To evaluate rural-urban disparities over time in the association of ACO participation and diabetes-related quality measures among health clinics.

We used data from the Wisconsin Collaborative for Healthcare Quality all-patient all-payer electronic health records data system between 2011 and 2018, for patients 18-75 years. Difference-in-differences regression models estimated the association between ACO participation and eight diabetes quality measures among populations in rural and urban areas, separately. Triple-difference models were also estimated to assess urban-rural disparities.

Considering the two measures used in ACO performance evaluation, patients in ACO clinics were less likely to receive tobacco cessation advice relative to those in non-ACO clinics (rural: marginal effect estimate (MEE) = -0.025, p = 0.033; urban: MEE = -0.231, p < 0.001). The triple difference across rurality was not statistically significant (MEE = -0.007 p = 0.56). For the remaining six ACO-non-incentivized measures, rural patients at ACO clinics performed better relative to their non-ACO counterparts on kidney function monitored, and diabetes all-or-none optimal testing and control.

ACO participation appeared to be more favorable for rural versus urban patients with diabetes. ACOs have potential to contribute to reducing existing rural-urban disparities in diabetes process measures.

Diabetes is a leading cause of kidney failure, and individuals with both diabetes and chronic kidney disease (CKD) experience significantly higher rates of complications and mortality. The international guideline developer Kidney Disease: Improving Global Outcomes (KDIGO) has produced clinical practice guidelines that reflect recent advances in pharmacotherapy for this population, extending beyond glycaemic control to include cardio-renal benefits. However, these guidelines were developed without specific consideration of the healthcare systems, access issues and population needs in Australia and New Zealand. In response, the Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guidelines Working Group has provided a regional commentary on the KDIGO 2022 guideline. This commentary highlights key recommendations and contextualises their implementation within the Australian and New Zealand healthcare environments. It addresses issues such as medication access, equity for Indigenous populations and the importance of shared decision-making, aiming to support clinicians in delivering evidence-based, locally relevant care for people living with diabetes and CKD.

Insulin allergy, although rare in type 1 diabetes (T1DM), poses a significant clinical challenge due to the indispensable role of insulin therapy. Rapid induction of insulin tolerance is critical for affected individuals, especially in acute complications such as diabetic ketoacidosis (DKA).

We report a case of a 50-year-old male with newly diagnosed T1DM who developed type I hypersensitivity reactions to multiple insulin analogs, manifesting as localized erythema, pruritus, and induration. After conventional management, including switching insulin preparations, proved ineffective, a rapid desensitization protocol was initiated using continuous subcutaneous insulin infusion (CSII). Preceding the pump initiation, half of the estimated basal dose of insulin glargine was administered subcutaneously. CSII with insulin aspart was then started at an extremely low initial rate, with increments every 30 minutes.

The target basal infusion rate was successfully achieved within 5 hours without the use of antihistamines or corticosteroids. The procedure was well-tolerated, with no systemic or local allergic reactions. Following desensitization, the patient successfully transitioned to daily injections of glargine and pre-meal aspart insulin, with no recurrence of allergic reactions during long-term follow-up.

A CSII-based rapid desensitization protocol is a safe, effective, and efficient strategy for managing insulin allergy in T1DM, including cases with sensitivities to multiple insulin preparations. This approach is particularly suitable for patients requiring urgent insulin therapy.

 Diabetic retinopathy (DR) and diabetic macular edema (DME) are well-established microvascular complications of type 2 diabetes mellitus (T2DM), resulting from chronic hyperglycemia-induced damage to retinal vasculature that, in their advanced forms, are associated with an increased risk of cardiovascular disease (CVD).

This study aims to estimate the potential association between DR or DME and CVD, as well as systemic vascular metrics.

In a cross-sectional design study, 73 patients with T2DM were recruited. Demographic data and clinical characteristics of patients regarding their diabetes status and comorbidities were recorded. Patients underwent a thorough ocular examination, as well as endothelial function and arterial stiffness evaluation. Specifically, central systolic blood pressure (cSBP), central diastolic blood pressure (cDBP), pulse wave velocity (PWV), augmentation index (Aix), and the perfused boundary region of the sublingual arterial microvessels (PBR5-25) were measured. Multivariate binary logistic regression and mixed linear regression models were used to examine the associations between CVD, as well as systemic vascular metrics, and DR or DME.

In a model adjusted for age, sex, BMI, smoking status, HbA1c levels, and hypertension, DR was significantly associated with higher odds for CVD (OR=13.3; 95% CI: 1.5-115.0, p=0.019). The presence of DME was not associated with CVD. Furthermore, higher PWV was significantly associated with more severe DR (b=0.09; 95% CI: 0.01-0.16, p=0.031).

There is a strong association between DR and CVD, while higher PWV was significantly associated with more severe DR. These findings suggest that screening for CVD is crucial in patients with DR, especially in cases of greater severity of DR.

Tuberculosis is an infectious disease that continues to present a major public health challenge. There is a recognized correlation between the condition and depression. This study aims to find out the prevalence and pattern of depression among drug-susceptible TB patients to improve treatment outcomes.

The study was a cross-sectional hospital-based survey across the directly observed therapy (DOT) centers in Ogbomosho. Sample size of 333 respondents was calculated using Leslie Fischer's formula (n = z²pq/d²). A multistage sampling technique was used to select respondents. Data was collected using a pre-tested semistructured questionnaire and analyzed using Statistical Package for Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY). The questionnaire covered sociodemographic characteristics, lifestyle, and comorbidities and included the Patient Health Questionnaire-9 (PHQ-9) to assess depression. Respondents who scored 0-4 were categorized as having no depression, those who scored 5-9 were categorized as having mild depression, those who scored 10-14 were categorized as having moderate depression, while those who scored 15-19 were categorized as having moderately severe depression. Descriptive analysis was done on all variables. Bivariate and multivariate analyses were done using chi-square and binary logistic regression, respectively. The level of significance is set with a p-value less than 0.05.

The overall prevalence of depression was 146 (43.8%). Among those who were depressed, 96 (65.6%) had mild depression, 36 (24.7%) had moderate depression, while 14 (9.7%) had moderately severe depression. Sex, marital status, level of education, and average monthly income were significantly associated with depression status at the bivariate level. Multivariate analysis revealed that level of education (AOR = 0.175, P = 0.001) and living with HIV (AOR = 35.303, P = 0.017) were significantly associated with depression status.

This study found a high prevalence of depression among TB patients. Factors such as level of education and comorbidities like TB/HIV and diabetes mellitus were statistically associated with depression.

The nose is one of the facial regions most commonly affected by skin cancer, and its reconstruction represents a dual aesthetic and functional challenge. When defects involve more than 50% of a subunit or multiple aesthetic units, reconstruction requires thin, flexible tissue with reliable vascularity. The paramedian forehead flap remains one of the most versatile options, particularly in recurrent tumors, where achieving clear margins and restoring nasal patency is essential. A 54-year-old male with a history of solid infiltrative basal cell carcinoma of the right nasal ala, previous paramedian forehead flap reconstruction, and positive margins underwent evaluation. Comorbidities included HIV with an undetectable viral load, diabetes mellitus type 2, hypertension, alcoholism, and smoking. Examination revealed a 10 × 15 mm, pearly, ulcerated lesion with telangiectasias. After tumor excision, a paramedian forehead flap was designed and elevated with a 2-cm vertical pedicle. A retroauricular full-thickness skin graft was fashioned into a tubular structure and sutured to the healthy nasal vestibule to re-create the right neovestibule. The flap was inset through an opening in the forehead flap, and a cotton-filled glove finger was placed intranasally for support. The patient progressed favorably with adequate flap vascularization. Paramedian forehead flaps remain the gold standard for large nasal defects due to their axial blood supply and color match. The addition of tubular full-thickness grafts expands their applicability in complex vestibular reconstruction, with literature supporting their reliability and functional outcomes. This case highlights a versatile technique combining a paramedian forehead flap with a tubular full-thickness graft to restore nasal contour and vestibular patency. It represents a reproducible strategy for complex nasal reconstruction with promising early aesthetic and functional results.

Emphysematous pyelonephritis (EPN) is a severe, necrotising infection of the renal parenchyma and surrounding tissues, most often accompanied by diabetes mellitus and Gram-negative bacilli. Tuberculosis superinfection is very rare, with only a few cases reported in the literature. We present the case of a 61-year-old woman with multiple comorbidities, in whom emphysematous pyelonephritis (EPN) was primarily due to typical bacterial pathogens and subsequently complicated by a superinfection with Mycobacterium tuberculosis, highlighting the importance of recognizing this unusual secondary infection to avoid unnecessary nephrectomy.

Diabetes mellitus is a leading cause of global mortality with significant health complications. Yoga and naturopathy have demonstrated beneficial effects on blood glucose control and psychological well-being.

A four-arm randomized study was conducted with 120 type 2 diabetic patients aged 40-60 years. Participants were randomly assigned to YG (yoga, 60 minutes), GH (gastro-hepatic pack, 20 minutes), CYG (combined yoga and gastro-hepatic pack, 80 minutes), or the control group. HbA1c, fasting and postprandial blood sugar, Perceived Stress Scale, and Diabetes Distress Scale were measured before and after intervention.

A significant reduction in glycemic parameters was observed in all groups post-intervention, with HbA1c decreasing from 8.17 ± 1.11 to 6.95 ± 0.85 in YG, 8.04 ± 0.98 to 6.93 ± 0.67 in GH, and 8.23 ± 1.23 to 6.29 ± 0.59 in CYG (p < 0.001). Fasting blood sugar (FBS) and post-prandial blood sugar (PPBS) also significantly declined (p < 0.001). Psychological measures improved, with PSS scores dropping from 17.7 ± 3.2 to 9.80 ± 1.67 in YG and 16.0 ± 2.3 to 9.53 ± 1.48 in CYG; smaller reductions occurred in GH and Control. DDS scores significantly decreased (p < 0.001). CYG showed the greatest overall improvement. No adverse events were reported.

 The combined yoga and gastro‑hepatic pack (CYG) intervention outperformed either alone in reducing stress and improving glycemic control in type 2 diabetes. This safe, holistic approach enhances overall quality of life, though long-term studies are needed to confirm the sustainability of these benefits and their impact on diabetes-related complications.

Bilothorax is a rare and pathological condition characterized by the accumulation of bile in the pleural cavity. This phenomenon most commonly occurs on the right side due to anatomical proximity to the liver and biliary system. Bilateral or left-sided bilothorax remains exceedingly rare. Diagnosis relies on pleural fluid analysis, particularly a pleural-to-serum bilirubin ratio >1, and imaging. We report the case of a male patient in his mid-60s with hepatitis C-related cirrhosis (Child-Pugh B7), hepatocellular carcinoma with pulmonary metastases, and multiple comorbidities, including diabetes mellitus and portal hypertension. The patient was undergoing systemic therapy with atezolizumab and bevacizumab, presented with chronic infected wounds and systemic symptoms and later developed gallbladder perforation with biliary peritonitis. Despite multidisciplinary management including percutaneous drainage, intravenous antibiotics, and intensive care support, his condition deteriorated. Subsequently, he developed a right-sided bilothorax, confirmed via thoracentesis, with a pleural-to-serum bilirubin ratio of 3.4 (normal < 0.6). Cultures isolated Enterobacter, and the patient was treated with targeted antibiotics and chest tube drainage. However, he experienced progressive hepatic decompensation, recurrent sepsis, and respiratory failure, ultimately leading to a transition to hospice care. This case is noteworthy due to the extreme rarity of bilothorax, the diagnostic complexity in distinguishing it from other pleural effusions, and the management challenges it poses in patients with advanced cirrhosis and malignancy.

Neuromelioidosis can present with abscesses, meningitis, or encephalomyelitis, but can be missed on blood culture. Linear enhancement of the corticospinal tract (white matter motor pathway) on magnetic resonance imaging (MRI) in the form of a 'tunnel sign' is an essential clue for early diagnosis of neuromelioidosis. This systematic review (SR) explores the clinical profile and outcomes of neuromelioidosis patients with tunnel signs.

An SR was conducted to look for articles reporting individual details of neuromelioidosis patients with tunnel signs (reported or present on published images) on MRI. This review followed PRISMA guidelines and was prospectively registered with PROSPERO (CRD42024597199). After title-abstract and full-text screening, clinical profile and outcome data were extracted and analysed.

Thirty cases (22 articles) with tunnel signs on MRI were included after screening 2985 articles. The traditional risk factors (diabetes mellitus, alcohol intake, steroids, etc.) for melioidosis were present in only 23 % (5/22) of patients. Limb weakness (89 %, 24/27) and cranial nerve involvement (46 %, 11/24) were commonly seen at presentation. Blood and cerebrospinal fluid (CSF) cultures for B.pseudomallei were only positive in 15 % (2/13) and 22 % (4/18). Due to low rates of clinical suspicion of neuromelioidosis (25 %, 6/24), empirical steroids and inappropriate antimicrobials were given in 47 % (8/17) and 65 % (9/17) of patients, respectively. A total of 30 % (n = 9) of the patients died.

In melioidosis-endemic areas with access to MRI, recognising the link between the presence of a tunnel sign and neuromelioidosis is crucial to initiate early adequate therapy.