Medicine and Health Sciences Commons^™

Design, Protocol And Baseline Data Of Nurturing Healthy Teachers, A Cluster Non-Randomized Controlled Trial To Improve The Health, Well-Being, And Food Security Of Preschool And Elementary School Teachers In Houston, Texas, Ru-Jye Chuang, Azar Gaminian, Jill Cox, Katherine French, Nalini Ranjit

Faculty, Staff and Student Publications

BACKGROUND: We present the conceptual framework, design, and study measures of Nurturing Healthy Teachers, a quasi-experimental study to examine the short- and long-term effectiveness of the Nurturing Healthy Teachers (NHT) nutrition intervention on food insecurity, dietary behaviors, mental health and cardiometabolic health among preschool and elementary school teachers.

METHODS: A convenience sample of 28 elementary schools with pre-kindergarten and elementary classrooms were recruited in Houston, Texas. Nurturing Healthy Teacher intervention includes Brighter Bites, an evidence-based coordinated school health program that combines access to fresh produce and nutrition education, and Create Healthy Futures, a web-based nutrition education program that targets nutrition …

Experiences Of Using The Mindset Self-Management Mobile Health App Among Hispanic Patients: Results Of A Qualitative Study, Charles Begley, Tomas Nuño, Shiela Soto, Cecilia Rosales, David Labiner

Faculty, Staff and Student Publications

BACKGROUND: Interventions focusing on epilepsy self-management (ESM) are vital for promoting the health of people living with epilepsy. E-technology and mobile health (mHealth) tools are becoming increasingly integrated into practice to promote self-management strategies for chronic diseases, enhance care delivery, and reduce health disparities. Management Information and Decision Support Epilepsy Tool (MINDSET), a bilingual decision support tool (available in English and Spanish), was found to be both feasible and effective in facilitating goal-based ESM in the clinic.

PURPOSE: To assess the experience of using MINDSET as an ESM intervention among Hispanic patients with epilepsy to inform future interventional studies.

METHODS: …

Innominate Artery Pseudoaneurysm From A Salter-Harris Fracture Of The Sternoclavicular Joint, Jessica P Simons

Faculty, Staff and Student Publications

Fractures and dislocations of the sternoclavicular joint (SCJ) are uncommon, accounting for <5% of all shoulder girdle injuries. They are relatively more common in the pediatric population than in the adult population and can often present concurrently as a posteriorly displaced medial clavicular dislocation with a fracture through the unfused physis. It is especially important to recognize this injury, because its management and potential sequelae are very different from those for fractures of the clavicle shaft. This type of injury frequently requires closed or open operative management because fracture-dislocation of the SCJ can be associated with potentially serious complications such as pneumothorax, brachial plexus injury, vagus nerve injury, tracheal injury, and vascular compromise. Few case reports describe fracture-dislocation of the SCJ resulting in vascular injuries. We describe the case of a 17-year-old boy who sustained a blunt hockey injury resulting in a right physeal fracture-dislocation of the SCJ causing an innominate artery pseudoaneurysm. This was treated with excision of the pseudoaneurysm, bovine pericardial patch angioplasty repair of the innominate artery, and open reduction and internal fixation of the medial clavicular physeal fracture.

Serum Metabolomic Markers Of Protein-Rich Foods And Incident Ckd: Results From The Atherosclerosis Risk In Communities Study, Lyn M Steffen, Andrew S Levey, Morgan E Grams, Eugene P Rhee, Casey M Rebholz

Faculty, Staff and Student Publications

RATIONALE & OBJECTIVE: While urine excretion of nitrogen estimates the total protein intake, biomarkers of specific dietary protein sources have been sparsely studied. Using untargeted metabolomics, this study aimed to identify serum metabolomic markers of 6 protein-rich foods and to examine whether dietary protein-related metabolites are associated with incident chronic kidney disease (CKD).

STUDY DESIGN: Prospective cohort study.

SETTING & PARTICIPANTS: A total of 3,726 participants from the Atherosclerosis Risk in Communities study without CKD at baseline.

EXPOSURES: Dietary intake of 6 protein-rich foods (fish, nuts, legumes, red and processed meat, eggs, and poultry), serum metabolites.

OUTCOMES: Incident CKD (estimated …

Does A Reduction In Receiving Assistance With Daily Activities Among Older Adults In Mexico Indicate An Increase In Unmet Needs Or A Decrease In Needs For Care?, Rebeca Wong

Faculty, Staff and Student Publications

OBJECTIVES: The percentage of older adults in Mexico with difficulty completing activities of daily living (ADL) who receive assistance from family appears to be decreasing. We compared 2 birth cohorts of older adults in Mexico to investigate whether this trend reflects an increase in unmet caregiving needs or a decrease in the need for care.

METHODS: We selected Mexican Health and Aging Study participants aged 60-76 in 2001 (n = 4,805) and 2018 (n = 6,494). ADL tasks were dressing, walking, bathing, getting in and out of bed, and toileting. Participants who reported difficulty with an ADL were asked if …

Concordance Of Human Papillomavirus Genotypes In Mailed Home-Based Self-Collected Versus Clinician-Collected Anal Swabs Among Sexual And Gender Minority Individuals, Maria E Fernandez, Jennifer S Smith, Alan G Nyitray

Faculty, Staff and Student Publications

Background: Home-based self-sampling may be a viable option for anal cancer screening among sexual minority men (SMM). Yet limited research has compared home-based self-collected with clinician-collected anal swabs for human papillomavirus (HPV) genotyping.

Methods: The Prevent Anal Cancer Self-Swab Study recruited SMM and transgender persons 25 years and over in Milwaukee, WI to participate in an anal cancer screening study. Participants were randomized to a home or clinic arm. Home-based participants were mailed an anal self-sampling kit to complete and return via postal mail. They were also asked to attend a clinic appointment where a clinician collected an anal swab. …

Maintaining Program Fidelity In A Changing World: National Implementation Of A School-Based Hiv Prevention Program, Stephenie C Lemon, Samiran Ghosh, Maxwell Poitier, Glenda Rolle, Sylvie Naar, Bo Wang

Faculty, Staff and Student Publications

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School …

Potential Impact Of Annual Vaccination With Reformulated Covid-19 Vaccines: Lessons From The Us Covid-19 Scenario Modeling Hub, Claire P Smith, Samantha J Bents, John Levander, Jessi Espino, Joseph C Lemaitre, Koji Sato, Clifton D Mckee, Alison L Hill, Matteo Chinazzi, Jessica T Davis, Kunpeng Mu, Alessandro Vespignani, Erik T Rosenstrom, Sebastian A Rodriguez-Cartes, Julie S Ivy, Maria E Mayorga, Julie L Swann, Guido España, Sean M Moore, T Alex Perkins, Shi Chen, Rajib Paul, Daniel Janies, Jean-Claude Thill, Ajitesh Srivastava, Majd Al Aawar, Kaiming Bi, Shraddha Ramdas Bandekar, Anass Bouchnita, Spencer J Fox, Lauren Ancel Meyers, Przemyslaw Porebski, Srini Venkatramanan, Aniruddha Adiga, Benjamin Hurt, Brian Klahn, Joseph Outten, Jiangzhuo Chen, Henning Mortveit, Amanda Wilson, Stefan Hoops, Parantapa Bhattacharya, Dustin Machi, Anil Vullikanti, Bryan Lewis, Madhav Marathe, Harry Hochheiser, Michael C Runge, Katriona Shea, Shaun Truelove, Cécile Viboud, Justin Lessler

Faculty, Staff and Student Publications

BACKGROUND: Coronavirus Disease 2019 (COVID-19) continues to cause significant hospitalizations and deaths in the United States. Its continued burden and the impact of annually reformulated vaccines remain unclear. Here, we present projections of COVID-19 hospitalizations and deaths in the United States for the next 2 years under 2 plausible assumptions about immune escape (20% per year and 50% per year) and 3 possible CDC recommendations for the use of annually reformulated vaccines (no recommendation, vaccination for those aged 65 years and over, vaccination for all eligible age groups based on FDA approval).

METHODS AND FINDINGS: The COVID-19 Scenario Modeling Hub …

Transitioning From An In-Person Intervention To Augmented Text Messaging During Covid-19 In Mexican Americans With Prediabetes: The Starr County Diabetes Prevention Randomized Clinical Trial, Mary M Velasquez, Eric L Brown, David Aguilar, Craig L Hanis

Faculty, Staff and Student Publications

PURPOSE: The purpose of the study was to explore the feasibility of using commonly available technology, such as text messaging, for diabetes prevention in rural Mexican American communities during COVID-19.

METHODS: Participants were selected from a diabetes prevention study funded by the National Institutes of Health that, prior to COVID-19, involved in-person group intervention sessions. Participants were predominantly female adults born in Mexico and Spanish-speaking. A subsample (n = 140) was divided into 3 cohorts: (1) 50 who completed the initial in-person intervention prior to the COVID-19 research pause, (2) 60 who needed additional support sessions to complete the intervention …

A Multitrait Genetic Study Of Hemostatic Factors And Hemorrhagic Transformation After Stroke Treatment, Natalia Cullell, Jesús M Martin-Campos, Tomás Sobrino, José Castillo, Mònica Millán, Lucía Muñoz-Narbona, Elena López-Cancio, Marc Ribó, Jose Alvarez-Sabin, Jordi Jiménez-Conde, Jaume Roquer, Silvia Tur, Victor Obach, Juan F Arenillas, Tomas Segura, Gemma Serrano-Heras, Joan Marti-Fabregas, Marimar Freijo-Guerrero, Maria Del Mar Castellanos, Alanna C Morrison, Nicholas L Smith, Paul S De Vries, Israel Fernández-Cadenas, Maria Sabater-Lleal

Faculty, Staff and Student Publications

BACKGROUND: Thrombolytic recombinant tissue plasminogen activator (r-tPA) treatment is the only pharmacologic intervention available in the ischemic stroke acute phase. This treatment is associated with an increased risk of intracerebral hemorrhages, known as hemorrhagic transformations (HTs), which worsen the patient's prognosis.

OBJECTIVES: to investigate the association between genetically determined natural hemostatic factors' levels and increased risk of HT after r-tPA treatment.

METHODS: Using data from genome-wide association studies on the risk of HT after r-tPA treatment and data on 7 hemostatic factors (factor [F]VII, FVIII, von Willebrand factor [VWF], FXI, fibrinogen, plasminogen activator inhibitor-1, and tissue plasminogen activator), we performed …

Unveiling Gene Interactions In Alzheimer's Disease By Integrating Genetic And Epigenetic Data With A Network-Based Approach, Xiangning Chen, Zhongming Zhao

Faculty, Staff and Student Publications

Alzheimer’s Disease (AD) is a complex disease and the leading cause of dementia in older people. We aimed to uncover aspects of AD’s pathogenesis that may contribute to drug repurposing efforts by integrating DNA methylation and genetic data. Implementing the network-based tool, a dense module search of genome-wide association studies (dmGWAS), we integrated a large-scale GWAS dataset with DNA methylation data to identify gene network modules associated with AD. Our analysis yielded 286 significant gene network modules. Notably, the foremost module included the BIN1 gene, showing the largest GWAS signal, and the GNAS gene, the most significantly hypermethylated. We conducted …

Digital Health Technologies For High-Risk Pregnancy Management: Three Case Studies Using Digilego Framework, Amy Franklin, Deevakar Rogith, Jerrie Refuerzo

Faculty, Staff and Student Publications

OBJECTIVE: High-risk pregnancy (HRP) conditions such as gestational diabetes mellitus (GDM), hypertension (HTN), and peripartum depression (PPD) affect maternal and neonatal health. Patient engagement is critical for effective HRP management (HRPM). While digital technologies and analytics hold promise, emerging research indicates limited and suboptimal support offered by the highly prevalent pregnancy digital solutions within the commercial marketplace. In this article, we describe our efforts to develop a portfolio of digital products leveraging advances in social computing, data science, and digital health.

METHODS: We describe three studies that leverage core methods from

RESULTS: Scalable social computing models using deep learning classifiers …

Identification Of Novel F2-Isoprostane Metabolites By Specific Udp-Glucuronosyltransferases, Warda Amin, Sarah Thomas, Camille Oger, Jean-Marie Galano, Harvey J Murff, Gong Yang, Thierry Durand

Faculty, Staff and Student Publications

UDP-glucuronosyltransferases (UGTs) catalyze the conjugation of glucuronic acid with endogenous and exogenous lipophilic small molecules to facilitate their inactivation and excretion from the body. This represents approximately 35 % of all phase II metabolic transformations. Fatty acids and their oxidized eicosanoid derivatives can be metabolized by UGTs. F2-isoprostanes (F2-IsoPs) are eicosanoids formed from the free radical oxidation of arachidonic acid. These molecules are potent vasoconstrictors and are widely used as biomarkers of endogenous oxidative damage. An increasing body of evidence demonstrates the efficacy of measuring the β-oxidation metabolites of F2-IsoPs rather than the unmetabolized F2-IsoPs to quantify oxidative damage in …

Social And Behavior Factors Of Alzheimer's Disease And Related Dementias: A National Study In The Us, Yinan Zheng, Hua Xu, Xiaoqian Jiang, Kun Huang, Kelley Pettee Gabriel, Hong-Wen Deng, Mary P Gallant, Kai Zhang

Faculty, Staff and Student Publications

Introduction: Considerable research has linked many risk factors to Alzheimer's Disease and Related Dementias (ADRD). Without a clear etiology of ADRD, it is advantageous to rank the known risk factors by their importance and determine if disparities exist. Statistical-based ranking can provide insight into which risk factors should be further evaluated.

Methods: This observational, population-based study assessed 50 county-level measures and estimates related to ADRD in 3,155 counties in the U.S. using data from 2010 to 2021. Statistical analysis was performed in 2022-2023. The machine learning method, eXtreme Gradient Boosting, was utilized to rank the importance of these variables by …

Evaluating And Improving The Usability Of A Mhealth Platform To Assess Postoperative Dental Pain, Nicholas Skourtes, David Holmes, Joel White, Elsbeth Kalenderian, Muhammad F Walji

Faculty, Staff and Student Publications

OBJECTIVES: The use of interactive mobile health (mHealth) applications to monitor patient-reported postoperative pain outcomes is an emerging area in dentistry that requires further exploration. This study aimed to evaluate and improve the usability of an existing mHealth application.

MATERIALS AND METHODS: The usability of the application was assessed iteratively using a 3-phase approach, including a rapid cognitive walkthrough (Phase I), lab-based usability testing (Phase II), and

RESULTS: The rapid cognitive walkthrough identified 23 potential issues that could negatively impact user experience, with the majority classified as system issues. The lab-based usability testing yielded 141 usability issues.; 43% encountered by …

Learning From Data In Dentistry: Summary Of The Third Annual Openwide Conference, Alfa Yansane, Bunmi Tokede, D Brad Rindal, Heiko Spallek, Joel White, Muhammad Walji

Faculty, Staff and Student Publications

The overarching goal of the third scientific oral health symposium was to introduce the concept of a learning health system to the dental community and to identify and discuss cutting-edge research and strategies using data for improving the quality of dental care and patient safety. Conference participants included clinically active dentists, dental researchers, quality improvement experts, informaticians, insurers, EHR vendors/developers, and members of dental professional organizations and dental service organizations. This report summarizes the main outputs of the third annual OpenWide conference held in Houston, Texas, on October 12, 2022, as an affiliated meeting of the American Dental Association (ADA) …

Artificial Intelligence-Powered Pharmacovigilance: A Review Of Machine And Deep Learning In Clinical Text-Based Adverse Drug Event Detection For Benchmark Datasets, Fang Li, Susan Fenton, Hua Xu, Cui Tao

Faculty, Staff and Student Publications

Objective: The primary objective of this review is to investigate the effectiveness of machine learning and deep learning methodologies in the context of extracting adverse drug events (ADEs) from clinical benchmark datasets. We conduct an in-depth analysis, aiming to compare the merits and drawbacks of both machine learning and deep learning techniques, particularly within the framework of named-entity recognition (NER) and relation classification (RC) tasks related to ADE extraction. Additionally, our focus extends to the examination of specific features and their impact on the overall performance of these methodologies. In a broader perspective, our research extends to ADE extraction from …

Identifying Cancer Subtypes Based On Embryonic And Hematopoietic Stem Cell Signatures In Pan-Cancer

Faculty, Staff and Student Publications

Purpose: Cancer cells with stem cell-like properties may contribute to cancer development and therapy resistance. The advancement of multi-omics technology has sparked interest in exploring cancer stemness from a multi-omics perspective. However, there is a limited number of studies that have attempted to subtype cancer by combining different types of stem cell signatures.

Methods: In this study, 10,323 cancer specimens from 33 TCGA cancer types were clustered based on the enrichment scores of six stemness gene sets, representing two types of stem cell backgrounds: embryonic stem cells (ESCs) and hematopoietic stem cells (HSCs).

Results: We identified four subtypes of pan-cancer, …

Fedfsa: Hybrid And Federated Framework For Functional Status Ascertainment Across Institutions, Yifang Dang, Yujia Zhou, Muskan Garg, Ronald C Petersen, Jennifer St Sauver, Sungrim Moon, Liwei Wang, Andrew Wen, Fang Li, Hua Xu, Cui Tao, Jungwei Fan, Hongfang Liu, Sunghwan Sohn

Faculty, Staff and Student Publications

Introduction: Patients' functional status assesses their independence in performing activities of daily living, including basic ADLs (bADL), and more complex instrumental activities (iADL). Existing studies have discovered that patients' functional status is a strong predictor of health outcomes, particularly in older adults. Depite their usefulness, much of the functional status information is stored in electronic health records (EHRs) in either semi-structured or free text formats. This indicates the pressing need to leverage computational approaches such as natural language processing (NLP) to accelerate the curation of functional status information. In this study, we introduced FedFSA, a hybrid and federated NLP framework …

Attempted Repair Of Chest Wall Injury Following Penetrating Injury With Surgical Stabilization Rib And Autologous Bone Graft: A Case Report., Vincent E Serapiglia, Krishna A Patel, Jaya Sai V Varre, Brian T Dusseau, William B Devoe

Trauma and Acute Care Articles

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in …

Endovascular Covered Stent Graft Repair By Through-And-Through Snaring Of An Acute Traumatic Femoral-Femoral Arteriovenous Fistula Following A Gunshot Wound., Anthony N Rizzo, Krishna Patel, Jordyn Perdue, Jon C Henry

Trauma and Acute Care Articles

Arteriovenous fistula (AVF) formation after penetrating injury underscores a rare and challenging complication of vascular trauma. Traumatic AVFs have various clinical presentations and reported methods of repair. Although open surgical repair is the most frequently used method of repair, the advancement of endovascular techniques has been increasingly used during the past 3 decades. We report a case of an acute traumatic AVF of the superficial femoral artery and superficial femoral vein from a gunshot wound repaired with a unique endovascular technique involving snaring to establish through-and-through access to allow deployment of a covered stent graft.

Successful Extravascular Implantable Cardioverter-Defibrillator Implantation In A Patient With Recurrent Transvenous Implantable Cardioverter-Defibrillator Erosion., Andrea Robinson, Sreedhar Billakanty, Eugene Fu, Anish Amin

Heart and Vascular Articles

No abstract provided.

Transitioning From Afmrd Entrustable Professional Activities To Abfm Core Outcomes To Measure Clinical Preparedness., Bryce A Ringwald

Medical Education Articles

No abstract provided.

Wellness As A Predictor Of Turnover Intention In The Active Duty Military, Thomas Clifford Seguin

Counseling & Human Services Theses & Dissertations

Due to the unique nature of military service compared to civilian professions, military attrition is difficult to predict using methods derived from career development theories, so turnover remains an ongoing concern for the active duty military. For this reason, military attrition, through turnover intention, should be investigated through a novel lens with the intention of capturing an essence of military service which previous methods may have overlooked, namely the holistic construct of perceived wellness. Previous studies have shown how wellness-related factors affect turnover intention, but none has studied the relationship between perceived wellness and turnover intention. The main hypothesis of …

The Effects Of Covid-19 Stressors And Supervisor Support On Emotional Exhaustion And Work Engagement, Meiqiao Gu

Psychology Theses & Dissertations

Since the onset of the COVID-19 pandemic, working conditions have worsened, subjecting employees to numerous stressors. Analyzing the impact of COVID-19 stressors on employees‘ well-being and work motivation is crucial. The job demands-resources model (JD-R; Demerouti et al., 2001a) provides a framework for evaluating how COVID-19 stressors affect employees‘ well-being and motivation in the workplace. Given the complexity of job characteristics during the COVID-19 pandemic, coupled with challenges in obtaining adequate support from supervisors who are also facing considerable work pressure, this study examines the continued relevance of the JD-R model in this evolving work environment. Specifically, four hypotheses were …

Evaluation Of Triple Therapy Use For Copd, Jessica Offerle Pharmd

Pharmacy Residency

Presented at the Great Lakes Pharmacy Residents Conference. West Lafayette, IN: April 2024.

This retrospective, cross-sectional study found that nearly all patients were not administered pulmonary function testing prior to treatment with COPD triple therapy (inhaled corticosteroid plus long-acting muscarinic-antagonist plus long-acting beta-2-agonist). Additionally, the vast majority did not have a documented elevated eosinophil count. These represent good opportunities to optimize population-based care for COPD patients.

Penicillin Allergy De-Labeling: Evaluating A Health System’S Implementation Of The Pen-Fast Tool Within An Infectious Disease Clinic., Jennifer Mccarthy Pharmd, Ms

Pharmacy Residency

Presented at the Great Lakes Pharmacy Residents Conference. West Lafayette, IN: April 2024.

This retrospective, post-implementation study found that 81% of patients with a documented penicillin allergy could be de-labeled, and that the majority could theoretically tolerate a penicillin challenge.

Identifying Improvement Opportunities For The Utilization Of Carbapenems At A Community Health System., Kendra Yarian Pharmd

Pharmacy Residency

Presented at the Great Lakes Pharmacy Resident Conference. West Lafayette, IN: April 2024.

This study found opportunities to improve utilization of carbapenems, such as by delabeling inappropriate penicillin and cephalosporin allergies, modifying order sets, providing education, and initiating alerts to prompt de-escalation.

Association Between Psychosocial Acuity And Glycemic Control In A Pediatric Type 1 Diabetes Clinic., Joseph Wardell, Dana K. Albright Phd, Claire Chang, Melissa A Plegue, Jung Eun Lee, Emily Hirschfeld, Ashley Garrity, Joyce M Lee, Melissa Dejonckheere

Health Services and Informatics Research

PURPOSE: The purpose of this study was to describe the frequency of psychosocial risk and its associations with glycemic levels in youth with type 1 diabetes (T1D) seen by social work staff during regular clinical care.

METHODS: A retrospective longitudinal analysis of observational clinical data was conducted. Individuals (1-26 years) with known T1D who were seen at a pediatric diabetes clinic in a US academic medical center between 2014 and 2021 were included. Variables included psychosocial acuity, A1C, and demographic characteristics. Chi-square tests, Wilcoxon rank sum tests, and mixed linear regressions were used to examine associations between demographic variables, psychosocial …

Developmental Programming Of Normal Versus Metabolically Altered Pancreas In Rat: Effect Of Gestational Diabetes, Sanabil Ali Ahmed

Dissertations

Diabetes Mellitus (DM) is a chronic condition characterised by pancreatic β-cell dysfunction and consistently elevated blood glucose levels (hyperglycaemia), either due to the inability of the body to produce any or adequate amounts of insulin or the inability of the body to effectively utilise the produced insulin (i.e., insulin resistance). DM can be classified into 3 main types: Type 1 DM (T1DM), Type 2 DM (T2DM), and Gestational Diabetes Mellitus (GDM). GDM is defined as “hyperglycaemia that is first diagnosed during pregnancy with glucose levels below those considered diagnostic of overt diabetes outside of pregnancy”.

The mature pancreas is a …