Type 1 Diabetes Mellitus Caused by COVID-19 mRNA Vaccination: A Case Report and Literature Review of 17 Published Cases.

Background/Objective: Multiple cases of postvaccination immune-related adverse events have been reported. We, hereby, present a patient who presented with new-onset type 1 diabetes mellitus (DM) after COVID-19 messenger RNA (mRNA) vaccination. Case Report: A 38-year-old Caucasian man presented with sudden onset of polyuria, polydipsia, and blurry vision for 1 month. The patient received the second dose of the COVID-19 mRNA vaccine (Pfizer-BioNTech) 4 weeks prior to symptom onset. Initial workup revealed glucosuria and hemoglobin A1c of 9.4%. Antibodies against multiple pancreatic beta cell autoantigens were detected. The patient was then initiated on insulin. Discussion: Hypothesized mechanisms for development of type 1 DM after COVID-19 mRNA vaccination include molecular mimicry, autoimmune/inflammatory syndrome induced by adjuvants, and possible interaction between the angiotensin-I converting enzyme-2 receptor on beta cells and viral mRNA. An initial high index of suspicion should be accompanied by early autoantibody testing and initiation of insulin, if indicated. Finally, if diagnosed with type 1 diabetes, patients must have long-term follow-up as there may be brief periods where glycemic control is maintained off insulin. Conclusion: New-onset type 1 DM has been reported after COVID mRNA vaccination. Clinicians should maintain a high index of suspicion and pursue early testing for the same to reduce adverse outcomes and improve long-term prognosis.

Real world treatment outcomes in polypoidal choroidal vasculopathy in a Caucasian population of British ethnicity.

PURPOSE: To assess treatment response of Polypoidal choroidal vasculopathy (PCV) in a Caucasian population of British ethnicity with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections alone and with a combination of anti-VEGF injections and photodynamic therapy (PDT). SETTING/VENUE: Department of Ophthalmology, University Hospital Southampton NHS Foundation Trust, United Kingdom. METHODS: Retrospective review of 95 Caucasian patients in a single centre with diagnosis of PCV between 2013 and 2018 were included. Best corrected visual acuity (BCVA), central retinal thickness (CRT), indocyanine green angiography (ICGA) characteristics, numbers and type of treatment were analysed at baseline and at 1 year. RESULTS: One hundred and one eyes included from 95 patients received either anti-VEGF injections (n = 79, 78.2%) alone or combination therapy with anti-VEGF and PDT (n = 6, 6%). A third untreated group was also observed (n = 16, 15.8%). Five eyes were excluded from the study due to structural retinal damage. Mean number of injections was 7.3 in the monotherapy group and 6.5 in the combination group. Both treatment groups showed improvement in BCVA at 1 year and this was statistically significant in the monotherapy group with a mean gain of 8.3 letters (p < 0.001). Mean CRT decreased in all treatment groups at twelve months and this change was significant (p < 0.01). In the observation group, vision and CRT remained stable. CONCLUSIONS: This study demonstrates significant improvements in BCVA at one year in our Caucasian cohort of British ethnicity with PCV in the treatment group.

Ethical Implications of Artificial Intelligence in Gastroenterology: The Co-pilot or the Captain?

Though artificial intelligence (AI) is being widely implemented in gastroenterology (GI) and hepatology and has the potential to be paradigm shifting for clinical practice, its pitfalls must be considered along with its advantages. Currently, although the use of AI is limited in practice to supporting clinical judgment, medicine is rapidly heading toward a global environment where AI will be increasingly autonomous. Broader implementation of AI will require careful ethical considerations, specifically related to bias, privacy, and consent. Widespread use of AI raises concerns related to increasing rates of systematic errors, potentially due to bias introduced in training datasets. We propose that a central repository for collection and analysis for training and validation datasets is essential to overcoming potential biases. Since AI does not have built-in concepts of bias and equality, humans involved in AI development and implementation must ensure its ethical use and development. Moreover, ethical concerns regarding data ownership and health information privacy are likely to emerge, obviating traditional methods of obtaining patient consent that cover all possible uses of patient data. The question of liability in case of adverse events related to use of AI in GI must be addressed among the physician, the healthcare institution, and the AI developer. Though the future of AI in GI is very promising, herein we review the ethical considerations in need of additional guidance informed by community experience and collective expertise.

Patients with Celiac Disease Have High Prevalence of Fatty Liver and Metabolic Syndrome.

OBJECTIVE: In recent years, patients with celiac disease (CeD) have been reported to have a high prevalence of fatty liver and metabolic syndrome. We conducted a systematic review and meta-analysis to assess the prevalence of fatty liver and metabolic syndrome in patients with CeD and effect of gluten-free diet in them. METHODS: The PubMed, Embase and the Cochrane Library databases were searched for original studies upto November 18, 2022. We included full-text articles published in the English language after 1990 that used well-defined criteria for CeD, fatty liver and metabolic syndrome. A random effects model was used to calculate pooled prevalence. RESULTS: Of 350 studies identified, 11 studies (n = 2578) were included in the analysis. On analysis of both cross-sectional and longitudinal studies, pooled prevalence of fatty liver and metabolic syndrome in treatment-naïve patients with CeD were 18.2% (95% CI 8.3-30.8%, n = 1237) and 4.3% (95% CI 2.4-6.7, n = 1239) and in those on GFD of varying duration was 28.2% (95% CI 20.7-36.4%, n = 1368) and 21.3% (95% CI 11.7-32.9%, n = 2193), respectively. There was no difference in the prevalence of fatty liver and metabolic syndrome between low- or high-income group countries. CONCLUSIONS: Patients with CeD have a high prevalence of fatty liver and metabolic syndrome which increases further with the initiation of GFD. Patients with CeD should thus be screened and monitored for development of fatty liver and metabolic syndrome. They should be counselled appropriately regarding their diet and inclusion of physical activity in their lifestyle.

Prevalence of endoscopy-related injuries and their impact on clinical practice: a systematic review and meta-analysis.

BACKGROUND: Endoscopy-related musculoskeletal injuries (ERIs) are commonly reported but their exact prevalence and clinical impact remain obscure. We conducted a systematic review and meta-analysis of the current literature aiming to answer these questions. METHODS: The MEDLINE, EMBASE, and SCOPUS databases were searched for studies evaluating ERIs in gastroenterologists and surgeons. The co-primary outcome was the prevalence of ERIs (i.e. carpal tunnel syndrome, de Quervain's tenosynovitis, and hand numbness). The second co-primary outcome was the prevalence of endoscopy-related pain syndromes. RESULTS: 12 studies, including 4563 respondents, were included. The majority of respondents were men (n = 3321; 72.8%) and most were right-handed (86.2%). The career prevalence of carpal tunnel syndrome (pooled from 10 studies) was 5.3% (95%CI 1.5%-8.9%; I 2 = 97.1%), while the prevalence of de Quervain's tenosynovitis (five studies) was 8.5% (95%CI 0.1%-17.0%). The pooled prevalences of thumb pain, neck pain, and back pain were 25.4%, 23.1%, and 19.7%, respectively, but the prevalence varied according to the type of questionnaire used. Only 341/864 respondents (39.5%) had received prior training in ergonomics, while 623/889 respondents (70.1%) expressed a desire for further training in ergonomics. Overall, there is a moderate risk of bias in the present literature. CONCLUSION: ERIs, including carpal tunnel syndrome, de Quervain's tenosynovitis, and endoscopy-related pain, are very common. These injuries can be severe, requiring surgery, and lead to loss of productivity. Most gastroenterologists report an unmet need for training in the proper ergonomics of endoscopy.

Can ChatGPT assist authors with abstract writing in medical journals? Evaluating the quality of scientific abstracts generated by ChatGPT and original abstracts.

INTRODUCTION: ChatGPT, a sophisticated large language model (LLM), has garnered widespread attention for its ability to mimic human-like communication. As recent studies indicate a potential supportive role of ChatGPT in academic writing, we assessed the LLM's capacity to generate accurate and comprehensive scientific abstracts from published Randomised Controlled Trial (RCT) data, focusing on the adherence to the Consolidated Standards of Reporting Trials for Abstracts (CONSORT-A) statement, in comparison to the original authors' abstracts. METHODOLOGY: RCTs, identified in a PubMed/MEDLINE search post-September 2021 across various medical disciplines, were subjected to abstract generation via ChatGPT versions 3.5 and 4, following the guidelines of the respective journals. The overall quality score (OQS) of each abstract was determined by the total number of adequately reported components from the 18-item CONSORT-A checklist. Additional outcome measures included percent adherence to each CONOSORT-A item, readability, hallucination rate, and regression analysis of reporting quality determinants. RESULTS: Original abstracts achieved a mean OQS of 11.89 (95% CI: 11.23-12.54), outperforming GPT 3.5 (7.89; 95% CI: 7.32-8.46) and GPT 4 (5.18; 95% CI: 4.64-5.71). Compared to GPT 3.5 and 4 outputs, original abstracts were more adherent with 10 and 14 CONSORT-A items, respectively. In blind assessments, GPT 3.5-generated abstracts were deemed most readable in 62.22% of cases which was significantly greater than the original (31.11%; P = 0.003) and GPT 4-generated (6.67%; P<0.001) abstracts. Moreover, ChatGPT 3.5 exhibited a hallucination rate of 0.03 items per abstract compared to 1.13 by GPT 4. No determinants for improved reporting quality were identified for GPT-generated abstracts. CONCLUSIONS: While ChatGPT could generate more readable abstracts, their overall quality was inferior to the original abstracts. Yet, its proficiency to concisely relay key information with minimal error holds promise for medical research and warrants further investigations to fully ascertain the LLM's applicability in this domain.

Correction: Contact tracing of COVID-19 in Karnataka, India: Superspreading and determinants of infectiousness and symptomatic infection.

[This corrects the article DOI: 10.1371/journal.pone.0270789.].

Isolated Proximal Black Esophagus in a COVID-19 Patient.

Black esophagus or acute esophageal necrosis (AEN) is a rare cause of upper gastrointestinal (UGI) bleeding usually involving distal esophagus. Proximal esophageal involvement is quite rare. We present an 86-year-old female with active coronavirus disease 2019 (COVID-19) infection who came in with newly diagnosed atrial fibrillation and was started on anticoagulation. She subsequently developed a UGI bleed, which was complicated by inpatient cardiac arrest. Following resuscitation and stabilization, UGI endoscopy showed circumferential black discoloration of proximal esophagus, with distal esophageal sparing. Conservative management was instituted and fortunately, repeat UGI endoscopy two weeks later showed improvement. This describes the first case of isolated proximal AEN in a COVID-19 patient.

Venous thromboembolism with renal infarct due to paradoxical embolism.

Paradoxical thromboembolism has variable presentation depending on site of embolisation. An African-American man in his 40s presented with severe abdominal pain, watery stools and exertional dyspnoea. At presentation, he was tachycardic and hypertensive. Labwork showed elevated creatinine with unknown baseline. Urinalysis showed pyuria. A CT scan was unremarkable. He was admitted with working diagnosis of acute viral gastroenteritis and prerenal acute kidney injury and supportive care was instituted. On day 2, the pain migrated to left flank. Renal artery duplex ruled out renovascular hypertension but showed a lack of distal renal perfusion. MRI confirmed a renal infarct with renal artery thrombosis. Transoesophageal echocardiogram confirmed a patent foramen ovale. Simultaneous arterial and venous thrombosis require hypercoagulable workup, including investigation for malignancy, infection or thrombophilia. Rarely, venous thromboembolism can directly cause arterial thrombosis by 'paradoxical thromboembolism'. Given the rarity of renal infarct, high index of clinical suspicion is necessary.

Contact tracing of COVID-19 in Karnataka, India: Superspreading and determinants of infectiousness and symptomatic infection.

BACKGROUND: India has experienced the second largest outbreak of COVID-19 globally, yet there is a paucity of studies analysing contact tracing data in the region which can optimise public health interventions (PHI's). METHODS: We analysed contact tracing data from Karnataka, India between 9 March and 21 July 2020. We estimated metrics of transmission including the reproduction number (R), overdispersion (k), secondary attack rate (SAR), and serial interval. R and k were jointly estimated using a Bayesian Markov Chain Monte Carlo approach. We studied determinants of risk of further transmission and risk of being symptomatic using Poisson regression models. FINDINGS: Up to 21 July 2020, we found 111 index cases that crossed the super-spreading threshold of ≥8 secondary cases. Among 956 confirmed traced cases, 8.7% of index cases had 14.4% of contacts but caused 80% of all secondary cases. Among 16715 contacts, overall SAR was 3.6% [95% CI, 3.4-3.9] and symptomatic cases were more infectious than asymptomatic cases (SAR 7.7% vs 2.0%; aRR 3.63 [3.04-4.34]). As compared to infectors aged 19-44 years, children were less infectious (aRR 0.21 [0.07-0.66] for 0-5 years and 0.47 [0.32-0.68] for 6-18 years). Infectors who were confirmed ≥4 days after symptom onset were associated with higher infectiousness (aRR 3.01 [2.11-4.31]). As compared to asymptomatic cases, symptomatic cases were 8.16 [3.29-20.24] times more likely to cause symptomatic infection in their secondary cases. Serial interval had a mean of 5.4 [4.4-6.4] days, and case fatality rate was 2.5% [2.4-2.7] which increased with age. CONCLUSION: We found significant heterogeneity in the individual-level transmissibility of SARS-CoV-2 which could not be explained by the degree of heterogeneity in the underlying number of contacts. To strengthen contact tracing in over-dispersed outbreaks, testing and tracing delays should be minimised and retrospective contact tracing should be implemented. Targeted measures to reduce potential superspreading events should be implemented. Interventions aimed at children might have a relatively small impact on reducing transmission owing to their low symptomaticity and infectivity. We propose that symptomatic cases could cause a snowballing effect on clinical severity and infectiousness across transmission generations; further studies are needed to confirm this finding.

Prognostic Value of SARS-CoV-2 Anti-RBD IgG Antibody Quantitation on Clinical Outcomes in Hospitalized COVID-19 Patients.

Background: Antibody levels against SARS-CoV-2 can be used as an indicator of recent or past vaccination or infection. However, the prognostic value of antibodies targeting the receptor binding protein (anti-RBD) in hospitalized patients is not widely reported. Purpose: Determine prognostic impact of SARS-CoV-2 antibody quantification at the time of admission on clinical outcomes in hospitalized COVID-19 patients. Methods: We conducted a pilot observational study on patients hospitalized with SARS-CoV-2 infection to determine the prognostic impact of antibody quantitation within the first two days of admission. Anti-nucleocapsid IgG (anti-N) and Anti-RBD levels were measured. Anti-RBD level of 500 AU/mL was used as a cutoff to stratify patients. Spearman's rank Coefficient (rs) was used to demonstrate association. Results: Of the 26 patients included, those who were vaccinated more frequently tested positive for Anti-RBD (100% vs 46.2%, P = 0.005) with higher median titer level (623 vs 0, P = 0.011) compared to unvaccinated patients. Anti-N positivity was more frequently seen in unvaccinated patients (53.9% vs 7.7%, P = 0.03). Anti-RBD levels >500 were associated with lower overall hospital length of stay (LOS)(5 vs 10 days, P = 0.046). The analysis employing a Spearman Rank coefficient demonstrated a strong negative correlation between anti-S titer and LOS (rs=-.515, p = 0.007) and a moderate negative correlation with oxygen needs (rs =-.401, p = 0.042). Conclusion: Anti-RBD IgG levels were associated with lower LOS and oxygen needs during hospitalization. Further studies are needed to determine if levels on admission can be used as a prognostic indicator.

Spectrum of height in patients with celiac disease.

BACKGROUND: Growth retardation is an important feature of celiac disease (CeD) that can lead to the failure of attainment of potential adult height. There is lack of data on the spectrum of height in treatment-naïve patients with CeD, with normal expected height at one end and short stature at the other. METHODS: We performed a retrospective analysis of a prospectively maintained database at our center, including a total of 583 treatment-naïve patients with CeD: 419 adults (183 [43.7%] males) and 164 adolescents (12-18 years) (72 [43.9%] males). The details extracted from the database included demographic details, height, weight, body mass index, clinical symptoms, biochemical parameters, anti-tissue transglutaminase antibody anti-tTG Ab) titer, and the severity of villous abnormalities (as per modified Marsh grade). The data from Indian National Family Health Survey-4 were used as comparators. RESULTS: Overall, 19.6% of adults and 57.9% of adolescents with CeD had short stature. While mean height of men with CeD was similar, women were taller than population controls. While a higher proportion of men with CeD had short stature as compared to the controls (32.2% vs. 20%, p<0.001), a lower proportion of women with CeD had short stature (9.7% vs. 18.9%, p<0.001). Higher proportion of adolescents with CeD had short stature compared to adults (57.9% vs. 19.6%, p<0.001). On multivariate analysis, adulthood was found to be associated with a lower prevalence of short stature. CONCLUSIONS: Overall, 19.6% of adults and 57.9% of adolescents with CeD had short stature. While the mean height of adult men with CeD was not significantly different from the population controls, women were taller. Adolescents with CeD were significantly shorter than their peers.

Prevalence of elevated alanine aminotransferase levels in adult participants from a community-based study from northern part of India.

Alanine aminotransferase (ALT) is a cytosolic enzyme specific to hepatocytes, and its elevated level in the peripheral blood denotes liver cell injury. Detection of persistently elevated ALT levels during routine health check-up in asymptomatic or symptomatic individuals provides a window of opportunity to explore the causes of liver cell damage and for the timely institution of appropriate treatment. This was a retrospective study using a subset of the data from a previous community-based prospective study done for the estimation of the prevalence of celiac disease (CD) in India,  during which estimation of ALT levels in the blood samples of participants was also carried out. Of the 11,053 individuals (4399 [39.8%] males; mean age 37.9 ± 13.3 years) screened, 6209 consented to provide blood samples for testing for CD. Of these, assessment of serum ALT levels was done in 6083 (2235 [36.7%] males) patients. ALT was elevated above the upper limit of normal (ULN) (> 40 IU/L) in 1246 (20.5%) of the participants and > 1.5 times (> 60 IU/L) in 329 (5.4%) participants. The ALT levels were elevated more frequently in men as compared to women (29.4% vs. 15.3%, p < 0.001). There was a significant positive correlation (Pearson correlation coefficient [r] = 0.25, p < 0.0001) between ALT levels and body mass index (BMI). With increasing age, there was a significant decrease in the proportion of subjects with ALT ≥ 1.5× ULN (p < 0.001). Our results suggest that a high proportion (20.5%) of individuals otherwise considered healthy have values of ALT level in the serum above the "normal" range/cut-off suggesting likely ongoing underlying liver damage. There is a need for measures to evaluate and, if found, treat the underlying cause for the same.

Diagnostic accuracy of non-contact infrared thermometers and thermal scanners: a systematic review and meta-analysis.

Infrared thermal screening, via the use of handheld non-contact infrared thermometers (NCITs) and thermal scanners, has been widely implemented all over the world. We performed a systematic review and meta-analysis to investigate its diagnostic accuracy for the detection of fever. We searched PubMed, Embase, the Cochrane Library, medRxiv, bioRxiv, ClinicalTrials.gov, COVID-19 Open Research Dataset, COVID-19 research database, Epistemonikos, EPPI-Centre, World Health Organization International Clinical Trials Registry Platform, Scopus and Web of Science databases for studies where a non-contact infrared device was used to detect fever against a reference standard of conventional thermometers. Forest plots and Hierarchical Summary Receiver Operating Characteristics curves were used to describe the pooled summary estimates of sensitivity, specificity and diagnostic odds ratio. From a total of 1063 results, 30 studies were included in the qualitative synthesis, of which 19 were included in the meta-analysis. The pooled sensitivity and specificity were 0.808 (95%CI 0.656-0.903) and 0.920 (95%CI 0.769-0.975), respectively, for the NCITs (using forehead as the site of measurement), and 0.818 (95%CI 0.758-0.866) and 0.923 (95%CI 0.823-0.969), respectively, for thermal scanners. The sensitivity of NCITs increased on use of rectal temperature as the reference. The sensitivity of thermal scanners decreased in a disease outbreak/pandemic setting. Changes approaching statistical significance were also observed on the exclusion of neonates from the analysis. Thermal screening had a low positive predictive value, especially at the initial stage of an outbreak, whereas the negative predictive value (NPV) continued to be high even at later stages. Thermal screening has reasonable diagnostic accuracy in the detection of fever, although it may vary with changes in subject characteristics, setting, index test and the reference standard used. Thermal screening has a good NPV even during a pandemic. The policymakers must take into consideration the factors surrounding the screening strategy while forming ad-hoc guidelines.

Facemasks for prevention of viral respiratory infections in community settings: A systematic review and meta-analysis.

BACKGROUND: There is paucity of evidence on the effectiveness of facemask use in COVID-19 in community settings. OBJECTIVES: We aimed to estimate the effectiveness of facemask use alone or along with hand hygiene in community settings in reducing the transmission of viral respiratory illness. METHODS: We searched PubMed and Embase for randomized controlled trials on facemask use in community settings to prevent viral respiratory illnesses published up to April 25, 2020. Two independent reviewers were involved in synthesis of data. Data extraction and risk-of-bias assessment were done in a standard format from the selected studies. Outcome data for clinically diagnosed or self-reported influenza-like illness (ILI) was recorded from individual studies. Pooled effect size was estimated by random-effects model for "facemask only versus control" and "facemask plus hand hygiene versus control." RESULTS: Of the 465 studies from PubMed and 437 studies from Embase identified from our search, 9 studies were included in qualitative synthesis and 8 studies in quantitative synthesis. Risk of bias was assessed as low (n = 4), medium (n = 3), or high (n = 1) risk. Interventions included using a triple-layered mask alone or in combination with hand hygiene. Publication bias was not significant. There was no significant reduction in ILI either with facemask alone (n = 5, pooled effect size: -0.17; 95% confidence interval [CI]: -0.43-0.10; P = 0.23; I2 = 10.9%) or facemask with handwash (n = 6, pooled effect size: (n=6, pooled effect size: -0.09; 95% CI: -0.58 to 0.40; P = 0.71, I2 = 69.4%). CONCLUSION: : Existing data pooled from randomized controlled trials do not reveal a reduction in occurrence of ILI with the use of facemask alone in community settings.

Fetal and maternal manifestations of tuberous sclerosis complex: Value of fetal MRI.

Tuberous sclerosis complex (TSC) is a genetic disorder characterized by benign hamartomas in various organ systems of the body. Prenatal screening of fetuses of mothers affected with TSC using ultrasonography (US) may detect cardiac lesions. Fetal US is not sensitive for evaluation of the brain. We describe brain MRI findings in a fetus with cardiac rhabdomyomas identified on prenatal screening US. Postnatal brain MRI at 5 days of age demonstrated fetal MRI findings without significant added information. Fetal MRI is the imaging modality of choice for evaluation of cerebral manifestations of TSC. Maternal manifestations of TSC in the abdomen or pelvis may also be demonstrated on fetal MRI.