Effect of tranexamic acid in prevention of postpartum hemorrhage in elective caesarean delivery: a randomized controlled study

Background: Postpartum hemorrhage is the ugly ghost that most obstetricians believe because many cases unpredicted and may be associated with rapid patient deterioration that may lead mortality or developing serious long-term morbidities. The objective of this study is to assess the efficacy of slowly intravenous administration of tranexamic acid in prevention and decline the severity of postpartum hemorrhage immediately prior to elective caesarean section.Methods: A double blinded, randomized, case control trial carried out at Obstetrics and Gynecology Department, Faculty of Medicine, South Valley University, Egypt from May 2017 to April 2018. This study was conducted on 500 full term pregnant women underwent elective caesarean section. The patients were divided randomly into: Group A (study group) included 250 patients received tranexamic acid 1gm slowly iv over 2 minutes at least 10 minutes before operation started and Group B (control group) included 250 patients that received placebo (normal saline NaCl 0.9%).Results: Incidence of PPH in group A and group B were (4.4% and 6.8) respectively, 1.2% in group A and 2.8% in group B had severe degree of PPH. Amount of blood loss immediately after placental delivery up to first 6 hours postoperative was statistically significant increase in placebo group than tranexamic acid group with p value <0.001.Conclusions: Tranexamic acid administration few minutes prior to elective cesarean section was effective in reducing the incidence and severity of PPH and decreased the use of additional uterotonic drugs and additional surgical interventions.

Preoperative factors that determine technical difficulty during laparoscopic cholecystectomy for symptomatic calcular cholecystitis

The increasing experience in laparoscopic cholecystectomy has led to more difficult cases being performed The methods to identify a potentially difficult laparoscopic cholecystectomy would be a valuable indicator for good management policies with improvement of the outcome. The aim of this study was to determine the correlation between preoperative clinical and abdominal sonographic findings in patients undergoing laparoscopic cholecystectomy for symptomatic calcular cholecystitis and the technical difficulty at operation. All consecutive patients with calcular cholecystitis undergoing laparoscopic cholecystectomy for the last 8 years [531 patients] were reviewed. The clinical preoperative factors assessed involved patient's age, sex, body weight and body mass index, of the disease, associated diabetes mellitus, the occurrence of biliary colic within the last 3 weeks, the presence of symptoms and signs of acute cholecystitis at presentation and history of acute cholecystitis. The laboratory preoperative factors assessed involved, full blood picture including total leucocytic count, liver functions including serum transaminases, serum bilirubin and prothrombin time. The preoperative abdominal sonographic findings assessed involved gallbladder size, gallbladder wall thickness, peri-cholecystic fluid, gallstones number and size and the liver condition. Laparoscopic cholecystectomy was attempted in all patients. Operative data were compared to preoperative data of all patients and statistically analyzed. It was found that the following 7 parameters are independently predictive of a difficult operation: male sex [p<0.01], the presence acute cholecystitis [p<0.01], thickening of the gallbladder wall [p<0.01], shrunken gallbladder [p<0.01], mucocele of the gallbladder [p<0.05] and enlarged liver [p<0.05] or liver cirrhosis [p<0.05]. The above-mentioned factors are important and should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties

pharmacological approach to reverse portal hypertention and hepatic schistosomal fibrosis in Egypt, control experimental study

Schistosoma mansoni is the most prevalent cause of liver fibrosis in Egypt. It is characterized by hepatocyte damage, inflammation and chronic parasite egg-induced granuloma formation leading to fibrosis. Its management, particularly fibrosis, has focused primarily on treating and preventing the complications of portal hypertension. Unfortunately, there is no therapy that has been proved to prevent progressive hepatic fibrosis which is associated with a significant morbidity and mortality due to granulomatous hypersensitivity to parasite eggs. However, recent developments in understanding hepatic fibrogenesis confirm that recovery from advanced fibrosis is possible. There is a considerable imperative to develop anti-fibrotic strategies that are applicable to liver fibrosis. It was noted that a marked increase in the amount of different interstitial collagens types are associated with the development of fibrotic liver diseases. Mean while, it has been suggested that as long as the relative portions of liver collagen are still within the normal limits, the fibrosis may still be reversible. If it exceeds the normal limits fibrogenesis will proceed to its end stage, even if the etiological agent is removed. Collagen type IV and procollagen type III are two of the most accurate fibrosis markers which allow reliable non-invasive diagnosis. The T lymphocytes and the immuno-regulatory cytokines may be important in the host response to S. mansoni granuloma formation and fibrosis. Chronic parasite egg-induced granuloma formation can lead to fibrosis, which is immunologically characterized by the dominant Th2 response. Corticosteroids and prostaglandins interfere with both efferent and afferent mechanisms of immune function. These data indicate that this adjuvant therapy can be a candidate for therapeutic intervention in hepatic fibrosis through induction of a balance between Th1 and Th2 cells response as will be documented by the fibrosis markers One hundred S. mansoni infected hamsters [150-250 gm] were obtained from the BRPU-TBRI [5 groups, 20 hamsters each]. Treatment was started 10 weeks post infection. First G [20 hamsters] was neither infected nor treated, second G. was infected but untreated, third group infected and PZQ treated, fourth G. infected and PZQ and MP treated and fifth group infected and PZQ and PgE1 treated. Samples [liver and blood] were obtained 20 weeks post infection. The serum level of: liver functions, procollagen type III, collagen type IV and Th1 cytokine [IL-2] and Th2 cytokine [IL-b] were performed. Histopathology was performed to study live fibrosis, measuring the proliferate activity of the hepatocytes using cell image analyzer system and granuloma cells using the indirect immuno-histochemistry by monoclonal antibody proliferating cell nuclear antigen [PCNA]. In this study, G. V showed high significant reduction in granuloma size, type and percentage of fibrosis and significant elevation in percentage of degenerated ova compared to Gs. III and IV. The proliferation index measured using PCNA showed high proliferative activity of hepatocytes in non treated group which declined in the treated Gs. III, IV and V. The proliferation activity of hepatocytes and granuloma forming cells decreased significantly in G.V compared to G.IV. There was a significant reduction in liver function tests even tendency for normalization in G.V compared to group III and IV. Procollagen type III and collagen type IV were significantly low in the serum in G.V compared to Gs. III and IV. Th1 [IL-2] level was significantly high in G.V compared to Gs. III, IV and Th2 [IL-10] was significantly low in G.V compared to Gs III and IV indicating the low amount of fibrosis was in the group treated with PZQ and PgE1.PgE1 with PZQ to treat S. mansoni infected hamsters can modulate liver fibrosis and improves the liver function tests up to normalization. The balance between Th1 and Th2 cytokines level could be modulated to help reverse or decrease fibrosis in S. mansoni infected hamsters. This may pave the way for clinical application as combined therapy PZQ and PgE1 may by an effective approach to reverse hepatic fibrosis in schistosomiasis by the induction of dominant Th1 response

Effect of preoperative endoscopic biliary drainage and stenting on postoperative infection and the outcome of surgery for benign obstructive jaundice

The effect of preoperative endoscopic biliary drainage on the outcome of surgery for patients presenting with obstructive jaundice [OJ] has been studied; increase the risk of morbidity, and mortality. This work aim to studying the bile samples from those patients before and after endoscopic retrograde cholangiopancreatography [ERCP] with biliary stenting and its possible association with postoperative septic complications. The study involved 79 patients with surgically corrected benign obstructive jaundice at Thodor Bilharze Research Institute. Preoperative [ERCP] was done for all of the patients and stent insertion was made in 60 of them. Bile specimens were obtained during endoscopic cholangiography by flushing technique and intra-operatively by puncture before incising the common bile duct. Bile samples were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant postoperative septic complications such as wound infection and cholangitis were also assessed. Bile culture of intra-operatively obtained specimens was positive in 39/60 [65.0%] of the patients in Group II [ERGP+ biliary stent], a significantly higher incidence than that observed in group I [ERCP only], in which 7/19 [36.8%] of the patients presented positive cultures [p=0.001]. There was no significant difference in general postoperative morbidity between groups. When infective complications [cholangitis, pneumonia, wound infection] were analyzed separately, a higher incidence, although without significance was found in Group II than in Group I. Preoperative biliary drainage using the endoscopic retrograde cholangiopancreatography [ERCP] and stent insertion in patients subjected to surgery for benign obstructive jaundice could provoke biliary bacterial colonization with a possible appearance of infective complications during the postoperative period

Sarcoidosis: case report

A male patient presented with wide spread multiple cutaneous nodules affecting forehead, nostrils, upper arms, thighs and trunk. The nodules were asymptomatic and had a violaceous color and erupted over a period of 2 years. The clinical diagnosis of sarcoidosis was confirmed by skin biopsy. Despite the wide spread lesions no systemic involvement was detected. Patient responded to systemic steroid and is periodically checked for possible future systemic involvement