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   Table of Contents - Current issue
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October-December 2016
Volume 53 | Issue 4
Page Nos. 193-273

Online since Friday, March 17, 2017

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ORIGINAL ARTICLES  

Cortisol level in depressed patients and its relation with suicidal risk and anhedonia Highly accessed article p. 193
Samia Ahmed, Fatma Moussa, Akmal Moustafa, Doaa R Ayoub
DOI:10.4103/1110-1083.202375  
Context In recent times, there has been an increased interest in research related to anhedonia. Nevertheless, its linkage to major depressive disorders and underlying neurobiology are still not well understood. High levels of cortisol are associated with an increased risk for suicide as evidenced by several studies; however, others have not found this association between cortisol levels and suicidality. Aim The aim of this work was to examine whether there is an increased activity of the hypothalamic–pituitary–adrenal axis in major depressive disorder patients and to detect the presence of an association between the level of cortisol and thoughts of death and anhedonia in at-risk patients with major depressive disorder. Settings and design This case–control study that was conducted on 20 patients with major depressive disorder, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, in comparison with 20 controls. Patients and methods All patients were assessed using the Present State Examination 10th revision of the Schedules of Clinical Assessment in Neuropsychiatry, Snaith Hamilton Pleasure Scale, Beck’s Suicidal Ideation Scale, and Beck’s Depressive Inventory. Blood samples were collected to assess plasma cortisol level in the morning and evening. Statistical analysis Statistical calculations were carried out using SPSS, version 15. Results There were increased levels of morning and evening cortisol in major depressive disorder patients. Thoughts of death were positively associated with elevated morning cortisol in depression. Anhedonia was associated with higher evening cortisol level in depressed patients in the studied sample. Conclusion There are relatively increased levels of morning and evening cortisol in major depressive disorder patients in comparison with controls; thoughts of death are positively associated with elevated morning and evening cortisol level.
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Visual dysfunction and neurological disability in multiple sclerosis patients in correlation with the retinal nerve fiber layer and the ganglion cell layer using optical coherence tomography p. 200
Said A Gomaa, Mohamed B Badawy, Amr M Elfatatry, Amr A Elhennawy
DOI:10.4103/1110-1083.202376  
Aim The aim of this study was to measure retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) complex thickness with Cirrus optical coherence tomography (OCT) in Egyptian multiple sclerosis (MS) patients, and to correlate the OCT findings with the visual functions and neurological conditions. Patients and methods This study design was a cross-sectional one. A total of 40 eyes of 22 MS patients diagnosed according to the McDonald criteria were included in this study. Exclusion criteria were as follows: optic neuritis less than 6 months ago; best-corrected visual acuity (BCVA) less than 0.5; intraocular pressure more than 21 mmHg; cup-to-disc ratio more than 0.5; myopia more than 5 D; and eyes with other ocular or central nervous system diseases. All patients were subjected to the following: full history taking; complete ophthalmic examination, including visual functions (BCVA, color vision, and contrast sensitivity), intraocular pressure, and anterior and posterior segment examination; ophthalmic investigations using the Cirrus OCT (peripapillary RNFL thickness and macular GCL complex thickness); and complete neurological examination containing Expanded Disability Status Scale (EDSS). Results There were statistically significant negative correlations (which is mostly still thickened or biased with BCVA selection) between BCVA and the GCL complex of the superior areas among the studied patients. There were statistically significant negative correlations between color total errors and the GCL complex of the inferior temporal areas among the studied patients. No statistically significant correlations between contrast or EDSS and the GCL complex of any area were found among the studied patients. Conclusion GCL complex thickness is correlated better compared with RNFL thickness in MS patients with their visual functions (mainly color vision with the inferior temporal area of the GCL complex), and visual function is better correlated with them than with neurological disability measured using EDSS.
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Correlation between median nerve conduction studies and ultrasonography in cases of carpal tunnel syndrome p. 206
Hala R El-Habashy, Reem A El-Hadidy, Sandra M Ahmed, Basma B El Sayed, Aya S Ahmed
DOI:10.4103/1110-1083.202378  
Background Nerve conduction studies (NCS) have long been the only objective measure used to confirm the diagnosis of carpal tunnel syndrome (CTS), localize median nerve abnormalities, and exclude alternative diagnosis. Ultrasonography (US) can give information about the contents of carpal tunnel (CT) as well as aid in assessing the size of the median nerve (MN). Aim The aim of this study was to detect the relation between median NCS and cross-sectional area (CSA) of the MN measured using US in different grades of CTS. Patients and methods This study was a case–control, age-group matched, cross-sectional one. It included 60 wrists of 30 patients diagnosed with CTS and 60 wrists from 30 controls. Candidates were subjected to clinical assessment, median NCS, and measurement of CSA using US. Results There was a significant positive correlation between CSA of the MN at CT inlet and both motor and sensory responses latencies (r=0.638, P<0.001 and r=0.629, P<0.001, respectively). There was a significant negative correlation of CSA of the MN with sensory and motor amplitudes (r=−0.656, P<0.001 and r=−0.657, P<0.001, respectively). Median nerve CSA at CT inlet in the patients’ group was significantly higher than that in the control group (P<0.0001). CSA at CT inlet in early CTS was 13.27±1.56 mm2; 15.13±1.97 mm2 in mild, 16.47±4.16 mm2 in moderate, and 21.43±3.96 mm2 in severe CTS. Conclusion US is highly correlated to NCS results in CTS. CSA of the MN at CT inlet measured using ultrasonography can be used as a screening tool for detection as well as discrimination of severe cases of CTS.
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Carotid artery stenting in high-risk patients: a single-center experience p. 211
Mohamed K Elewa
DOI:10.4103/1110-1083.202380  
Background Carotid artery stenting (CAS) is a valid alternative to carotid endarterectomy in selected patients. Periprocedural risk of complications is the main determinant for CAS validity. Certain patients’ features may increase the risk of complication. Purpose To assess the management and outcome of the CAS in high-risk patient population. Patients and methods Clinical, treatment, and outcome variables of consecutive high-risk CAS candidates between January 2011 and June 2016 in one center were analyzed. Results Among 29 patients, 21 patients had successful CAS, and only one (3.45%) patient had minor periprocedural stroke. In total, six (20.69%) patients were shifted to carotid endarterectomy, and two (6.90%) patients were managed with medical treatment. Regression analysis showed that bovine arch was independent predictor of CAS infeasibility (P=0.006). The mean follow-up duration was 21.38±15 months. Follow-up duration passed uneventfully. Conclusion CAS in high-risk patients appears to be technically safe. The adverse outcome in high-risk patients is low and accepted. The morbidity and mortality is avoidable with better patient selection and the avoidance of aggressive manipulation whenever possible. CAS should be avoided in patients with certain anatomic risk factors such as type III arch and bovine arch.
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Importance of early recognition of amyotrophic lateral sclerosis-like disorders in the Egyptian population p. 219
Heba Raafat, Radwa M Azmy, Reham Shamloul, Amr El Deeb
DOI:10.4103/1110-1083.202381  
Background Early stages of amyotrophic lateral sclerosis (ALS)-like syndrome when only one limb is affected can be missed by physicians suggesting other unrelated disorders especially with evidenced concomitant pathology of the same limb, leading to diagnostic pitfalls and unnecessary procedures. Objective The aim of this study was to support the diagnosis of early stages of ALS-like disorders in clinically suspected patients by electrophysiological studies (EDX) including segments that may be clinically unaffected, and searching for the possible etiology. Patients and methods This study was conducted on 120 adult patients with unilateral limb symptoms associated with irrelevant imaging abnormalities. Diagnostic workup included history taking, general and neurological examination, and EDX using the El Escorial diagnostic criteria. Further investigations included laboratory studies and paraneoplastic and hormonal assays. Results Motor nerve conduction studies revealed reduced amplitude of compound muscle action potential in 62.5% of patients, borderline conduction velocities, normal distal latencies, conduction block in one case, and normal sensory nerve conduction studies. Electromyography of the cranial, cervical, lumbosacral, and dorsal segments showed acute denervation in 80% of patients and chronic denervation in all segments in 35% and in three body segments in 65% of patients. Laboratory investigations revealed 50.83% of patients with chronic hepatitis C, with significant statistical association between EDX and laboratory results, 30.83% with hyperthyroidism, 8.33% with paraneoplastic syndrome, one case with multifocal motor neuropathy with conduction block, one case with myasthenia gravis, and 8.3% with negative results. Conclusion ALS-like disorder should be investigated whenever ALS is suspected, and further laboratory workup might unveil a coexisting ‘possibly causative’ pathological condition.
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Neuropsychiatric complications after liver transplantation p. 225
Mohamed E Elwan, Rasha A El-Kabany, Amr S Shalaby, Ibrahim E Alahmar, Osama Hegazy, Mona S Elkholy
DOI:10.4103/1110-1083.202382  
Background Neuropsychiatric complications are responsible for significant mortality and morbidity after liver transplantation (LT). Objective The aim of this study was to detect the neuropsychiatric complications after LT, and to identify any possible relationship between these complications and certain perioperative risk factors. Materials and Methods The study was performed on 35 patients admitted in the National Liver Institute, Menoufiya University, who underwent LT. Patients were assessed 2 weeks preoperatively and followed up for 3 months postoperatively. Preoperatively, clinical assessment, mini mental state examination, Bender–Gestalt test, trail making test, structured clinical interview for DSM-IV axis I disorders scale, assessment using the hospital anxiety depression scale, laboratory tests for hepatic disease and comorbidities, cerebral computerized tomography and/or MRI, carotid duplex and electroencephalography were carried out. Intraoperatively, assessment of warm and cold ischemia time, operative time, and blood transfusion was carried out. Postoperatively, clinical examination, mini mental state examination, Bender–Gestalt test, trail making test, assessment with the structured clinical interview for DSM-IV axis I disorders scale and the hospital anxiety depression scale, brain imaging, electroencephalography, nerve conduction studies, and electromyogram were carried out. Results Postoperatively, neurological complications were detected in 13 (37.1%) patients in the form of central complications, such as encephalopathy, seizures, and cerebrovascular strokes, and peripheral neuropathies. However, psychiatric complications were detected in 15 (42.9%) patients in the form of cognitive disorders, maladjustment, anxiety disorders, major depressive disorders, and brief psychotic episode. Conclusion This work showed that, in adult patients undergoing living donor LT, there was a relevant variety of neurological and psychiatric complications, which represented significant causes of postoperative morbidity and should be diagnosed and managed early.
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Frequency and determinants of subclinical neuropathy in type 1 diabetes mellitus p. 232
Yosria A Al-Taweel, Rasha M Fahmi, Nahed Shehta, Tamer S Elserafy, Hala M Allam, Ahmed F Elsaid
DOI:10.4103/1110-1083.202383  
Background Diabetic neuropathy is the most common complication of diabetes. We hypothesized that uncontrolled diabetes is associated with subclinical diabetic neuropathy that is influenced by duration of disease. Assessment of the prevalence and associated determining factors will be important for the prevention and treatment of neuropathy. Objective This aim of this study was to assess the frequency and determining factors of subclinical peripheral neuropathy in type 1 diabetic (T1DM) patients. Patients and methods The current hospital-based, case–control study was conducted at Zagazig University Hospitals. It included three age-matched and sex-matched groups. Each group comprised 30 participants: group A included diabetic patients with a duration of T1DM of 5 years or less; group B included patients with a duration of T1DM of more than 5 years; and the control group included normal healthy individuals. Clinical assessment was carried out to exclude symptoms and signs of neuropathy. Laboratory investigations including fasting and 2-h postprandial blood glucose level, glycosylated hemoglobin (HbA1c), lipid profile, liver function, kidney function, and nerve conduction studies were carried out for every participant. Results The frequency of subclinical neuropathy in group A and group B was 46.6 and 76.6%, respectively, and this difference was statistically significant (P=0.03). Univariate analysis revealed significantly higher levels of HbA1c, dyslipidemia, and nerve conduction parameters in group B compared with group A and the control group. Multivariate logistic regression analysis showed that duration of diabetes (P=0.02) and HbA1c (P=0.02) were the only independent factors associated with subclinical neuropathy. Conclusion The high frequency of subclinical neuropathy in diabetic patients highlights the importance of nerve conduction studies for the early detection of neuropathy in T1DM.
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Role of interleukin-6 in refractory epilepsy p. 238
Nervana M El-Fayoumy, Hatem A El-Massry, Montasser M Hegazy, Amany H Ragab, Rabab A Mohamed, Sara G Abdel Alim
DOI:10.4103/1110-1083.202384  
Background There is increasing evidence of a complex relationship between epilepsy and the immune system. Objective The aim of this study was to ascertain the relationship between inflammatory cytokines, immune system dysregulation, and the pathogenesis of refractory epilepsy by determining the level of interleukin-6 (IL-6) in patients with refractory epilepsy and its relation to different factors. Patients and methods This study was conducted on 30 patients with refractory epilepsy and 10 healthy control participants. All patients were assessed using clinical evaluation, conventional digital electroencephalogram, brain MRI, routine laboratory tests, and IL-6 level in serum. Results Serum IL-6 level was significantly higher in patients with refractory epilepsy than in the control group. Conclusion There is a significant association between serum IL-6 level and refractory epilepsy.
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Evaluation of neurotrauma in motorcycle-related accidents at a tertiary hospital in Egypt p. 244
Ahmed El-Fiki, Omar El Falaky
DOI:10.4103/1110-1083.202385  
Background Although traffic laws in Egypt obligate drivers to wear helmets, they are not strictly followed, resulting in an increased incidence of neurotrauma during accidents. Objective The aim of the present study was to evaluate head and spine injuries as a result of motorcycle accidents in 1 year. Patients and methods This study was conducted in the Neurosurgical Emergency Department of Cairo University Hospitals. Only motorcycle-related neurotrauma patients were included. Demographic data, types of lesions inflicted, operations and procedures carried out, hospital stay, and outcome were investigated by analyzing admission files and operation records. The results were then compared with the published literature. Results Out of 117 patients, there were 93% males and 7% females. The age group 20–40 years represented 61.5% of the cases. Extradural hematoma was present in 42 (36%) cases, fissure fracture and base of skull fracture in 64%, brain contusion in 29%, and spine fracture in four (0.034%). Helmeted drivers represented only 9.5% of the patients. Thirty-nine percent of patients had other associated injuries than of head and spine. Operations were performed on 45 (38.5%). Nearly half of the operation procedures comprised evacuation of extradural hematoma. Others included elevation of depressed fracture, frontal sinus repair, decompressive craniotomy, and spinal fixation surgeries. Hospital stay ranged from 2 to 28 days with an average of about 4.5 days; furthermore, 22.2% of the victims became handicapped and dependent. Conclusion Following safety measures during motorcycling significantly reduces morbidity and mortality at time of accidents. Although these patients have a short median hospital stay but surgery rates are obviously high. Follow-up for victims may reveal other potential burdens and help in the reintegration of society.
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Correlation between clinical neuropathy scores and nerve conduction studies in patients with diabetic peripheral neuropathy Highly accessed article p. 248
Lamia Afifi, Ahmed M Abdelalim, Amal S Ashour, Aussan Al-Athwari
DOI:10.4103/1110-1083.202386  
Background Diabetic peripheral neuropathy (DPN) represents one of the most common complications of diabetes mellitus. Objective The aim of this study was to assess the correlation between clinical neuropathy scores and nerve conduction studies (NCS). Patients and methods This study included 30 (12 men and 18 women) Egyptian patients with type 2 diabetes mellitus complaining of symptoms suggestive of DPN. All patients underwent a clinical evaluation using three clinical scores: the Neuropathy Disability Score (NDS), the Neuropathy Impairment Score in the Lower Limbs (NIS-LLs), and the Diabetic Neuropathy Examination (DNE) score. Neurophysiological studies using NCS as well as measurement of glycated hemoglobin (HbA1C) were carried out. Results HbA1C was significantly correlated with NDS, NIS-LL, and DNE. The NDS was statistically correlated to median nerve sensory amplitude, sensory conduction velocity; ulnar nerve sensory amplitude, sensory conduction, motor amplitude, motor conduction velocity; and peroneal nerve sensory amplitude, sensory conduction velocity, motor amplitude, and motor conduction velocity. NIS-LL was significantly correlated with median nerve sensory amplitude, sensory conduction velocity; motor amplitude, motor conduction velocity; ulnar nerve sensory amplitude, sensory conduction velocity, motor conduction velocity; and peroneal nerve sensory amplitude, sensory conduction velocity, motor amplitude, and motor conduction velocity. DNE was significantly correlated with median nerve sensory amplitude, sensory conduction velocity, motor amplitude, motor conduction velocity; ulnar nerve sensory amplitude, sensory conduction velocity, motor amplitude, motor conduction velocity; and peroneal nerve sensory amplitude, sensory conduction velocity, motor amplitude, and motor conduction velocity. Conclusion Clinical neuropathy scores represent a simple tool for evaluation and follow-up of patients with DPN in comparison with NCS, and we recommend the use of these scores in clinical practice on a routine basis.
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Influence of cognitive dysfunction on spatiotemporal gait parameters in patients with diabetic polyneuropathy p. 253
Mohamed S El-Tamawy, Moshera H Darwish, Shereen S Mohamed, Montaser Hegazy, Mye A Basheer
DOI:10.4103/1110-1083.202387  
Background An accurate rehabilitation program of diabetic polyneuropathy (DPN) depends on a precise assessment of cognition and determination of its relation to gait using different objective and valid methods. Objective Our aim was to assess cognitive function and analyze the influence of cognitive dysfunction on the spatiotemporal gait parameters under three different gait conditions (walking without a cognitive task, walking with verbal fluency, and walking with an arithmetic task) in DPN patients. Patients and methods Twenty patients with type II diabetes mellitus with moderate polyneuropathy (PN) (group 1) and 20 matched patients with type II diabetes mellitus without PN (group 2) represented the sample of this study. Different cognitive domains of cognition were assessed using a computer-based RehaCom procedure. Spatiotemporal gait parameters were assessed using a 2D video-based motion analysis under the three different gait conditions. Results The results showed a significant decrease in all cognitive domains in the DPN patients (group 1) (P<0.05). All spatiotemporal gait parameters were significantly affected in the DPN (group 1), especially during dual-task performance (P<0.05). Conclusion There is an association between cognitive dysfunction and PN complications in diabetic patients. Spatiotemporal gait parameters are affected more in DPN patients, especially under dual-task conditions, than in diabetic patients without PN.
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Hormonal profile and clinical characteristics of epileptic females with abnormal ovarian morphology p. 258
Asmaa M Ebraheim, Reham M Shamloul, Soha Talaat
DOI:10.4103/1110-1083.202388  
Background Women with epilepsy (WWE) tend to have ovarian echographic abnormalities, raising concerns about an interaction between the brain and the ovaries. Objective This study aims to determine the relationship between abnormal ovarian follicular morphology as detected by ultrasonography (US) and clinical features, hormonal profile, and antiepileptic drugs (AEDs) in epileptic females. Participants and methods WWE who attended Kasr Al-Ainy Epilepsy Clinic and fulfilled the inclusion criteria were recruited and assessed clinically. Transabdominal US of the ovaries and the uterus was performed; in addition, serum levels for luteinizing hormone (LH), follicle-stimulating hormone, estradiol, testosterone, and fasting insulin were determined for all the participants. Thirteen WWE who had ovarian echographic abnormalities were compared with 67 epileptic females with normal ovarian US. Results Significantly elevated LH was detected in patients with ovarian morphologic abnormality compared with the control group. The clinical parameters, the frequency of use of different AEDs, and the mean values of the other hormones were comparable in both groups. Conclusion Elevated LH in patients with an ovarian echographic abnormality points to altered gonadotropin secretion in these patients, which could be explained by the effect of epileptic discharges on the hypothalamus, but not the use of AEDs.
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Barriers for acute ischemic stroke treatment using recombinant tissue plasminogen activator in Mansoura Emergency Hospital: prehospital and inhospital delay factors p. 263
Mohammad Abu-Hegazy, Ibrahim Elmenshawi, Mohamed Saad
DOI:10.4103/1110-1083.202377  
Introduction Effective treatment must start as early as possible as brain cells die rapidly after stroke. To increase the number of patients who are eligible to receive tissue plasminogen activator, measures are needed to reduce the prehospital and inhospital delay time. The study aimed to evaluate the possibility of thrombolytic therapy in acute ischemic stroke patients in Mansoura Emergency Hospital (MEH) by studying the effect of prehospital and inhospital delay factors. Patients and methods A standardized, structured questionnaire was completed for every stroke suspect; in it we documented the exact time of stroke onset, the way of referral and transport to hospital, and their demographic data. The exact time of patient arrival, time to neurology consultation, and detailed time delay inside MEH was marked on the forms of the hospital as well. Results In total, 435 patients had arrived MEH in less than 24 h, their mean age being 61.7 years. The median prehospital time was 2.7 h. Patients with younger age, locals, those who reached by private vehicle, or reached directly without any medical reference were significantly associated with early hospital admission. Sex, time of arrival, or severity of stroke had no influence on reaching hospital early. The median times to computed tomography request and acquisition were 20 and 35 min versus 25 and 45 min, respectively, National Institute of Neurological Disorders and Stroke recommendations. Conclusion Hyperacute treatment of ischemic stroke is possible in MEH. Methods to improve the emergency medical services and reduction of the patient circulation system in MEH will give more chance for these therapies by reducing prehospital and inhospital delay times.
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The subclinical epileptiform discharges among nonepileptic cerebral palsy patients p. 268
Mohamed K Elewa, Magdy A Mostafa
DOI:10.4103/1110-1083.202379  
Background Subclinical epileptiform discharges (SEDs) are assumed to play a role in the development of cognitive dysfunction in cerebral palsy (CP) patients. Purpose The aim of this study was to estimate the prevalence of SEDs among nonepileptic CP patients and their cognitive correlates. Patients and methods Fifty-one nonepileptic CP patients were recruited. All patients were subjected to history taking, neurological examination, assessment using Gross Motor Function Classification System for CP, the Stanford–Binet scale (5th edition), encephalography, and MRI of the brain. They were divided into two groups: group 1, which included 19 CP patients without SEDs, and group 2, which included 32 CP patients with SEDs. A comparison between patients’ features studied in groups 1 and 2 was made using independent-samples t-test and the χ2-test. A correlation between SEDs and the studied features was made using Spearman’s rank correlation coefficient (ρ). Results The prevalence of SEDs among nonepileptic CP patients was 62.7%. The presence of MRI abnormality and moderate mental retardation showed a highly significant positive correlation with SEDs. Meanwhile, central nervous system malformation and severe mental retardation showed a significant positive correlation with SEDs. However, normal intelligence showed a highly significant negative correlation with SEDs. Kernicterus and dyskinetic CP showed a significant negative correlation with SEDs. Conclusion SEDs are a common finding among nonepileptic CP children. They are positively correlated to cognitive dysfunction. This finding supports the assumption that SEDs are therapeutic target in mentally subnormal children. Larger studies are needed to confirm our results and to evaluate the clinical benefit of treating SEDs.
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