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This study demonstrates the development of alloying process and identifies the different alloys patterns used in Jezirah during the third millennium B.C. and examines if there was any relation between alloys patterns and the types of objects to be manufactured. To achieve these goals, findings of published studies that have analysed copper-based alloys chemically have been assembled and re-evaluated. In this multi-disciplinary paper, archaeometallurgical and archaeometric, 1279 copper-based alloys objects, from Jezirah, Mesopotamia and South-eastern Anatolian sites, were studied. Results of compositional analyses show that alloying process development in Jezirah during the third millennium B.C. was non-linear as was the case in the Mesopotamian and Anatolian schema. Three major types of different compositional patterns of copper-based alloys during the third millennium B.C. were used. At the beginning of third millennium B.C. arsenical copper alloys with arsenic content ≥ 4% were used alongside tin-bronze alloys with tin concentration from ≥ 2 to ≤ 5%. By the middle of the third millennium B.C., tin-bronze with tin content from ≥ 2 to ≥ 10%, arsenical copper alloys with arsenic content ≤ 2.5% and arsenical bronze with low tin and varied arsenic concentrations were diffused.

Background Actinomyces species are Gram-positive anaerobic branching bacilli which are commensal of oropharynx, urogenital and gastrointestinal tracts that is associated with infrequent chronic granulomatous diseases including cervicofacial, intrabdominal and genital infections. Actinomyces Blood Stream Infections (BSIs) are usually rare but becoming more frequent with advanced modern diagnostic techniques. The presented study aims to evaluate the spectrum and clinical relevance of Actinomyces BSI at Hamad Medical Corporation (HMC), Qatar. Methods A retrospective observational study was conducted for all reported Actinomyces species BSI at HMC between January 2016 to November 2020. Isolates were identified using modern automated BD PhoenixTM and MALDI-TOF microbiological methods. Results Over the five years study period, 37 episodes of Actinomyces BSIs were recorded the majority of which identified as Actinomyces odontolyticus (40.5 %, 15/37). The mean age was 32 years (range 1 month – 81 years), 62.2 % were females (23/37), 64.8 % had chronic medical conditions while 78.4 % developed fever as presenting illness. Out of the total cases, cultures were considered significant in only 48.6 % of cases (18/37), in which primary source of infection was oropharyngeal (10) followed by genitourinary (4), gastrointestinal (2) and 2 infected diabetic foot. However, 86.5 % (32/37) received antimicrobial therapy mainly as βlactam antibiotics or cephalosporins ranging between 3 days to 6 months. Antimicrobial therapy was given for a short duration in 87.5% (28/32) of cases for less than 14 days with no long-term complications while only four cases received prolonged therapy. The remaining Five patients did not receive any antibiotics as the cultures were considered contaminants by the primary provider. Conclusion Actinomyces species blood stream infection is becoming more frequent with advanced diagnostic techniques affecting all age groups. Females and patients with chronic comorbidities are more commonly affected while A. odontolyticus is the predominant isolated species. Almost half of the cases were not clinically relevant, but most cases received short courses of antimicrobial therapy with no long-term complications. Disclosures All Authors: No reported disclosures.

Euglycemic diabetic ketoacidosis (EDKA) is a well-known complication of sodium-glucose co-transporter 2 inhibitors, and many cases with variable onset following the initiation of these agents are reported before, with a median onset of approximately 2 wk. This letter discusses a 45-year-old lady who initially presented with ischemic stroke but developed EDKA 4 d after starting empagliflozin, a rare occurrence. The patient had severe metabolic acidosis that necessitated admission into the intensive care unit. Prompt discontinuation of empagliflozin and DKA management resulted in clinical recovery.

Introduction and importance Retroperitoneal fibrosis (RPF) is a rare disease characterized by the replacement of normal tissue with fibrosis and inflammation. We present the case of a 40-years-old gentleman with RPF whose presenting complaints were bilateral flank pain and weight loss and was found to have IgG4 related disease. To the best of our knowledge, IgG4-related disease with isolated retroperitoneal involvement is a very rare occurrence. Case presentation The diagnosis of IgG4-Related retroperitoneal fibrosis was made based on clinical, radiological and histopathological criteria. Imaging revealed isolated retroperitoneal involvement and the patient was started on oral steroids with a good clinical response after ten days. Repeated imaging months later showed significant regression in the fibrosis. Clinical discussion RPF can occur due to many etiologies and is categorized to idiopathic and secondary. Factors associated with secondary RPF include medications, autoimmune disease, malignancy and IgG4 related disease. Almost all the reported cases of IgG4 related disease had evidence of multifocal involvement such as the pancreas, aorta and kidneys. Our patient was diagnosed with isolated RPF due to IgG4 disease. He met all the suggested diagnostic criteria, was started on oral steroids and had an excellent clinical outcome. Conclusion IgG4 related disease can present with isolated retroperitoneal fibrosis without involvement of other organ systems. The diagnosis should be based on specific criteria. Treatment with corticosteroids can lead to remission both clinically and radiographically., Highlights • Retroperitoneal fibrosis can present in a variety of clinical pictures. • IgG4 related disease can present with isolated retroperitoneal fibrosis. • It is diagnosed based on clinical, radiological and pathological criteria. • Treatment with corticosteroids can lead to clinical and radiological remission.

Human immune deficiency virus (HIV) infection remains a major health problem since discovery of the virus in 1981. Globally, since introduction of antiretroviral therapy, AIDS-related mortality was reduced by 47% since 2010. Also, HIV-related opportunistic infections (OIs) became less common, especially with use of prophylaxis to prevent such infections. In this study, we aim to assess the incidence of HIV infection and related OIs in Qatar for 17-year period, and to assess the spectrum of these infections, risk factors and treatment outcomes.This is a retrospective cohort study for all HIV infected patients registered in the state of Qatar from 2000 to 2016. Incidence of HIV infection and related opportunistic illness was calculated per 100,000 population. Demographic and Clinical characteristic were compared between two groups of patients with and without opportunistic illness.of 167 cases with HIV infection 54 (32.3%) had opportunistic illness. The average incidence rate of HIV infection over 17 years is 0.69 per 100,000 population, and the incidence rate for opportunistic illness is 0.27 per 100,000 population. The most common opportunistic illness is pneumocystis jirovecii pneumonia (PCP) which constituted 25% of cases, followed by cytomegalovirus (CMV) retinitis 7.2%, Tuberculosis 5.4%, Toxoplasmosis 4.2% and, less than 2% for each of Kaposi sarcoma, lymphoma and cryptococcal infection.The outcome of treatment of cases with opportunistic illness showed cure rates of 59.3%, one year relapse rates of 8.76% and overall, 90-day mortality of 3.7% however, 33.4% of patients left the country before completion of therapy.Most of our patients in both groups were of young age, majority males, and almost half of them were Qatari. The CD4 count, CD4%, CD4/CD8 ratio and viral load were statistically significant risk factors in cases with opportunistic illness with a p value 0.05, however presence of comorbidities was lower in patients with opportunistic illness P value of 0.032.Qatar has a low prevalence rate for HIV infection and related opportunistic illness. Early diagnosis and use of antiretroviral therapy are important measures to decrease the rate of opportunistic illness.

Manifestations of infection byWe are reporting 15 cases with isolatedWe are reporting 15 cases with isolated12 of the 15 reported cases were considered significant and received a complete course of antimicrobial therapy. The patients presented with a wide variety of clinical pictures and were of variable age.

The non-typhoid Salmonella (NTS) species are commonly associated with gastroenteritis and other forms of intestinal disease. Thoraco-pulmonary infections are less commonly reported. We describe the case of a 66-year-old Qatari lady who presented with subacute cough. Chest imaging revealed multiple pulmonary and a pericardial cavitary lesion with air fluid levels. Bronchoalveolar lavage culture grew Salmonella species group D. The patient was treated with 4 weeks of appropriate antibiotics. Clinical and radiological improvement were documented on subsequent follow up. To our knowledge, this is the first reported case of pulmonary and pericardial salmonella abscesses in the state of Qatar.

Amyloidosis is a well‐known disease with various types and subtypes. One of the most recently identified types is leukocyte chemotactic factor 2 amyloidosis (LECT 2), which was found to be common in certain ethnic backgrounds. It is suggested that the diagnosis of this type is vital to prevent any therapy‐related complications when it is erroneously diagnosed as AL amyloidosis. The clinical presentation is usually slowly progressive kidney disease and mild hepatic impairment. We report a case of LECT2 amyloidosis, which presented with severe painless cholestasis and hepatic encephalopathy alongside progressive kidney disease., We report this case to raise awareness about this type of amyloidosis and its possible association with severe hepatic disease.It is essential to identify LECT2 amyloidosis and to differentiate it from other types of amyloidosis, because treatment is different.

One of the most recently identified types is Leukocyte chemotactic factor 2 amyloidosis (LECT 2) which was found to be common in certain ethnic backgrounds. It is suggested that the diagnosis of this type is vital to prevent any therapy-related complications when it is erroneously diagnosed as AL amyloidosis.

Introduction Guillain-Barré syndrome (GBS) is an immune-mediated peripheral neuropathy that was reported following meningococcus, polio, influenza and rabies vaccines. However, an association with the COVID-19 vaccine is yet to be established. Presentation of case We present the case of an elderly gentleman with no history of SARS-CoV-2 infection or any recent viral or bacterial illnesses who presented with GBS 20 days after the second dose of COVID-19 vaccination. The diagnosis was established based on physical examination, magnetic resonance imaging (MRI) of the spine, cerebrospinal fluid (CSF) analysis and electromyography (EMG). Discussion Due to the occurrence of GBS after certain types of infections, molecular mimicry has become widely acceptable as the underlying pathophysiology. The reported cases of GBS following vaccination further supported this theory, however proving a causal relationship between vaccines and GBS on the molecular level remains a challenge. Conclusions To the best of our knowledge this is the first reported case in the state of Qatar. It is important to mention that more research is needed to establish an association between COVID-19 vaccine and GBS. In our opinion, the benefits of COIVID-19 vaccine largely outweigh its risks., Highlights • COVID-19 vaccines and their adverse events are an emerging topic in medicine. • GBS was reported following influenza, hepatitis A and COVID-19 vaccines. • It is an immune-mediated peripheral neuropathy triggered by molecular mimicry. • More research is needed to confirm an association with COVID-19 vaccine.

Background Actinomyces species are Gram positive anaerobic, non-sporulating, non-acid fast, non-motile, irregularly staining bacterium. It is associated with a wide range of infections including; dental caries, abscesses, intraabdominal and bloodstream infections. A. odontolyticus normally a commensal organism found in the mouth, was first isolated from dental caries in 1958. The incidence of Actinomyces odontolyticus bacteremia is less common. Methods We are reporting 15 cases of isolated A. odontolyticus blood stream infection at HMC, State of Qatar from 1/1/2016 to 1/11/2020. We aim to describe their clinical characteristic, risk factors and treatment outcome. Results Our patients with bacteraemia fall into one of two groups. The first group consists of paediatric patients with unremarkable co-morbidities. The second group includes older adults, often with co-morbidities that pre-dispose to infection, such as diabetes mellitus or hypertension. Fever was the main presenting sign and symptom in 12 patients (80%). Nine of the patients were females (60%). 13 patients (86%) received antibiotics. Maximum duration of antibiotics was 60 days and minimum duration was three days. The infectious disease team was consulted for six patients (40%). One patient died while the other 14 recovered uneventfully with a case fatality rate of 6.6%. Reported cases of Actinomyces odontolyticus bacteraemia in Hamad Medical Corporation between 1/1/2016 to 1/11/2020 Minimal inhibitory concentrations (MICs) of selected antibiotics against A. odontolyticus, including interpretations and breakpoints, as reported by the AMRHAI reference unit, PHE Colindale Conclusion Clinicians of all specialties need to be aware of the rising number of reports of Actinomyces species bacteraemia due to widespread availability of molecular identification techniques, including MALTI-TOF. 3 Furthermore, more studies are needed to determine guidelines for treating these resilient microbes Disclosures All Authors: No reported disclosures

Euglycemic diabetic ketoacidosis (EuDKA) secondary to Sodium-glucose co-transporter-2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2D) is a rare but increasingly reported phenomenon. Not much is known about the burden of EuDKA in patients on SGLT2i or the associated factors. This retrospective cohort study tries to delineate the differences in factors associated with the development of EuDKA as compared to hyperglycemic DKA. We conducted a multicentre, retrospective study across three tertiary care centers under Weill Cornell affiliated-Hamad Medical Corporation, Qatar. The cohort comprised of T2D patients on SGLT2i who developed DKA between January 2015 to December 2020. The differences between the subjects who developed EuDKA or hyperglycaemic DKA (hDKA) were analyzed. A total of 9940 T2D patients were on SGLT2i during 2015–2020, out of which 43 developed DKA (0.43%). 25 developed EuKDA, whereas 18 had hDKA. The point prevalence of EuDKA in our cohort was 58.1%. EuDKA was most common in patients using canagliflozin, followed by empagliflozin and Dapagliflozin (100%, 77%, and 48.3%, respectively). Overall, infection (32.6%) was the most common trigger for DKA, followed by insulin non-compliance (13.7%). Infection was the only risk factor with a significant point estimate between the two groups, being more common in hDKA patients (p-value 0.006, RR 2.53, 95% CI 1.07–5.98). Canagliflozin had the strongest association with the development of EuDKA and was associated with the highest medical intensive care unit (MICU) admission rates (66.6%). In T2D patients on SGLT2i, infection is probably associated with an increased risk of developing EuDKA. The differential role of individual SGLT2i analogs is less clear and will need exploration by more extensive prospective studies.Other Information Published in: Scientific Reports License: https://creativecommons.org/licenses/by/4.0See article on publisher's website: http://dx.doi.org/10.1038/s41598-021-89752-w

COVID-19 complications present a huge burden on healthcare systems and warrant a predictive risk model for disease severity of SARS-CoV-2 infection to enable early intervention, prospective decision-making and triaging of patients. We profiled plasma proteins from COVID-19 patients (severe n=50, and mild n=50) and controls (n=50) using function- and pathway-based panels developed with the highly specific proximity extension assays. Several biological pathways were specific for patients with severe complications. Based on these dysregulated profiles, we propose candidate FDA-approved drugs that target multiple upregulated proteins to treat severe complications. In addition, the set of differentially expressed plasma proteins in severe disease contained a robust 46-protein signature, the COVID-19 molecular severity score, which predicts the risk of severe complications. We cross-validated this molecular severity score in an independent cohort and found it useful within three days after hospital admission to predict COVID-19 severity and outcomes. Associated with the molecular severity score, we identified a set of clinical parameters available at admission, that act as a clinical risk score for complications. The molecular and clinical risk scores described in our study may be prognostic tools for severe COVID-19 disease and help alleviate the pressure on healthcare systems during infection peaks.

COVID-19 complications still present a huge burden on healthcare systems and warrant predictive risk models to triage patients and inform early intervention. Here, we profile 893 plasma proteins from 50 severe and 50 mild-moderate COVID-19 patients, and 50 healthy controls, and show that 375 proteins are differentially expressed in the plasma of severe COVID-19 patients. These differentially expressed plasma proteins are implicated in the pathogenesis of COVID-19 and present targets for candidate drugs to prevent or treat severe complications. Based on the plasma proteomics and clinical lab tests, we also report a 12-plasma protein signature and a model of seven routine clinical tests that validate in an independent cohort as early risk predictors of COVID-19 severity and patient survival. The risk predictors and candidate drugs described in our study can be used and developed for personalized management of SARS-CoV-2 infected patients.

Highlights • Hydatidosis is an endemic infection and can involve a variety of organ systems. • The mediastinum is one of the rarest locations of hydatidosis. • It can occur primarily or secondarily to intrathoracic and intraabdominal Echinococcus. • Surgical treatment remains very crucial in the management of these cases. • The exact mechanism by which primary mediastinal hydatidosis occurs remains a debatable subject., Mediastinal involvement of hydatidosis is rare even in endemic areas. Isolated mediastinal without lung or liver involvement is even less commonly reported. We present the case of a young gentleman who was diagnosed with primary mediastinal hydatidosis based on clinical, radiological and pathological criteria. He underwent successful resection of the lesion by VATS (Video-assisted thoracoscopic surgery) preceded by two weeks of medical treatment with albendazole and had an excellent outcome. To the best of our knowledge, this is the first reported case in the state of Qatar.

Snakebites occur worldwide with varying frequency. Outcomes associated with snakebite are varied and depend on the type of snake and the general health of the patient. We report a case of snakebite by Cerastes cerastes or desert horned viper. Consumptive coagulopathy and cardiotoxicity with electrocardiographic changes complicated the clinical course of the patient. To the best of our knowledge, this is the first reported case in the state of Qatar.

The Actinomyces bacteria are associated with cervicothoracic disease in immunocompromised patients; however, Actinomyces odontolyticus cervical infection with extensive spread to the mediastinum in a previously healthy patient was not reported before in Qatar. The patient underwent drainage of collections in synchrony with intravenous antibiotics and recovered with an excellent outcome.

Vitamin B(12) deficiency and its sequelae are well described and reported, especially in vegetarians. However, its association with haemodynamic instability is not well identified. We report a case of a young man, previously healthy, presenting with fever, hypotension requiring vasopressors and pancytopenia. Extensive workup was unrevealing for possible infective, inflammatory or endocrine causes except for vitamin B(12) deficiency. Fever and haematological parameters stabilised after adequate supplementation of cyanocobalamin (vitamin B(12)).

Vitamin B 12 deficiency and its sequelae are well described and reported, especially in vegetarians. However, its association with haemodynamic instability is not well identified. We report a case of a young man, previously healthy, presenting with fever, hypotension requiring vasopressors and pancytopenia. Extensive workup was unrevealing for possible infective, inflammatory or endocrine causes except for vitamin B 12 deficiency. Fever and haematological parameters stabilised after adequate supplementation of cyanocobalamin (vitamin B 12). - BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ. Scopus

Black hairy tongue is a temporary, harmless oral condition that gives the tongue a dark, furry appearance. The distinct look usually results from a build-up of dead skin cells on the papillae of the surface of the tongue that contains taste buds. The differential diagnosis includes a variety of medical conditions and medication side effect. We present a medical quiz about an occasionally missed cause of black hairy tongue.