ORIGINAL_ARTICLE
EFFECT OF MULTIMODAL PHYSIOTHERAPY ON OUTCOME OF MECHANICALLY VENTILATED PATIENTS AT ZAGAZIG UNIVERSITY RESPIRATORY INTENSIVE CARE UNIT IN (2014-2015)
ABSTRACTBackground: In critically ill patients,physiotherapy and inspiratory muscle training are considered important components of pulmonary rehabilitation;as they enhance the weaning process and help patients to return to their optimal functional capacities. The aim of this work was to compare the possible benefits and risks of delivering multimodal physiotherapy (PT) to mechanically ventilated patients to improve patients’ outcome.Patients and Methods: Forty mechanically ventilated patients with acute or acute on top of chronic respiratory failure from ZUH (RICU) were enrolled in a randomized controlled clinical trial. The patients were classified equally into test group and control group, control group patients were subjected to conventional PT, while test group patients were subjected to inspiratory muscle training in addition to conventional PT. Pre and post assessment of SAPSII and Barthel index scores, PImax, RSBI and weaning outcomes were done for both studied groups.Results: Both patients’ groups were matched together as regards age, sex, ABG, diagnosis and comorbidities. The test group had a high significant lower frequency of conventional PT sessions in relation to control group 8 and 12 sessions respectively (P<0.01). Barthel index was improved post physiotherapy in the test group better than control group but without statistical significant difference (P>0.05).There was high significant improvement in PImax post-PT in the test group when compared to control group (-34.36.02 cmH2O) versus (-24.62.45 cmH2O) respectively (P<0.001).The indices of weaning were significantly improved in test group than control group as regards PaO2/FIO2, PImax and RSBI (P<0.05).The incidence of complications (VAP, Bed sore and Electrolyte imbalance) increased among the control group than the test group but without statistical significance differences (P>0.05).The weaning success was (90% &70%) in test group versus control group, while the duration of MV, duration of weaning and length of ICU stay were significantly reduced in test group (5, 4.5 and 8.8 ± 2.22 days) versus control group (6, 6 and 11.95 ± 3.4.2 days), (P<0.05, P<0.01 and P<0.001), respectively.Conclusion: Conventional chest physiotherapy is safe ICU intervention with few complications. Adding inspiratory muscle training (using a threshold pressure device) to the conventional physiotherapy can improve maximum inspiratory pressure,functional capacity and RSBI, with potential reductions in length of ICU stay and the duration of invasive mechanical ventilation.
https://zumj.journals.ekb.eg/article_13092_405bdaa396fd1c827ea929c3de21bb6d.pdf
2018-05-01
178
191
10.21608/zumj.2018.13092
Physiotherapy
Inspiratory muscle training
Mechanical Ventilation
Intensive Care Unit
Ramadan
Nafae
1
AUTHOR
Hanan
El-Shahat
2
AUTHOR
Samah
Shehata
3
AUTHOR
Lamiaa
Zaki
4
AUTHOR
ORIGINAL_ARTICLE
PRIVATE SURGEONS’ ATTITUDE TOWARDS INFORMED CONSENT, KUWAIT
Background: Surgeons’ role in informed consent is crucial and should know the basic principle of informed consent in collecting and providing information to patients. Surgeons’ attitudes toward informed consent depends on the knowledge they possess. Objectives: Surgeons should become aware of the informed consent guidelines. New guidelines for consent have resulted in changes in health care environment that surgeons must adhere to. This study aims to highlight the way the surgeons in private hospitals view the informed consent for surgery processes. Methods: This study is a cross-sectional survey that was conducted from January to June 2016 in two private hospitals. The sampling unit used in this survey was private hospitals in Kuwait. A custom designed questionnaire about informed consent for surgery was completed by surgeons working at private hospitals in Kuwait. The questionnaire was developed to examine the surgeons' attitudes towards informed consent. The participants, who were surgeons and working in the various surgical specialties in the two hospitals, were made aware that the emphasis was on the verbal or written information about the operation they provide their patients with and not merely about the signing of the consent form which could take place at the same time or later. They were asked to respond to each question by Yes (agreeing) or No (disagreeing) or Unsure. The responses of the surgeons to each statement were calculated, using Statistical analysis SPSS version 21.Results: A high proportion 98.1% of private surgeons considered informed consent routinely achieved in their current practice. They thought that all surgeons should receive formal training on informed consent 81.6%. They have been received formal training on informed consent 76.7%. On the other hand, private surgeons thought that written information leaflets should be provided for patients during informed consent46.6%. However, only 30.1% of private surgeons provide their patients with leaflets during informed consent. A high proportion of private surgeons 86.4% thought that the main purpose of informed consent is to provide the surgeon with greater protection against litigation. Furthermore, 95.1% of private surgeons thought that the main purpose of informed consent is to respect the patient’s right of autonomy. The majority of private surgeons 94.3% thought that the main purpose of informed consent is to improve the doctor patient relationship, and 83.5% of private thought that the main purpose of informed consent is to improve the patient’s compliance with medical care. On other hand, lower percentages 42.7% of private surgeons thought that informed consent may be unnecessary because most patients depend on their doctor to make the decision for them, and 62.1% of private surgeons thought that the doctor who is going to perform the operation, who should do the informed consent. Also, more private surgeons thought that the patients age, complexity and duration of surgery, gender, the patient social class, the timing of surgery, and the need for referral to another doctor or hospital affects the amount of information given during informed consent. Conclusion: Surgeons in private should be more aware of the informed consent guidelines and they should adhere to them. Training on informed consent in both hospitals are recommended, and to provide more leaflet for patient during informed consent is required and important.
https://zumj.journals.ekb.eg/article_13093_8aecb97390dedb2cbe1952912c8ebe43.pdf
2018-05-01
192
199
10.21608/zumj.2018.13093
Informed consent
surgical risk
private
Saadoun
Al Azmi
1
AUTHOR
Bashair
Almutairi
2
AUTHOR
ORIGINAL_ARTICLE
MAGNETIC RESONANCE SPECTROSCOPY OF NORMAL APPEARING WHITE MATTER IN EARLY RELAPSING-REMITTING MULTIPLE SCLEROSIS
Back ground: Multiple sclerosis (MS) is an inflammatory disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged .MS is a chronic disease of the central nervous system characterised by multicentral inflammation and myelin destruction .Magnetic resonance imaging (MRI) is now widely used for diagnosing MS and detecting clinically silent lesions. However, correlations found between conventional techniques, such as T2-weighted lesion load, and disability, are weak or absent and therefore, neither the magnetic resonance techniques nor clinical measurements are gold standard to assess disease or disability.Alteration of NAWM is of great importance because its true patho-physiological significance is not completely understood. Decrease in N-Acetyl Aspartate (NAA) has been used as an marker of axonal damage or loss that presumably appears secondary to inflammation or demyelination ,although primary axonal damage is not excluded .Objectives : Demonstrate the limitation of convenential magnetic resonance techniques.Observation the pathological processes in NAWM by MRS.Correlation between the results of MRS and the physical disability of the patients using EDSS .Subjects and methods: This study was carried out on 23 patients with clinically definite multiple sclerosis patients, who met the criteria of clinically definite MS according to McDonald criteria 2010, selected from Neurology Department, Zagazig University Hospitals ]10[.Results: We found that the mean value of NAA and the mean ratios of NAA/CR and NAA/ CHO were significant lower in the Cases but the mean values of MI and GLX are significant higher. . Also there was significant negative correlation between the mean value of NAA in MS plaque by MRS and EDSS score as a measure of disability.There was significant negative correlation between the mean value of NAA in NAWM and EDSS score .Discussion: We have clearly demonstrated a correlation between an MRS measure and EDSS. EDSS seems to reflect the existence of irreversible disability probably related to axonal degeneration.
https://zumj.journals.ekb.eg/article_13095_74851fb6e660ac1758adebb9879bc084.pdf
2018-05-01
200
207
10.21608/zumj.2018.13095
Multiple sclerosis
Magnetic Resonance Imaging
Normal appearing white mater
Proton magnetic resonance spectroscopy
Expanded Disability Status Scale
Enas
Mohamed Ahmed
1
AUTHOR
Mahmoud
Zaiton
2
AUTHOR
Hanan
Hassan
3
AUTHOR
Wael
ElSayed
4
AUTHOR
Khalid
Shawki
5
AUTHOR
ORIGINAL_ARTICLE
samar.zag1234@gmail.com
Kidney and thyroid functions interact with each other. Drugs used in treatment of any of them could have side reactions on any other organ. The effects of antithyroid medications on extrathyroidal organs could be due to oxidative stress and to damage in the renal cells.
Aim: This work is designed to demonstrate the role of T4 in protection against the increase in oxidative stress caused by methimazole, and to detect if antithyroid drug-induced hypothyroidism (methimazole) or removal of thyroid by surgery causes damage of kidney cells or not.
Methods:Twenty-five healthy adult male albino rats were used in the study. The animals were randomly separated into groups. Each group contained five rats: Group I (control group): This group received no drugs or treatment. Group II included rats with false thyroidectomy. Group III included thyroidectomized albino rats. Group IV included methimazole-induced hypothyroidism albino rats through receiving 60 mg/kg/day of methimazole in drinking water. Group V were administered methimazole (60 mg/kg/day) and l-thyroxine (T4) subcutaneous injection (20 μg/kg/day).The animals were anasethized and their abdomens were opened and both kidneys were removed, and immediately processed for histological & immunohistochemical study. Also oxidative enzymes were estimated.
Rresults:Light microscopic examination of H&E stained sections showed marked damage of the structure of renal cortex in methimazole induced hypothyroidism group. This damage was concomitant with a decrease in kidney antioxidant enzymes. This damage was less pronounced in group of rats administrated T4 in association with methimazole. The cortex of kidney in rats of thyroidectomized group did not show any alterations in its micro structure.
Conclusion: Methimazole causes both of hypothyroidism and alteration of the kidney cortex. This alteration is not noticed in case of surgical thyroidectomy inducing hypothyroidism. L-Thyroxine (T4) could decrease the effect of methimazole on kidney cortex.
https://zumj.journals.ekb.eg/article_13194_d59c563abbdcfc6a29dcc866248823d8.pdf
2018-05-01
208
219
10.21608/zumj.2018.13194
Kidney and thyroid functions interact with each other. Drugs used in treatment of any of them could have side reactions on any other organ. The effects of antithyroid medications on extrathyroidal organs could be due to oxidative stress and to damage
and to detect if antithyroid drug-induced hypothyroidism (methimazole) or removal of thyroid by surgery causes damage of kidney cells or not. Methods: Twenty-five healthy adult male albino rats were used in the study. The animals were randomly separa
and immediately processed for histological & immunohistochemical study. Also oxidative enzymes were estimated. Rresults: Light microscopic examination of H&E stained sections showed marked damage of the structure of renal cortex in methimazole induce
Manar
Khatab
1
AUTHOR
Mohey
Hulail
2
AUTHOR
Abdelmonem
Hegazy
3
AUTHOR
Heba
Mohammed
4
AUTHOR
ORIGINAL_ARTICLE
CORRELATION BETWEEN RADIOLOGICAL AND ENDOSCOPIC FINDINGS IN CASE OF CHRONIC RHINOSINUSITIS
Background: Paranasal sinus diseases are one of the commonest causes of patients visit to an Otorhinolaryngologist. The symptoms are multiple and vague, while an examination is often limited as sinuses cannot be examined directly. Anterior rhinoscopy gives little information about middle meatus and osteomeatal unit. Objective: The study was carried out with an objective to compare the Diagnostic nasal endoscopic findings and radiological appearance in patients with paranasal sinus disease. Methods: This study included twenty four patients with chronic sinusitis resistant to medical treatment for a period not less than six weeks. The study work was done in Otorhinolaryngology Department in Zagazig University Hospitals for a duration from August 2016 to October 2017. Results: Patients' age ranged from 20 to 58 years with a mean of 32.6 ± 10.68. They were 6 males and 18 females. These patients were divided into two groups: The first group does CT 1-3 months before surgery. The second group repeats CT at the day before operation. Then detection of correlation between CT and intra operative endoscopy findings in both groups. Interpretation and conclusion: In our study, a high association is found between both the modalities of investigation , i.e. CT scans and Diagnostic nasal endoscopy with one scoring over the other in different parameter. Diagnostic nasal endoscopy is found to be highly sensitive investigatory modality for parameters like frontal recess, spheno-ethmoid recess and hiatus semilunaris, whereas CT scan is found to be highly sensitive for parameters like maxillary sinus, uncinate process and posterior ethmoids. So, a case of sinus disease should be diagnosed as early as possible using both these modalities as together they complement each other. Early diagnosis and effective management cures the pathology and prevents disastrous complications.
https://zumj.journals.ekb.eg/article_13196_66bd75f8a199123d3a1d24b3d0d5a2e8.pdf
2018-05-01
220
229
10.21608/zumj.2018.13196
Paranasal sinus disease
CT scan
Diagnostic nasal endoscopy
Middle meatus
Osteomeatal unit
Hany
Al Shamy
1
AUTHOR
Magdy
Albramay
2
AUTHOR
Abdel-Raof
Mohammed
3
AUTHOR
Olfat
Abdel-Hamed
4
AUTHOR
ORIGINAL_ARTICLE
EFFECT OF ANTIREFLUX THERAPY ON THE VOICE OUTCOMES OF PHONOMICROSURGERY FOR VOCAL FOLD POLYPS
Objective: to study the effect of antireflux therapy in the form of PPI and sodium alginate, on the voice outcome after phonomicrosurgery of vocal fold polyps. Study Design: All patients with vocal folds polyps were seen in the outpatient clinic and phoniatric unit of otorhinolaryngology department, Zagazig University Hospitals in the period from July 2016 to January 2018. Patients were divided into 2 groups one group received antireflux therapy in the form of proton pump inhibitors (omeprazole 20mg twice daily plus liquid alginate (gaviscon advance) one table spoonful 10ml 1×3after meal and at bed time. The duration of treatment was 8 weeks. The other group wasn’t received antireflux therapy postoperative. Results: A total of 24 patients met inclusion criteria and divided into two groups. In the two groups of 12 patients each from our study there was a statistically significant improvement regarding laryngeal evaluation, grades of dysphonia, the acoustic and aerodynamic parameters i.e. jitter (p = 0.001), shimmer (p = 0.02) and maximum phonation time (p = 0.001) and AFF (p = 0.04) in the group in which proton pump inhibitor and gaviscon advance were taken postoperative (group A) while in group B there is no Statistically significant difference in Average fundamental frequency.AFF, Jitter, Shimmer (p value above 0.05), but there was statistically significant difference in HNR (p = 0.05) and Maximal phonation time(MPT) (p value 0.008).
Conclusion: The intake of combination of proton pump inhibitor and gaviscon advance liquid is beneficial if taken after phonomicrosurgery for vocal fold polyp to overcome the acidic and non acidic components of the reflux with statistically significant results
https://zumj.journals.ekb.eg/article_13198_459c7bad909cb04d803099a1ab3501c2.pdf
2018-05-01
230
238
10.21608/zumj.2018.13198
Voice–Dysphonia–Phonomicrosurgery–Laryngopharyngeal reflux
Ezzat
Merwad
1
AUTHOR
Adely
Tantawy
2
AUTHOR
Hazem
Amer
hazemamerent@yahoo.com
3
AUTHOR
Alhusin
Mohamed
4
AUTHOR
ORIGINAL_ARTICLE
STUDY OF SERUM NEOPTERIN, INTERLEUKIN-10 AND NEUTROPHIL TO LYMPHOCYTE RATIO IN CONTRAST INDUCED NEPHROPATHY
Background: Recent improvements in radio-diagnostic procedures and in cardiovascular percutaneous interventions, together with increased life expectancy, have resulted in the subjection of an increasing number of patients to contrast medium-enhanced examinations or cardiac and angiographic procedure requiring iodinated contrast medium injection.
Subjects and methods: This study was carried out at Internal Medicine, Cardiology, Radiology and Clinical Pathology departments, Zagazig University Hospitals. The study was approved by Institutional Review Board (IRB) and included a total of 60 patients.
Based on the development of contrast induced nephropathy after IV administration of high osmolar contrast agent, Patients were classified into CIN and NO CIN groups. We measured serum neopterin and IL-10 and calculating neutrophil to lymphocyte ratio before contrast administration, 24 and 48 hours after in 45 patients underwent coronary angiography for diagnostic and therapeutic purposes and 15 patients underwent renal angiography.
Results: About 25 % of the present studied patients (14 patients) fulfilled the criteria of contrast nephropathy with more cases in the percutaneous coronary angiography group (11 patients).This study revealed that serum neopterin, IL 10 and neutrophil to lymphocyte ratio were higher in patients with CIN following IV contrast media at 24 & 48 hours compared to patients without CIN. In our study; we found increased pre-procedural and post-procedural CRP, ESR and uric acid levels at 48 hours in patients with CIN. We found a decreased basal serum total bilirubin level in patients with CIN following IV contrast media compared to patients without CIN.
Conclusion: Serum neopterin, IL 10 and neutrophil to lymphocyte ratio proved that they can be used as early biomarkers of contrast induced nephropathy instead of serum creatinine as they rise 24 hours before any change in the serum creatinine. Decreased serum total bilirubin levels had a higher incidence of CIN after the use of contrast media. Measuring ESR & CRP levels at admission may offer additional assistance in predicting the development of CIN. Elevated serum uric acid level is independently associated with an increased risk of CIN.
Abbreviations: CIN = Contrast induced nephropathy, AKI = Acute kidney injury, CRP = C-reactive protein, NLR= Neutrophil to lymphocyte ratio, ESR = Erythrocyte sedimentation rate, UA = Uric acid, eGFR = estimated glomerular filtration rate.
https://zumj.journals.ekb.eg/article_13200_e56993174abedeaac00d7f3a433f6973.pdf
2018-05-01
239
252
10.21608/zumj.2018.13200
Contrast induced nephropathy
Neopterin
IL-10
Neutrophil to Lymphocyte Ratio
Mohamed
Fahmy Zanaty
1
AUTHOR
Yousef
Kadry
2
AUTHOR
Hisham
Omar
3
AUTHOR
Mohamed
Abd el-Rehim
4
AUTHOR
ORIGINAL_ARTICLE
IMPACT OF GLN/GLU27 POLYMORPHISM OF B2 ADRENERGIC RECEPTOR ON BRONCHIAL ASTHMA SUSCEPTIBILITY AND DRUG RESPONSE IN CHILDREN
Background: Bronchial asthma is one of the most prevailed non-communicable diseases among Egyptian children and all over the world. Genetic-environmental interaction can influence the nature of many diseases including asthma and considering β2 agonists as one of the most commonly prescribed bronchodilators for relieving asthma symptoms, so this study was conducted to investigate the possible relationship between Gln27/Glu polymorphism of ADRβ2 from one side and bronchial asthma susceptibility, severity and responsiveness to Albuterol (short-acting ADRβ2 agonist) from the other side.
Subjects and methods: A case control study of one hundred Egyptian children was designed. All participants were genotyped using allele-specific Polymerase chain reaction (PCR) to assess single nucleotide polymorphism (SNPs) of ADRβ2. Fifty asthmatics, their mean age was (8.10+2.52), who were selected and classified according to GINA guidelines, 2017 and spirometerically assessed to evaluate pulmonary functions. Another fifty matched healthy participants were selected as a control group with a mean age of (8.44+2.40).
Results: Gln allele frequency = 0.59 and Glu allele frequency = 0.41 for cases with Chi- squared X2 = 0.12 and Gln allele frequency = 0.56 and Glu allele frequency = 0.44 for control participants with X2 = 0.93. There were no statistically significant differences between patients and control regarding Gln27/Glu polymorphism. Gln27 was the only genotype having positive association with both asthma severity and drug response, as it represents only 17.2% of all mild cases, 56.3% of all moderate cases and about 80.0% of all sever studied cases; P value (0.003).
Conclusion: B2 adrenergic receptor polymorphism at codon 27 is not associated with asthma susceptibility; however it can be a determinant factor for asthma severity and bronchodilating response to B2 agonists in Egyptian asthmatic children, to be confirmed by further Pharmacogenomic studies
https://zumj.journals.ekb.eg/article_13202_7e2104fd5d1ddb8b07ca6f875b217c9f.pdf
2018-05-01
253
262
10.21608/zumj.2018.13202
Khalid
Salah
1
AUTHOR
Hadeel
Abd El-Rahman
2
AUTHOR
Ahmed
Fakhr
3
AUTHOR
Mohamed
Marghany
4
AUTHOR
ORIGINAL_ARTICLE
EVALUATION OF LAPAROSCOPIC HERNIOPLASTY IN GROIN HERNIA
Background:laparoscopic groin hernia repair has gained wide popularity in surgical practice in the last two decades. Trans abdominal pre peritoneal (TAPP) and totally extra peritoneal (TEP) repair are standing head to head as the most common laparoscopic techniques for groin hernia.
Methods:This prospective randomized study was conducted between December 2013 and December 2015. Sixty male patients suffering from non complicated inguinal hernia were included. Patients were randomized into group A (TAPP) and group B (TEP). Intra operative variables and postoperative pain and complications were recorded in a pre structured form
Results:In TEP group patient had lees post operative pain, were able to resume their normal daily activities and spent less operative time than TAPP group. No significant difference in terms of Intra operative and post operative complications between both groups.
Conclusion:. TEP has a significant advantages over TAPP in reduction of operative time and postoperative pain, which resulted in earlier recovery and return to normal activity. Although both techniques seem to effective, TEP has a step over TAPP.
https://zumj.journals.ekb.eg/article_13204_0c3d86decc9365b4366544dbea4f699f.pdf
2018-05-01
263
272
10.21608/zumj.2018.13204
Mahmoud
Abd Al-Aziz
1
AUTHOR
Abd Al-Azem
Mohammed
2
AUTHOR
Ibrahim
Dawoud
3
AUTHOR
Ahmed
Negm
4
AUTHOR
Magdy
Basheer
5
AUTHOR
Mohamed
Samir
6
AUTHOR
Hosam
Elghadban
7
AUTHOR
Abdelrahman
Elbahy
8
AUTHOR
ORIGINAL_ARTICLE
A COMPARATIVE STUDY OF PATIENTS’ ATTITUDE TOWARDS INFORMED CONSENT IN PUBLIC AND PRIVATE HOSPITALS
Background: Patient’s autonomy is an imperative issue in the health service field. It is a known fact that patient’s awareness and understanding of legal and ethical issues related to the consent process is often limited. Adequate information before a surgical procedure is fundamental to give informed consent. Information should include a description of the benefits, risks and complications of the intended procedure as well the alternative treatment options.
Objectives: The aim of this study was to compare patients in public and private hospitals of Kuwait as regards their understanding of legal implications, viewabout the scope, value and function of consent form during the clinical practice.
Methods: A comparative descriptive cross-sectional survey was conducted in 6 public and 2 private hospitals from January to June 2016 in the state of Kuwait. A total of 910 patients aged 18 years old and above admitted to the surgery departments in the selected hospitals were invited. Structured self-administered questionnaires were distributed to the patients hospitalized in the selected departments of Kuwaiti hospitals. The questionnaire was pilot-tested prior to being finalized. Statistical analysis for the achieved data was done.
Results: Of 910 patients, 805 (88.5%) completed the questionnaires. Patients in public hospitals were 584 (72.5%) while those in private hospitals were 221 (27.5%). Significantly higher proportion of patients in private hospitals were in the view that signing the consent form is a legal requirement (88.7%). Significantly more private sector patients agreed that signing the consent form means that all exactly are present in the consent form (91.0%), and the doctor cannot do anything different from what was on the form unless it is lifesaving (82.4%). More patients in private sector hospitals agreed about the statements that the consent form made it clear what was going to happen (79.6%) and the consent form gave the doctors control over what happened (72.9%). There were no statistical significant differences observed between patients in the two disciplines as regards their responses to the statements: the consent form is important (p = 0.167), the consent form made the patient aware of the risks of the operation (p = 0.520), the consent form made the patient wishes known (p = 0.393), the consent form prevents mix ups during the operation (p = 0.470), the consent form was just another piece of paper (p = 0.361), the patient just signed the consent form so he/she could have the operation (p = 0.053) and signing the consent form was mainly to protect the hospital (p = 0.049).
Conclusion: Patients in public and private hospitals have limited knowledge of the legal implications of signing or not signing consent forms, indicates that consenting in its current form is not informed and should be reassessed in order to achieve patient autonomy. The policy and decision makers need to develop educational program towards inform consent.
https://zumj.journals.ekb.eg/article_13205_8f269cc40cb040588c2f46beacf4e69b.pdf
2018-05-01
273
282
10.21608/zumj.2018.13205
hospitals
patients
Medical ethics
Informed consent
Saadoun
Al Azmi
1
AUTHOR
Bashair
Almutairi
2
AUTHOR
Ahmad
Al Jafar
3
AUTHOR