Medical Research and Practice

REVIEW ARTICLES
	Comparison between early and late cholecystectomy after gallstone pancreatitis	p. 67
	Ahmed M Mohammed, Hesham A Reyad, Mohamed K Ewis DOI:10.4103/JCMRP.JCMRP_108_18   Acute biliary pancreatitis is one of the most common gastrointestinal illnesses necessitating inpatient hospital admission. With an increasing incidence of gallstone disease, in the setting of a changing healthcare landscape, surgical indications must be carefully examined. The principles of management, including common duct clearance, bowel rest, and interval cholecystectomy to avoid recurrent disease have not changed, however with the refi nement of minimally invasive techniques, timing of intervention deserves re-examination. We seek to make evidence based recommendations on the timing of cholecystectomy following acute biliary pancreatitis.
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	Early postoperative outcomes of coronary artery bypass grafting patients on-pump versus off-pump	p. 69
	El Shafiee M Mohamed, Ghoniem F Ahmed, Taha M Ahmed, Roushdi Z Mohamed DOI:10.4103/JCMRP.JCMRP_81_18   Coronary artery bypass grafting (CABG) is defined as "open-heart surgery in which a section of a blood vessel is grafted from the aorta to the coronary artery to bypass the blocked section of the coronary artery. Cardiac surgery became more feasible in the late 1930s with the development of the heart-lung machine by Dr. John Gibbon which enabled cardiopulmonary bypass (CPB). This study aimed at comparing early postoperative outcomes between patients undergone CABG on-pump versus off-pump. The study was done on 40 patients, 20 of them was done by on-pump technique and the other 20 was done by off-pump technique. All the patients were transferred to intensive care unit and were observed for the following criteria: Early postoperative bleeding, Cardiac support (Medical or Mechanical), Different types of Arrythmias, Renal function and Hospital stay. Early postoperative bleeding: appears to be more with On-pump technique in the first 3 post operative days. Cardiac support (Medical or Mechanical): No significant difference with both techniques. Different types of Arrythmias: No significant difference with both techniques. Renal function: No significant difference with both techniques except of only one patient needed renal dialysis was done by on-pump technique. Hospital stay: No significant difference with both techniques with mean days of hospital stay for all patients of 8 days. In conclusion, our trial did not show any overall advantage to the use of the off-pump as compared with the on-pump cardiac surgical approach for coronary bypass grafting.
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ORIGINAL ARTICLES
	Effect of topical and systemic tranexamic acid on bleeding and quality of surgical field during ear exploration surgery: a double-blind, randomised clinical trial	p. 75
	Ahmed M Mohareb, Sherif S. A. Elrahim, Saeid M Elsawy, Seham M Moeen, Ragaa A Herdan, Sally A Kamel DOI:10.4103/JCMRP.JCMRP_56_18   Background The surgical field during microscopic ear surgery is small and needs specific anesthetic considerations to improve the surgical field quality and control the bleeding during ear surgery, as little amount of bleeding can impair the quality of the surgical field and the surgical outcome. This can be achieved by different methods, which carry specific risks, such as hypotensive anesthesia, and use of local vasoconstrictors, which are associated with cardiac and hemodynamic risks. The objective of this study was to assess the effect of tranexamic acid (TXA) topically and systemically on bleeding and quality of surgical field during ear exploration surgery. Materials and methods A total of 90 patients undergoing ear exploration surgery were randomly divided into three group. Group A included 30 patients who received systemic TXA in a dose of 10–15 mg intravenous over 30 min, followed by infusion in a dose of 1 mg/kg/h throughout surgery. Group B included 30 patients who received topical TXA in dilution of 1 g diluted in 200 ml saline for surgical wash and soaking the used gauze for compression on the bleeding site. Group C included 30 patients who received diluted adrenaline 1 mg diluted in 200 ml saline used for surgical wash and soaking gauze used for compression of the bleeding site, and this was considered as a control group. Assessment parameters included intraoperative blood loss, quality of surgical field using Boezaart grading with 0–5 scores, hemodynamics and perioperative adverse effects. Results There were no significant differences between groups in the demographic and clinical characteristics regarding age, sex, weight, and height and in anesthesia time, surgical time or time of recovery. The quality of the surgical field was better in group B than groups A and C. The intraoperative bleeding was significantly reduced in group B more than groups A and C, and postoperative nausea, vomiting and blurring of vision were more in group A than the other groups. Conclusion Topical application of TXA has a more significant effect on reducing bleeding and improving the quality of the surgical field during ear exploration surgery with nonsignificant adverse effects.
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	Thoracoscopic evacuation compared with reinsertion of thoracostomy tube in persistent traumatic hemothorax	p. 81
	Hussein Elkhayat, Mohamed A.K Salama Ayyad, Mohamed Emad, Abdelradi Farhgaly DOI:10.4103/JCMRP.JCMRP_123_18   Objective Hemothorax is the most frequent complication from chest trauma. In most of the cases, chest tube will be sufficient for treatment, but in a minority of patients, more intervention will be needed to evacuate a retained hemothorax. We aimed in this study to compare between video-assisted thoracoscopy (VATS) evacuation of retained clotted blood and reinsertion of thoracostomy tube to explore the safety and complications of such techniques. Patients and methods A prospective randomized case–control study was conducted on patients who presented with retained hemothorax admitted to trauma unit from July 2017 to July 2018. Results During the time frame from July 2017 to July 2018, our trauma unit got 44 879 patients. Approximately 14 722 of them needed admission, with only 288 patients requiring primary chest tube for hemothorax, of which 35 patients met the inclusion criteria of this study. They were then divided into two groups: group A (16 patients) underwent evacuation by VATS. The operative time for VATS ranged from 24 to 130 min, with mean time 79.8 min (after VATS), and needed drainage days range from 2 to 7 days, with mean of 3.31 days. One (6.25%) patient need thoracotomy. No wound infection or empyema was present in group A. Control group (group B) included 19 patients in whom the chest tube was reinserted. The needed days of drainage range from 4 to 10 days, with mean 6.47 days, with significant value (P = 0.001). Three (15.78%) patients had wound infection at the site of thoracostomy tube. On follow-up, we noticed four (20.05%) patients with empyema. Conclusion Early VATS for evacuation of retained hemothorax is feasible and safe in trauma patients. Moreover, VATS evacuation leads to shorter hospital stay and less need for open thoracotomy in comparison with reinsertion of a chest tube.
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	Comparison of epithelium-off and transepithelial corneal collagen cross-linking for the treatment of keratoconus	p. 87
	Mahmoud N Gamal, Saleh Y Samir, Sayed A Mohamed, Ali A Asmaa DOI:10.4103/JCMRP.JCMRP_89_18   Objective The aim of the study was to assess the safety and efficacy of epithelium-off corneal cross-linking versus epithelium-on cross-linking in the treatment of keratoconus. Patients and methods This study was performed on 42 eyes of 22 patients who were divided into two groups. The first group was the epithelium-off cross-linking (CXL) group that included 23 eyes of 12 patients, whereas the second group was the epithelium-on cross-linking group (the TECXL group) that included 19 eyes of 10 patients. Results On comparing the effect of epi-off and epi-on we found that epithelium-on CXL is superior to epithelium-off CXL regarding pain, complications, early patient convalescence as we found significant difference between epi-on and epi-off groups in postoperative complications. In epithelium-on CXL regarding eight (42%) eyes had pain, 0 eye had delayed reepithelization, one (5.26%) eye had stromal haze, and six (31.57%) eyes had treatment failure. However, epithelium-off CXL is superior to epithelium-on CXL regarding the efficacy in visual stabilization and improvement as we found a significant improvement in anterior elevation and Kmax with P = 0.04 and 0.02, respectively. Epithelium-off CXL had significant reduction in Kmax with P = 0.03, anterior elevation had significant reduction with P = 0.04 epithelium-on CXL having nonsignificant change in Kmax and anterior elevation. ConclusionActually, in this study, it was found that TECXL was the procedure of choice for patient comfortability, safety, and convalescence. However, the results of the study confirmed that epithelium-off CXL was the procedure of choice for the patient benefit and guaranteed visual stabilization and additional visual improvement convalescence.
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	The role of histone H3K27 dimethylation in early-stage urinary bladder carcinoma: the relevance of risk factor	p. 93
	Ragaa H Salama, Marwa A Gaber, Khalid M Rezk, Samia F Hamed DOI:10.4103/JCMRP.JCMRP_102_18   Background Epigenetic alterations, including post-translational modification of histone tails by methylation may play an important role in carcinogenesis. Objective The aim was to evaluate the global histone H3K27 dimethylation (H3K27me2) levels in bladder cancer (BC) and to compare these levels in different types and stages of BC. Materials and Methods Venous blood from 45 BC patients and 45 apparently healthy controls was used. The two risk factors such as Schistosoma haematobium infection and smoking were investigated. Histone extraction was done and used to determine the global levels of H3K27 dimethylation. Results Global level of H3K27 dimethylation was significantly lower in BC patients than in healthy controls. We observed a negative correlation between histone dimethylation levels and the smoking state (both in patients and controls). Receiver operating characteristic curve showed that histone H3K27me2 at a cut-off point less than 49.68 ng/μl has 69% sensitivity and 64.5% specificity for the prediction of BC with an area under the curve of 0.67 (P = 0.001). However, there was no statistically significant difference in H3K27me2 levels as regards history of S. haematobium infection (P = 0.6), histopathological types (P = 0.3), and the stages of cancer (P = 0.8).Conclusion The global histone H3K27 dimethylation may substantiate the potential to improve the detection of early-stage urinary bladder carcinoma. Also, the decreased level of histone H3K27me2 in smokers (either patients or controls) could be one entity that explain smoking as a risk factor for BC.
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	The added value of ST-elevation in lead aVR to clinical thrombolysis in myocardial infarction risk score in predicting the angiographic severity and extent of coronary artery disease in patients with non-ST-elevation acute coronary syndrome	p. 100
	Mohammad F Badry, Khaled M Elmaghraby, Hatem A Helmy, Salwa R Demitry DOI:10.4103/JCMRP.JCMRP_10_18   Introduction The use of ST-segment elevation (STE) in lead aVR in addition to thrombolysis in myocardial infarction (TIMI) risk score may improve the early risk stratification and the management of patients at high-risk coronary artery disease, with subsequent effect on morbidity and mortality. Patients and methods A total of 65 patients who underwent coronary angiograms in Sohag Heart Specialized Center in the period between September 2013 and March 2014 were the participants of the study. All patients were subjected to full history taking, clinical evaluation, laboratory investigations, ECGs, TIMI scoring, and coronary angiography by femoral approach. Results Of the 65 patients, 59 patients were found to have significant coronary artery disease with 39 of them had STE in aVR lead, and none of the normal coronary angiography (CA) cases had STE in this lead. Of the 39 with STE-aVR, 13 patients had left main disease and 30 of them had multivessel disease. ST-aVR was elevated in 17 cases with low or intermediate risk according to TIMI score (9.1 and 55% of both groups, respectively), and was normal in three (12%) of the patients with high-risk TIMI score. Thus, STE-aVR could predict another 28.8% of high-risk cases that would not be detected by TIMI. Conclusion STE in lead aVR has a diagnostic and prognostic value in patients with non-STE acute coronary syndrome and may provide an additional prognostic value to the conventional cardiovascular risk factors, particularly in patients from the TIMI low-risk and intermediate-risk groups.
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	99mTc-DMSA renal cortical quantitative SPECT/CT imaging in diabetic patients: Feasibility and initial results	p. 106
	Hebat-Allah A.A.R Askar, Hemat Abdel-Samea, Yasser G Ali, Mohamed A Mekkawy, Wlaa A Mohamd DOI:10.4103/JCMRP.JCMRP_136_18   Introduction Diabetes mellitus is a common cause of chronic kidney disease. Radionuclide imaging of the kidneys using technetium-99m-labeled dimercaptosuccinic acid (99mTc-DMSA) is a well-established method for the evaluation of kidney parenchyma. We hypothesize that early preclinical detection of renal affection in diabetic patients can be done by quantitative single-photon emission computed tomography (SPECT) imaging using 99mTc-DMSA. Patients and methods In this study we included 29 patients: 13 diabetic and 16 volunteers as control. All must have within normal renal function. We excluded patients with known history of renal disease or abnormal renal function, patients with systemic diseases directly affect kidney function rather than diabetes. All patients included in our study were subjected to detailed clinical history, renal function, and quantitative 99mTc-DMSA renal imaging using SPECT/computed tomography techniques. About 5 mCi of 99mTc-DMSA were injected intravenously. Then imaging was acquired after 2–4 h in the supine position using a dual-head gamma camera with a low-energy all-purpose collimator. SPECT/computed tomography images are then taken. Data were reconstructed; then a 3D ball region of interest is drawn over each kidney to assess the counts of the kidney. Results There was a significant difference in the mean of the BMI-corrected counts divided by the injected dose (P = 0.024). The same results were obtained when the counts were summed and corrected according to the injected dose between the two groups (P = 0.034). Conclusion Quantitative SPECT 99mTc-DMSA imaging may have a role in the evaluation of renal functions in diabetics with no clinical evidence of renal affection.
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	Percutaneous ethanol injection for benign cystic thyroid nodules	p. 110
	Mustafa T Ahmed, Mohamed B M. Kotb, Mohamed S Shahine, Hassan M Harby, Mahmoud T A. Mohamed DOI:10.4103/JCMRP.JCMRP_95_18   Aim The aim of this study was to evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in managing predominantly cystic benign thyroid nodules in euthyroid individuals and avoid complication of surgery, provide symptomatic, cosmetic improvement, decrease the hospital stay and rapid recovery. Patients and methods The study is an experimental clinical trial. Twenty patients (34.20 ± 7.52 years; 60% women) with symptomatic benign thyroid cysts were included. In all cases, cytology before treatment, thyroid function before and after PEI, maximum cyst diameter, and volume were determined. PEI was conducted using 99% sterile ethanol, and pain perceived by the patients was assessed. After follow-up, final cyst diameter and volume were determined. Results The patients mean age was 34.20 ± 7.52 years, and 60% were females. A single session of PEI was required to complete the procedure. Mean initial maximum cyst diameter was 4.3 cm. Mean reduction in the cyst volume was 94.38%±4.04. During PEI, 40% of patients experienced pain. No complications of PEI were observed. After 6 months of follow-up, cysts were reduced more than 95% in 75% of patients, and reduced less than 95% in 25% of patients. Conclusion PEI can be the first-line treatment of benign thyroid cysts. It is a highly efficacious and safe technique with improvement in clinical conditions, with very low recurrence rate, and with no complications except pain associated with injection, which can be managed by analgesic.
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	Presternal local analgesia for postoperative pain relief after open heart surgery: A randomized, controlled study	p. 115
	Safya A Hamed Mostafa, Emad Z Kamel, Mohammed I Seddik, Ahmed S Shahin, Mohamed M Ahmed DOI:10.4103/JCMRP.JCMRP_88_17   Infiltration of local anesthetics near the surgical wound has shown to improve early postoperative pain in various surgical procedures, especially after open heart surgery. Inadequate pain control reduces the capacity to cough, mobility, increases the frequency of atelectasis, and prolongs recovery. Patients and methods This study is designed to examine the efficacy of postoperative 1 g paracetamol/6 h, ketorolac tromethamine 30 mg/8–12 h as conventional analgesia versus bupivacaine plus magnesium sulfate through a single presternal catheter for postoperative pain relief after cardiac surgery. Forty patients were scheduled for valve replacement cardiac surgeries and were randomly assigned into two groups (20 patients in each group). Group M: each patient has received bupivacaine 0.125% with 5% magnesium sulfate through the presternal soft catheter at a fixed rate of 5 ml/h. Group B: each patient only has received postoperative 1 g paracetamol/6 h, ketorolac tromethamine 30 mg/8 h. For postoperative breakthrough pain, rescue analgesia in the form of 25 μg fentanyl was used, with recording of total required doses in both groups. Results The mean numeric pain scale was significantly lower in group M than in group B at most time points. The overall fentanyl requirements over the first 48 h were significantly lower in group M than in group B (33 ± 11.7 vs. 150 ± 1.6 μg, respectively). There was no statistically significant difference between the two groups regarding ICU stay and blood glucose level. Conclusion Local presternal bupivacaine with magnesium sulfate provided adequate postoperative analgesia and less opioid requirements.
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	Outcomes of ureteroscopy in Assiut University Hospital: A prospective study	p. 120
	Amr E Darwish, Mohamed M Gadelmoula, Islam F Abdelkawi, Atef M Abdel-Latif, Ahmed M Abdel-Moneim DOI:10.4103/JCMRP.JCMRP_100_18   Context Recent technological advances have led to the expansion of indications and success of ureteroscopy (URS) for stone disease, while decreasing complication rates. Aims The aim was to evaluate the outcomes of URS for treatment of ureteral stones in our hospital. Settings and design This was a descriptive case series.Materials and methods Patients included were adults with ureteral stone(s) managed by URS. Perioperative together with long-term postoperative data were analyzed. Follow-up extended for 12 months. Statistical analysis Data analysis was done using SPSS version 19. χ2 and Fisher exact tests were used to compare between qualitative variables. Mann–Whitney test was used to compare between two quantitative variables. Multiple logistic regression analysis was done to measure the risk factors. P value was considered statistically significant when less than 0.05. Results During the period from May 2015 to August 2016, 251 adult patients underwent 263 ureteroscopies for treatment of 304 ureteral stones. The mean total stone burden was 12.8 ± 5.9 mm. Treatment of bilateral and ipsilateral multiple stones was performed in 12 and 34 cases, respectively. Impacted stone(s) were treated in 49 (18.6%) procedures. The mean operative time was 54.8 ± 22.68 min. Initial and final stone-free rates were 83.3 and 100%, respectively. The overall complications rate was 28.1%, including mucosal injury (n = 20, 7.6%), false passage (n = 25, 9.1%), perforation (n = 7, 3.8%), and stricture (n = 4, 1.5%). Multivariable analysis revealed that impacted stones had a significant association with intraoperative complications. Conclusion URS is a safe and effective procedure for treatment of ureteral stones. However, impacted stones are associated with significantly higher complications rate.
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