Abstract Introduction: Non-invasive ventilation (NIV) is becoming more common in the treatment of respiratory failure in children, but its effectiveness varies with the severity of the underlying disease. Aim: The study’s objective was to assess, over a four-year period, the indications, physiological effects, and clinical outcomes of NIV in children admitted to a pediatric intensive care unit (PICU) with acute or chronic respiratory failure. Materials and methods: This retrospective, single-center study included 25 children who received NIV between 2021 and 2025. Demographic data, underlying diagnoses, type of respiratory failure, inflammatory markers, radiological findings, NIV interface, gas exchange parameters before and after NIV, and clinical outcomes were analyzed. Results: The median age was 3.9 years (range 0–17), with 68% being male. Neuromuscular disorders were the leading indication (55%), followed by primary pulmonary disease (37%). Spinal muscular atrophy type 1 was the most common specific diagnosis. Interface use was age-dependent: infants predominantly received nasal masks/prongs, while older children used oronasal or full-face masks. NIV produced significant improvements in gas exchange (p<0.05), indicating effective correction of respiratory acidosis and hypoxemia. Radiology and inflammatory markers distinguished two clinical phenotypes. Children with primary respiratory disease, genetic syndromes, or systemic comorbidities frequently showed pneumonic infiltrates and markedly elevated CRP/PCT, indicating infection-driven respiratory failure. In contrast, neuromuscular patients demonstrated minimal inflammatory elevation and chronic or atelectatic radiographic patterns, consistent with ventilatory pump failure. The S/F ratio at initiation strongly predicted outcome: all children with an S/F ratio <150 experienced NIV failure or death, whereas those with an S/F ratio >250 showed successful recovery. NIV duration was longest in neuromuscular disorders (mean 48 days), reflecting chronic ventilatory insufficiency. Conclusion: NIV is effective in improving gas exchange in both acute and chronic respiratory failure in children. Clinical outcome depends on underlying diagnoses, inflammatory activity, radiologic pattern, and initial oxygenation status. The S/F ratio is a reliable predictor of NIV success.
INTRODUCTION:Acute kidney injury is a common complication in children with oncological diseases. Its etiology is multifactorial, with key risk factors including drug-induced nephrotoxicity, tumor lysis syndrome, and infection-including sepsis during periods of aplasia. The classical diagnostic criteria for AKI rely on monitoring serum creatinine levels and detecting oliguria. In the context of drug-induced nephrotoxicity, the predominant pathophysiological mechanism is tubular injury, which is typically non-oliguric and may not cause changes in serum creatinine, even in cases of severe damage.
INTRODUCTION:The article examines the role of the sphenopalatine ganglion (SPG) in the pathogenesis of various pain syndromes involving the head and neck, particularly in trigeminal autonomic cephalalgias.
Abstract Achalasia is a rare childhood disease. We report a case of a 15-year-old child with recurrent respiratory infections over the past 5 years. Due to positive household contacts with relatives with positive sputum pulmonary tuberculosis, he was referred to our pulmonology clinic. The child exhibited symptoms of failure to thrive, fatigue, intermittent fever, and chronic dry cough. A detailed medical history revealed that the child vomited almost after every meal and had regurgitation and odynophagia. On physical examination, the child was in a poor general condition, with an intoxicated appearance, febrile (38.5°C), with asthenic habitus, and with evidence of respiratory failure. The chest X-ray shows a strongly enlarged paratracheal shadow and infiltrative changes in the left lower lung lobe, which indicated various conditions affecting the trachea, mediastinum, or pleura. A CT scan of the lungs revealed severe long-term esophageal achalasia with an extremely dilated lumen measuring 69×58 mm in axial size. The bird’s beak sign in the esophagus was seen on a barium swallow. An esophagoscopy was performed in a surgery clinic, during which a large amount of food material was removed. Three dilations of the esophagus were performed, followed by a one-month period of nutritional support. A laparoscopic Heller myotomy was performed, followed by four balloon dilations of the cardia under endoscopic control using pneumatic and hydrostatic dilators over a period of one year with significant clinical improvement.
Abstract Postintubation tracheal stenosis, a complication of prolonged mechanical ventilation via orotracheal intubation, often presents with stridor and dyspnea due to tracheal fibrosis and scarring, typically distal to the cricoid cartilage. Its complex nature necessitates a multidisciplinary approach and expertise in tracheal, thyroid, mediastinal, and neurovascular surgical techniques. This case report details the clinical management of postintubation tracheal stenosis, highlighting a successful tracheal resection and anastomosis procedure. A patient, S.A., presented at the Thoracic Surgery Department, UMHAT Kaspela, Plovdiv, with respiratory distress, including stridor and dyspnea, following 10 days of mechanical ventilation for aspiration pneumonia. The diagnostic workup included thoracic computed tomography (CT), video bronchoscopy, echocardiography, and pulmonary function tests. Surgical intervention involved Kocher’s cervicotomy, tracheal mobilization, circular resection of the stenotic segment, and termino-terminal anastomosis. Intraoperative video bronchoscopy confirmed stenosis location and post-anastomosis tracheal integrity. The patient recovered uneventfully and was discharged in satisfactory condition. Surgical management of postintubation tracheal stenosis, when guided by early diagnosis, precise imaging, and a multidisciplinary approach, yields favorable outcomes. This case underscores the importance of surgical expertise and meticulous planning in achieving successful results.
Abstract Introduction: The bidirectional relationship between sarcopenia and type 2 diabetes mellitus (T2DM) in the elderly creates a detrimental metabolic cycle where insulin resistance accelerates muscle wasting. In resource-limited primary care settings, the lack of advanced diagnostic imaging necessitates the validation of accessible, non-invasive screening tools, such as anthropometric parameters, muscle strength, physical performance, and glycemic control, as surrogate markers for identifying muscle mass depletion. Aim: To evaluate correlations between anthropometric parameters, muscle strength, physical performance, and glycemic control with skeletal muscle mass (SMM) in elderly patients with T2DM. Methods: A cross-sectional study was conducted with 203 elderly T2DM patients at a primary healthcare center. Anthropometric measurements included mid-upper arm circumference (MUAC) and calf circumference (CC). The skeletal muscle mass was measured via bioelectrical impedance analysis, muscle strength via handgrip dynamometry, and physical performance via the timed up and go test (TUGT). Glycemic control data (HbA1c and fasting blood glucose) were retrieved from medical records. Data were analyzed using Pearson and Spearman correlation tests and multiple linear regression. Results: The prevalence of sarcopenia was 41.4%. Multiple linear regression identified CC as the strongest independent predictor of SMM (β=0.370, p=0.000), followed by BMI (β=0.327) and MUAC (β=0.193), with the model explaining 49.6% of SMM variance (R2=0.496). Conclusion: CC and MUAC are valid, low-cost screening alternatives for SMM assessment in resource-limited settings. CC, in particular, serves as a robust indicator for early sarcopenia detection.
Abstract Aim : Describe the management of blunt splenic trauma in a 10-year period in our department and perform a systematic review of the relevant literature. Materials and methods : Retrospective analysis of registry data from patients with splenic injury from 2014 to 2024 and systematic review of the publications in PubMed, Scopus and the Cochrane Library. Results : Sixty-eight patients, 58 males and 10 females with a mean age of 42 years, were included. Sixteen were grade I, 14 grade II, 12 grade III, 6 grade IV, and 20 grade V. Forty-two patients were treated non-operatively, and 26 underwent splenectomy. Two patients failed the non-operative management (NOM) (95.2% success rate). An increasing tendency for the number of platelets was noted. A statistically significant difference on days 5 and 10 between grade II and grade V ( p =0.00056 and p =0.0118, respectively) and grades III and V ( p =0.01 and p =0.01) was found, with grade V platelet count peaking on day 10. In our qualitative synthesis, 17 studies were included, with 5137 patients, mostly males with a mean age of 37 years. 1189 were grade I and II, and 2916 were grade ≥3. A significant shift towards NOM has been noted (60.5%, with success rates ranging from 76% to 100%). A preference for splenic preservation over splenectomy, which may be achieved with embolization, is indicated. Clinical and laboratory evaluation should be carefully conducted when considering splenic embolization. Conclusion : A shift towards NOM is noticed with surgical intervention restricted for hemodynamically unstable patients. Splenic embolization is an effective alternative which may be used to further establish non-surgical management.
Abstract Rotator cuff tear arthropathy (RCTA) is a complex condition characterized by rotator cuff insufficiency, altered shoulder kinematics, and progressive joint degeneration. In advanced stages, it results in pain, loss of active elevation, and significant functional impairment. Reverse shoulder arthroplasty (RSA) is now the best surgical option for advanced RCTA because it restores shoulder elevation by changing how the joint works and making the rotator cuff less important. The original RSA concept focused on medialization and distalization of the center of rotation to increase the deltoid moment arm, improve joint stability, and allow active elevation in the absence of a functional rotator cuff. Although this design provided clinical improvement, it also revealed biomechanical limitations, including scapular notching and restricted rotational range of motion, among others. In response, contemporary RSA systems have evolved design modifications, such as lateralization and glenosphere eccentricity, inferior tilt, variable humeral neck-shaft angles, and modular humeral socket configurations. These strategies aim to optimize deltoid efficiency, minimize impingement, and improve range of motion. Despite the availability of numerous implant designs, no consensus exists regarding the optimal combination of components or positioning parameters. A comprehensive understanding of RSA biomechanics associated with modern designs is essential for implant selection and surgical planning in patients with RCTA.
Abstract Introduction : Postoperative anastomotic leakage is a serious complication in rectal surgery that affects quality of life, increases morbidity and mortality rates, and worsens oncologic outcomes. One of the methods that can minimize septic complications is a diverting ostomy. Although intended as temporary, approximately 20% of diverting stomas become permanent or are converted to end colostomies. Factors significantly increasing the risk of permanent stomas include advanced age, local recurrence, stoma-related complications, and impaired anal sphincter function caused by denervation during surgery or due to neo-adjuvant or adjuvant radiotherapy. Aim : This study aimed to identify the risk factors that increase the possibility of temporary stoma becoming permanent after low anterior resection. Materials and methods : For the described period, we reviewed a total of 418 histologically confirmed rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy. Results : Our study included 348 patients, of whom 324 (93.1%) had their stomas reversed. After a median follow-up of 50.4 months (range 6-106 months), 324 (93.1%) patients had temporary stomas and 24 (6.9%) had permanent ones. Of the 24 permanent stoma patients, there were 12 ileostomies (50.0%), 6 colostomies (25.0%), six patients with abdominoperineal resections (25.0%) due to total dehiscence of the anastomosis. Conclusion : Neo-adjuvant or adjuvant chemo and/or radiation therapy, local recurrence, and anastomotic leakage could be important risk factors for the stoma’s nonclosure or re-creation after primary closure in low rectal cancer patients. Surgeons should be more alert in the stoma closure of these risk patients.
Abstract Introduction : Major β-thalassemia is a severe hereditary anemia caused by defective β-globin production and characterized by a permanent transfusion requirement, which leads to an overload of systemic iron and subsequent liver dysfunction. MicroRNA-451 (miR-451) is an erythroid-specific microRNA that plays a critical role in erythropoiesis, oxidative stress regulation, and iron metabolism. Nevertheless, there is still insufficient research on the connection between β-thalassemia major and liver function. Aim : The study aimed to evaluate the expression of miR-451 in Iraqi patients with β-thalassemia major and correlate it with liver function parameters. Materials and methods : This case-control study involved 50 patients diagnosed with β-thalassemia major and 50 healthy individuals serving as controls. Total RNA was extracted from whole blood samples, and the expression levels of miR-451 were quantified using quantitative real-time PCR (qRT-PCR). U6 small nuclear RNA was utilized as the endogenous control for normalization. Hematological indices and liver function parameters, specifically ALT, AST, and total serum bilirubin, were assessed and analyzed statistically. Results : The expression of miR-451 was upregulated significantly in patients in comparison with the controls (≈260-fold increase). The patients had significantly lower levels of hemoglobin and elevated platelet counts ( p ≤0.05). The liver enzymes, ALT and AST, and the total serum bilirubin were significantly increased in the patient group ( p ≤0.01). This study found a positive association between the overexpression of miR-451 and hepatic dysfunction markers. Conclusion : In β-thalassemia major, miR-451 is significantly upregulated, suggesting it could be a biomarker for disease severity and liver function.
Abstract Introduction : Periprosthetic fractures’ incidence is increasing, leading to growing concerns on their impact on patients’ clinical conditions and healthcare systems budgets. Aim : Evaluation of the clinical impact of periprosthetic fractures and their treatment on patients’ functionality and quality of life Materials and methods : We reviewed all hip periprosthetic fractures treated surgically between 2018 and 2024. Fractures were classified with the Vancouver classification. Surgical delay, surgical times, and postoperative hospitalization (days) were recorded. The number of blood units administered was counted. We also assessed whether cases could walk and bear weight on the treated limb after our treatments. Results : Ninety-four cases with proximal femur periprosthetic fractures were included. (4 type A, 36 type B1, 30 type B2, 5 type B3, and 19 type C). Patients’ mean hospitalization was 10.6 days (5–27). Vancouver classes did not represent prognostic factors in our cohort. Seventy-eight cases experienced postoperative anemia and required transfusion. In our cohort, longer surgical delays led to longer postoperative hospitalizations. The complication rate was 11.7%. Nine percent of our cases died within six months after the fracture. During their follow-up, 65% of our patients had their preoperative walking ability restored; those who had complications were most likely to have reduced postoperative mobility. Conclusion : The Vancouver classification is a useful tool for surgical planning, but does not represent a prognostic factor. Periprosthetic hip fractures can reduce patients’ walking ability, especially in case of complications, and even put at risk the survival of the most fragile patients.
Abstract Cardiopulmonary exercise testing (CPET) is a complex functional test that allows for dynamic monitoring of the cardiovascular and respiratory systems during progressive incremental physical activity. CPET is well-established in adult patients, as it provides diagnostic and prognostic value. Pediatric CPET proves informative, although it entails numerous challenges, stemming from the developmental characteristics of children, as well as factors regarding test conduction and interpretation. Pediatric CPET applicability ranges from estimating exercise capacity in healthy and athletic children to diagnosis and prognosis in cases of chronic disease, such as respiratory or cardiovascular conditions. It can be used as a basis for the assessment of functional capacity in cases of asthma and cystic fibrosis, as well as quality of life scoring in kids with chronic heart failure. Furthermore, exercise testing is used as part of the indirect bronchoprovocation procedures for pulmonary function testing. Main challenges include the lack of standardized reference values, protocol selection, and the need for special pediatric equipment, as well as the high cost associated with the test. CPET represents a valuable and increasingly utilized tool for assessment of the pediatric population. Future studies should focus on establishing normative datasets and improving methodological standardization.
Introduction : Patients often present to the clinic with radiographs taken without weight bearing. However, weight-bearing radiographs are typically required for surgical planning, resulting in additional cost and radiation exposure. Aim : This study aimed to evaluate the effect of weight-bearing X-ray imaging on angular measurements and clinical decision-making in patients with hallux valgus. Materials and methods : Sixty-one feet from thirty-two patients presenting to our hospital in 2023–2024 were included. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) measurements were compared between weight-bearing and non-weight-bearing radiographs. The association between these imaging differences and surgical decision-making was analyzed. Results : HVA was significantly higher on non-weight-bearing radiographs, whereas IMA was significantly higher on weight-bearing radiographs ( p =0.004 and p <0.001, respectively). Surgical planning differed between the two imaging modalities in only 2 of 61 feet (3.3%). Conclusion : Despite measurable differences in angular values, non-weight-bearing radiographs can be reliably used for preoperative planning in most cases. Surgeons often base their decisions on experience and preferred techniques rather than small variations in measurements.
Abstract We describe a 57-year-old man who had initial isolated weakness in the deep finger flexors of his non-dominant hand, followed by quadriceps weakness and wasting a year later. Despite the distribution specific for sporadic inclusion body myositis (s-IBM) and early myogenic abnormalities found in deep finger flexors, the case was initially misdiagnosed as polymyositis based on the initial biopsy results, which revealed endomysial inflammation with partial invasion/compression of non-necrotic fiber, without rimmed vacuoles. As a result, the patient received unnecessary treatment, including immunosuppressants, which caused serious side effects. The second biopsy revealed rimmed vacuoles, and the diagnosis of s-IBM was confirmed. The role of clinical, pathological, and electrophysiological features for early diagnosis of s-IBM and differentiation from PM is discussed.
Abstract Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related death worldwide and ranks among the top three in Indonesia. Most patients were diagnosed in a locally advanced stage, with a high recurrence rate despite standard oxaliplatin-based chemotherapy. The hypoxic tumor microenvironment through activation of HIF-1α and systemic inflammation reflected by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) could be associated with the tumor progression.Aim: To evaluate the association of HIF-1α expression, NLR, and PLR with three-year progression-free survival (PFS) in locally advanced CRC patients.Methods: This retrospective cohort study included 50 patients with high-risk stage II and stage III CRC who underwent surgical resection and adjuvant oxaliplatin-based chemotherapy in Cipto Mangunkusumo National Hospital. HIF-1α expression was assessed by immunohistochemistry, while NLR and PLR were calculated from pre-treatment blood tests. Data were analyzed using Kaplan–Meier and Cox regression methods, with p<0.05 considered statistically significant.Results: The median HIF-1α expression was 96.32%, with a cut-off value of 96.51% (AUC 0.472; p=0.746). There was no significant association between HIF-1α expression and three-year PFS (HR 1.274; p=0.495). The cut-off points for NLR and PLR were 3.46 (AUC 0.486; p=0.872) and 198.31 (AUC 0.505; p=0.952), respectively, and both were not significantly associated with three-year PFS (NLR: HR 0.947; p=0.874; PLR: HR 1.060; p=0.869).Conclusions: HIF-1α expression, NLR, and PLR were not significantly associated with three-year progression-free survival in locally advanced CRC patients.
Abstract Congenital melanocytic nevus (CMN) is predominantly distinguished by the presence of nevomelanocytes or nevus cells arranged in well-ordered clusters within the epidermis, as well as organized in the dermis. Giant congenital melanocytic nevus (GCMN) is an uncommon dermal lesion defined by benign proliferative growths of nevomelanocytes that are present at the time of birth. CMNs arise in utero between the 5th and 24th weeks of gestation, attributable to localized genetic anomalies that provoke the excessive proliferation of melanocytes. In individuals with giant CMN, a gain-of-function mutation in the NRAS gene is identified, leading to the aberrant proliferation of embryonic melanoblasts. Previously, elucidation of a murine model for giant congenital nevus demonstrated that both nevi and melanoma exhibit significant expression of Sox10. CMNs represent aggregates of melanocytes situated within the dermis, with varying degrees of extension into subcutaneous adipose tissue, musculature, and peri-adnexal regions. The present report deals with unveiling the embryological and molecular basis of congenital melanocytic nevus.
Abstract Introduction : Glioblastoma (GBM) is the most common and aggressive primary malignant brain tumor. PD-1 inhibitors have shown potential use in GBM. There is some evidence to suggest that programmed death-1 (PD-1) inhibitors may be effective in treating GBM. However, the results of clinical trials conducted to date have been inconclusive, which has led to questions regarding the efficacy of PD-1 inhibitors in this context. Aim : This systematic review aimed to evaluate whether PD-1 inhibitors provide a survival advantage over the standard regimens in GBM. Materials and methods : This review followed the PRISMA guidelines. Comprehensive searches were conducted in PubMed, Scopus, and the Cochrane Library from 2015 to 2025. The extracted data included the study design, sample characteristics, interventions, comparators, and reported survival outcomes. The risk of bias was assessed using the Cochrane RoB 2 tool. Results : Four trials were included in this review. In newly diagnosed GBM, PD-1 inhibitors plus radiotherapy showed an inferior overall survival (OS) rate compared to standard regimens (median OS [mOS] 13.4 vs. 14.9 months, HR 1.31 [95% CI: 1.09-1.58]). PD-1 inhibitors as an adjuvant to temozolomide-based therapy also showed no statistically significant improvement in OS (mOS 11.6 vs. 11.8 months, HR 0.85 [95% CI 0.54-1.33]) or progression-free survival (PFS) (median PFS [mPFS] 7.4 vs. 5.9 months, HR 0.77 [95% CI 0.49- 1.19]) compared to placebo. For recurrent GBM, there was no significant difference in OS between nivolumab and bevacizumab (mOS 11.6 vs. 10.0 months, HR 1.04 [95% CI: 0.83-1.3]). Consistently, PD-1 inhibitors did not demonstrate a survival advantage in either newly diagnosed or recurrent glioblastoma. Conclusion : PD-1 inhibitors showed no statistically significant improvement in OS and PFS in patients with GBM.
Abstract Hyper-IgE syndromes (HIES) are rare inborn errors of immunity (≈1 per million) caused by pathogenic variants in STAT3, DOCK8 or IL6ST. They present with very high serum immunoglobulin E (IgE), recurrent bacterial or fungal infections, eczema and characteristic organ involvement. The autosomal dominant STAT3-deficient form features early-onset eczema, “cold” abscesses, recurrent pneumonias with pneumatoceles and skeletal or dental anomalies. Autosomal recessive forms such as DOCK8 or PGM3 deficiency show a more severe phenotype with viral skin infections, allergy, asthma and increased malignancy risk. HIES should be suspected in children with IgE >2000 IU/mL plus recurrent sinopulmonary or skin infections, severe eczema, atypical viral infections or a National Institutes of Health Hyper-IgE Syndrome (NIH HIES) score >40. Differentiation from severe atopic dermatitis, asthma, eosinophilic disorders and parasitic infections is essential. Evaluation includes eosinophils, lymphocyte subsets, T-helper 17 (Th17) cell analysis and targeted genetic testing. Management involves antimicrobial prophylaxis, treatment of complications, dermatologic care and genotype-based hematopoietic stem cell transplantation (HSCT), which is curative in DOCK8 but less effective in STAT3 deficiency. Early genomic confirmation enables timely recognition, identification of red flags, and genotype-specific therapy to improve long-term outcomes.
Background : During root canal therapy, one of the most often overlooked anatomical structures in maxillary first molars is the second mesiobuccal canal. Even with the use of ultrasonic devices and magnification, its detection remains difficult. Aim : To evaluate whether cone beam computed tomography provides additional clinical benefit for identifying and negotiating the second mesiobuccal canal after exploration under a dental operating microscope combined with ultrasonic troughing. Methods : A total of 129 maxillary first molars undergoing primary endodontic treatment were examined using a two-stage clinical protocol. In the first stage, canal identification was performed under a dental operating microscope and ultrasonic endodontic tips. Teeth in which the second mesiobuccal canal could not be located or fully negotiated proceeded to the second stage, which included a cone beam computed tomography scan. When an additional canal was visualized, a second clinical attempt at detection and negotiation of the MB2 canal was performed. Detection rates, canal morphology, and negotiation outcomes were recorded and analyzed statistically. Results : The second mesiobuccal canal was detected in 79.1% of teeth during microscopic exploration, with full negotiation achieved in most cases. Cone beam computed tomography identified an additional canal in 40.7% of teeth that remained undetected after the first stage. The combined approach resulted in an overall detection rate of 87.6%. Canal morphology, particularly patency and canal confluence, strongly influenced detectability. Conclusion : Cone beam computed tomography provides added value for identifying the second mesiobuccal canal only when microscopic and ultrasonic methods fail. Its benefit depends on anatomical conditions, while favorable morphology remains the key determinant of successful canal detection and negotiation.
Abstract A thyroid nodule (TN) is a structurally discrete lesion within the thyroid gland that can be readily distinguished from the adjoining normal thyroid parenchyma. TNs are more frequently detected these days because of the widespread use of high-resolution imaging techniques for various neck pathologies. A well-circumscribed macroscopic lesion measuring 17 mm ×14 mm ×12 mm was observed in the left lobe of the thyroid gland during routine dissection performed on an embalmed elderly female cadaver for undergraduate teaching. It was firm to the touch and greyish brown in color. In the histological examination, the lesion appeared intensely stained and encapsulated by a thick fibrous capsule having various sizes of thyroid follicles lined by cuboidal to low-columnar epithelium with focal areas of calcification and hemorrhages. There was no sign of local tissue or vascular invasion by the lesion. No nuclear atypia was observed. The lesion was identified as a benign follicular adenoma. This report underscores the significance of recognizing that a thyroid gland that appears to be within normal limits may, in fact, harbor a thyroid nodule of considerable size. The identification of such nodules is of paramount importance, as a significant proportion of benign thyroid lesions found in geriatric women have a high propensity to undergo malignant transformation.
