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Background: Transcatheter implantation of the Edwards Sapien 3 valve (Edwards Lifesciences, Irvine CA) within the bioprosthetic mitral valve (MV) is an established method of treatment in adults. However, it has not been well studied in the pediatric age group. Methods: Transcatheter mitral valve-in-valve implantation was attempted in 4 symptomatic pediatric patients with a dysfunctional MV bioprosthesis implanted at an earlier stage due to severe MV stenosis or regurgitation. We reviewed our experience with MV implantation in this cohort. Results: The mean age and weight of the patients at the time of the procedure were 11.4 years (range: 10-14 years) and 36 kg (range: 31-44 kg), respectively. The transmitral mean gradient dropped from a mean of 19.75 mm Hg (range: 15-22 mm Hg) to a mean of 1 mm Hg (range: 0-3 mm Hg) after the procedure. The mean fluoroscopy time was 55.25 minutes (range: 40-72 minutes), and the mean hospital length of stay was 4 days (range: 3-7 days). The patients’ functional class improved from New York Heart Association class IV to class I during the follow-up period. Conclusions: Transcatheter mitral valve-in-valve implantation can be performed safely for dysfunctional bioprosthetic MVs in the pediatric age group with favorable early and midterm outcomes. This procedure offers a viable alternative in patients who have high surgical risk or are deemed unfit for conventional surgery. However, we still recommend a long-term study of this approach in a large cohort, multicentre study. Résumé: Introduction: L’implantation de la prothèse valvulaire Edwards Sapien 3 (Edwards Lifesciences, Irvine, CA) par cathéter dans la bioprothèse valvulaire mitrale (VM) est une méthode de traitement établie chez les adultes. Toutefois, cette méthode n’a pas fait l’objet d’études approfondies auprès d’enfants. Méthodes: Une tentative d’implantation valvulaire mitrale de type valve-in-valve par cathéter a été réalisée chez quatre enfants symptomatiques qui avaient une bioprothèse VM dysfonctionnelle implantée antérieurement en raison d’une sténose VM ou d’une régurgitation grave. Nous avons passé en revue notre expérience d’implantation VM auprès de cette cohorte. Résultats: L’âge et le poids moyens des patients au moment de l’intervention étaient respectivement de 11,4 ans (étendue : 10-14 ans) et de 36 kg (étendue : 31-44 kg). La moyenne du gradient moyen transmitral a baissé. Elle est passée de 19,75 mmHg (étendue : 15-22 mmHg) à 1 mmHg (étendue : 0-3 mmHg) après l’intervention. La durée moyenne de la fluoroscopie était de 55,25 minutes (étendue : 40-72 minutes), et la durée moyenne du séjour à l'hôpital était de quatre jours (fourchette : 3-7 jours). La classification fonctionnelle des patients selon la New York Heart Association a montré une baisse. Les patients sont passés de la classe IV à la classe I durant la période de suivi. Conclusions: L’implantation valvulaire mitrale de type valve-in-valve par cathéter peut être pratiquée de façon sûre chez les enfants porteurs d’une bioprothèse VM dysfonctionnelle dont les issues à court ou à moyen terme sont favorables. Cette intervention est une alternative viable pour ces patients dont le risque lié à l’intervention chirurgicale est élevé ou considérés inaptes à subir une intervention chirurgicale traditionnelle. Toutefois, nous recommandons encore une étude à long terme sur cette approche, voire une vaste étude multicentrique de cohorte.

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, over 103214008 cases have been reported, with more than 2231158 deaths as of January 31, 2021. Although the gold standard for diagnosis of this disease remains the reverse-transcription polymerase chain reaction of nasopharyngeal and oropharyngeal swabs, its false-negative rates have ignited the use of medical imaging as an important adjunct or alternative. Medical imaging assists in identifying the pathogenesis, the degree of pulmonary damage, and the characteristic features in each imaging modality. This literature review collates the characteristic radiographic findings of COVID-19 in various imaging modalities while keeping the preliminary focus on chest radiography, computed tomography (CT), and ultrasound scans. Given the higher sensitivity and greater proficiency in detecting characteristic findings during the early stages, CT scans are more reliable in diagnosis and serve as a practical method in following up the disease time course. As research rapidly expands, we have emphasized the CO-RADS classification system as a tool to aid in communicating the likelihood of COVID-19 suspicion among healthcare workers. Additionally, the utilization of other scoring systems such as MuLBSTA, Radiological Assessment of Lung Edema, and Brixia in this pandemic are reviewed as they integrate the radiographic findings into an objective scoring system to risk stratify the patients and predict the severity of disease. Furthermore, current progress in the utilization of artificial intelligence via radiomics is evaluated. Lastly, the lesson from the first wave and preparation for the second wave from the point of view of radiology are summarized.

Appendicitis is a common disease in paediatric age group. Surgical management by way of appendectomy is the gold standard of treatment. Introduction of minimally invasive approach via laparoscopic technique has revolutionised the surgical management of this condition. In this paper we compare between single incision versus conventional approach for laparoscopic appendectomy. This was a retrospective review and analysis of a prospectively maintained database. The cohort was matched for age and sex. The total number of patients (n = 29) were divided into two groups. Group A (n = 15) underwent single incision laparoscopic appendectomy and group B (n = 14) underwent appendectomy via the conventional laparoscopic approach. The patient data was selected from patients who underwent appendectomy from July 2015 to December 2019. The data was analysed on various parameters like operative time, post-operative complications, starting of oral feeds, ambulation time, hospital stay, etc. The findings were compared using various statistical tools and conclusions drawn accordingly. There was a significant difference in operative times by the two approaches. The results showed no significant differences in the two approaches with respect to post-operative mobilization, feeding and recovery. The difference in the operative time can be attributed primarily to the complexity of cases that were operated by either approach. Minimally invasive laparoscopic technique is the standard of care for appendectomy in today’s age. Both single incision and conventional approach can be used for removal of appendix as there is no significant difference between the two methods. The single incision approach gives a better cosmetic result and can be better suited in uncomplicated appendicitis, whereas the conventional approach is more suitable for complicated cases.

Background: Facial paralysis is the most common pathologyof the cranial nerves. The most reliable muscle transferspresently being used include the temporalis and massetertransfers. The aim of this study is to evaluate the clinicalusefulness of transposition of the temporalis muscle in treatinglong-standing facial palsy.Methods: Ten patients attended the outpatient clinic ofPlastic Surgery Department at Assiut University Hospitalbetween April, 2014 and May, 2015 with unilateral longstandingfacial nerve paralysis. Temporalis muscle transfer usedfor correction of eye and mouth movements to improve facialsymmetry at rest as well as to recreate a new smile.Results: Patient satisfaction was moderate to high. Patientsphotographs were generally evaluated as good. There was nodonor site morbidity noted after the surgery.Conclusion: Using temporalis muscle transfer for correctionof eye closure in patients with longstanding facial paralysisis superior to other classic methods

Introduction Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. Methods This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18–49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54–5.02), frailty (CFS 8 versus 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1–3: odds ratio 7.00, CI 5.27–9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusion Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.

After more than four decades of post-approval, cisplatin is still an important treatment for numerous cancers. However, acute kidney injury (AKI), defined as significant impairment of renal filtration as discussed below, is the major limiting side effect of cisplatin, occurring in approximately 30% of patients (25–33% after the first course). Cisplatin also damages the kidneys’ ability to reabsorb magnesium in 40–100% of patients, with collateral health risks due to subsequent hypomagnesemia. Multiple methods and drugs have been proposed for preventing cisplatin-induced AKI, including saline infusion with or without mannitol, which has not always prevented AKI and has been found to activate a cellular stress response in renal tubular cells. While numerous reports and trials, as well as the National Comprehensive Cancer Network (NCCN), support premedication with magnesium and hydration, this practice has not been universally accepted. Many clinics administer intravenous magnesium (IV) only after identification of hypomagnesemia post-cisplatin treatment, thus placing patients at risk for AKI and chronic renal loss of magnesium. We present the following case report and additional supporting evidence identifying the immediate effect of IV magnesium prior to intraperitoneal cisplatin for cycle 4 because of documented hypomagnesemia resulting in normalization of oliguria, which had been experienced for the first three cycles. The patient subsequently requested and received IV magnesium before cisplatin for the next two cycles with continuation of normal urinary output. The effect of pretreatment with IV magnesium on urine output following cisplatin has not been previously reported and further supports pre-cisplatin administration. In addition, two recent meta-analyses of clinical trials and pre-clinical research are reviewed that demonstrate effectiveness of magnesium pretreatment to preventing AKI without reducing its chemotherapeutic efficacy. This case report with additional evidence supports the adoption of administration of 1–3 g IV magnesium before cisplatin as best practice to prevent cisplatin induced AKI and hypomagnesemia regardless of patient baseline serum magnesium levels.

Background: Little information is available about breast cancer (BC) in Sudan. Therefore, the present study aimed to provide baseline information about the demographic features and tumor characteristics, and also to investigate the associations between demographic variables and presentation stage in BC patients attending the National Cancer Institute-University of Gezira (NCI-UG), Sudan.Methods: In this cross-sectional study, we included all BC patients treated at the NCI-UG from January to December 2013. Patients' demographic, clinical and pathological data were retrieved from the hospital records and analyzed using SPSS version 20, and associations between these factors were tested as well.Results: A total of 232 cases were included in this research. The majority (97.8%) of subjects were females and 2.2% were males. The median age at diagnosis was 50 years (range, 22-90). The mean time between identification of symptoms and diagnosis was 13 months (SD=16.1). Clinical stages I, II, III, and IV represented 6.9%, 37.0%, 40.9% and 15.2%, respectively. Advanced stage at diagnosis was associated with longer duration between identifying the symptoms to diagnosis (P=0.006). Also the level of education of BC patients was significantly associated with clinical stage at presentation (P = 0.01).Conclusions: Sudanese patients with BC present at a younger age and with more advanced stage at diagnosis than those in developed countries. Patients' education level and duration from identification of BC symptoms to diagnosis significantly impact the stage at the time of presentation. In limited resource setting, early diagnosis of symptomatic BC is crucial in reducing the disease burden.

Post operative pyrexia is one of the most common problems seen in the post operative ward. Aims: to identify risk factors of post operative pyrexia in infants and children at Assuit University Children Hospital. Subjects and Method: Descriptive research design was used. The present study was conducted in the pediatric surgical unit at Assuit University Children Hospital. The sample included two groups. Group I pyrexia group 212 children with pyrexia, group II non pyrexia group 76 of children who have no pyrexia. One tool was used to collect the required data Results: blood transfusion was given to approximately half of group I compared to only (6.6%) of group II. More than two fifths of children had signs of wound infection, urinary catheterizations respectively in group I compared to13.2% children in group II respectively. The majority of children received intravenous fluid after operation in group I compared to (14.6%) of children group II. Conclusion: Risk factors of post operative pyrexia are wound infection, respiratory problem, urinary tract infection, blood transfusion, drains and catheters, medications and intravenous line infection. Recommendations: Increasing mother's and nurses awareness related to risk factors of post operative pyrexia, health education about importance of hand washing before and after wound dressing and giving medication.

International guidelines have recommended the use of NOACs in line with their established safety, efficacy and compliance [29], [30], [31]. The safety of NOAC is supported by real world post-marketing surveillance registry studies, such as the Danish registry where bleeding and MI were not attributed to dabigatran [32]. In addition, reports from the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA™-AF) which emphasizes the under clinical utility of NOACs, have recently emerged. Dabigatran was coined as the most prescribed NOAC in the Phase II registry [33], [34]. The GLORIA™-AF was the largest, global observational study to date on the use of anticoagulants in patients with AF. The early reported findings were based on treatment trends in 3415 AF patients who entered the GLORIA™-AF registry from November 2011 to February 2014. The GLORIA™-AF results demonstrated that 21.9% of patients with occasional AF and a CHADS2-VASC score of 2 or higher were either undertreated with aspirin or given no anticoagulant treatment at all, compared to 12.4% and 11.2% of those diagnosed with persistent or permanent AF, respectively [33]. Current AF guidelines call for patients to receive oral anticoagulant therapy based on their risk of stroke, rather than their type of AF [34], [35]. Furthermore, given the availability of NOACs, guidelines state that the use of antiplatelet therapies (such as aspirin) for stroke prevention in AF should be limited to the few patients who refuse any form of oral anticoagulant, as the evidence for effective stroke prevention from Apixaban versus acetylsalicylic acid (ASA) is weak, with a potential for harm [35]. NOAC is the standard therapy in significantly reducing the risk of stroke and systemic embolism in AF patients. Physicians have diverse factors to consider when selecting a NOAC option for antithrombotic treatment in AF patients. Revealing factors such as risk stratification for bleeding, therapeutic monitoring, and renal status may serve in bridging the treatment gap. NOAC limitations There was no treatment evidence for NOACs in patients with valvular AF (valves/devices). There are other NOAC limitations, such as not having a reversal agent in the event of bleeding. Currently, however, antidote trials for each specific NOAC reversal are underway (Phase II and III trials); and these include idarucizumab for dabigatran (RE-VERSE AD trial), andexanet for apixaban-alfa (ANNEXA™, Andexanet Alfa a Novel Antidote to the Anticoagulant Effects of factor XA Inhibitors trial) [36]. There is no FDA-approved NOAC antidote for clinical use in case of medical emergencies. Despite the fact that no routine laboratory monitoring is required for general outpatient follow-up, some laboratory assays such as ECT and aPTT are available for emergency situations in which patients are suffering from life-threatening bleeding. Activated charcoal can be used to decrease the absorption of dabigatran [37], and prothrombin complex concentrates (PCC) have been shown to completely reverse the anticoagulant effect of rivaroxaban in healthy subjects [38]. However, a recent randomized, double-blind, placebo controlled trial of 145 healthy volunteers demonstrated that idarucizumab, a humanized antibody that binds dabigatran with high affinity, could result in immediate and sustained reversal of the anticoagulant effect [39], [40]. The study reported that idarucizumab is well tolerated without adverse events and completely reverses prolonged clotting time within five minutes of administration. This was the sole specific antidote for one of the NOACs; however, further research is required to demonstrate its clinical utility. In order to be implicated in clinical practice, the following points need to be considered: 1. Clinical use according to patient need: life-threatening hemorrhage, trauma, procedure with anticipated risk for major bleeding. 2. Careful risk assessment will be needed as the risk for bleeding outweighs the benefit of thrombo-prophylaxis. 3. Attention to fundamentals of hemostasis and supportive measures. 4. Will the availability of NOAC antidotes drive the uptake of NOACs? The future of NOACs Some gaps need to be addressed in order for clinicians to select a NOAC and/or convert and switch from warfarin to a NOAC. These gaps have to be highlighted by expert opinions from the gained meta-analysis, registries and from global experiences who can summarize them for clinicians without bias or conflict of interest. This may help solve the various controversies and disparities in the clinical utility of NOACs. The research conducted by clinicians working in day-to-day clinical practice will be of extreme value as their views and that of their patients (treatment satisfaction) will provide deeper insights into the authentic clinical utility of NOACs. Researchers are encouraged to focus on patient satisfaction and quality of life aspects of these NOACs. The emerging betrixaban novel once-daily factor Xa inhibitor has been shown in a small phase II study to competitively bind to factor Xa and to inhibit its activity. The EXPLORE-Xa study was designed to evaluate the safety and tolerability of betrixaban compared to warfarin in patients with AF who are receiving or are eligible for VKA. This phase II study of betrixaban, at doses of 40–80 mg per day, indicated that it was well tolerated in AF patients at risk for stroke, with a risk of bleeding that was similar to, or lower than, that of well-managed warfarin. The most important fact about this drug is its hepatic elimination, which may provide preferences over other NOACs in patients with renal impairment of