cis,cis,cis-Di-chlorido-bis-(N4,N4-di-methyl-pyridin-4-amine-κN1)bis-(dimethyl sulfoxide-κS)ruthenium(II).

The structure of the title compound, [RuCl2(C7H10N2)2(C2H6OS)2], has monoclinic (P21/n) symmetry. The Ru-N distances of the coordination compound are influenced by the trans chloride or di-methyl-sulfoxide-κS ligands. The mol-ecular structure exhibits disorder for two of the terminal methyl groups of a dimethyl sulfoxide ligand.

Global perspectives on bipolar disorder treatment: in-depth comparative analysis of international guidelines for medication selection.

BACKGROUND: Bipolar disorder, a chronic mental health condition characterised by fluctuations in mood, energy and functionality, affects millions of individuals worldwide. Its management requires a comprehensive approach, and, as such, treatment guidelines have a pivotal role in guiding clinicians to alleviate symptoms, prevent relapse and enhance overall patient well-being. However, the treatment landscape is far from homogenous, with significant variations existing across different countries. AIMS: This study aimed to explore and compare treatment guidelines for bipolar disorder in various regions, shedding light on the factors that influence therapeutic approaches and thus offering insights that could contribute to the ongoing refinement of evidence-based practices in management. METHOD: The study explores various international treatment guidelines for bipolar disorder that have been updated after 2014. Guidelines from the UK, Canada, Australia/New Zealand, South Korea and the International College of Neuropsychopharmacology are scrutinised to identify factors contributing to the observed differences among them. RESULTS: The variations in recommended drugs across guidelines arise from the approaches employed in guideline development - whether relying on expert consensus or meta-analysis results. Timing disparities in conducting these analyses and the selection of studies also exert influence. Moreover, differences in metabolic enzymes among diverse races and the health policies implemented by individual nations play a significant part in shaping these differences. CONCLUSION: The primary hindrance to consistent treatment conclusions lies in the scarcity of high-quality research results, leading to variations in guidelines. Enhancing evidence-based recommendations necessitates the undertaking of large-scale studies dedicated to assessing treatments for bipolar disorder.

Case Report of COVID-19 and Pneumocystis coinfection in a pediatric patient with a history of receiving high dose steroid therapy.

We report the first case of a critically ill pediatric patient coinfected with coronavirus disease 2019 (COVID-19) and Pneumocystis jirovecii pneumonia (PCP). Instances of coinfection of COVID-19 and PCP are being increasingly reported as the COVID-19 pandemic continues. Because the combination can be life-threatening, timely diagnosis and treatment for PCP is necessary in cases where an immunocompromised patient contracts COVID-19.

B. subtilis MutS2 splits stalled ribosomes into subunits without mRNA cleavage.

Stalled ribosomes are rescued by pathways that recycle the ribosome and target the nascent polypeptide for degradation. In E. coli, these pathways are triggered by ribosome collisions through the recruitment of SmrB, a nuclease that cleaves the mRNA. In B. subtilis, the related protein MutS2 was recently implicated in ribosome rescue. Here we show that MutS2 is recruited to collisions by its SMR and KOW domains, and we reveal the interaction of these domains with collided ribosomes by cryo-EM. Using a combination of in vivo and in vitro approaches, we show that MutS2 uses its ABC ATPase activity to split ribosomes, targeting the nascent peptide for degradation through the ribosome quality control pathway. However, unlike SmrB, which cleaves mRNA in E. coli, we see no evidence that MutS2 mediates mRNA cleavage or promotes ribosome rescue by tmRNA. These findings clarify the biochemical and cellular roles of MutS2 in ribosome rescue in B. subtilis and raise questions about how these pathways function differently in diverse bacteria.

The impact of pediatric intensivists on the management of pediatric diabetic ketoacidosis in pediatric intensive care units.

INTRODUCTION: The impact of pediatric intensivists on managing pediatric patients with diabetic ketoacidosis (DKA) remains unknown. This study aimed to evaluate the impact of pediatric intensivists on outcomes in pediatric intensive care units (PICUs). METHODS: This was a two-institution retrospective study of patients with DKA admitted to the PICU between 2012 and 2023. Pediatric patients (< 19 years of age) were included if they met the moderate to severe DKA criteria on PICU admission. The patients were subsequently divided into two groups based on the presence or absence of a pediatric intensivist. The primary outcome was the PICU length of stay (LOS). Secondary outcomes were adverse events during DKA treatment, hospital LOS, and mortality. RESULTS: Fifty-two patients admitted to the PICU with a median age of 13.00 years (range, 0-18 years) were included; 32 (61.54%) were female. Patients managed by pediatric intensivists had significantly shorter PICU LOS (2.52 vs. 3.69 days, p < 0.05). Also, adverse events during DKA treatment were significantly decreased in the high-intensity group compared to the low-intensity group (12.50% vs. 50.00%, p < 0.05). CONCLUSIONS: High-intensity ICU staffing was associated with shorter PICU LOS and lower adverse events in pediatric patients with DKA. Our results suggest that dedicated pediatric intensivists can improve outcomes of critically ill pediatric patients with DKA.

Complications of the Central Nervous System in Pediatric Patients With Common Cold Coronavirus Infection During 2014-2019.

BACKGROUND: In pediatric patients, the common cold coronavirus (ccCoV) usually causes mild respiratory illness. There are reports of coronavirus causing central nervous system (CNS) infection in experimental animal models. Some immunocompromised patients have also been reported to have fatal CNS infections with ccCoV. The aim of this study was to investigate the clinical characteristics of CNS complications related to ccCoV infection. METHODS: From January 2014 to December 2019, a retrospective analysis was performed of medical records from hospitalized patients under 19 years of age whose ccCoV was detected through polymerase chain reaction in respiratory specimens. The CNS complications were defined as clinically diagnosed seizure, meningitis, encephalopathy, and encephalitis. RESULTS: A total of 436 samples from 420 patients were detected as ccCoV. Among the 420 patients, 269 patients were immunocompetent and 151 patients were immunocompromised. The most common type of ccCoV was OC43 (52% in immunocompetent, 37% in immunocompromised). CNS complications were observed in 9.4% (41/436). The most common type of CNS complication was the fever-provoked seizure under pre-existing neurologic disease (42% in immunocompetent and 60% in immunocompromised patients). Among patients with CNS complications, two immunocompetent patients required intensive care unit admission due to encephalitis. Three patients without underlying neurological disease started anti-seizure medications for the first time at this admission. There was no death related to ccCoV infection. CONCLUSION: ccCoV infection may cause severe clinical manifestations such as CNS complications or neurologic sequelae, even in previously healthy children.

Feeding climate and biodiversity goals with novel plant-based meat and milk alternatives.

Plant-based animal product alternatives are increasingly promoted to achieve more sustainable diets. Here, we use a global economic land use model to assess the food system-wide impacts of a global dietary shift towards these alternatives. We find a substantial reduction in the global environmental impacts by 2050 if globally 50% of the main animal products (pork, chicken, beef and milk) are substituted-net reduction of forest and natural land is almost fully halted and agriculture and land use GHG emissions decline by 31% in 2050 compared to 2020. If spared agricultural land within forest ecosystems is restored to forest, climate benefits could double, reaching 92% of the previously estimated land sector mitigation potential. Furthermore, the restored area could contribute to 13-25% of the estimated global land restoration needs under target 2 from the Kunming Montreal Global Biodiversity Framework by 2030, and future declines in ecosystem integrity by 2050 would be more than halved. The distribution of these impacts varies across regions-the main impacts on agricultural input use are in China and on environmental outcomes in Sub-Saharan Africa and South America. While beef replacement provides the largest impacts, substituting multiple products is synergistic.

Incidence and Mortality Trends in Critically Ill Children: A Korean Population-Based Study.

BACKGROUND: Monitoring mortality trends can help design ways to improve survival, but observation of national mortality trends in critically ill children is lacking for the Korean population. METHODS: We analyzed the incidence and mortality trends of children younger than 18 years admitted to an intensive care unit (ICU) from 2012 to 2018 using the Korean National Health Insurance database. Neonates and neonatal ICU admissions were excluded. Multivariable logistic regression analyses were performed to estimate the odds ratio of in-hospital mortality according to admission year. Trends in incidence and in-hospital mortality of subgroups according to admission department, age, presence of intensivists, admissions to pediatric ICU, mechanical ventilation, and use of vasopressors were evaluated. RESULTS: The overall mortality of critically ill children was 4.4%. There was a significant decrease in mortality from 5.5% in 2012 to 4.1% in 2018 (P for trend < 0.001). The incidence of ICU admission in children remained around 8.5/10,000 population years (P for trend = 0.069). In-hospital mortality decreased by 9.2% yearly in adjusted analysis (P < 0.001). The presence of dedicated intensivists (P for trend < 0.001, mortality decrease from 5.7% to 4.0%) and admission to pediatric ICU (P for trend < 0.001, mortality decrease from 5.0% to 3.2%) were associated with significant decreasing trends in mortality. CONCLUSION: Mortality among critically ill children improved during the study period, and the improving trend was prominent in children with high treatment requirements. Varying mortality trends, according to ICU organizations, highlight that advances in medical knowledge should be supported structurally.

Clinical Use of Continuous Glucose Monitoring in Critically Ill Pediatric Patients with Diabetic Ketoacidosis.

Background: The use of continuous glucose monitoring (CGM) in pediatric patients with diabetic ketoacidosis (DKA) remains investigational, and data on its accuracy in pediatric intensive care units (PICU) are limited. This study evaluated the accuracy of three CGM devices in pediatric patients with DKA in the PICU. Methods: We compared 399 matched pairs of CGM and point-of-care capillary glucose (POC) values and grouped patients based on whether they changed their CGM sensor during their PICU stay. Results: Eighteen patients with a mean age of 10.98 ± 4.20 years were included, with three patients in the sensor change group. The overall mean absolute relative difference (MARD) was 13.02%. The Medtronic Guardian Sensor 3 (n = 331), Dexcom G6 (n = 41), and Abbott FreeStyle Libre 1 (n = 27) showed MARD values of 13.40%, 11.12%, and 11.33%, respectively. The surveillance error grid (SEG), Bland-Altman plot, and Pearson's correlation coefficient demonstrated satisfactory clinical accuracy of the CGM devices (SEG zones A and B, 98.5%; mean difference, 15.5 mg/dL; Pearson's correlation coefficient [r2], 0.76, P < 0.0001). MARD was significantly lower in subjects who did not experience a sensor change (11.74% vs. 17.31%, P = 0.048). Also, a statistically significant negative correlation was found between serum bicarbonate levels and POC-CGM values (r = -0.34, P < 0.001). Conclusions: The severity of DKA has a major effect on reducing the accuracy of the CGM, especially during the first several days in the intensive care unit. The reduced accuracy appears to be related to acidosis, as reflected in the serum bicarbonate levels.

Intestinal endothelial cells increase HIV infection and latency in resting and activated CD4 + T cells, particularly affecting CCR6 + CD4 + T cells.

BACKGROUND: With suppressive antiretroviral therapy, HIV infection is well-managed in most patients. However, eradication and cure are still beyond reach due to latent viral reservoirs in CD4 + T cells, particularly in lymphoid tissue environments including the gut associated lymphatic tissues. In HIV patients, there is extensive depletion of T helper cells, particularly T helper 17 cells from the intestinal mucosal area, and the gut is one of the largest viral reservoir sites. Endothelial cells line lymphatic and blood vessels and were found to promote HIV infection and latency in previous studies. In this study, we examined endothelial cells specific to the gut mucosal area-intestinal endothelial cells-for their impact on HIV infection and latency in T helper cells. RESULTS: We found that intestinal endothelial cells dramatically increased productive and latent HIV infection in resting CD4 + T helper cells. In activated CD4 + T cells, endothelial cells enabled the formation of latent infection in addition to the increase of productive infection. Endothelial-cell-mediated HIV infection was more prominent in memory T cells than naïve T cells, and it involved the cytokine IL-6 but did not involve the co-stimulatory molecule CD2. The CCR6 + T helper 17 subpopulation was particularly susceptible to such endothelial-cell-promoted infection. CONCLUSION: Endothelial cells, which are widely present in lymphoid tissues including the intestinal mucosal area and interact regularly with T cells physiologically, significantly increase HIV infection and latent reservoir formation in CD4 + T cells, particularly in CCR6 + T helper 17 cells. Our study highlighted the importance of endothelial cells and the lymphoid tissue environment in HIV pathology and persistence.

B. subtilis MutS2 splits stalled ribosomes into subunits without mRNA cleavage.

Stalled ribosomes are rescued by pathways that recycle the ribosome and target the nascent polypeptide for degradation. In E. coli, these pathways are triggered by ribosome collisions through recruitment of SmrB, a nuclease that cleaves the mRNA. In B. subtilis, the related protein MutS2 was recently implicated in ribosome rescue. Here we show that MutS2 is recruited to collisions by its SMR and KOW domains and reveal the interaction of these domains with collided ribosomes by cryo-EM. Using a combination of in vivo and in vitro approaches, we show that MutS2 uses its ABC ATPase activity to split ribosomes, targeting the nascent peptide for degradation by the ribosome quality control pathway. Notably, we see no evidence of mRNA cleavage by MutS2, nor does it promote ribosome rescue by tmRNA as SmrB cleavage does in E. coli. These findings clarify the biochemical and cellular roles of MutS2 in ribosome rescue in B. subtilis and raise questions about how these pathways function differently in various bacteria.

Is physical pain causally related to suicidal behavior: An experimental test.

Existing evidence suggests a link between physical pain and suicide, but the nature of this relationship remains unknown. To address this critical gap in knowledge, the present study leveraged a validated virtual reality (VR) suicide paradigm to experimentally examine the causal effects of physical pain on subsequent virtual suicidal behaviors. Based on previous findings, we hypothesized that physical pain would causally drive virtual suicidal behavior only if suicide was conceptualized as having desirable anticipated consequences (e.g., a means of escaping from current pain; an opportunity to avoid future pain). We tested this by randomizing 326 participants across four different conditions: a physical pain condition, an anticipated escape condition, an anticipated avoidance condition, and a control condition. As predicted, physical pain alone did not result in statistically significant increases in VR suicide rates; however, the anticipation that virtual suicidal behavior would result in the avoidance of future physical pain had a large causal effect on VR suicide rates (B = 1.61, p < .001, IRR = 5.01). We failed to find evidence that anticipating that VR suicide would provide an escape from currently experienced physical pain increases the likelihood of VR suicide. Our findings add to a growing body of evidence suggesting that the anticipated consequences of suicide (e.g., avoidance of future physical pain) may serve as primary causes of suicidal behavior.

Trends in Incidences and Survival Rates in Pediatric In-Hospital Cardiopulmonary Resuscitation: A Korean Population-Based Study.

Background Although the outcome of cardiopulmonary resuscitation (CPR) is still unsatisfactory, there are few studies about temporal trends of in-hospital CPR incidence and mortality. We aimed to evaluate nationwide trends of in-hospital CPR incidence and its associated risk factors and mortality in pediatric patients using a database of the Korean National Health Insurance between 2012 and 2018. Methods and Results We excluded neonates and neonatal intensive care unit admissions. Incidence of in-hospital pediatric CPR was 0.58 per 1000 admissions (3165 CPR/5 429 471 admissions), and the associated mortality was 50.4%. Change in CPR incidence according to year was not significant in an adjusted analysis (P=0.234). However, CPR mortality increased significantly by 6.6% every year in an adjusted analysis (P<0.001). Hospitals supporting pediatric critical care showed 37.7% lower odds of CPR incidence (P<0.001) and 27.5% lower odds of mortality compared with other hospitals in the adjusted analysis (P<0.001), and they did not show an increase in mortality (P for trend=0.882). Conclusions Temporal trends of in-hospital CPR mortality worsened in Korea, and the trends differed according to subgroups. Study results highlight the need for ongoing evaluation of CPR trends and for further CPR outcome improvement among hospitalized children.

Preditores de maus-tratos ao idoso relacionados a idosos e a seus cuidadores primários / Predictores de malos tratos a personas mayores relacionados con las personas mayores y sus cuidadores principales / Predictors for elder mistreatment related to older adults and their primary caregivers

Resumo Objetivos Identificar fatores preditivos de maus-tratos ao idoso relacionados a idosos e seus principais cuidadores e a relação entre formação profissional de saúde e identificação de maus-tratos. Métodos Estudo quantitativo e analítico. Os potenciais fatores de risco para maus-tratos relacionados a 40 idosos e seus cuidadores foram coletados por meio da observação de 12 profissionais de saúde e em uma associação de enfermeiras visitantes. O treinamento de profissionais de saúde na identificação de maus-tratos foi investigado. Estatística descritiva, teste exato de Fisher e análise de regressão linear múltipla foram usados para investigar as relações entre a ocorrência de maus-tratos ao idoso e fatores de risco relacionados ao idoso e ao cuidador, e os fatores preditivos para maus-tratos ao idoso. Resultados A dependência dos idosos em relação aos cuidadores e as condições crônicas de saúde dos cuidadores principais foram preditores de maus-tratos ao idoso. Os fatores de risco apresentados pelos cuidadores primários tendiam a afetar mais os maus-tratos ao idoso do que a dependência dos idosos. O número de treinamentos em maus-tratos ao idoso realizado pelos participantes, seu conhecimento sobre quem é responsável por notificar os maus-tratos ao idoso, o tipo de cuidador principal dos idosos e a condição crônica de saúde dos cuidadores foram os fatores correlacionados que afetaram os maus-tratos ao idoso. Conclusão As descrições de maus-tratos ao idoso das vítimas e perpetradores são difíceis de avaliar; portanto, recomenda-se a triagem mais ampla sob perspectiva dos profissionais de saúde. Futuras pesquisas de enfermagem devem explorar intervenções indiretas, como manipular os fatores de risco que os cuidadores primários representam, a fim de diminuir a ocorrência de maus-tratos ao idoso. Estudos futuros testando modelos de previsão de trajetória dentro de uma amostra maior e mais controlada devem ser conduzidos.

Resumen Objetivos Identificar factores predictivos de malos tratos a personas mayores relacionados con las personas mayores y sus cuidadores principales y la relación entre la formación profesional en salud y la identificación de malos tratos. Métodos Estudio cuantitativo y analítico. Los factores potenciales de riesgo de malos tratos relacionados con 40 personas mayores y sus cuidadores fueron recopilados mediante la observación de 12 profesionales de la salud y en una asociación de enfermeras visitantes. Se investigó la capacitación de profesionales de la salud en la identificación de malos tratos. Se utilizó la estadística descriptiva, la prueba exacta de Fisher y el análisis de regresión lineal múltiple para investigar las relaciones entre los casos de malos tratos a personas mayores y los factores de riesgo relacionados con personas mayores y su cuidador, y los factores predictivos de malos tratos a personas mayores. Resultados La dependencia de personas mayores con relación a los cuidadores y las condiciones crónicas de salud de los cuidadores principales fueron predictores de malos tratos a personas mayores. Los factores de riesgo presentados por los cuidadores principales tendían a afectar más los malos tratos a personas mayores que la dependencia de las personas mayores. El número de capacitaciones en malos tratos a personas mayores realizado por quienes participaron, sus conocimientos sobre quién es responsable de notificar los malos tratos a personas mayores, el tipo de cuidador principal de personas mayores y la condición crónica de salud de los cuidadores fueron los factores correlacionados que afectaron los malos tratos a personas mayores. Conclusión Las descripciones de malos tratos a personas mayores por parte de las víctimas y perpetradores son difíciles de evaluar; por lo tanto, se recomienda un triaje más amplio bajo la perspectiva de profesionales de la salud. Futuros estudios de enfermería deben investigar intervenciones indirectas, como manipular los factores de riesgo que los cuidadores principales representan, a fin de reducir los casos de malos tratos a personas mayores. Deben realizarse estudios futuros probando modelos de previsión de trayectoria dentro de una muestra más grande y más controlada.

Abstract Objectives To identify predictive factors for elder mistreatment (EM) related to older adults and their primary caregivers and the relationship between healthcare professional training and identification of EM. Methods This was a quantitative and analytic study. Potential risk factors for EM related to 40 older adults and their caregivers were collected through observation by 12 healthcare professionals and in a visiting nurses association. Training of healthcare professionals on EM identification was investigated. Descriptive statistics, Fisher's exact test, and multilevel regression analysis were used to investigate the relationships between the occurrence of EM and older adults and caregiver-related risk factors, and the predictive factors for EM. Results The older adults' dependency on caregivers and primary caregivers' chronic health conditions predicted EM. The risk factors the primary caregivers posed tended to affect EM more than the dependency older adults posed. The number of EM training the participants attended, their knowledge of who is responsible for reporting EM, the type of older adults' primary caregivers, and caregivers' chronic health condition were the correlating factors affecting EM. Conclusion Victims' and perpetrators' descriptions of EM are difficult to gauge; therefore, the broader screening of healthcare professionals' views is recommended. Future nursing research should explore indirect interventions, such as manipulating the risk factors primary caregivers pose, to decrease the occurrence of EM. A subsequent study testing Path prediction models within a bigger and more controlled sample are also warranted.

Effect of life-sustaining treatment decision law on pediatric in-hospital cardiopulmonary resuscitation rate: A Korean population-based study.

AIM: The 2018 life-sustaining treatment (LST) decision law is expected to improve end-of-life quality in Korea. This study evaluated the national effect of the LST decision law on the cardiopulmonary resuscitation (CPR) rate among pediatric patients who died during hospital admission. METHODS: This retrospective cohort study was based on the Korean National Health Insurance database. Pediatric admissions within 12 months before or after implementation of the LST decision law were compared, allowing a 1-month transition period (February 2018). The changes in mortality, CPR, and documentation of LST decision were evaluated. RESULTS: The CPR rate of patients who died in hospital decreased after establishment of the LST decision law (49.6 vs 43.4 %, P = 0.04), without change of in-hospital mortality between pre/post-LST decision law activation (0.83 vs 0.81 per 1000 admissions, P = 0.67). In addition, in-hospital CPR (0.73 vs 0.67 per 1000 admissions, P = 0.15) and survival to discharge after in-hospital CPR (43.6 vs 47.2 %, P = 0.27) were slightly improved, although there was no statistical significance. Patients with LST decision documentation were less frequently mechanically ventilated (69.8 % vs 80.4 %, P < 0.01) and used fewer inotropes (76.5 % vs 90.1 %, P < 0.01) and more frequent opioids (67.1 % vs 57.4 %, P = 0.04). CONCLUSIONS: The legally guided process of LST decision can decrease the CPR rate of children who die in hospitals. This result highlights the possibility of improving end-of-life quality by reducing non-beneficial in-hospital CPR.

Effect of high-flow nasal cannula on mechanical ventilator duration in bronchiolitis patients.

OBJECTIVES: High-flow nasal cannula (HFNC) therapy is a widely used non-invasive respiratory support that may decrease invasive mechanical ventilation. This study evaluated the real-world effect of HFNC on the duration of mechanical ventilation among acute bronchiolitis patients on a nationwide level. METHODS: We retrospectively analyzed bronchiolitis patients (28 days-3 years old) who were admitted to tertiary hospitals for respiratory support from 2012 to 2019 using the Korean National Health Insurance database. We defined the pre-/post-HFNC period as 12 months periods before and after the initiation of HFNC in each hospital, allowing 6 months for a transition period. We compared ventilator-free days (VFDs) of two periods using a multivariable regression model. RESULTS: In 45 hospitals, 3359 and 3565 patients of pre-HFNC and post-HFNC periods were evaluated. During the post-HFNC period, 11% of patients used HFNC, and 18.7% used mechanical ventilation. VFDs did not vary in the two periods (26.8 vs. 26.7 days, p = 0.46). In the adjusted model, VFDs did not increase in the post-HFNC period (0.08 days, 95% confidence interval: 0.09, 0.25). HFNC application rate in each hospital was not associated with an increase in mean VFDs of pre- and post-HFNC (p = 0.24). CONCLUSIONS: The application of HFNC did not increase VFDs in bronchiolitis patients in a nationwide tertiary hospital setting. This finding suggests that bronchiolitis patients may not benefit from the routine use of HFNC as rescue therapy in terms of reducing invasive procedures or utilizing resources.

Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients.

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

Multiple endocrine neoplasia type 2 and autoimmune polyendocrine syndromes (type 1 diabetes mellitus and Graves' disease) in a 16-year-old male with Kabuki syndrome.

Multiple endocrine neoplasia type 2A (MEN2A) is caused by germline pathogenic variants in the RET proto-oncogene and is characterized by medullary thyroid cancer (MTC), pheochromocytoma, and hyperparathyroidism. Autoimmune polyendocrine syndromes (APS) are defined as multiple endocrine gland insufficiency associated with loss of immune tolerance. APS type 2 (APS-2) consists of at least two of the following diseases: type 1 diabetes mellitus (T1DM), autoimmune thyroid disease, and Addison's disease. We describe the clinical, molecular, and biochemical findings of MEN2A, APS-2, and Kabuki syndrome (KS) in a 16-year-old male. Whole exome sequencing was performed to identify the genetic cause of the pheochromocytoma and syndromic features including facial dysmorphism, developmental delay, and epilepsy. RET pathogenic variant and KMT2D pathogenic variant were identified, and he was diagnosed with MEN2A and KS. This is the first case of association between MEN2 and APS in adolescence and the second proven case in humans. In addition, this is the first report of MEN2 and APS in KS.