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   Table of Contents - Current issue
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July-September 2018
Volume 30 | Issue 3
Page Nos. 97-174

Online since Thursday, September 27, 2018

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ORIGINAL ARTICLES  

Thyroid dysfunction and insulin resistance in patients with nonalcoholic fatty liver disease Highly accessed article p. 97
Maha Assem, May Fawzi, Alhosaeyn Ibrahim, Aasem Saif
DOI:10.4103/ejim.ejim_3_18  
Introduction Nonalcoholic fatty liver disease (NAFLD) is a common cause of impaired liver functions. It is associated with hepatic and adipose tissue insulin resistance (IR) as well as decreased whole-body insulin sensitivity. Thyroid hormones are important for the intrahepatic metabolism of lipids. Thyroid disorders have been associated with IR owing to various mechanisms such as altered insulin secretion and lipid levels. Aim The aim of our study was to assess thyroid functions, thyroid autoimmunity, and IR in nondiabetic patients with NAFLD. Materials and methods The study was conducted on 90 nondiabetic participants (60 patients with NAFLD and 30 participants with normal liver). Both groups were sex matched. Ultrasonography was used to categorize the study participants into NAFLD and normal liver groups. Thyroid functions and thyroid peroxidase antibody were assessed in all participants. Homeostatic model assessment (HOMA IR) was used to assess IR in the study population. Results Our results showed a significantly higher HOMA IR in the NAFLD compared with the normal liver group (P<0.001). Moreover, significantly higher percentage of patients with NAFLD have IR (HOMA IR) compared with the normal liver group (56.7 vs. 6.7%, respectively; P<0.001). Our results also showed higher percentage of thyroid dysfunction in patients with NAFLD compared with individuals without NAFLD (P<0.02). Overall, 22 (36.7%) 60 patients in the NAFLD group versus three (10%) of 30 patients in the non-NAFLD group had subclinical hypothyroidism. Thyroid functions did not show any statistically significant correlations with IR, but thyroid peroxidase antibody showed significant positive correlation with IR (P<0.02) within the total study population. Conclusion There is an increased prevalence of subclinical hypothyroidism in nondiabetic patients with NAFLD who also have higher IR. The role of thyroid autoimmunity in this relationship needs further assessment.
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Role of interleukin 6 and highly sensitive C-reactive protein in diabetic nephropathy p. 103
Alshabrawy M Abdelnabi, Ayman M.E.M Sadek
DOI:10.4103/ejim.ejim_27_18  
Context The pathogenesis of diabetic nephropathy (DN) is still incompletely understood. Few studies have linked the cellular inflammatory markers, interleukin 6 (IL-6) and highly sensitive C-reactive protein (hs-CRP), to the development of DN. Aim We aimed to explore the link among IL-6, hs-CRP, and grades of DN in both types of diabetes mellitus (DM). Settings and design We carried out a case–control study on participants selected from the outpatient clinic of Internal Medicine Department. Patients and methods We worked on 91 participants, comprising 78 patients and 13 controls. The patient group was further subdivided into two subgroups: subgroup I [39 patients type 1 DM (T1DM)] and subgroup II [39 patients type 2 DM (T2DM)]. Each subgroup was categorized according to the urinary albumin excretion rate into three divisions: A (<20 μg/min), B (20–200 μg/min), and C (>200 μg/min). We applied history taking, clinical examination, routine investigation, and IL-6 with hs-CRP testing to all participants. Statistical analysis We used Shapiro–Wilk test, χ2 test, Student’s t test, one-way analysis of variance, Kruskal–Wallis test, least significant difference test, and Pearson’s correlation coefficient for data analysis. Results Despite the significant difference of laboratory data between patient and control groups, least significant difference analysis revealed a nonsignificant difference between patients with T1DM and those with T2DM. On the level of the in-groups analysis, the most significant key players were hs-CRP and IL-6 among the three urinary albumin excretion rate categories of patients with T1DM and T2DM, with P values less than 0.01. Conclusions We concluded that IL-6 and hs-CRP might be used as sensitive markers for the development of DN.
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Effect of early versus delayed feeding following emergency endoscopic therapy for acute esophageal variceal bleeding on short-term outcomes p. 110
Tarek Goda, Abdelrahman Mokhtar, Rokaya Anwar, Hazem Hakim, Ali Eleraki
DOI:10.4103/ejim.ejim_22_18  
Background/aim It is generally assumed that systematic fasting is obligatory in the context of acute variceal bleeding owing to the fear of increasing the risk of rebleeding if patients instituted feeding early after endoscopy. However, this assumption is generally built on experts’ beliefs instead of being based on large clinical trials. Such lack of clinical trials was the reason why we conducted this controlled study. Patients and methods Patients were selected from those with acute esophageal variceal bleeding admitted at the Hematemesis Unit at Mansoura Emergency Hospital. The study involved 90 patients who divided into two equal groups: group I included 45 patients as the early-feeding group and group II included 45 patients as the late-feeding group. Results There was no statistically significant difference regarding treatment complications distribution between the studied groups. The successful hemostatic rate was 100% in both groups. Neither rebleeding incidents nor deaths were encountered in the first 5 days in either group. Conclusion Early feeding with a liquid diet after successful endoscopic therapy of bleeding esophageal varices did not enhance rebleeding or increase mortality in the first 5 days following endoscopic intervention.
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Evaluation of cardiac function in patients with liver cirrhosis using tissue Doppler study p. 115
Mohammed M Ashmawy, Hosny A Younis, Mahmoud A Abd Elbaset, Haitham A Abdel Rahman, Ahmed M Ashmawy, Muhammad A Shawky, Mohammed M Abd Elnasser
DOI:10.4103/ejim.ejim_28_18  
Background and aim Cardiac dysfunction is a prevalent finding in patients with liver cirrhosis. We aimed to evaluate left ventricular function by tissue Doppler imaging in patients with liver cirrhosis. Patients and methods This is a cross-sectional case–control study that involved 90 patients with liver cirrhosis: 30 patients with Child A, 30 patients with Child B, and 30 patients with Child C cirrhosis. Moreover, 45 healthy volunteers were included in the study as a control group. All patients and controls were examined by conventional Doppler and tissue Doppler echocardiography. Results Patients with liver cirrhosis showed significantly lower ejection fraction (EF) levels than control group (P=0.001), but only nine patients showed EF levels less than 55. Moreover, there is significantly decrease in EF in patients with decompensated cirrhosis than those with compensated cirrhosis (P=0.005). A total of 60 patients showed diastolic dysfunction: 10 patients with Child A, 20 patients with Child B, and 30 patients with Child C cirrhosis. There were significantly differences between patients with liver cirrhosis and control group in the other parameters of systolic (S wave and myocardia performance index) and diastolic (early and late velocity and deceleration and isovolumetric relaxation time) functions. Conclusion Patients with liver cirrhosis showed significantly decreased left ventricular systolic and diastolic functions than control group, which is more pronounced in decompensated than compensated patients.
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Fetuin-A level in type 2 diabetic patients: relation to microvascular complications p. 121
Nehal H Al-Said, Fatma M Taha, Ghada M Abdel-Aziz, Marwa S Abdel-Tawab
DOI:10.4103/ejim.ejim_24_18  
Background Fetuin-A is a hepatic secretory protein that binds to insulin receptors and inhibits insulin resistance (IR) kinase activity as well as IR autophosphorylation in vivo and in vitro. Aim This study aimed to investigate fetuin-A levels in patients with type 2 diabetes mellitus (T2DM) and their relation to microvascular complications. Patients and methods This descriptive study was conducted on 160 patients. Group 1 included (n=40) diabetic patients without microvascular complications, group 2 (n=40) included diabetic patients with nephropathy, group 3 (n=40) included diabetic patients with retinopathy, and group 4 represented (n=40) healthy control. Serum fetuin-A and insulin were measured by enzyme-linked immunosorbent assay. Glucose was measured, and homeostasis model assessment for IR (HOMA-IR) was estimated. Results Fetuin-A levels were significantly higher in all T2DM groups compared with controls. There was a significant positive correlation between fetuin-A, insulin, and HOMA-IR in all studied groups. There was a significant positive correlation between fetuin-A and some of metabolic syndrome criteria in all diabetic patients. There were high significant increases in the mean levels of fetuin-A, insulin, and HOMA-IR in the diabetic patients with nephropathy group than other groups. There was a nonsignificant increase in fetuin-A levels in diabetic patients with retinopathy than the diabetics without microvascular complications. Conclusion Fetuin-A may be used as a marker for microvascular complications in T2DM, especially the diabetic nephropathy. Antifetuin drugs may be invented to delay diabetic microvascular complications.
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Prevalence and risk factors for gestational diabetes mellitus according to the Diabetes in Pregnancy Study Group India in comparison to International Association of the Diabetes and Pregnancy Study Groups in El-Minya, Egypt p. 131
Ghada M El Sagheer, Lamia Hamdi
DOI:10.4103/ejim.ejim_11_18  
Background The prevalence of gestational diabetes mellitus (GDM) has increased dramatically worldwide in the last decades, but unfortunately it was not studied in Egypt. Objective Assessment of the prevalence of GDM in El-Minya city, Egypt using the Diabetes in Pregnancy Study Group India (DIPSI) in comparison to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria, and assessment of the risk factors for GDM in this locality. Patients and methods There were 700 pregnant women who underwent the 75 g oral glucose tolerance test irrespective of the meal and plasma glucose measurement after 2 h. In the next morning, fasting and 1 h, and 2 h post-75 g oral glucose tolerance test were assessed. Diagnosis of GDM was carried out according to the DIPSI and IADPSG criteria. Results GDM was diagnosed in 62/700 women (8.86%) by DIPSI versus 52/700 (7.43%) by IADPESG. Compared with IADPSG, the sensitivity and specificity of DIPSI were 100 and 98.5%, respectively, while the positive and negative predictive values were 83 and 100%, respectively. The multiple logistic regression analysis has shown that BMI, urban residency, gestational hypertension, previous history of GDM, gestational hypertension, family history of DM, and the educational level less than secondary school were determined as independent risk factors of GDM. Conclusion The GDM prevalence in El-Minya city was 8.86% by DIPSI versus 7.43% by IADPSG with high sensitivity, specificity, and predictive values. The DIPSI could be considered as a simple, single, convenient, and economical method of GDM screening. However, more evaluation in a bigger patient sample is recommended.
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Acetylcholine iontophoresis in diabetic patients with and without peripheral neuropathy: a potential therapeutic tool p. 140
Ibrahim Ismail Abu Zaid, Mohamed Ahmed Hussein, Gihan Samir Mousa, Amany Raafat Mohamed, Nagwa Mohamed Badr, Alaa A Hamid
DOI:10.4103/ejim.ejim_51_17  
Background Iontophoresis had been widely used as a therapeutic option in the field of dermatology and physiotherapy. In vascular medicine, vasodilating response to acetylcholine (ACh) iontophoresis had been also previously studied in the evaluation of endothelial dysfunction in diabetes mellitus and its microvascular complications but less was published about its therapeutic implementations. The current study aimed at investigating the therapeutic role of ACh iontophoresis in the improvement of endothelial dysfunction seen in diabetic patients with and without peripheral neuropathy (PN). Patients and methods Forty patients with type 2 diabetes mellitus, 20 with and 20 without PN, were subjected to a therapeutic program of ACh iontophoresis three times a week for 2 successive weeks ‘long-term iontophoresis’. Percentage change in perfusion was measured in the two groups using laser Doppler flowmetry. Readings were taken pretreatment and post-treatment on three occasions: at baseline temperature, after local warming to 35°C, and at maximal flow after exposure to ACh iontophoresis ‘short-term iontophoresis’. Results Perfusion significantly improved after 2 weeks of therapy in the two groups with percentage change improvement of 180.65 vs. 131.50% in the baseline, 219.45 vs. 149.40% after local warming to 35°C and 269.60 vs. 236.95% after short-term ACh iontophoresis in patients without and those with PN, respectively, with P values of 0.0004, 0.0005, and 0.049, respectively. Conclusion ACh iontophoresis may be an optional treatment procedure for improving cutaneous perfusion in diabetics for further randomized control studies.
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Do patients with rheumatoid arthritis have aorta stiffer than general population? p. 145
Petar Avramovski, Maja Avramovska, Marija Arsovska − Nalbanti, Pece Nikolovski, Emilija Sikole
DOI:10.4103/ejim.ejim_65_17  
Objective The aim of this study was to compare the aortic stiffness in patients with rheumatoid arthritis (RA) with the aortic stiffness in general population (GP) and to evaluate the determinants of their stiffness. Patients and methods The study group consisted of 80 patients with RA and 71 matched GP. Pulse wave velocity (PWV) was assessed by Doppler ultrasonography. Biochemical analyses were conducted for serum using standard laboratory procedures. Results The mean PWV values were 7.687±1.03 versus 7.253±0.97 m/s in the patients with RA and GP, respectively. The average coordination of PWV and RA duration (RAD) variations is present by equation of linear regression: y=7.1309+0.0971x. By multiple regression analysis, C-reactive protein, (βst=0.1096, P=0.0009), RAD (βst=0.0917, P=0.0018), high-density lipoprotein cholesterol (βst=−1.0610, P=0.0271), and cholesterol (βst=0.8491, P=0.0350) were independently associated with PWV in the patients with RA. C-reactive protein (βst=0.1057, P=0.0016), triglycerides (βst=0.1730, P=0.0117), low-density lipoprotein cholesterol (βst=0.1467, P=0.0206), and cholesterol (βst=0.0305, P=0.0261) were independently associated with PWV in the GP. Conclusion Arterial stiffness was more pronounced in the patients with RA than in the GP. The independent determinants of arterial stiffness in both groups include traditional risk factors. RAD is determinant in patients with RA only.
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Rifaximin plus cefotaxime versus cefotaxime alone in treatment of spontaneous bacterial peritonitis in patients with cirrhosis p. 154
Asmaa N Mohammad, Mahmoud K Elsamman, Amr M Zaghloul, Hameda H Mohamed, Walaa I Mohammed
DOI:10.4103/ejim.ejim_19_18  
Background/purpose of the study Spontaneous bacterial peritonitis (SBP) is a cause of significantly higher morbidity and mortality in patients with cirrhosis. This study was conducted to assess the effect of adding rifaximin to cefotaxime in treatment of SBP. Materials and methods The study was a prospective one that involved 98 patients with cirrhosis with SBP, who were divided randomly into two equal groups. Patients in group I received cefotaxime, whereas patients in group II received a combination of cefotaxime and rifaximin. Patients were evaluated clinically, and diagnostic aspiration was repeated on the third day of antibiotic therapy. Results Both groups showed significant reduction in white blood cells on the third day compared with the first day (P<0.0001). Polymorphonuclear leukocyte count in ascetic fluid in both groups showed significant reduction on the third day compared with the first day, and the reduction was statistically significant in group II compared with group I (P<0.0001). One the third day of therapy, serum creatinine levels in group I and group II were 1.61±0.19 and 1.28±0.37, respectively. Both groups showed significant decrease in serum creatinine level. The reduction in group II compared with group I was statistically significant, with P value less than 0.0001. Conclusion Rifaximin plus cefotaxime showed some favorable effects in treatment of SBP than cefotaxime alone. However, the clinical effects of these effects need to be clarified in further studies.
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Association between subclinical hypothyroidism and diabetic nephropathy in type 2 diabetes p. 160
Ayman Abd-Elrahman Mohamed Nsr-Allah, Azza H Abd-El Fatah, Mahmoud Azab, Maggie M Fawzi
DOI:10.4103/ejim.ejim_25_18  
Introduction Diabetes mellitus and thyroid dysfunction are two endocrine disorders that can affect each other, and the effects of which are poorly understood until now. Association between subclinical hypothyroidism (SCH) and diabetic nephropathy (DN) remains unclear. Aim The aim was to evaluate the association between subclinical hypothyroidism and diabetic nephropathy in patients with type 2 diabetes mellitus (T2DM). Patients and methods A total of 242 patients with type 2 diabetes were recruited in the study who, according to the results, were subdivided into three groups: euthyroid group [thyroid stimulating hormone (TSH) 0.30–4.2 mIU/ml], SCH group (TSH >4.2 and <10 mIU/ml) with negative antithyroid peroxidase antibodies (anti-TPO), and SCH group with positive anti-TPO. Results Our study shows a high prevalence of subclinical hypothyroidism (29.8%) and DN (47.1%) among type 2 diabetic patients. SCH predicted diabetic nephropathy with an odd ratio of 1.86 (1.01–3.41) and P value of 0.03. There is a significant positive correlation between albuminuria with TSH (P<0.001), and there is a significant positive correlation between albuminuria with anti-TPO (P<0.001). Moreover, there are significant inverse correlations between glomerular filtration rate (GFR) with TSH (P<0.05) and between GFR and anti-TPO (P<0.001). Conclusion and recommendation There is an association between subclinical hypothyroidism and diabetic nephropathy in T2DM. Regular testing of the thyroid function is recommended for all patients with T2DM to avoid DN or more deterioration of the kidney functions. Future larger studies are needed to know the exact mechanism by which high serum TSH leads to renal impairment and for evaluating the proper TSH target in patients with T2DM.
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CASE REPORTS Top

Vocal cord hematoma: an unusual complication of dengue fever p. 168
Vadivelu Tamilarasan, Malapaka Rama Krishna Ravi Chandra, Bangalore Venkatraman Murali Mohan, Madhavi Kadambi
DOI:10.4103/ejim.ejim_7_18  
Dengue is known for its nonspecific onset and frequently can rapidly deteriorate into a range of feared systemic complications including hemorrhagic fever and shock syndromes. However, vocal cord hematomas associated with dengue fever are a rare presentation. Here, we describe a case of vocal cord hematoma in a patient with dengue and thrombocytopenia, highlighting this rare association, which has a potential to aggravate into a life-threatening complication. The patient was treated conservatively and made a complete recovery.
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Tubercular round pneumonia simulating a mass lesion in an adult p. 170
Ved Prakash, Ajay K Verma, Ankit Bhatia, Arpita Singh, Surya Kant, Abhijeet Singh
DOI:10.4103/ejim.ejim_18_18  
Round pneumonia, a benign cause of spherical lesions seen on chest imaging, can many a times be difficult to distinguish from bronchogenic carcinomas. Although relatively less common in adults, this entity is seen in most pulmonary medicine and radiology practices and may lead to computed tomography and biopsy. Because round pneumonia can be easily managed with antibiotics and antitubercular drugs, this diagnosis should be considered in all patients with a spherical lesion, keeping in mind that bronchogenic carcinoma can be a diagnosis as well.
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LETTER TO THE EDITOR Top

Irrational proton pump inhibitor use during corticosteroid therapy p. 173
Rakesh Agarwal, Rashmi Baid
DOI:10.4103/ejim.ejim_2_18  
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