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Abstract Background/ introduction Regional shelter-in-place (SiP) mandates had a substantial impact on physical health and access to care. The impact of SiP on chronic disease management, specifically diabetes mellitus, is unknown. We sought to quantify the impact of California’s 2020 SiP order on various health parameters in the Kaiser Permanente Northern California (KPNC) diabetic population. Methods This retrospective cohort study included 168,621 diabetic patients, stratified by pre-pandemic HbA1c level. Our primary outcome was the difference in HbA1c, systolic blood pressure (SBP), and diastolic blood pressure (DBP) comparing the pre- (September 1, 2019, to March 31, 2020) to post-SiP period (June 1, 2020, to December 31, 2020). Our secondary endpoints included use of insulin or oral hypoglycemic agents (OHAs) during the post-SiP period and change in body mass index (BMI). This study utilized a paired t-test and chi-squared testing in order to assess for statistically significant differences in pre- versus post-SiP values. Results Patients in this cohort were 52.29% male with 37.68% White, 22.35% Hispanic, 9.30% Black and 23.54% Asian and a mean age of 63 years. In this cohort, 44.02% of patients had a HbA1c

Abstract Background Pregnancy-related Acute kidney injury (PR-AKI) accounts for approximately 15% of maternal mortality, with 10–30% progressing to end stage renal disease (ESRD). However, there are no comparative studies of obstetric and non-obstetric AKI. This study compares the outcomes of both groups with short-term follow-up to day 90. Materials and methods This prospective observational study was conducted over 1.5 years, enrolling 260 cases divided into non-obstetric and obstetric AKI groups. Inclusion criteria: Non-obstetric group - patients > 18 years with AKI; Obstetric group - pregnant or up to 42 days postpartum with AKI, as per KDIGO criteria. Patients with known Chronic kidney disease (CKD) or transplant were excluded. Demographics, clinical profiles and relevant investigations (including renal biopsy) were analysed. Outcomes assessed at days 7, 30, and 90 for complete recovery, dialysis dependency, CKD progression, and mortality. Results Of 260 patients, 83.4% were in non-obstetric group while 16.6% were in the obstetric group. Sepsis was leading cause of AKI (51.5%), affecting 47.7% of non-obstetric and 74.4% of obstetric patients. Renal biopsies (12.3% of cases) predominantly showed acute tubular injury, lupus nephritis, Minimal change disease, Focal segmental glomerulosclerosis, ANCA-associated Glomerulonephritis (GN), IgA nephropathy, and Membranoproliferative GN. In Obstetric AKI, acute cortical necrosis and thrombotic microangiopathy (TMA) were common biopsy findings. At 3-months follow-up, complete recovery was higher in the non-obstetric group (40.5% vs. 33.3%), with the obstetric group having more progression to CKD and dialysis dependency. Mortality was higher in non-obstetric AKI (50.4% vs. 33.3%), likely due to underlying comorbidities. Conclusion Non-obstetric AKI showed higher early mortality but better long-term recovery, while obstetric AKI had poorer renal outcomes and a higher risk of progression to CKD. Early detection and intervention are critical for improving outcomes.

Background: MRI fusion prostate biopsy has improved the detection of clinically significant prostate cancer (CSC). Continued refinements in predicting the pre-biopsy probability of CSC are essential for optimal patient counseling. We investigated potential factors related to improved cancer detection rates (CDR) of CSC in patients with PI-RADS ≥ 3 lesions. Methods: The pathology of 980 index lesions in 980 patients sampled by transrectal mpMRI-targeted prostate biopsy across four medical centers between 2017–2020 was reviewed. PI-RADS lesion distribution included 291 PI-RADS-5, 374 PI-RADS-4, and 315 PI-RADS-3. We compared CDR of index PI-RADS ≥ 3 lesions based on location (TZ) vs. (PZ), PSA density (PSAD), and history of prior negative conventional transrectal ultrasound-guided biopsy (TRUS). Results: Mean age, PSA, prostate volume, and level of prior negative TRUS biopsy were 66 years (43–90), 7.82 ng/dL (5.6–11.2), 54 cm3 (12–173), and 456/980 (46.5%), respectively. Higher PSAD, no prior history of negative TRUS biopsy, and PZ lesions were associated with higher CDR. Stratified CDR highlighted significant variance across subgroups. CDR for a PI-RADS-5 score, PZ lesion with PSAD ≥ 0.15, and prior negative biopsy was 77%. Conversely, the CDR rate for a PI-RADS-4 score, TZ lesion with PSAD < 0.15, and prior negative biopsy was significantly lower at 14%. Conclusions: For index PI-RADS ≥ 3 lesions, CDR varied significantly based on location, prior history of negative TRUS biopsy, and PSAD. Such considerations are critical when counseling on the merits and potential yield of prostate needle biopsy.

Type 1 diabetes mellitus (T1DM) is an autoimmune illness that targets specific organs and associated with other autoimmune conditions. Dermatomyositis is an idiopathic systemic autoimmune condition involving skeletal muscles and skin. Co-occurrence of both disorders is quite rare. We diagnosed dermatomyositis in a young male with T1DM who presented with muscle weakness and cutaneous manifestations. There is an additional metabolic hurdle in T1DM, as high doses of glucocorticoids used in dermatomyositis management are related to glycemic instability which requires regular blood sugar monitoring and insulin dose titration accordingly. Considering the prognostic consequences, early diagnosis and management of dermatomyositis is essential.

Background: The association between cardiovascular disease and advanced liver disease is incompletely understood. To explore this interaction, we compared management, clinical outcomes, readmission rates, and resource utilization in ST-elevation myocardial infarction (STEMI) patients with and without liver disease. Methods: The Nationwide Readmissions Database (2016–2020) was queried to identify hospitalizations for STEMI. Cohorts were stratified by presence of liver disease. Liver disease was defined as documented diagnosis of liver cirrhosis or liver failure. Multivariable regression model and propensity score matching was used to compare the risk of outcomes. Results: Among 1,029,608 hospitalizations for STEMI; 45,478 (4.4 %) patients had a history of significant liver disease. Patient with liver disease had higher baseline prevalence of diabetes, chronic kidney disease, anemia, and heart failure. After propensity matching (N = 24,067 in each group), patients with liver disease had higher in-hospital mortality (48.8 % vs 17.3 %, aOR: 6.80 [CI: 6.55–7.06], p

Aims •This case study investigates a rare occurrence of symptom transition in a chronic schizophrenia patient following high-frequency repetitive transcranial magnetic stimulation (rTMS), aiming to understand the unexpected shift from predominantly negative to positive symptoms. •rTMS, known for inducing changes in neuronal activity based on Faraday's law, is believed to enhance cortical excitability through high-frequency stimulation. •Schizophrenia, a severe and chronic mental disorder, presents with both positive (e.g., delusions, hallucinations) and negative symptoms (e.g., apathy). Current treatments, predominantly antipsychotic drugs, often show limited efficacy, especially for negative symptoms. Non-invasive neuromodulation techniques like rTMS are emerging as potential interventions. Methods This case involves a 27-year-old banking executive with a 30 months illness duration primarily marked by negative symptoms over the past 3 months. Despite various antipsychotics, there was no improvement, leading to the initiation of high-frequency rTMS on the left dorsolateral prefrontal cortex (DLPFC) as an adjunct strategy for persistent negative symptoms. Surprisingly, after the 5th rTMS session, positive symptoms like delusions and hallucinations emerged. Serial assessments demonstrated a decrease in negative symptom domain scores on PANSS but an increase in positive symptom domain scores on PANSS. Results •Results suggest that 5 Hz rTMS over the left DLPFC may have contributed to the transition to positive symptoms. The discussion explores limited literature on rTMS-induced positive symptoms, with case reports dating back to 2004 indicating the possibility of such induction. Studies propose a link between higher pulse frequency, motor threshold intensity, left prefrontal cortex stimulation, and longer trial durations with the exacerbation of positive symptoms, possibly linked to dopamine changes in specific brain tracts. •Recent trials indicate potential improvement in positive symptoms, such as excitement, with low frequency rTMS of the temporo parietal area. However, the efficacy of rTMS varies with the stimulation site, with left prefrontal rTMS showing promise for negative symptoms and left temporo-parietal junction stimulation possibly reducing auditory hallucinations. Conclusion This case report suggests that a subset of schizophrenia patients may experience a transient exacerbation of positive symptoms following rTMS. This underscores the need for increased awareness of potential side effects, serving as an exploratory study that calls for future research to refine these findings for a clearer understanding of rTMS-induced symptom switches in schizophrenia.

Background Diabetes is the strongest risk factor for cardiovascular disease, and although glycosylated hemoglobin (HbA1c) levels are known to vary by race, no racial and ethnic–specific diagnostic thresholds exist for diabetes in prediction of cardiovascular disease events. The purpose of this study is to determine whether HbA1c thresholds for predicting major adverse cardiovascular events (MACEs) differ among racial and ethnic groups. Methods and Results This is a retrospective cohort study of Kaiser Permanente Northern California adult members (n=309 636) with no history of cardiovascular disease who had HbA1c values and race and ethnicity data available between 2014 and 2019. Multivariable logistic regression was used to evaluate the odds of MACEs by the following racial and ethnic groups: Filipino, South Asian, East Asian, Black, White, and Hispanic. A Youden index was used to calculate HbA1c thresholds for MACE prediction by each racial and ethnic group, stratified by sex. Among studied racial and ethnic groups, South Asian race was associated with the greatest odds of MACEs (1.641 [95% CI, 1.456–1.843]; P

Interior Design of a room is the main aspect that contributes to the beauty of the room and also the comfort of people in the room. Globalization contributes to the rampant development of sales of products for interior design needs with a supply of quality goods and competitive prices. Many new entrepreneurs act as part of the distribution channel and open retail businesses. One of them is SA Interior. The theories used in this study are price, product quality, service quality and purchasing decisions. Price Level, Product Quality and Quality of Service are free/independent variables (X), Purchasing Decisions are bound/dependent variables (Y) and the object of research is the SA Interior store at ITC Cempaka Mas. The sample used in this study was SA Interior customers who purchased SA Interior products at least 1 time. The data collection technique uses communication techniques by distributing questionnaires (via Google Form) with a total of 100 respondents. This research shows that the price level has a positive and significant influence on the purchasing decisions of SA Interior customers, the quality of the products has a positive and significant influence on the purchasing decisions of SA Interior customers and the quality of service has a positive and significant influence on the purchasing decisions of SA Interior customers. Simultaneous price levels, product quality and service quality have a significant influence on the purchasing decisions of SA Interior customers. The conclusion of this study is that the price level, product quality and service quality have a positive and significant influence on the purchasing decisions of SA Interior customers at ITC Cempaka Mas.

Introduction: Nonmaturation of arteriovenous fistula (AVF) is a common obstacle due to neointimal hyperplasia (NIH). The present study evaluated the clinical and histopathological factors predicting AVF nonmaturation. Methodology: This prospective observational study was conducted over 18 months in 100 patients. AVF site venous tissue samples of 55 4/5 chronic kidney disease stages patients were collected. Histopathological analysis was done to detect four immunohistochemistry (IHC) markers, namely cluster of differentiation (CD68), CD31, α-SMA, and Ki67. IIntimal composition, hyperplasia, and calcification were also assessed. Fistulae were followed up at the 2nd, 6th, and 12th weeks and classified into mature and nonmature groups at 12 weeks based on clinical and Doppler examination. A comparison between the two groups was done and an association of radiological, histopathological, and IHC parameters of nonmature AVF was also carried out. Results: Among 55 patients, 35 (63.6%) had mature AVF and 26 (47%) had preexisting NIH. Preexisting NIH had no significant association with maturation (odds ratio: 0.44). Subjects without preexisting NIH had a significantly higher luminal diameter in 2nd week (P ≤ 0.05). There was a significant increase in blood flow both between the 2nd and 6th and between the 6th and 12th week (P < 0.05). Of the four IHC markers, three markers viz., CD68 (ρ = 0.525), CD31 (ρ = 0.420), and α-smooth muscle actin (ρ = 0.718) correlated significantly (P < 0.05) with the NIH. The mean AVF diameter and blood flow in the matured arm were more than that in the nonmatured arm at all the follow-ups (P < 0.09). Conclusion: The presence of CD68, CD31, and α-smooth muscle actin in the venous tissue suggests preexisting NIH which postoperative luminal diameter and blood flow may have long-term consequences in AVF functioning.

Background: Despite of several guidelines metformin and glimepiride remains the first prescribed drug in most people with diabetes. Very often canagliflozin and teneligliptin remain the third prescribed OHA. Efficacy of teneligliptin and canagliflozin as solo drug or in combination with other single OHA’s on glycaemic parameters, lipid profiles & blood pressure is already established. But their efficacy on above parameters when used as third drug next to metformin and sulfonylurea is still not investigated. Aims and objectives: Aim of this study is to compare glycaemic and non-glycemic effects of canagliflozin and teneligliptin as third line drug. Objective is to establish their multiple pleotropic effects at this position. Methods: Subjects with uncontrolled glycaemic parameters with hypertension and diabetic dyslipidaemia already on half maximal doses of metformin and glimepiride were enrolled in the study. Out of 87 selections, 45 were prescribed canagliflozin 100 mg/d and to 42 subjects, teneligliptin 20mg/d, each for 24 weeks. Effects over HbA1c, fasting and post prandial plasma glucose, systolic and diastolic blood pressures, HDL’c and triglycerides were observed pre and post intervention. Results: As a third drug both canagliflozin and teneligliptin show significant reduction in HbA1c (1.5 versus 1.6%), fasting (-20.2 versus -28.8 mg %), and post prandial (-39.9 versus – 58.5mg %). Effects over systolic (4 mmHg versus 1.1 mmHg) and diastolic BP (3.1 mmHg versus 0.2 mmHg) was clinically and statistically significant (p = 0.3 and 0.1) respectively in both groups. A statistically insignificant (9.6 versus 4.1 mg%; p =) reduction in Triglycerides but significant (7.6 versus 1.2; p

Maternally inherited diabetes and deafness (MIDD) is a rare subtype of diabetes with a prevalence of up to 1% globally but often missed if not suspected. We present a case of MIDD and a thorough review of the literature related to it. The phenotypic presentation of diabetes depends on heteroplasmy levels of m.3243A>G mutation of the individual patient. Patients with MIDD may have involvement of other organs such as eye, muscles, kidney, and heart. In our patient, along with diabetes and deafness, there was also an associated vision loss with a strong maternal inheritance of diabetes. A young male who presented with diabetic ketoacidosis (DKA) and hearing and vision impairment and on further diagnostic work up turned out to be a case of genetically confirmed (m.3243A>G mutation) MIDD. To the best of our knowledge, this should be the first case of MIDD presenting as DKA being reported from India.

Objective: To study cardiovascular sequelae of post-COVID-19 patients with moderate to severe computed tomography (CT) severity score. Methods: A prospective, non-randomized, observational study was conducted on 100 post-COVID-19 patients with moderate to severe CT severity scores from January 2021 to December 2021. Fifty- nine were male [mean age (54.1±12.2) years] and 41 were female [mean age (46.9±15.1) years]. Patients with previous cardiovascular disease, previous chronic lung disease, and pre-existing primary or secondary pulmonary hypertension were excluded. Patients were examined, and serial electrocardiogram and 2D echocardiography were performed to detect any cardiovascular abnormality. Results: Post-COVID-19 patients had persistent symptoms, the most common being fatigue (59%). Most of these symptoms were relieved on follow-up. A rise in systolic, diastolic blood pressure, and pulse rate was observed. The electrocardiographic evaluation revealed ST-T segment changes, sinus tachycardia, ventricular hypertrophy, and arrhythmias among a considerable number of patients. On echocardiography, left ventricular diastolic dysfunction was most common (43%). Pulmonary hypertension, as evidenced by elevated pulmonary artery systolic pressure, was seen in 15% of patients. Conclusions: The present findings reveal an increased incidence of cardiovascular complications after recovery from COVID-19 infection in those without pre-existing cardiovascular or chronic lung disease.

Introduction: Multiple mechanisms were proposed for the etiopathogenesis of type 1 diabetes mellitus (T1DM). An interplay between genetic, environmental, and immunological factors leads to generate autoantibodies against glutamic acid decarboxylase 65, intracellular adhesion (ICA)-512, and insulin autoantibodies (IAA) proteins of beta cells. Molecular mimicry is the best proposed mechanism of the above, but yet needs much solid evidence. Zinc transporter 8 (ZnT8) and proinsulin (PI) proteins of beta cells act as epitopes for some partially recognized proteins (MAP3865c, MAP1, 4αgbp, and MAP2404c) of mycobacterium paratuberculosis (MAP) generating autoantibodies against them. Similarly, other protein molecular mimickers were also reported. This review collects the latest evidence for the environmental etiopathogenesis of T1DM pertaining to MAP at the background of the phenomenon of molecular mimicry, and it proposes more directions for research in the field. Materials and Methods: Using the keywords “MAP and T1DM,” “MAP and zoonotic diseases,” T1DM and Molecular mimicry” and “T1DM and epitopes” searches were conducted in PubMed, Science Direct, and Google Scholar following PRISMA guidelines. This review related original articles and case reports were collected for the compilation of all proposed proteins having a tendency of molecular mimicry. This review includes 12 original articles and 17 case reports published till date. Results: A strong association was found in peptide pairs MAP3865c/ZnT8, 4αgbp/PI, and MAP2404c/PI between MAP and human beings. Discussion: Multiple MAP proteins show strong homology to human proteins generating antibodies against pancreatic beta cells. MAP exists in dairy products, posing a high risk of transmission to human beings. An uninterrupted but silent exposure of human beings to MAP could be an environmental trigger for T1DM.

Abstract South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a “risk enhancer” in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30–70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low

Background/ introduction: Regional shelter-in-place (SiP) mandates had a substantial impact on physical health and access to care. The impact of SiP on chronic disease management, specifically diabetes mellitus, is unknown. We sought to quantify the impact of California's 2020 SiP order on various health parameters in the Kaiser Permanente Northern California (KPNC) diabetic population. Methods: This retrospective cohort study included 168,621 diabetic patients, stratified by pre-pandemic HbA1c level. Our primary outcome was the difference in HbA1c, systolic blood pressure (SBP), and diastolic blood pressure (DBP) comparing the pre- (September 1, 2019, to March 31, 2020) to post-SiP period (June 1, 2020, to December 31, 2020). Our secondary endpoints included use of insulin or oral hypoglycemic agents (OHAs) during the post-SiP period and change in body mass index (BMI). This study utilized a paired t-test and chi-squared testing in order to assess for statistically significant differences in pre- versus post-SiP values. Results: Patients in this cohort were 52.29% male with 37.68% White, 22.35% Hispanic, 9.30% Black and 23.54% Asian and a mean age of 63 years. In this cohort, 44.02% of patients had a HbA1c < 7%, while 29.17%, 13.67%, 6.34% and 6.81% had an HbA1c of 7-7.9%, 8-8.9%, 9-9.9% and ≥ 10%, respectively (range 4.10 to 19.50%). Mean HbA1c, SBP, and DBP increased significantly across all groups; OHA use and insulin utilization also increased overall. Patients with lower pre-SiP HbA1c demonstrated larger increases in HbA1c and OHA utilization, while patients with higher pre-SiP HbA1c demonstrated increased rates of insulin initiation and decreases in their post-SiP HbA1c. Notably, mean BMI decreased in every HbA1c subgroup. Due to the large sample size, all p-values were < 0.0001. Conclusions: Among the KPNC diabetic population, several metrics for diabetes health management were significantly worsened after California's SiP. However, diabetic patients with the highest HbA1c values showed clinically significant improvement in their HbA1c, indicating a differential effect of the SiP on diabetes management. Our study helps identify higher-risk diabetic patients who require more intensive monitoring in the setting of the recent pandemic and highlights the importance of considering long-term implications of policy decisions on diabetes care. [ABSTRACT FROM AUTHOR]

Background: Pregnancy-related Acute kidney injury (PR-AKI) accounts for approximately 15% of maternal mortality, with 10–30% progressing to end stage renal disease (ESRD). However, there are no comparative studies of obstetric and non-obstetric AKI. This study compares the outcomes of both groups with short-term follow-up to day 90. Materials and methods: This prospective observational study was conducted over 1.5 years, enrolling 260 cases divided into non-obstetric and obstetric AKI groups. Inclusion criteria: Non-obstetric group - patients > 18 years with AKI; Obstetric group - pregnant or up to 42 days postpartum with AKI, as per KDIGO criteria. Patients with known Chronic kidney disease (CKD) or transplant were excluded. Demographics, clinical profiles and relevant investigations (including renal biopsy) were analysed. Outcomes assessed at days 7, 30, and 90 for complete recovery, dialysis dependency, CKD progression, and mortality. Results: Of 260 patients, 83.4% were in non-obstetric group while 16.6% were in the obstetric group. Sepsis was leading cause of AKI (51.5%), affecting 47.7% of non-obstetric and 74.4% of obstetric patients. Renal biopsies (12.3% of cases) predominantly showed acute tubular injury, lupus nephritis, Minimal change disease, Focal segmental glomerulosclerosis, ANCA-associated Glomerulonephritis (GN), IgA nephropathy, and Membranoproliferative GN. In Obstetric AKI, acute cortical necrosis and thrombotic microangiopathy (TMA) were common biopsy findings. At 3-months follow-up, complete recovery was higher in the non-obstetric group (40.5% vs. 33.3%), with the obstetric group having more progression to CKD and dialysis dependency. Mortality was higher in non-obstetric AKI (50.4% vs. 33.3%), likely due to underlying comorbidities. Conclusion: Non-obstetric AKI showed higher early mortality but better long-term recovery, while obstetric AKI had poorer renal outcomes and a higher risk of progression to CKD. Early detection and intervention are critical for improving outcomes. [ABSTRACT FROM AUTHOR]

Primary cardiac tumors account for only 0.3% of all cardiac tumors; of these, lymphomas account for only 2% of all primary cardiac tumors. Cardiac lymphomas have a grim prognosis, often less than 1 year due to delays in diagnosis and treatment. Cardiac MRI is the gold standard for the imaging of cardiac tumors. We describe the case of a 76-year-old man with no significant past medical history who presented to the emergency department with a large pericardial effusion that was found to be consistent with cardiac lymphoma on cardiac MRI prior to tissue diagnosis of a primary cardiac diffuse large B-cell lymphoma. The clinical and radiological features of cardiac lymphoma are reviewed, and the therapeutic management and side-effects that the patient experienced are discussed.