Acute respiratory distress syndrome (ARDS) remains a leading cause of mortality among critically ill patients with COVID-19. Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, is often used as rescue therapy to improve oxygenation; however, its impact on survival remains uncertain. To evaluate the clinical outcomes of iNO therapy in patients with COVID-19-related ARDS and to stratify patients into Early, Delayed, and Non-Responder groups based on the timing of their oxygenation response. A retrospective cohort study of 99 patients with COVID-19-related ARDS who received iNO was conducted. Patients were categorized as. ≥20% improvement in the PaO2/FiO2 ratio within 8 h. ≥20% improvement in the PaO2/FiO2 ratio between 8 and 24 h. <20% improvement in the PaO2/FiO2 ratio within 24 h, including those who showed in their PaO2/FiO2 ratio within 24 h of iNO initiation.Baseline demographics, comorbidities, and outcomes, including duration of mechanical ventilation, ICU and hospital length of stay, and mortality, were compared. Early and Delayed Responders showed significant improvement in oxygenation (mean PaO2/FiO2: 137.3 vs. 126.9 vs. 106.4; p = 0.004), with mean percentage increases of 65.3%, 56.6%, and 8.2%, respectively (p < 0.001). However, this did not translate into differences in ICU mortality (64.8%, 62.5%, and 71.4%, respectively; p = 0.81) or other hospital outcomes. Rates of acute kidney injury (AKI), methemoglobinemia, and other complications were comparable among the groups. iNO improved oxygenation in a subset of patients with COVID-19-related ARDS but did not reduce mortality. Stratification by timing of response highlights patient heterogeneity and supports response-guided, time-limited use of iNO in critical care.

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with heterogeneous clinical presentations influenced by ethnicity, geography, and healthcare practices. This audit evaluated adherence to key quality indicators for SLE management at Hamad General Hospital (HGH), a major public tertiary care center in Doha, Qatar, in line with international standards. A retrospective cross-sectional audit was conducted between March and July 2024 involving 61 patients with SLE attending the rheumatology clinic at HGH. This audit assessed adherence to four selected key quality indicators: hydroxychloroquine (HCQ) use, annual proteinuria screening, annual ophthalmologic screening for HCQ-related retinopathy, and medication reconciliation documentation during the most recent clinic visit. All patients were initiated on HCQ, with 11.5% discontinuing it due to adverse effects. Annual proteinuria screening was completed in 95% of patients. Ophthalmologic screening for HCQ-related retinopathy was documented in 65%, and medication reconciliation was completed in 72% of cases. The cohort represented a total of 21 nationalities, including Qataris who accounted for 31%-a proportion higher than their estimated 11.6% representation in Qatar's national population. While adherence to HCQ initiation and renal monitoring met international benchmarks, ophthalmologic screening and medication reconciliation rates were suboptimal and required improvement. Targeted system-level and educational interventions are planned to enhance adherence to these standards. Re-audit following implementation will be essential to assess progress and to sustain the quality of care.

Background and objective:CT-guided cryoablation (CRA) has emerged as a safe and effective minimally invasive treatment for renal cell carcinoma (RCC), though outcomes can vary. The mRENAL score may help to predict clinical outcomes. The main objective of this study was to evaluate the correlation between mRENAL score and clinical outcomes in RCC cases treated by CT-CRA.Methodology:This was an observational, retrospective, single-center study that included CT-CRA procedures performed on RCCs between 2017 and 2023. Tumors were classified into three categories based on the mRENAL score: low, intermediate, and high risk. We employed the Firth logistic regression for multivariate analysis due to the small sample size and rare outcome events.Results:Our data included 53 cases, with a mean age of 53 ± 12 years. Technical success was achieved in all cases. Four cases had disease recurrence at the site of previously treated RCC (4/42, 9.5%), as 11 cases lost follow-up imaging. The Firth logistic regression analysis revealed that increasing mRENAL score was associated with a higher risk of recurrence (adjusted odds ratio = 0.42 [95% CI, 0.19–0.95]; P = 0.038). This trend towards statistical significance implies that for every 1-point increase in mRENAL score, the odds of clinical success decrease by at least 5% with over 95% confidence. No procedure-related mortality was observed.Conclusion:Our analysis demonstrates that the mRENAL score may help predict clinical outcomes, with lower mRENAL scores associated with higher clinical success rates following CT-CRA of RCC.

: Osmotic demyelination syndrome (ODS) is a rare but potentially life-threatening neurological disorder. It is characterized by non-inflammatory demyelination, usually triggered by sudden shifts in serum osmolality. However, emerging evidence suggests that abrupt osmotic shifts caused by severe hyperglycemia, even in the absence of sodium imbalance, can also precipitate ODS. : A 57-year-old male with poorly controlled type 2 diabetes mellitus and chronic alcohol use presented with recurrent seizures and altered sensorium. Initial blood work revealed severe hyperglycemia (390 mg/dL), an elevated HbA1c level (15.2%), and a normal corrected serum sodium level (135 mEq/L). During hospitalization, the patient developed progressive neurological deterioration, culminating in quadriplegia. : Initial non-contrast computed tomography (NCCT) of the brain was unremarkable. Magnetic resonance imaging (MRI) on day 11 showed symmetric T2/FLAIR (Fluid-AttenuatedInversionRecovery) hyperintensities in the central pons extending into the middle cerebellar peduncles. These findings, in the absence of diffusion restriction or enhancement, were characteristic of central pontine myelinolysis (CPM). No extrapontine involvement was observed. : Radiological differentials considered included acute disseminated encephalomyelitis (ADEM), multiple sclerosis (MS), ischemic infarction, vasculitis, and brainstem glioma. However, the symmetric pontine involvement without enhancement or mass effect, along with the clinical context of hyperosmolar hyperglycemia, favored a diagnosis of ODS. : Supportive therapy involving careful glucose correction, intravenous hydration, and close monitoring of metabolic parameters was initiated. The patient showed gradual neurological recovery during the hospital course. : This case highlights a rare presentation of CPM secondary to hyperosmolar hyperglycemia in the absence of hyponatremia. It underscores the importance of early recognition, neuroimaging, and cautious metabolic correction in diabetic patients presenting with new-onset neurological deficits.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by excessive immune activation. Children with Down syndrome (DS) (trisomy 21) are at increased risk of severe infections and immune dysregulation. Although viral infections are known triggers of secondary HLH, H1N1 influenza is an uncommon cause in this population.Case presentation: We report a 1.8-month-old male infant with DS and multiple comorbidities-including gastroesophageal reflux disease (GERD), recurrent aspiration pneumonia, and seizures-who presented with fever, hypoxemia, and splenomegaly. Laboratory investigations revealed cytopenias, hyperferritinemia (>1,650 ng/mL), and hypofibrinogenemia, fulfilling five of the HLH-2004 diagnostic criteria. H1N1 influenza was confirmed as the infectious trigger. The patient was treated with standard-dose dexamethasone and etoposide, along with oseltamivir. Despite concerns about treatment-related toxicity in DS, he tolerated the regimen without hematologic or infectious complications. He achieved clinical remission with normalization of inflammatory markers and hematologic parameters. At discharge and at three-month follow-up, he remained well with no recurrence or neurological sequelae.Discussion: This case highlights the diagnostic and therapeutic challenges of managing HLH in children with DS. The use of conventional HLH therapy, including etoposide, was effective and well-tolerated despite theoretical concerns in this population. Although central nervous system symptoms were present, they resolved with treatment. H1N1 influenza should be considered a potential viral trigger in immunocompromised children presenting with HLH-like features. H1N1 influenza-induced HLH is exceptionally rare in infants with DS. The positive outcome in this case supports the safe use of standard HLH protocols in this vulnerable population and highlights the importance of early diagnosis and multidisciplinary management to optimize outcomes.

Introduction:Cyberlindnera fabianii is an uncommon opportunistic yeast increasingly recognized as a cause of invasive fungal infections, particularly in immunocompromised patients and those with indwelling medical devices. Clinical experience remains limited, with most published cases involving neonates or adults with significant comorbidities.Case Presentation:We report a case of C. fabianii fungemia in a 26-year-old man with end-stage renal disease on maintenance hemodialysis via a long-term tunneled catheter. The patient presented with fever following dialysis and was found to have leukocytosis and elevated inflammatory markers. Blood cultures from both peripheral and catheter sites grew yeast after 48 hours. Empiric antibacterial therapy was initiated, and the hemodialysis catheter was removed. Antifungal treatment with anidulafungin was started, leading to clinical improvement. Species identification was achieved using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), which revealed C. fabianii. Antifungal susceptibility testing demonstrated low minimum inhibitory concentrations (MICs) for echinocandins and variable susceptibility to azoles. The patient completed a 14-day course of anidulafungin with full recovery.Discussion:This case underscores the importance of accurate identification of rare yeasts such as C. fabianii, which may be misidentified as other less pathogenic species. MALDI-TOF MS and molecular diagnostics are critical tools for early detection. Due to its potential for azole resistance and biofilm formation, echinocandins appear to be an effective treatment option. Prompt catheter removal and appropriate antifungal therapy were pivotal to the patient’s successful outcome.Conclusion:C. fabianii should be considered in patients with fungemia and risk factors for invasive candidiasis, especially when initial identification is inconclusive. Awareness of this emerging pathogen and its management is essential to ensure timely intervention and improve clinical outcomes.

Biliary atresia (BA) is a lfe-threatening neonatal liver disease characterized by inflammation and obstruction of bile ducts. Identifying the most reliable and valid ultraaound (US) parameter or combination of parameters can enhance noninvasive diagnosis accuracy, potentially reducing unnecessary surgeries and treatment delays. We aimed to detect the mosi reliable and valid US parameter or combination of parameters to diagnose BA, thereby minimizing unnecessary surgical exploration or treatment delays. We conducted a prospective cohort study on cholestatic pediatric patients. Data were nollected between January 2013 and July 2019 from the Fattouma Bourguiba University Hospital Monastir, Tun isia, in callaboration with the pediatric surgical and radiological departments. After full clinical and laboratory evaluation, abdominal ultrasonography was performed to assess the biliary structure, with three possible outcomes: BA ruled out, confirmed, or inconclusive. Accordingly, the patients were divided into group 1 (diagnosed with BA) and group 2 (diagnosed with other biliary conditions). The participants, 61 cholestatic neonates and infants,were aged 6 to 160 postnatal days (mean, 58.28 ± 34.24 days); 60.7% were male (n = 37). The gallbladder (GB) was not detected usig, US in 20 patients. BA diagnosis correlated with cord sign [X2 (1, n = 61) = 53.52], GB evacuation alteration [X2 (1, n = 61) = 18.41%], and hepatic artery/portal vein ratio [X2 (1, n = 61) = 30.25; normal value <0.49]. A positive cord sign or the presence of alteration of evacuation indicates the possibility of BA with a 100% sensitivity and 86.2% specificity. Similarly, with the presence of evacuation alteration or porta hepatic thickness (≥2.4), the sensitivity reached 100%; however, a specificity of 86.2% was observed. US parameters can detect patients with BA with approximately 100% sensitivity. However, additional research is needed to confirm negative cases. Multicenter studies are needed to verify our findings.

Introduction:Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by a dysregulated immune response against self-antigen, leading to multi-organ involvement. Myositis, as an initial manifestation of SLE, is a rare clinical entity, particularly in newly diagnosed patients.Case Presentation:A 27-year-old male presented with massive head and neck swelling, initially suspected to be superior vena cava syndrome (SVCS). Other symptoms included non-scarring alopecia, prolonged fever, oral ulcers, a history of hyperpigmented skin lesions, and progressive lower extremity weakness with edema. Hematological findings revealed persistent pancytopenia (anemia, leukopenia, and thrombocytopenia). Laboratory investigations demonstrated elevated muscle injury markers, including aspartate aminotransferase predominance and elevated creatine kinase. Immunological analysis showed a negative antinuclear antibody by indirect immunofluorescence, high anti-dsDNA titers, and normal complement levels. Bone marrow biopsy revealed trilineage dysplasia with macrophage activation, suggesting underlying hematologic involvement. Contrast-enhanced head and neck computed tomography ruled out SVCS, showing only diffuse muscle and subcutaneous edema. Based on the constellation of clinical, hematological, and imaging findings, the patient was diagnosed with myositis-associated SLE. The therapeutic approach included total plasma exchange (TPE), high-dose corticosteroid pulse therapy, and immunosuppressive induction therapy. Within 1 month of hospitalization, the patient demonstrated significant clinical and laboratory improvement and was subsequently transitioned to maintenance therapy with hydroxychloroquine (200 mg once daily), methylprednisolone (8 mg daily in a tapering regimen), and mycophenolate mofetil (500 mg twice daily). The patient achieved a lupus low disease activity state at follow-up.Discussion:This case represents a unique presentation of head and neck myositis in a newly diagnosed SLE patient, a manifestation not previously described in the literature. While orbital myositis in SLE has been reported, extensive myositis involving the head and neck as an initial SLE manifestation remains undocumented. Combining TPE, high-dose corticosteroids, and immunosuppressants was critical in disease control. Early recognition and aggressive immunomodulatory therapy are essential in managing such rare and severe SLE presentations.Conclusion:This case highlights an uncommon initial manifestation of SLE, emphasizing the importance of early clinical suspicion, comprehensive immunological and hematological evaluation, and prompt intervention. A multimodal therapeutic approach, including steroid pulse therapy, induction immunosuppression, and TPE, can lead to favorable clinical outcomes in severe and atypical SLE presentations.

Background: Prothymosin alpha (PTMα) is a small acidic polypeptide from the thymosin family with immune activity and protective properties against oxidative stress induced by reactive oxygen species trimethylamine-N-oxide (TMAO), produced in the liver from gut bacterial metabolite trimethylamine and associated with increased cardiovascular disease risk and higher all-cause mortality. Ischemia-modified albumin (IMA) is a significant oxidative stress biomarker, particularly in ischemia-reperfusion conditions. This study investigates PTMα, TMAO, and IMA levels in type 2 diabetes mellitus (T2DM) patients, both with and without hyperlipidemia, to explore their relationships and their potential role as biomarkers or therapeutic targets.Method: The study received ethical approval from the Selcuk University Faculty of Medicine Hospital committee under approval number 2024/33. The study included male and female T2DM patients aged 30–60, with 30 having hyperlipidemia and the rest being non-lipemic. TMAO was performed using API 3200 LC-MS\\MS while PTMα was analyzed using an ELISA kit from BT LAB, serum IMA levels were evaluated by the spectrophotometric method.Results: Comparisons were made between those with T2DM and control groups. In the T2DM group, PTMα was significantly higher in females (p = 0.047), while TMAO and IMA showed no significant gender difference. The control group had no significant differences in PTMα, TMAO, and IMA levels. Comparisons among healthy controls, non-lipemic T2DM patients, and hyperlipidemic T2DM patients revealed significantly decreased PTMα levels with no change in IMA levels across groups. In contrast, TMAO was significantly higher in the patient group.Conclusion: The findings of this study have potential implications for the field, suggesting that PTMα might serve as a prognostic indicator for T2DM and that reduced TMAO levels might play a role in T2DM pathogenesis, opening up new avenues for research and treatment.

Background: Myelomeningocele (MMC) is a severe congenital malformation of the CNS (central nervous system) that often leads to seizures due to factors such as shunt complications and hydrocephalus. This study aims to develop a machine learning model to predict the likelihood of seizures in MMC patients by analyzing various predictors. Methods: This retrospective study involved 103 MMC patients. Factors such as demographics, MMC location, shunt history, and imaging were analyzed using the random forest classifier, the support vector classifier, and logistic regression. Model performance was assessed through bootstrap estimates, cross-validation, classification reports, and area under the curve (AUC). Results: Of the evaluated patients, 11 experienced seizures. The key influencing factors included gestational age, sacral location, hydrocephalus, shunt history, and corpus callosum dysgenesis. Machine learning (ML) models predicted seizure risk with an accuracy of 86–92% and an AUC ranging from 0.764 to 0.865. Significant predictors were imaging findings, shunt infection history, and gestational age. Conclusion: ML models effectively predict seizure risk in MMC patients, with certain variables showing strong associations and significant impact.