The Incidence of Alcohol Use Disorders during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has introduced a myriad of challenges to healthcare systems and public health policies across the globe. Individuals with alcohol use disorders are at peaked risk due to mental, socio-demographic, and economic factors leading to hindered mental health service access, misinformation and adherence. METHODS: Keywords including "alcohol use", "death", "hand sanitizer", "overdose" and "COVID-19" were used to obtain 8 media reports for case analysis. A review of 34 manually extracted records were also conducted using PubMed, MEDLINE, Scopus, and the Embase database with no time and language restrictions. RESULTS: A total of 2,517 individuals with alcohol overdose across the United States, India, Canada, and Iran were presented. The majority of cases were male, ages 21-65. Common contributors were linked to socio-economic changes, disruption to mental health services, and physical isolation. CONCLUSION: While original studies are essential to evaluate the etiologies of alcohol use and misuse during pandemics, the dissemination of misinformation must be curbed by directing vulnerable individuals towards accurate information and access to mental health services.

Clinical characteristics and oncological outcomes in negative multiparametric MRI patients undergoing robot-assisted radical prostatectomy.

BACKGROUND: Efforts are ongoing to try and find ways to reduce the number of unnecessary prostate biopsies without missing clinically significant prostate cancers (csPCa). The utility of multiparametric magnetic resonance imaging (mpMRI) in detecting prostate cancer (PCa) shows promise to be used as triage test for systematic prostate biopsy. Our aim is to Study clinical parameters and oncological outcomes in men with negative mpMRI (nMRI; PI-RADS v2 scores of ≤ 2) who underwent robot-assisted radical prostatectomy (RARP) to evaluate nMRI's practicality as a biopsy triage test. METHODS: Retrospective analysis of 331 men with nMRI who underwent RARP between 2014 and 2020 compared with men with positive mpMRI (pMRI; PI-RADS v2 scores ≥ 3, N = 1770). csPCa was defined as Gleason score ≥ 3 + 4 and biochemical recurrence (BCR) was defined as PSA > 0.2 ng/ml on two occasions. Biopsies were graded with the International Society of Urologic Pathology [ISUP] grade. Descriptive statistics for nMRI and pMRI were performed. Mann-Whitney U test was used for continuous variables and χ 2 for categorical variables. Univariable and multivariable regression analyses were performed. RESULTS: Univariable analysis shows statistically significant difference (p < .05) between median age (nMRI-61 years vs. pMRI 63 years), race (higher incidence of nMRI in African American men), use of 5-alpha reductase inhibitors (higher rate in nMRI). While incidence rates of family history of PCa, suspicious digital rectal examination (DRE) findings, median PSA levels and 4Kscore, were lower in nMRI versus pMRI. Rates of positive surgical margins and BCR were comparable in nMRI versus pMRI. Biopsy ISUP Grades I and II upgraded by 51% and 12%, respectively in final pathology. African American race and no history of the prior negative biopsy were significant predictors for upgrading. CONCLUSION: Men with nMRI pose diagnostic challenges as they tend to be younger patients with lower rates of suspicious DRE findings and lower 4K scores, yet comparable oncological outcomes in csPCa rates, positive surgical margins, and BCR rates.

Dynamics of antimicrobial resistance of Helicobacter pylori isolates in the Smolensk region of Russian Federation.

BACKGROUND: Efficacy of Helicobacter pylori eradication therapy depends on the chance of having a resistant H. pylori strain, which is ultimately related to the local antimicrobial resistance epidemiology. AIM: To assess H. pylori resistance to clarithromycin, amoxicillin, metronidazole, levofloxacin, and tetracycline in adult patients in the Smolensk region of Russian Federation over a 9-year period. MATERIALS AND METHODS: Biopsy samples were taken from the gastric antrum and body of 573 and 210 patients with dyspepsia symptoms and positive rapid urease test during esophagogastroduodenoscopy in 2015-2017 and 2009-2010, respectively. Antimicrobial susceptibility testing was performed for clarithromycin, amoxicillin, metronidazole, levofloxacin, and tetracycline by the agar dilution method. RESULTS: A total of 143 strains of H. pylori isolated during 2015-2017 and 133 strains isolated during 2009-2010 were tested. Culture success rates were 30% vs 64% for the two periods. Over the 2015-2017, the prevalence of resistance to clarithromycin was 6.3%, to amoxicillin 1.4%, to metronidazole 23.8%, to levofloxacin 24.5%, and to tetracycline 0.7%. Over the 2009-2010, the corresponding resistance rates were 5.3%, 4.5%, 3.8%, 8.3%, and 0%, respectively. There were no significant increases in resistance to clarithromycin, amoxicillin, and tetracycline (P > 0.05) over the 9 years period. Significant increase in resistance to levofloxacin (8.3% in 2009-2010% vs 24.5% in 2015-2017, P < 0.01) and metronidazole (3.8% in 2009-2010% vs 23.8% in 2015-2017, P < 0.01) was observed. CONCLUSIONS: H. pylori resistance to clarithromycin remained low in the Smolensk region of Russian Federation between 2009 and 2017. Resistance to levofloxacin and metronidazole increased between 2009 and 2017.

Artificial intelligence in neuro-oncology: advances and challenges in brain tumor diagnosis, prognosis, and precision treatment.

This review delves into the most recent advancements in applying artificial intelligence (AI) within neuro-oncology, specifically emphasizing work on gliomas, a class of brain tumors that represent a significant global health issue. AI has brought transformative innovations to brain tumor management, utilizing imaging, histopathological, and genomic tools for efficient detection, categorization, outcome prediction, and treatment planning. Assessing its influence across all facets of malignant brain tumor management- diagnosis, prognosis, and therapy- AI models outperform human evaluations in terms of accuracy and specificity. Their ability to discern molecular aspects from imaging may reduce reliance on invasive diagnostics and may accelerate the time to molecular diagnoses. The review covers AI techniques, from classical machine learning to deep learning, highlighting current applications and challenges. Promising directions for future research include multimodal data integration, generative AI, large medical language models, precise tumor delineation and characterization, and addressing racial and gender disparities. Adaptive personalized treatment strategies are also emphasized for optimizing clinical outcomes. Ethical, legal, and social implications are discussed, advocating for transparency and fairness in AI integration for neuro-oncology and providing a holistic understanding of its transformative impact on patient care.

Applications of artificial intelligence in prostate cancer histopathology.

The diagnosis of prostate cancer (PCa) depends on the evaluation of core needle biopsies by trained pathologists. Artificial intelligence (AI) derived models have been created to address the challenges posed by pathologists' increasing workload, workforce shortages, and variability in histopathology assessment. These models with histopathological parameters integrated into sophisticated neural networks demonstrate remarkable ability to identify, grade, and predict outcomes for PCa. Though the fully autonomous diagnosis of PCa remains elusive, recently published data suggests that AI has begun to serve as an initial screening tool, an assistant in the form of a real-time interactive interface during histological analysis, and as a second read system to detect false negative diagnoses. Our article aims to describe recent advances and future opportunities for AI in PCa histopathology.

Global Perspective on COVID-19 Therapies, Cardiovascular Outcomes, and Implications for Long COVID: A State-of-the-Art Review.

The COVID-19 pandemic has resulted in many therapies, of which many are repurposed and used for other diseases in the last decade such in Influenza and Ebola. We intend to provide a robust foundation for cardiovascular outcomes of the therapies to better understand the rationale for the clinical trials that were conducted during the COVID-19 pandemic, and to gain more clarity on the steps moving forward should the repurposing provide clinical benefit in pandemic situations. With this state-of-the-art review, we aim to improve the understanding of the cardiovascular involvement of the therapies prior to, during, and after the COVID-19 pandemic to provide meaningful findings to the cardiovascular specialists and clinical trials for therapies, moving on from the period of pandemic urgency.

Impact of exercise on continence in prostate cancer patients post robotic assisted radical prostatectomy: a systematic review.

INTRODUCTION: Urinary incontinence is one of the most common long term side effects after robotic prostatectomy (RALP), and significantly impacts patient quality of life. Pelvic floor muscle training (PFMT) has been a standard part of the urologist's armamentarium for maximizing continence outcomes post-op. Recently, aerobic and resistance exercises have been described as improving functional outcomes post RALP. We performed a systematic review to determine the influence of exercise, in the form of PFMT, aerobic exercise, and resistance training, on incontinence post-RALP. MATERIALS AND METHODS: This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with database searches performed on January 14, 2022 and again on August 10, 2022 to account for any new publications. The search identified 1675 papers. Of the 1675 papers, 1007 were found to be duplicates, leaving 668 total studies for screening. Of the 668 papers, nine met all inclusion criteria. Of the nine, four studies presented data from patients who had undergone RALP and were included in the final descriptive systematic review. RESULTS: Sayilan et al. and Milios et al. showed postoperative PFMT and physical activity resulted in significantly improved continence outcomes at 1 and 6 months and 2, 6, and 12 weeks postoperatively, respectively. Heydenreich et al. combined PFMT with an oscillating rod therapy, which was found to significantly improve both postoperative urinary continence and health related quality of life compared to PFMT and relaxation techniques alone. On the contrary, Goode et al. examined delivery of exercise information and demonstrated no difference in continence outcomes between focused telehealth PFMT program and generic prostate cancer education. CONCLUSION: Pelvic floor muscle training, with or without adjunct therapies, results in improved continence outcomes post RALP. Supervised training programs may or may not accelerate this finding. There is no recent literature to support or refute the benefit of aerobic exercise or resistance training on reducing post-prostatectomy incontinence after RALP.

Trends in the surgical management of kidney cancer by tumor stage, treatment modality, facility type, and location.

Partial nephrectomy (PN) is an alternative to radical nephrectomy (RN) in the appropriate localized renal tumor. The scope of PN has expanded over time and, since the advent and proliferation of minimally invasive surgery, more surgeons have access to and have been trained in laparoscopic and robotic technology. Amid the changing surgical landscape, we sought to characterize the trends in management by cancer stage, institution type, and geographic location using the National Cancer Database (NCDB). We queried the NCDB for patients with kidney cancer from 2004 to 2019. Overall, 241,311 patients who underwent PN or RN were included in the study. The nephrectomy approach was categorized as robotic partial (RPN), robotic radical (RRN), laparoscopic partial (LPN), laparoscopic radical (LRN), open or unspecified partial (OPN), and open or unspecified radical (ORN). The categorical variables were presented as frequency and percentages. Overall, there was an increase in the utilization of robotic approaches from 2010 to 2019. For cT1 tumors, the use of RPN and RRN increased from 14.27 to 33.06% and 5.24% to 19.63%, respectively. The use of ORN for cT2 and cT3 tumors declined, with rates dropping from 54.71 to 10.76% and 64.71 to 46.64%, respectively. Conversely, the utilization of RRN rose during this period. However, ORN remained the most common approach for cT3 tumors. The use of RPN increased across different facility types, with the highest utilization observed in academic/research programs. The use of ORN for cT2 and cT3 tumors declined across facility types, although it remained most prevalent in community cancer programs. The use of robot-assisted surgery to treat localized renal cancer increased in the US between 2010 and 2019 across all stages of disease. RPN became the most used approach for cT1 disease, while LRN was preferred for cT2 disease. ORN remained the approach of choice for cT3 disease throughout the study period. Trends in facility type and geographic location largely mirrored the overall trends.

Biopsy and Erectile Functional Outcomes of Partial Prostate Ablation: A Systematic Review and Meta-analysis of Prospective Studies.

OBJECTIVE: To provide a systematic summary of prospectively performed studies evaluating ablative therapies for the treatment of prostate cancer (PCa) that included protocol-mandated assessment of (1) residual disease by post-treatment biopsy and/or (2) erectile functional outcomes. MATERIALS AND METHODS: We performed a comprehensive literature search in September 2022. Studies were evaluated according to a predefined and registered plan in PROSPERO (CRD42022302777). Only prospective trials with protocol-mandated post-treatment prostate biopsies or functional assessments were included. Targeted focal therapy was the only ablation pattern with sufficient data to perform meta-analyses (29 studies, 1079 patients). RESULTS: At baseline, 65.0% of patients treated with targeted focal therapy harbored grade group (GG) ≥2 PCa. One year after treatment, in-field treatment failure with ≥GG1 and ≥GG2 PCa occurred in 25.7% (range 11.1%-66.7%) and 8.8% (range 0%-27.8%) of men, respectively. In patients that received whole-gland biopsies 1year after ablation, residual ≥GG1 and ≥GG2 PCa was detected anywhere in the prostate in 43.7% (range 19.4%-71.7%) and 13.0% (range 0%-35.9%) of men. Erectile function was negatively affected by treatment, but 78.7% were potent 1year after targeted focal therapy (7 studies, 197 patients), and the average decrease in erectile function scores was 8.8% at 1year (21 studies, 760 patients). CONCLUSION: Though long-term data after targeted focal therapy are limited, oncologic and treatment failure occurred in 13% and 9% (≥GG2 at 6-12months after treatment). Most men were able to maintain potency. This work can help benchmark new techniques and power future trials.

Side-specific, Microultrasound-based Nomogram for the Prediction of Extracapsular Extension in Prostate Cancer.

Background: Prediction of extracapsular extension (ECE) is essential to achieve a balance between oncologic resection and neural tissue preservation. Microultrasound (MUS) is an attractive alternative to multiparametric magnetic resonance imaging (mpMRI) in the staging scenario. Objective: To create a side-specific nomogram integrating clinicopathologic parameters and MUS findings to predict ipsilateral ECE and guide nerve sparing. Design setting and participants: Prospective data were collected from consecutive patients who underwent robotic-assisted radical prostatectomy from June 2021 to May 2022 and had preoperative MUS and mpMRI. A total of 391 patients and 612 lobes were included in the analysis. Outcome measurements and statistical analysis: ECE on surgical pathology was the primary outcome. Multivariate regression analyses were carried out to identify predictors for ECE. The resultant multivariable model's performance was visualized using the receiver-operating characteristic curve. A nomogram was developed based on the coefficients of the logit function for the MUS-based model. A decision curve analysis (DCA) was performed to assess clinical utility. Results and limitations: The areas under the receiver-operating characteristic curve (AUCs) of the MUS-based model were 81.4% and 80.9% (95% confidence interval [CI] 75.6, 84.6) after internal validation. The AUC of the mpMRI-model was also 80.9% (95% CI 77.2, 85.7). The DCA demonstrated the net clinical benefit of the MUS-based nomogram and its superiority compared with MUS and MRI alone for detecting ECE. Limitations of our study included its sample size and moderate inter-reader agreement. Conclusions: We developed a side-specific nomogram to predict ECE based on clinicopathologic variables and MUS findings. Its performance was comparable with that of a mpMRI-based model. External validation and prospective trials are required to corroborate our results. Patient summary: The integration of clinical parameters and microultrasound can predict extracapsular extension with similar results to models based on magnetic resonance imaging findings. This can be useful for tailoring the preservation of nerves during surgery.

Multidimensional mechanisms of metformin in cancer treatment.

Metformin has been in clinical use for more than half a century, yet its molecular mechanism of action is not entirely understood. Metformin has been shown to have antiproliferative and synergistic effects on various types of cancers. The anticancer effects of metformin are potentially applicable to both diabetic and nondiabetic patients. Areas of ongoing investigation focus on metformin's ability to activate adenosine monophosphate kinase (AMPK), in addition to its effect on Myc mRNA, monocarboxylate transporter 1 (MCT1), hypoxia-inducible factor 1 (HIF1), mammalian target of rapamycin (mTOR), and human epidermal growth factor receptor 2 (HER2). Additional anticancer effects are exhibited by acting on liver kinase B1 (LKB1), CREB-regulated transcription coactivator 2 (CRTC2), nitric oxide, and reactive oxygen species. Further investigation will be focused on elucidating metformin's metal-binding properties and how they may be harnessed for their anticancer effect. The acquired knowledge about metformin properties has expanded the number of targets for drug discovery such as microRNA, hexokinase, adenylate cyclase, transcription factors, various cyclins, and copper. In order to design anticancer drugs that mimic metformin's mechanism of action, binding assay studies must be conducted to fully understand and utilize the AMPK-dependent and independent mechanisms. Metformin's complex mechanisms that can potentially make this drug a multifaceted therapy targeting tumorigenesis in addition to information from ongoing clinical trials implicate that metformin can be a potential chemotherapeutic drug or adjuvant that could prove to be vital to future strategies against several types of cancer.

The association of COVID-19 severity and susceptibility and genetic risk factors: A systematic review of the literature.

BACKGROUND: COVID-19 is associated with several risk factors such as distinct ethnicities (genetic ancestry), races, sexes, age, pre-existing comorbidities, smoking, and genetics. The authors aim to evaluate the correlation between variability in the host genetics and the severity and susceptibility towards COVID-19 in this study. METHODS: Following the PRISMA guidelines, we retrieved all the relevant articles published until September 15, 2021, from two online databases: PubMed and Scopus. FINDINGS: High-risk HLA haplotypes, higher expression of ACE polymorphisms, and several genes of cellular proteases such as TMPRSS2, FURIN, TLL-1 increase the risk of susceptibility and severity of COVID-19. In addition, upregulation of several genes encoding for both innate and acquired immune systems proteins, mainly CCR5, IFNs, TLR, DPPs, and TNF, positively correlate with COVID-19 severity. However, reduced expression or polymorphisms in genes affecting TLR and IFNλ increase COVID-19 severity. CONCLUSION: Higher expression, polymorphisms, mutations, and deletions of several genes are linked with the susceptibility, severity, and clinical outcomes of COVID-19. Early treatment and vaccination of individuals with genetic predisposition could help minimize the severity and mortality associated with COVID-19.

Leveraging 5G technology for robotic surgery and cancer care.

BACKGROUND: The field of robotic surgery has seen significant advancements in the past few years and it has been adopted in many large hospitals in the United States and worldwide as a standard for various procedures in recent years. However, the location of many hospitals in urban areas and a lack of surgical expertise in the rural areas could lead to increased travel time and treatment delays for patients in need of robotic surgical management, including cancer patients. The fifth generation (5G) networks have been deployed by various telecom companies in multiple countries worldwide. Our aim is to update the readers about the novel technology and the current scenario of surgical procedures performed using 5G technology. In this article, we also discuss how the technology could aid cancer patients requiring surgical management, the future perspectives, the potential challenges, and the limitations, which would need to overcome prior to widespread real-life use of the technology for cancer care. RECENT FINDINGS: The expansion of 5G technology has enabled some countries to conduct remote surgical procedures, tele-mentored and real-time interactive procedures on animal models, cadavers, and humans, demonstrating that 5G networks could offer a potential solution to previously experienced latency and reliability hurdles during the remote surgeries performed in the 2000s. CONCLUSION: New technological advancements could serve as a ground for emerging novel therapeutic applications. While limitations and challenges related to the 5G infrastructure, cost, compatibility, and security exist; researching to overcome the limitations and comprehend the potential benefits of integrating the technology into practice would be imminent before widespread clinical use. Remote and tele-mentored 5G-powered procedures could offer a new tool in improving the care of patients requiring robotic surgical management such as prostate cancer patients.

Current strategies to improve erectile function in patients undergoing radical prostatectomy - preoperative scenario.

Radical prostatectomy (RP) is a common procedure for localized and locally advanced prostate cancer (PCa). Despite advances in the technique with the introduction of robotic surgery, erectile dysfunction (ED) remains a major drawback. Therefore, a personalized evaluation that considers the patient's expectations and cultural background, baseline erectile function (EF), health status, and tumoral extension is important to optimize outcomes. Since EF has a tremendous impact on the quality of life of the patient and the intimate partner, it is timely to review multidisciplinary approaches to be implemented in the preoperative setting. Here we propose various strategies divided into two main categories, namely, comprehensive preoperative planning and prehabilitation (Figure 1.).

Current strategies to improve erectile function in patients undergoing radical prostatectomy - postoperative scenario.

In order to optimize functional outcomes following radical prostatectomy (RP), early rehabilitation programs should be stablished in the clinical practice. A multidisciplinary approach to assess the patient's mental, physical and social well-being are as important as the implementation of pharmacological and mechanical interventions. In current article of the seminar, we focus on strategies to improve erectile function (EF) after surgery. These strategies have been grouped into 4 main categories: pharmacologic and mechanical interventions, psychosocial interventions, hormonal assessment and a final section dedicated to strategies under research.

Current strategies to improve erectile function in patients undergoing radical prostatectomy-intraoperative scenario.

Results after radical prostatectomy (RP) are generally judged by complete removal of the cancer, return of urinary control, and the ability to have intercourse. Given the complexity of the anatomy of the prostate and its relationship to the surrounding nerves, muscles, and fascia, RP is considered a challenging and technically demanding surgery. Here we propose multiple intraoperative strategies to optimize oncological and functional outcomes.

Treatment with therapeutic plasma exchange in severe COVID-19 pneumonia: A case report and review of the literature.

The role of various therapeutic approaches on the clinical improvement in patients with severe COVID-19 is being researched. Few published studies show positive outcomes after the use of therapeutic plasma exchange (TPE). However, additional clinical evidence is required to understand better the role of therapeutic plasma exchange in severe COVID-19 patients. Thereby, we report a case of a 57-year-old female with laboratory-confirmed COVID-19 who was included in clinical trial NCT04592705. Prompt treatment with TPE facilitated improved clinical-laboratory parameters and speedy recovery and prevented further deterioration of the condition or complications. Successful therapeutic strategies in our case suggest that TPE as a therapeutic option in critically ill COVID-19 patients could prevent the disease from worsening and reduce the need for mechanical ventilation and intensive supportive care in these patients.

The impact of misinformation on the COVID-19 pandemic.

Since the inception of the current pandemic, COVID-19 related misinformation has played a role in defaulting control of the situation. It has become evident that the internet, social media, and other communication outlets with readily available data have contributed to the dissemination and availability of misleading information. It has perpetuated beliefs that led to vaccine avoidance, mask refusal, and utilization of medications with insignificant scientific data, ultimately contributing to increased morbidity. Undoubtedly, misinformation has become a challenge and a burden to individual health, public health, and governments globally. Our review article aims at providing an overview and summary regarding the role of media, other information outlets, and their impact on the pandemic. The goal of this article is to increase awareness of the negative impact of misinformation on the pandemic. In addition, we discuss a few recommendations that could aid in decreasing this burden, as preventing the conception and dissemination of misinformation is essential.

Usefulness of Electoral Models for COVID-19 Vaccine Distribution.

Purpose of Review: In response to the COVID-19 pandemic, there has been a remarkably accelerated development of vaccines worldwide. However, an effective distribution system is crucial for vaccination at a national level. Ecuador was one of the first Latin American countries to be most severely affected by the pandemic. It has been struggling to expand its vaccination drive and requires a strategy that provides an achievable vaccination rate and maintains its primary care services. This study aims to provide an efficient vaccination model to achieve herd immunity by utilizing the country's existing infrastructure (the centralized electoral system) for mass vaccination. Recent Findings: The national electoral data from 2017 and 2021 were used to create estimates for the proposed vaccination model. Two model variations, total personnel, needed, and the number of days needed to vaccinate 50%, 75%, and 100% of the population were considered. The numbers of vaccines needed, and vaccination sites were estimated based on the current number of registered voters and polling stations. The results from the proposed model show that 17,892,353 people can be vaccinated, at 40,093 polling stations, by 90,209 personnel if one vaccinator was available per polling station. Summary: Based on this model, even a conservative estimate shows that 12.56 days are needed to achieve herd immunity, and 16.74 days are needed to vaccinate the entire population of Ecuador. Additionally, we propose that this vaccination model can be used as a blueprint for any country to address similar catastrophes in the future. Supplementary Information: The online version contains supplementary material available at 10.1007/s40475-022-00251-y.

Hyperammonemic Encephalopathy in an Adolescent Patient of Citrullinemia Type 1 With an Atypical Presentation.

Citrullinemia refers to a family of autosomal recessive disorders involving the urea cycle. Three forms exist, which have different implications. Type I citrullinemia exists in both mild and severe forms. It arises due to mutations with argininosuccinate synthase leading to accumulation of ammonia and producing symptoms of lethargy, poor feeding, and seizures. Type II citrullinemia occurs due to citrin mutations involved in the urea cycle transport or during neonatal cholestasis. Management of both conditions requires low-protein diets along with arginine, sodium benzoate, and sodium phenylacetate. While traditional treatment shows improved outcomes, modifications may be necessary depending on a patient's presentation. We present a unique case of a 19-year-old wheelchair-bound female with a past medical history of heterozygous type I citrullinemia, seizures, and chronic encephalopathy presented to a local children's hospital for evaluation of altered mental status with a lethargic mental state. She was initially found to have an ammonia level of 329 µmol/L and choledocholithiasis on admission. Dietary modification with intravenous dextrose and intralipids with oral lactulose saw improvement in her labs. However, her ammonia level increased to 381 µmol/L despite such interventions. Intensive care was required to normalize her serum ammonia level and clear her for a magnetic resonance cholangiopancreatography (MRCP). We present a unique case of heterozygous type I citrullinemia with some overlap with type II citrullinemia features. Further studies are needed to understand better the observed unique presentation and long-term clinical implications associated with the disease.