorbid psychiatric disorders (anxiety and depression) among female medical students at Al-Azhar University in Cairo. Participants and methods A cross-sectional study was carried out on 599 female medical students from grade 1 to grade 6 at Faculty of Medicine for Girls, Al-Azhar University, Cairo, over a period of 1 month during the academic year 2014–2015. The studied female medical students were 18–26 years old. Through a self-administrated questionnaire, sociodemographic data were reported. In students without migraine with aura symptoms, the effects of migraine on daily activities, sleeping pattern, seeking of medical care, educational attendance, and influence on career decision were investigated. For each student, the reported migraine neurological symptoms were verified through meeting the International Headache Society (IHS) criteria for diagnosis, whereas comorbid psychiatric evaluation was assessed through the valid and reliable version of Neuropsychiatric Assessment by Hospital Anxiety and Depression Scale. Results The reported migraine prevalence among the studied female medical students was 35.8%. The mean age of students having migraine was significantly higher than those without migraine (21.09±1.98 vs. 20.61±1.91 years) (P<0.05). Among the students having migraine, 70.2% reported reducing their usual daily activities during migraine episode, 53.5% reported poor sleeping pattern, and 58.6% were found to be felt obliged to attend educational activities despite their migraine symptoms. Seeking medical care was reported by only 20.0% of migraine students. The reported mean episodes of migraine per month was 5.11±4.47. Stress, noise, and menses were the most common triggers of migraine, as recorded by 83.7%. The prevalence of anxiety, depression, and mixed psychiatric disorders among students with migraine was found to be 23.3, 7.4, and 15.4%, respectively, as compared with 20.3, 4.4, and 7%, respectively, among nonmigraine group, without statistically significant differences between them (P>0.05). Conclusion and future vision The prevalence of migraine is considered high among the studied female medical students. It is found to be an important health problem because of its negative effect on diminishing students’ performance, disrupting their sleep, and implied stress. Anxiety and/or depression among medicals students with migraine as well as those without are urgent burdens that should be investigated more and targeted by health care providers. Curriculum should include stress-coping tools, counseling, and psychosocial support to reduce distress and severe effect of migraine on students’ well-being.
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Tacrolimus versus narrowband ultraviolet b in the treatment of vitiligo: a clinical and laboratory evaluation p. 155
Moustafa A El Taieb, Emad F Kholef, Sara Moustafa, Essam Nada
DOI:10.4103/AZMJ.AZMJ_65_17  
Background Etiopathogenesis of vitiligo is unclear. Immunological background has a role. Interleukin 17 (IL-17) may play a role in its pathogenesis. There is no standard treatment regimen for vitiligo; however, calcineurin inhibitors may be an effective treatment option. Objective The aim was to evaluate tacrolimus versus narrowband ultraviolet B (NB-UVB) in treatment of vitiligo, both clinically and by measurement of IL-17 before and after treatment. Patients and methods A total of 45 patients with generalized vitiligo were included in the study. Overall, 21 patients were treated with NB-UVB, whereas 24 were treated with tacrolimus for 3 months. Vitiligo area scoring index (VASI) and IL-17 were measured before and after treatment. Results VASI was significantly improved after both treatments (P<0.001 for both groups). IL-17 was significantly decreased after treatment in both study groups (P<0.001 for both groups). IL-17 was significantly correlated with VASI. Conclusion NB-UVB and tacrolimus are both effective in the treatment of vitiligo and in decreasing IL-17. IL-17 may play a role in pathogenesis of vitiligo as its level was decreased significantly after treatment.
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CASE REPORT Top

Hypotrichosis with keratosis pilaris: a case report and review of literature p. 160
Ayman M Mahran, Aya Y Badran, Asmaa M Ahmad, Mahmoud R Hussein
DOI:10.4103/AZMJ.AZMJ_35_17  
Hypotrichosis or sparse hair is a relatively common feature of several hereditary syndromes. Hypotrichosis with keratosis pilaris is a very rare inborn skin disorder of unknown etiology. Here we report a rare case of hypotrichosis with keratosis pilaris in a 7-year-old boy. To the best of our knowledge, this is the first case to be reported from Egypt. The clinicopathological features were presented and the relevant literature was addressed.
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