The SARS-COV2 (COVID-19) Pandemic: What Clinicians should Know

In late 2019, a novel coronavirus, now designated SARS-CoV-2, emerged and was identified as the cause of an outbreak of acute respiratory illness in Wuhan, a city in China, named as COVID-19. Since then the waves of the virus exponentially hit many countries around the globe with high rates of spread associated with variable degrees of morbidity and mortality. The WHO announced the pandemic state of the infection in March 2020 and by June 1st 2020 more than 6 million individuals and more than 370 thousands case fatalities were documented worldwide. In this article, we discussed many aspects regarding this emerged infection based on the available evidence aiming to help clinician to improve not only their knowledge but also their practices toward this infection.

The SARS-COV2 (COVID-19) Pandemic: What Clinicians should Know

In late 2019, a novel coronavirus, now designated SARS-CoV-2, emerged and was identified as the cause of an outbreak of acute respiratory illness in Wuhan, a city in China, named as COVID-19. Since then the waves of the virus exponentially hit many countries around the globe with high rates of spread associated with variable degrees of morbidity and mortality. The WHO announced the pandemic state of the infection in March 2020 and by June 1st 2020 more than 6 million individuals and more than 370 thousands case fatalities were documented worldwide. In this article, we discussed many aspects regarding this emerged infection based on the available evidence aiming to help clinician to improve not only their knowledge but also their practices toward this infection.

Peri-Operative Liver Fibrosis and Native Liver Survival in Pediatric Patients with Biliary Atresia: A Systematic Review and Meta-Analysis / 대한소아소화기영양학회지

No systematic review to date has examined histopathological parameters in relation to native liver survival in children who undergo the Kasai operation for biliary atresia (BA).A systematic review and meta-analysis is presented, comparing the frequency of native liver survival in peri-operative severe vs. non-severe liver fibrosis cases, in addition to other reported histopathology parameters. Records were sourced from MEDLINE, Embase, and CENTRAL databases. Studies followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and compared native liver survival frequencies in pediatric patients with evidence of severe vs. non-severe liver fibrosis, bile duct proliferation, cholestasis, lobular inflammation, portal inflammation, and giant cell transformation on peri-operative biopsies. The primary outcome was the frequency of native liver survival. A random effects meta-analysis was used. Twenty-eight observational studies were included, 1,171 pediatric patients with BA of whom 631 survived with their native liver. Lower odds of native liver survival in the severe liver fibrosis vs. non-severe liver fibrosis groups were reported (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.08–0.33; I2 =46%). No difference in the odds of native liver survival in the severe bile duct destruction vs. non-severe bile duct destruction groups were reported (OR, 0.17; 95% CI, 0.00–63.63; I2 =96%). Lower odds of native liver survival were documented in the severe cholestasis vs. non-severe cholestasis (OR, 0.10; 95% CI, 0.01–0.73; I2 =80%) and severe lobular inflammation vs. non-severe lobular inflammation groups (OR, 0.02; 95% CI, 0.00–0.62; I2 =69%). There was no difference in the odds of native liver survival in the severe portal inflammation vs. non-severe portal inflammation groups (OR, 0.03; 95% CI, 0.00–3.22; I2 =86%) or between the severe giant cell transformation vs. non-severe giant cell transformation groups (OR, 0.15; 95% CI, 0.00–175.21; I2 =94%). The meta-analysis loosely suggests that the presence of severe liver fibrosis, cholestasis, and lobular inflammation are associated with lower odds of native liver survival in pediatric patients after Kasai.

Clinical comparative study between dexmedetomidine, magnesium sulphate and ketofol versus midazolam for sedation during awake fiberoptic nasotracheal intubation in predicted difficult air ways patients

Background and objectives: Awake fiber optic intubation [AFOI] is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries

Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal [AFOI] under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine [DEX], group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score [vocal cord movement and coughing] were assessed

Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR [<10% fall when compared with the baseline value] after loading of drug and during intubation in contrast to midazolam, ketofol and magnesium sulphate, which increase during intubation. There was no statistically significant difference in the intubation scores, grimace score, time of intubation, number of attempts and saturation in between the groups with one episode of desaturation in group ketofol and two in group midazolam [P > 0.05]. Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 [modified OAA/S score] in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups

Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction

Non-invasive assessment of liver fibrosis in patients with hepatitis C: shear wave elastography and colour Doppler velocity profile technique versus liver biopsy

Background and study aims: Determination of the presence and degree of liver fibrosis is essential for the prognosis and treatment of patients with chronic hepatitis C. Non-invasive methods of assessing fibrosis have been developed to reduce the need for biopsy. We determined the efficacy of shear wave elastography [SWE] and colour Doppler velocity as non-invasive methods for the assessment of liver fibrosis compared to liver biopsy among patients with chronic hepatitis C virus [HCV] infection

Patients and methods: In total, 117 patients with chronic HCV infection and 50 healthy age- and sexmatched control subjects were included. For each patient and control, abdominal ultrasonography, Doppler ultrasonography of the right portal vein [PV], and SWE were performed, whereas liver biopsy was performed for patients

Results: The mean value of the right PV maximum velocity was lower in patients with different stages of fibrosis than in controls [p < 0.001]. The mean value of liver stiffness determined by SWE was significantly higher in patients with different stages of fibrosis than in controls. Cutoff values for liver stiffness determined by SWE for assessing fibrosis stages were F2 >/= 4.815, F3 >/= 6.335, and F4 = 7.540 with a sensitivity of 84.6%, 96.2%, and 100.0%; specificity of 88.5%, 93.8%, and 100.0%; positive predictive value [PPV] of 93.6%, 98.0%, and 100.0%; negative predictive value [NPV] of 74.2%, 88.2%, and 100.0%; and overall accuracy of 85.9%, 95.6%, and 100.0% [area under the ROC curve [AUC]: 0.89, 0.96, and 1.0], respectively. Cutoff values for the right PV maximum velocity for assessing fibrosis stages were F2 < 23.4, F3 < 21, and F4 < 20 with a sensitivity of 65.0%, 57.4%, and 57.1%; specificity of 59.8%, 76.4%, and 75.5%; PPV of 33.8%, 58.3%, and 32.0%; NPV of 84.4%, 75.7%, and 89.7%; and overall accuracy of 61.1%, 69.5%, and 72.5% [AUC: 0.614, 0.696, and 0.625], respectively

Conclusion: SWE is effective for the non-invasive assessment of liver fibrosis in patients with HCV infection. SWE provides a more accurate correlation with liver fibrosis stage than colour Doppler velocity profile for the assessment of liver fibrosis, especially in advanced stages [F3 and F4]

Impact of metformin on liver perfusion in women with polycystic ovary syndrome [PCOS] and non-alcoholic fatty liver disease [NAFLD]

To evaluate the impact of 6-month treatment with metformin on some liver functions and hepatic perfusion in obese women with PCOS and NAFLD. Twenty women with PCOS and NAFLD were given a total daily dose of 1.7 g of metformin for six consecutive months. BMI, fasting serum glucose, serum cholesterol, LDL, HDL, triglycerides, ALT, AST, alkaline phosphatase [ALP], gamma-glutamyltransferase [GOT], total and conjugated bilirubin and serum albumin were assayed. Total liver blood flow was assessed by Doppler ultrasound and was taken as the sum of flow volumes in the common hepatic artery and portal vein. All parameters were measured before and six months after metformin treatment. BMI, fasting serum glucose, total cholesterol, serum triglycerides and LDL decreased significantly, whereas HDL increased significantly, after metformin treatment. Basal serum ALT levels were higher than normal with a tendency towards reduction after metformin therapy, which did not reach statistical significance. Hepatic arterial blood flow, portal vein blood flow and consequently total hepatic blood flow increased significantly in PCOS women six months after metformin therapy. Six-month treatment with metformin had a favorable impact on some liver function tests and hepatic perfusion in PCOS women with NAFLD

What are the most discriminating two-dimensional and doppler sonographic features in differentiation of benign and malignant adnexal masses?

To determine the two-dimensional and doppler sonographic features that best allow differentiation between malignant and benign adnexal masses, besides develop a new scoring system enable more accurate diagnosis with these features. A cross sectional prospective study was conducted on patients scheduled for surgery due to presence of adnexal masses at Women's Health Hospital, Assiut, Egypt between October 2012 and October 2013. All patients were evaluated by 2D ultrasound for morphological features of the masses aided by doppler examination of their vessels. The final diagnosis was based on histopathological reports used as gold standard. One hundred forty-six patients were recruited, 104 with benign masses, 42 with malignant masses. Features that allowed statistically significant discrimination of benignity from malignancy were; volume of mass, type of mass, presence and thickness of septae, presence and length of papillary projections, location of vessels at colour Doppler and colour score. A scoring formula was supposed combined those features together to develop a new scoring system; Assiut Scoring System [ASS]. The cut-off score with the highest accuracy in detection of malignancy had a sensitivity of 93.5% and specificity of '92.2%. Assiut Scoring System; a multiparameter scoring that use four 2D ultrasound and two doppler features, has a high sensitivity and specificity for prediction of malignancy in adnexal masses

Pullout capacity of batter pile in sand

Many offshore structures are subjected to overturning moments due to wind load, wave pressure, and ship impacts. Also most of retaining walls are subjected to horizontal forces and bending moments, these forces are due to earth pressure. For foundations in such structures, usually a combination of vertical and batter piles is used. Little information is available in the literature about estimating the capacity of piles under uplift. In cases where these supporting piles are not vertical, the behavior under axial pullout is not well established. In order to delineate the significant variables affecting the ultimate uplift shaft resistance of batter pile in dry sand, a testing program comprising 62 pullout tests was conducted. The tests are conducted on model steel pile installed in loose, medium, and dense sand to an embedded depth ratio, L/d, vary from 7.5 to 30 and with various batter angles of 0[degree], 10[degree], 20[degree], and 30[degree]. Results indicate that the pullout capacity of a batter pile constructed in dense and/or medium density sand increases with the increase of batter angle attains maximum value and then decreases, the maximum value of P[chi] occurs at batter angle approximately equal to 20[degree], and it is about 21-31% more than the vertical pile capacity, while the pullout capacity for batter pile that constructed in loose sand decreases with the increase of pile inclination. The results also indicated that the circular pile is more resistant to pullout forces than the square and rectangular pile shape. The rough model piles tested is experienced 18-75% increase in capacity compared with the smooth model piles. The suggested relations for the pullout capacity of batter pile regarding the vertical pile capacity are well predicted

Impact of chewing Khat on the mode of delivery of Yemeni pregnant women

Khat chewing is common among Yemeni women, even during pregnancy where it may affect the wellbeing during pregnancy and during delivery of these pregnant women. This study was conducted to determine the impact of Khat chewing on the mode of delivery of pregnant Yemeni women. This is a prospective study for 60 regular Khat chewing pregnant women and 120 non-Khat chewing pregnant women, selected from those attended with singleton pregnancy in their first or second trimester from the ANC unit of AL-Gamhouri Teaching Hospital in Taiz [Republic of Yemen]. Khat chewer pregnant women, when compared with the control, showed statistically significant risk of 6.06 times to deliver at gestational age earlier than 37 weeks and insignificant risk of 2.27 times to deliver after 42 weeks. They showed a statistically significant risk of 2.65 times to deliver by cesarean section [CS] and insignificant risk of 4.86 times for instrumental delivery. This study concluded that Khat chewing is associated with higher rate of cesarean and instrumental deliveries that may affect maternal and fetal wellbeing

Cord blood ghrelin, leptin, and IGF-1: their inter-relations and relationships to gestational age, gender and anthropometrics

The main purposes of this study was to: 1] compare cord blood ghrelin, leptin and IGF-1 concentrations in PT-AGA and FT-SGA infants to that of FT-AGA. 2] determine the independent contributions of these metabolic hormones to intrauterine fetal growth and infant birth size. 3] investigate their inter-relations and relationships to anthropometric parameters. 4] determine the effect of gender on cord blood hormone concentrations. We studied 75 newborns [45 males, 30 females], classified into 3 sub-groups: Group A: included 45 infants [25 males, 20 females], FT-AGA as controls. Their gestational ages ranged from 37-42 weeks and birth weights ranged from 2575-3930 gm. Group B: included 19 infants [12 males, 7 females], PT-AGA. Their gestational ages ranged from 28-36 weeks and birth weights ranged from 1855-2350 gm. Group C: included 11 infants [7 males, 4 females], FT-SGA. Their gestational ages ranged from 37-41 weeks and birth weights ranged from 2080-2650 gm. All studied newborns were subjected to a detailed history and clinical evaluation. Demographic and anthropometric characteristics, including body weight, length, HC and BMI were registered immediately after birth. At delivery, cord blood sample was collected from all studied newborns for hormonal assay of ghrelin, leptin and IGF-1. A comparative statistical analysis and correlation studies were done for anthropometric and laboratory data within and between studied groups. Ghrelin, leptin and IGF1 were detectable in cord blood of all newborns. Cord blood ghrelin concentration of group A was significantly lower than that of group B and C, while that of group B was significantly lower than that of group C. Cord blood leptin concentration of group A was significantly higher than that of group B and C, while that of group B was significantly higher than that of group C. Cord blood IGF-1 concentration of group A was significantly higher than that of group B and C, while that of group B was significantly higher than that of group C. Cord blood ghrelin, leptin and IGF-1 were significantly higher in female than in male infants. Cord blood leptin correlated positively with gestational age, birth weight, BMI and cord blood IGF-1. Cord blood ghrelin correlated negatively with birth weight, BMI and cord blood IGF-1. IGF-1 correlated positively with birth weight and BMI. Metabolic hormones, ghreiln, leptin and IGF-1 were detectable in cord blood of all newborns, even at early gestation [as early as 28 weeks gestation] Their interrelations and correlations with gestational age and anthropometric parameters suggest that these hormones are gestation related and may play an important role in energy balance and homeostasis and regulating growth in utero

Comparative study between caudal ropivacaine and bupivacaine with and without neostigmine in pediatric surgery

In a randomized, double-blinded study we examined the analgesic efficacy of caudal nesostigmine-ropivacaine mixture and caudal neostigmine-bupivacaine mixture in 75 pediatric patients schedulled for various surgical procedures such as lower abdominal, urologic and lower limb operations-After induction of general anaesthesia patients were allocated randomly into [5] equal group [n=15] to receive caudal analgesia. [I] Bupivacaine group 0.25% 1 mL/kg [2] Ropivacaine group 0.25% 1 mL/kg [3] Neostigmine group 2 micro g/kg [4] Bupivacaine 0.25% 1 mL/Kg +/- Neostiginine 2 micro g/Kg group [5] Ropivacaine .0.25% 1 mL/Kg+Neostigmine 2 micro g/Kg Group. There were no differences between the groups in demographic and haemodynamic data. Intraoperatively, children receiving caudal mixture of bupivacaine-neostigmine and ropivacaine-Neostigmine maintained haemodynaniiic stability and required less inhaled anaesthelics and had a short recovery time compared with the other groups. Postoperatively the caudal ropivacaine neostigmine mixtures resulted in superior analgesia and less motor blocks compared with the caudal bupivacaine-neostigmine mixtures. Recovery to first rescue analgesic times were [mean +/- SD] 384.33 +/- 302 min, 508 +/- 87.44 min, 266 +/- 58.7 and, 893.67 +/- 429.46 min and 1325 +/- 207.11 mm in the bupivacaine group, ropivacaine group, neostigmine group, bupivacaine neostigmine mixture group and ropivacaine-neostigmine mixture group respectively [P<0.001]. In addition, "ropivacaine-neostigmine" mixture group received the least number of paracetamol suppositories followed by "bupivacaine-neostigmine" mixture group then ropivacaine-group" followed by "bupivacaine group" and lastly "neostigmine group" which received the biggest number of paracetamol-suppositories to maintain adequate analgesia in the first 24 h postoperatively. Postoperative vomiting occurred in [2] patients [13.3] in both of caudal "bupivacaine-neostigmine and ropivacaine-neostigmine group. And in [4] patients [26.6%] in the neostigmine group otherwise, no patient in any of the other [2] groups had emetic side-effects. We conclude that caudal ropivacaine-neostigmine mixture resulted in superior analgesia and less motor blocks in the postoperative period compared with the caudal bupivacaine-neostigmine mixture

Fetal cardiovascular hemodynamics in diabetic and hypertensive pregnancies

Fetal echocardiography is a useful technique in the evaluation of the fetal cardiovascular system. The purpose of this work was to evaluate fetal cardiac anatomy and function in two of the most common medical problems seen in pregnancy, diabetes mellitus and chronic maternal hypertension. In this cross sectional study, 60 fetuses between 20-30 weeks of gestation were included. Twenty of them were fetuses of diabetic mothers [FODMs], 20 fetuses of hypertensive mothers [FOHMs] and the remaining twenty were normal fetuses of matchable gestational age as controls. Transabdominal fetal echocardiography was obtained and the cardiac diameters and thickness were measured. The systolic function [stroke volume and cardiac output] and the diastolic function [E/A ratio] were obtained. There was a significant increase in cardiac diameters and thickness in FODMs and decrease in diameters in FOHMs. The pulmonary and aortic blood flow velocities were significantly faster in FODMs and slower in FOHMs. The diastolic functions were impaired in all patients. The stroke volume and cardiac output were significantly higher in FODMs and lower for the right ventricule in FOHMs than controls. Fetal echocardiographic examination showed significant changes in both cardiac anatomy and function in FODMs and FOHMs. The practical value of this non invasive technique is in need for further prospective comparative studies with the well established methods in obstetric decision making

Late results of valve replacement experience of the National Heart Institute Imbaba Cairo Egypt

A randomized retrospective study of 5 years follow up of all valve replacement of a series inserted in The National Heart Institute has been done to evaluate the late results of such a procedure. Between January 1st 1984 and December 31st 1988 a total number of 958 valve prosthesis were inserted in 685 patients, The immediate post-operative mortality is 46 patients [6,71%] of different causes. This work concerns the long term results of the 639 patients discharged from hospital after the post-operative period. A follow up of these patients between 32 months and 81 months [mean period of 47,23 months] showed that 496 pts are living [survival rate: 77,62%]. None of the patients of this series were lost to follow up. Out of the 496 pts, 322 pts have improved post-operatively the quality of their life; 82 pts are living postoperatively in stage II NYHA and 92 in stage III NYHA living on digitalo-diuretic therapy and vasodilators. The pre-operative state of the heart, the quality of myocardial protection which were standardized in all patients of the series and the wall stress of LV played an important role in post-operative results. Out of the 143 dead patients, 82[57,34%] died of anticoagulation problems, 23 pts [16,08%]from endocarditis, 6[4,19%] from aseptic detachment of prosthesis; 10 [6,99%] valve prosthesis dysfunction; 22 [15,38%] the cause of death is unknown. No haemolysis occurred as a late complication. Apart from the Wessex and the Ionescu valve prosthesis, there was no significant difference between the different prostheses used in this series. From the above results one may conclude, that valve replacement is not the ideal treatment. All efforts should be directed to preserve the patients native valve as long as possible. anticoagulation problems and endocarditis are the main complications of valve replacement in Egypt. Well selected patients for valve replacement improve considerably the post-operative functional results