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   2020| January-March  | Volume 18 | Issue 1  
    Online since March 26, 2020

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Repetitive transcranial magnetic stimulation in the management of poststroke depression
Amgad A.M Gabr, Mohamed Hamed, Mohammad Abdul-Fattah
January-March 2020, 18(1):18-23
Background Poststroke depression (PSD) occurs in nearly 33% of stroke survivors. Noteworthy, PSD might lead to severe consequences such as functional disability, poor rehabilitation outcomes, and quality of life, which in turn contribute noticeably to suicidal tendencies, restroke occurrence, and high mortality rate among survival patients. Aim This study was performed to show the psychiatric outcomes of repetitive transcranial magnetic stimulation (rTMS) in the management of PSD survivors. Patients and methods Patients with clinical and neuroradiological evidence consistent with either brainstem, hemispheric, or cerebellar ischemic stroke were included in this study. Hamilton depression rating scale and Beck depression inventory scores were performed for psychiatric assessment of these patients. Results In all, 40 patients were included in this study who developed PSD and fulfilled the eligibility criteria. There were 22 (55%) women and 18 (35%) men with a mean age of 64.1±9.3 years. All patients suffered from depression, 13 (32.5%) from severe depression, 27 (67.5%) have a complete response to rTMS not only at the end of the treatment protocol, but also after a month from the cessation of rTMS. There was a statistically significant difference regarding the levels of Hamilton depression rating scale 17 Beck depression inventory scores at baseline, end of treatment, and one month after the stoppage of treatment. Conclusions This study showed that rTMS is an effective, safe, and promising therapeutic treatment, mostly for severely depressed patients after stroke.
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Some biochemical and radiological markers of bone mineral content in premature neonates
Amira M.M Hamed, Mohammed M.M Rayan, Wafaa A.E Abd El-Hafeez Salem
January-March 2020, 18(1):8-17
Background and aim Inadequate supplementation of calcium and phosphorus in preterm infants significantly increases the risk of reduction of bone mineral content. As birth weight and/or gestational age increase, metabolic bone disease prevalence decreases and vice versa. This study aims to investigate and evaluate biochemical and radiological markers as early predictors of bone mineral content in preterm infants of up to 4 months of age. Patients and methods A case–control study included 20 preterm infants born less than 37 weeks of last menstrual period and 20 full term infants born greater than 37 weeks are involved as a full term group. Both groups are presented to the Neonatology Department, Al-Azhar University, Assuit, Egypt. Full history, full clinical examination, and investigations were done: complete blood count, serum alkaline phosphatase (ALP), serum total calcium (Ca), serum phosphorus (P), and wrist radiograph. Results According to investigations, there was no significant difference between preterm and full term infants in serum calcium and serum ALP at birth (P>0.05 for each), while there was significant difference between preterm and full term infants according to serum phosphorus, as the mean serum phosphorus in the preterm group (1.06±0.21) was lower than the mean serum phosphorus in the full term group (2.16±0.19) (P<0.05 for each) at birth. There was significant difference between investigation results in the preterm group at 2 months and at 4 months according to serum phosphorus, serum ALP, as these investigations increase after 4 months in the preterm group. There was no significant difference according to serum calcium at 2 months and 4 months (P>0.05). Also, cases with rickets increase after 4 months in the preterm group (P<0.05 for each). There was significant difference between the age of 2 and 4 months regarding bone changes in patients with rickets, as cases with widening, cupping, and fraying increases after 4 months in the preterm group (P<0.05). Conclusion Metabolic bone disease in preterm infants is affected by gestational age and birth weight. As birth weight and/or gestational age increase, metabolic bone disease prevalence decreases and vice versa. Assessment of serum ALP and serum phosphorus have helped to identify and expect preterm infants with high risk of metabolic bone disease.
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Right ventricular function in pregnant women with or without preeclampsia
Ola H Abd Elaziz, Aziza H Nassef
January-March 2020, 18(1):1-7
Background Preeclamsia (PE) is a multisystem disorder that affects maternal and fetal outcomes. We aimed to assess right heart function in PE by echocardiography using conventional, tissue Doppler techniques, and 2D and 4D strain. Patients and methods This study comprised 100 pregnant women aged between 32 and 41 weeks divided into two groups: group 1 included 50 pregnant women with PE, who were compared with 50 age-matched normotensive pregnant women as a control group (group 2). They were subjected to proteinuria detection, pelviabdominal ultrasound, conventional echo, tissue Doppler imaging, and 2D and 4D speckle tracking echocardiography for measurement of right ventricular (RV) dimensions and RV systolic and diastolic function indices. Results The higher percentages of cesarean delivery, low birth weight, and need for NICU were present in group 1 compared with group 2. There were significantly increased RV dimensions in group 1 compared with group 2. TAPSE (2D and 4D), RV FAC (2D and 4D), average RV Sa, 4D-RV EF, 2D-RV strain, 4D septal strain, and 4D-RV free wall strain were significantly lower in group 1. RV MPI (PW and TDI) was higher in group 1 patients. Both tricuspid E/A and RV E/Ea were significantly higher in group 1. There was a positive correlation between proteinuria and mean arterial pressure, 2D-TAPSE, RV PW-MPI, and RV TD-MPI, whereas there was a negative correlation with 2D and 4D-RV strain, 4D RVEF, 4D-FAC, and T E/A. Conclusion Women with PE had significant RV structural and functional changes. Assessment of RV by newer echocardiographic modalities such as speckle tracking echocardiography and 4D-echocardiography can detect subtle cardiac changes that may help in early diagnosis of maternal and fetal complications.
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Role of platelet-rich plasma in treatment of knee osteoarthritis
Ismail A Yassin, Faisal H Zayed, Ahmed F Abd El-Aziz, Mahmoud K Beltagy
January-March 2020, 18(1):32-35
Background Osteoarthritis (OA) is a degenerative joint disease of multifactorial etiology and affects synovial joints. The risk of developing OA substantially increases with each decade after the age of 45 years. It is characterized by progressive deterioration and loss of articular cartilage with structural and functional changes in the entire joint, including the synovium, periarticular ligaments, and subchondral bone. Objective To assess the clinical effects of intra-articular injection of platelet-rich plasma (PRP) into the knee joint with mild to moderate OA regarding pain, quality of life, and return to activity. Patients and methods The study included 30 patients in the age range of 30–70 years complaining of knee OA grade II and III based on Kellgren and Lawrence classification and confirmed by radiographs. The patients received three intra-articular PRP injections with weekly intervals. Results A statistically significant improvement in the joint function was observed after 6 months according to the Western Ontario and McMaster Universities Osteoarthritis Index scoring index. Conclusion From the results of our study, intra-articular PRP injection is considered as a safe and low-cost line of knee OA treatment with few adverse effects.
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Role of rectal NSAID administration time in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis
Zakarya M Zakarya, Mohammed S Hussein, Abdullah M Gaafar
January-March 2020, 18(1):66-69
Objectives Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Many NSAIDs have been used to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We aimed to evaluate the appropriate time to start rectal indomethacin in patients undergoing ERCP for treatment of calcular obstructive jaundice for prevention of PEP. Patients and methods Over 10 months, 80 consecutive patients with calcular obstructive jaundice underwent ERCP. Patients were assigned to receive indomethacin suppository 100 mg either just before the procedure (group A=30 patients), directly after the end of the procedure (group B=30 patients), or just before and 5 h after the procedure (group C=20 patients). Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP. Results Of 80, 18 (22.5%) patients developed PEP. The rate of PEP was lower in group C patients (15.0%) when compared with groups A and B (30.0 and 20.0%, respectively). No patients in group C had severe PEP in comparison with 11% in group A and 17% in group B. Conclusion This study shows that rectal indomethacin given immediately before and 5 h after ERCP can reduce the incidence and severity of PEP.
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Value of screening for nonalcoholic fatty liver disease in hyperuricemic patients with normal body mass index by two-dimensional ultrasound: Upper Egypt experience
Amro M Hassan, Mohammed H.A Elhaw, Ahmed Abd-Elrady Ahmed, Tarek M.M Mansour, Tarek M Abd-Elaziz, Mohamed Z.A Shoaeir
January-March 2020, 18(1):104-109
Background Nonalcoholic fatty liver disease (NAFLD) is major health problem, as it affects 20‑30% of the general population, and patients with NAFLD are at risk of progression toward liver cirrhosis and hepatocellular carcinoma and consequently lead to liver transplantation. NAFLD is strongly associated with obesity and metabolic syndrome, so NAFLD is usually seen in patients who have increased BMI, type 2 diabetes, and high cholesterol and triglycerides. Uric acid (UA) could play a role in pathogenesis of metabolic syndrome through oxidative stress and inflammatory response. Moreover, UA has been shown to promote lipid peroxidation, which could play a role in initiation and progression of NAFLD. Aim To evaluate the value of screening for NAFLD in hyperuricemic patients with normal BMI by two-dimensional ultrasound. Patients and methods This cross-section study was conducted on 100 persons: 50 patients diagnosed with hyperuricemia as the case group, and 50 persons with normal serum uric acid (SUA) who were crossed matched with the cases as a control group. Results This study showed that hyperuricemic patients had high rate of NAFLD (38%) more than people with normal SUA (20%), with P value was 0.025, and grade of NAFLD was higher in individuals with high SUA than individuals with normal SUA group, with P value was 0.048. Moreover, the levels of alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase were significantly increased in hyperuricemic patients more than individuals with normal UA level. Conclusions This study showed high rate of NAFLD among individuals with high SUA than individuals with normal SUA, and the ultrasound grading of NAFLD was higher in individuals with high SUA group than individuals with normal SUA.
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Correlation between the presence of aortic valve sclerosis and mitral annular calcification and severity of coronary artery disease
Mohammed Mahmoud, Tariq Abdelwadoud Hamed Bakr, Ali Elsharkawi
January-March 2020, 18(1):70-80
Background Despite numerous improvements in risk scoring regarding assessment of severity of coronary artery disease (CAD), there still remain patients distinguished as being low risk who experience CAD events, just as patients regarded high risk who stay free of CAD events. Aim To evaluate whether the presence and severity of aortic valve sclerosis (AVS) and/or mitral annular calcification (MAC) as detected by transthoracic echocardiography could be a predictor for the presence and extent of CAD in patients less than or equal to 65 years Patients and methods The study included 80 patients with suspected CAD, referred for coronary angiography for assessment of chest discomfort between January 2015 and April 2017. The patients were divided into two primary groups: group I included 20 patients with ordinary aortic and mitral valve, and group II included 60 patients with AVS and/or MAC. The group II was additionally subdivided into group IIa, comprising 30 patients with AVS, and group IIb, comprising 30 patients with AVS and MAC. The following was accomplished for all groups: detailed clinical history taking, total general and cardiovascular assessment, full laboratory data, 12-lead resting ECG, complete transthoracic echocardiographic assessment, and coronary angiography. Results In the correlation between group I and group II with respect to number of vessels affected, there was an extremely high statistically significant difference between both groups. There was a high statistically significant positive correlation between the sum of aortic valve cusp thickness and severity of CAD evaluated by vessel score in group IIa. Among group IIb, there was a high significant positive correlation between MAC and severity of CAD assessed by vessel score. Conclusions AVS is firmly interrelated with the coronary angiographic Friesinger score to yield a proportion of the degree and of severity of CAD. There is a positive correlation between MAC severity and CAD. Echocardiographically detected MAC can be an indicator of significant CAD.
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Short-term outcome after percutaneous coronary intervention in patients with impaired left ventricular systolic function by conventional, tissue Doppler, and speckle-tracking echocardiographic study
Mohamed M Ahmed
January-March 2020, 18(1):81-97
Background Myocardial revascularization with chronic left ventricular (LV) dysfunction improved LV functional and survival. Echocardiographic (echo) remains the test for assessing cardiac function in clinical practice. Tissue Doppler imaging (TDI) and speckle-tracking echocardiography (STE) are new techniques in assessing LV functions. Aim To assess the short-term outcome of LV functions after percutaneous coronary intervention (PCI) in impaired LV systolic function using conventional, tissue Doppler, and STE. Patients and methods This study included 100 patients presented with ischemic cardiac chest pain, ejection fraction (EF) less than 55%, significant coronary occlusion (>70%) in a recent angiography, and were candidates for PCI. Echo study was done before and 3 months after PCI including conventional echo and TDI of both LV functions. Moreover, two-dimensional-STE: automated function imaging is used to reflect the systolic LV function by assessment of the LV global longitudinal strain (GLS). Results Three months after PCI, there was a significant increase in LV systolic function: EF (by M-mode and modified Simpson’s methods), FS (by M-mode), and mean Sm (by TDI), GLS (by STE). Moreover, LV diastolic function significantly increased: E wave velocity and E/A ratio, with no change in A wave velocity (by PW Doppler) and E’ velocity and E/E’ ratio (by TDI). EF measured by both M-mode and with modified Simpson’s methods was significantly correlated with average Sm (by TDI) and GLS (by STE) both before and after PCI. Moreover, Sm and GLS were positively correlated both before and after PCI. There was no statistically significant correlation between E/A ratio and average E’ both before and after PCI. E/A ratio was not correlated with E/E’ ratio before PCI but significantly correlated after PCI. Average E’ and E/E’ ratio were significantly correlated before PCI but not after PCI. Conclusion Significant improvement in the global LV systolic and diastolic functions occurs after PCI in patients with baseline impaired LV systolic function owing to coronary artery disease as assessed using conventional echo, TDI, and STE.
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A comparative study between sutureless total thyroidectomy by harmonic scalpel and traditional method (clamp and tie)
Rasha Abd Elaziz Abd Elghany, Mohammed S Zarad
January-March 2020, 18(1):98-103
Objective The objective of our study is to compare the outcome of sutureless total thyroidectomy performed by the focus harmonic scalpel (HS) versus operations that were performed with the traditional technique (clamp and tie). Study design This is a prospective randomized clinical trial that has been carried out at the Department of General Surgery, Al-Zahraa University Hospital. Patients and methods This clinical trial was carried out between April 2016 and April 2019. In all, 200 patients who underwent total thyroidectomy were randomly divided into two equal groups : group A (100 patients) underwent total thyroidectomy with HS and group B (100 patients) underwent total thyroidectomy with the traditional hemostatic method ligation with clamp and tie. Results The intraoperative time was significantly shorter in the HS group (A) than in the traditional hemostasis group (B); intraoperative blood loss and total fluid drainage volume were lower in the HS group (A) than the traditional hemostasis group (B). Postoperative bleeding was observed in five (5%) patients in the traditional hemostatic group (B), versus two (2%) patients in the HS group (A). Postoperative seroma was observed in only four patients in the traditional thyroidectomy group. Conclusion HS in total thyroidectomy significantly reduces intraoperative time, intraoperative blood loss, drainage volume, and postoperative complications.
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Intrathecal dexmedetomidine versus magnesium sulfate as adjuvant to hyperbaric bupivacaine in total abdominal hysterectomy
Abeer E Farhat, Mona E Elkafrawy
January-March 2020, 18(1):40-45
Background Different adjuvants have been added to local anesthetics to increase the duration of regional anesthesia, delay onset of postoperative pain, and decrease pain-relieving drugs. The present study aims to compare the effect of adding dexmedetomidine versus magnesium sulfate to intrathecal hyperbaric bupivacaine in total abdominal hysterectomy regarding onset, duration of sensory and motor blockade, duration of postoperative analgesia, hemodynamic stability, and complications. Patients and methods A prospective randomized double-blind clinical study included 40 women aged 40–56 years, with American Society of Anesthesiologists physical status I and II, scheduled for total abdominal hysterectomy. They were randomly divided into two groups: group I (n=20) got 15 mg of 0.5% hyperbaric bupivacaine in addition to 10 μg dexmedetomidine, whereas group II (n=20) got 15 mg of 0.5% hyperbaric bupivacaine in addition to 100-mg magnesium sulfate, in a total volume of 4 ml in both groups. The primary outcome is onset, duration, and intensity of sensory and motor blockade. The secondary outcomes are hemodynamic stability, duration of postoperative analgesia, and complications. Results The onset of sensory and motor blockade was significantly faster and of prolonged duration in dexmedetomidine group than magnesium sulfate group (P<0.001). The duration of postoperative analgesia was significantly prolonged in dexmedetomidine group (P<0.001). Regarding hemodynamic and complications, there were no significant differences between both groups (P˃0.005). Conclusion Addition of dexmedetomidine to intrathecal bupivacaine appears to be superior to magnesium sulfate as it produce faster onset and prolongs the duration of sensory and motor blockade and postoperative analgesia.
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Comparative study between open and ultrasound-guided central venous access devices
Sayed A Elhady, Elsayed M Abd El-Hamid
January-March 2020, 18(1):46-51
Background and aims Pediatric populations represented a challenge for insertion of central venous access devices (CVADs). Ultrasound guidance seems to provide advantages over the open surgical method. However, there are no enough data to advocate this notion. An additional goal was to compare between ultrasound-guided and open surgical venous cut down for central venous catheter (CVC) placement. Patients and methods The study included 40 patients, divided into two equal groups: group A (open CVAD group) and group B (ultrasound-guided CVAD group). For each group, patient data, procedure success rate, time of the procedure, and any complications were documented and compared in both groups. Results Both groups were comparable regarding patient age, sex, cauterized vein, indication for CVC insertion, success rate, first-attempt success, number of attempts, and complications. Conclusion Ultrasound guidance was confirmed to be effective and safe as an open method for insertion of CVC insertion with preservation of the vein intact.
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Use of elastographic techniques as noninvasive tools in assessment of renal allograft fibrosis
Mohamed A Alsenbesy, Abdelkader A Hashem, Ghada M Abdelrazek, Mohammed H Hassan
January-March 2020, 18(1):60-65
Context Chronic allograft dysfunction is still the main cause of late allograft loss in kidney transplantation. Increased serum creatinine could be an indicator of progressive damage of the renal allograft and tubular atrophy and interstitial fibrosis, which need to be confirmed by the invasive, sometimes hazardous renal allograft biopsy. Aims We aimed to assess the possibility of using transient elastography (fibroscan) either based on ultrasound or MRI as noninvasive tools for evaluation of renal allograft fibrosis and chronic allograft index (CAI). Setting and design A prospective cohort study was conducted. Patients and methods The study included 15 patients with renal allograft. Pelvi-abdominal sonar, renal Doppler, and fibroscan have been performed for the included patients. Serum urea and creatinine have been measured, and estimated glomerular filtration rate (eGFR) has been calculated for all patients. Renal biopsies were done in seven cases. Statistical analysis Statistical package for the social sciences (version 13.0) was used for statistical analysis. Results Stiffness was significantly correlated with interstitial fibrosis (P<0.05) and inversely related with eGFR (P<0.05). Stiffness values of patients with eGFR more than 50 ml/min were lower than those patients with eGFR less than 50 ml/min (P<0.05). Patients classed as CAI Banff grade 0 had significantly less parenchymal stiffness than patients with Banff grade 1 or grade 2 CAI (P<0.05). Stiffness values of patients have insignificant relationship between parenchymal stiffness and resistive index (P<0.225). Conclusion Parenchymal renal allograft stiffness by TE is an effective method for identifying patients with CAI indicative for biopsy and modification of the immunosuppressive regimen.
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Assessment of renal artery resistive index as a predictor of esophageal varices and its bleeding risk in post-hepatitic cirrhosis
Samy Zaki, Waleed M Mousa, Abdullah H Ahmed
January-March 2020, 18(1):52-59
Background Bleeding from rupture esophageal varices (EV) is a major and life-threatening complication of liver cirrhosis (LC). Early detection of EV and prediction of its bleeding risk is important. Objective To assess and evaluate the resistive index (RI) of the renal artery (RA) by Doppler in various stages of portal hypertensive manifestations of LC, and their values for detection of EV and its bleeding. Patients and methods The study included 90 patients, comprising 75 patients with confirmed diagnosis of LC, classified into the following groups: group 1 included 25 patients with EV and having history of variceal bleeding episodes, group 2 included 25 patients with EV and having no variceal bleeding episodes history, and group 3 included 25 patients without EV; in addition, 15 noncirrhotic controls were included as group 4. All patients were subjected to history taking, clinical examination, laboratory investigations, calculation of some important noninvasive indices (CHILD, FIB 4, and APRI) in cirrhotic groups, abdominal ultrasonography, renal Doppler, and upper gastrointestinal endoscopy. Results RA RI served as a predictor of the presence as well as bleeding risk of EV. LT RA RI revealed that a cutoff value of 0.70 has a sensitivity of 90% and a specificity of 76% to predict EV. Moreover, LT RA RI revealed that a cutoff value of 0.70 has a sensitivity of 92% and a specificity of 40% to predict EV bleeding. RT RA RI revealed that a cutoff value of 0.70 has a sensitivity of 80% and a specificity of 76% to predict EV. In addition, RT RA RI revealed that a cutoff value of 0.70 has a sensitivity of 88% and a specificity of 52% to predict EV bleeding. Conclusion RI of the RA may help in predictions of EV and its bleeding risk. LRA RI was more sensitive for prediction of EV bleeding.
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Self-injury behavior: manifestations and risk factors in school-aged children in Assuit Governorate
Amira M Mohammed, Islam S Mohammed, Nashwa H Hassan
January-March 2020, 18(1):24-31
Background Nonsuicidal self-injury is any self-directed behavior that causes immediate destruction of body tissues. This behavior is manifested in a variety of forms, such as cutting, skin carving, burning, severe abrading, scratching and punching, hitting of head or any part of the body, pica, vomits, hair pulling, inserting objects in orifices, pulling fingers or toes or nails, inserting fingers in orifices, extreme eating or drinking, and grinding. The aim of this study was to detect self-injury and risk factors that lead to this behavior among children from 5 to 16 years in the Al-Azhar University Hospital Clinic. Patients and methods This study included 50 cases aged 5–16 years. Another 50 of the matched children regarding age (5–16 years) and sex were included in the study as a control group. Results The most common forms of self-injury in our study were pica (40%), vomiting (12%), burning (4%), loud sounds and shouting (8%), nail eating (26%), head hitting and body hitting (20%), interfering with wound healing and playing with electricity (8%), and some of them had multiple forms of self-injury. Self-injury is related to family history (56%), common in low-educated parents, and fewer incidences of intellectual jobs among parents of the studied group. Conclusion Self-injuries among the pediatric population are underestimated and should be focused especially among children with social, developmental, or intellectual problems. Self-injuries are common among children with attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, conduct disorders, and intellectual disabilities. Low social class and low education of parents are risk factors of self-injury and must be studied to decrease self-injury and suicide. Child abuse is one of the risk factors of self-injury, which should be limited.
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Spina bifida occulta in children with nocturnal enuresis
Ebrahim A Elkashlan, Mohamed M Shaaban, Anas M AlShreif, Maged Ghanem
January-March 2020, 18(1):36-39
Background Enuresis is defined as the voluntary or involuntary wetting of clothes or bedding with urine for a period of at least three consecutive months in children older than 5 years of age. It is a common disorder in children affecting about 15–20% of 5-year-old children. Enuretic children have a higher incidence of spina bifida occulta (SBO). Presence of SBO can affect the response of enuretic children to the management. Objective The aim of this study was to detect the incidence of SBO in children with nocturnal enuresis and the response to treatment of these enuretic children with SBO compared with enuretics without SBO. Patients and methods From January 2014 to June 2015, we prospectively reviewed 100 patients who visited Al-Hussain University Hospital in Cairo, Egypt, with nocturnal enuresis as the chief complaint to determine the relationship between the SBO and enuresis and also the response to the treatment of children with and without SBO. Results The overall incidence of SBO in enuretic children was 33% and the presence of SBO could affect the treatment results. Conclusion The incidence of SBO is higher in enuretic children and its presence may adversely affect the response to treatment. The cause-and-effect relationship between SBO and nocturnal enuresis (NE) should not be overlooked and should be further elucidated.
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Erratum: Assessment of left ventricular functions and its correlation to the severity of liver cirrhosis caused by hepatitis C virus by different echocardiography modalities (two-dimensional speckle-tracking echocardiography study)

January-March 2020, 18(1):110-110
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