Postprandial Thermogenesis Is Reduced in Obesity

Background and Aims: Postprandial thermogenesis is thought to be important for the control of metabolism. This process could be reflected by minute changes in body temperature after glucose load. In this study, we measured body temperature before and its change during a glucose challenge and investigated the relationships with anthropometric and glycemic traits. Methods: We prospectively studied 383 volunteers (251 females, 132 males) with a mean age of 46.6 (SD ± 16) years and a BMI of 27.9 kg/m2 (SD ± 5.9). All participants underwent a 75 g oral glucose tolerance test (OGTT) and repeated bilateral measurements of intra-auricular temperature at time points 0, 30 and 120 minutes during the OGTT using a tympanic thermometer (Covidien Genius 2). Results: Baseline temperature was 0.17°C lower in males compared to females (p = 0.001) and inversely associated with age (p < 0.0001). During the OGTT, there was a significant increase in body temperature (0.18 ± 0.34°C). This response was present in females and males. BMI was negatively associated with the increase of temperature during the OGTT (p = 0.0147). Participants with higher BMI displayed higher fasting temperatures, but less increase of temperature during the OGTT. Body temperature was not associated with glycemia, insulin sensitivity or insulin secretion, neither in females nor males. Conclusions: There is a robust increase in body temperature during a glucose load that can be captured by intra-auricular temperature measurements. We did not detect any associations of the body temperature with glucose metabolism, arguing against a major contribution of the variability of body temperature in the pathogenesis of diabetes. However, the rise in temperature in response to oral glucose is reduced in obesity and might therefore be involved in body weight regulation.

Glycemic Control in Type 1 Diabetes Mellitus During COVID-19 Quarantine and the Role of In-Home Physical Activity

Background: To limit the spread of coronavirus disease 2019 (COVID-19), governments have ordered a series of restrictions that may affect glycemic control in individuals with type 1 diabetes mellitus (T1DM), since physical activity (PA) was not allowed outside home. Methods: We retrospectively evaluated glycemic control of individuals with T1DM using hybrid closed loop (HCL) system in the period before the SARS-CoV-2 outbreak in Italy (February 10–23, 2020–Time 1), when movements were only reduced (February 24–March 8, 2020–Time 2) and during complete lockdown (March 9–22, 2020–Time 3). Information about regular PA (at least 3 h per week) prior and during the quarantine was collected. Results: The study included 13 individuals with a median age of 14.2 years and a good glycemic control at baseline (glucose management indicator of 7%, time in range [TIR] of 68%, time below range [TBR] of 2%). All individuals continued to show good glycemic control throughout the study period. There was an increase in TIR during the study period (+3%) and TIR was significantly higher during Time 3 (72%) than during Time 2 (66%). TBR was significantly lower during Time 3 (1%) both compared with Time 1 and Time 2 (2%). A meaningful variance in TIR at Time 3 between individuals who performed or not PA during quarantine and a significant increase in TIR between Time 2 and Time 3 in individuals both doing PA at baseline and during quarantine was found. At logistic regression, only the presence of PA during quarantine significantly predicted a TIR >70%. Conclusions: Glycemic control of T1DM in adolescents using HCL system did not worsen during the restrictions due to COVID-19 pandemics and further improved in those who continued PA during the quarantine. Maintaining regular PA in a safe home environment is an essential strategy for young individuals with T1DM during the COVID-19 crisis.

Improving diabetes care in Ealing, London: an analysis of the NDA and diabetes‐related admissions data during first year of COVID‐19

In this paper, we present and analyse National Diabetes Audit (NDA) and diabetes‐related emergency admissions data in Ealing during the period 1 January 2020 to 31 March 2021. Care for diabetes and other long‐term conditions was disrupted and significantly impacted during this initial period of the COVID‐19 pandemic.The NDA analysis shows that for type 1 and type 2 diabetes Key Care Processes (KCPs), both the eight and nine KCPs fell between 2019/20 and 2020/21, but the relative fall for NHS Ealing was lower than that seen for England. Type 1 diabetes Three Treatment Targets (3TTs) for NHS Ealing increased from 22.6% in 2019/20 to 26.4% in 2020/21;in contrast the 3TTs for England increased slightly from 19.8% in 2019/20 to 20.8% in 2020/21. Type 2 diabetes 3TTs for NHS Ealing changed from 40.9% in 2019/20 to 38.9% in 2020/21, while in England it was 40.3% in 2019/20 and 35.5% in 2020/21.The diabetes‐related emergency admissions analysis shows that there were reductions in the number and rate of emergency admissions for cerebrovascular accident and myocardial infarction;admissions and rates for diabetic ketoacidosis and amputations were the same;those for diabetes mellitus and hypoglycaemia increased. There were overall cost savings of £874,147 due to estimated avoided admissions.In Ealing, the NDA data, diabetes‐related emergency admissions and estimated avoided admissions data show that improvements in diabetes care achieved in previous years in Ealing, faltered, but were broadly sustained in the first pandemic year. Support from the Ealing diabetes care teams, improved self‐management of diabetes and the empowering of people with diabetes through digital technologies could explain these trends in Ealing. Continued access to health care practitioners during the COVID‐19 pandemic is important to ensure the appropriate management of long‐term conditions such as type 1 diabetes mellitus and type 2 diabetes mellitus. Copyright © 2023 John Wiley & Sons.

Health inequalities and diabetes

Inequalities in health care exist in many countries in the world. In 2008 the then UK Secretary of State for Health commissioned the Marmot review, ‘Fair Society, Healthy Lives', to propose strategies to address health inequalities in the UK. Most of Marmot's proposals were not acted upon and in 2020, 10 years after the initial recommendations were published, Marmot found that there had been no improvement and some things were worse.In diabetes care inequalities are widespread, impacting on prevention, treatment, access to technology, screening for complications, risk of complications, morbidity and mortality. Ethnicity is a major risk factor, starkly demonstrated by the increased COVID‐19 related mortality in people from minority ethnic groups with diabetes. Disadvantaged groups include, but are not limited to, those with social deprivation, intellectual and physical disabilities and severe mental illness.The decision to shelve the long‐awaited white paper on tackling health inequalities, taken recently by the last Secretary of State for Health amid protests from a coalition of medical organisations, makes it unlikely that the government will take the actions proposed by Marmot. In the absence of a national strategy, responsibility to recognise and address inequalities in diabetes care falls on health care professionals, in teams and as individuals. Copyright © 2023 John Wiley & Sons.

Impact of using fasting plasma glucose and HbA1c instead of OGTT as a screening tool for gestational diabetes: a retrospective study

Aims: To examine the impact of using the Royal College of Obstetricians and Gynaecologists (RCOG) COVID‐19 Gestational Diabetes (GDM) criteria on identifying women with GDM.Methods: Data were collected between November 2018 and June 2019, from women previously diagnosed with GDM using NICE guidelines, who also had HbA1c data available. These were used to determine whether they would have been diagnosed had the RCOG criteria been applied. Data were also collected to compare birth and fetal outcomes, and to compare medical management.Results: Eighty‐nine women were included;43 (48%) met both the RCOG and NICE GDM diagnostic criteria (RCOG + NICE group), while 46 (52%) only met the NICE GDM criteria and would have been missed using the RCOG GDM criteria (NICE only group). There were no significant differences in outcomes between the groups in terms of neonatal and delivery complications. More women in the RCOG + NICE group required treatment with insulin (11 [25.6%] vs 1 [2.2%], p=0.0010) or metformin (23 [53.5%] vs 14 [30.4%], p=0.03).Conclusions: Applying the RCOG criteria resulted in approximately half of women previously diagnosed with GDM to be missed, one‐third of whom had severe insulin resistance requiring treatment with metformin or insulin. The retrospective design of this study may not represent the neonatal and delivery outcomes these women may have had if their diagnosis had been missed. Women should be informed about this risk when not offered an oral glucose tolerance test to guide decision making. Copyright © 2023 John Wiley & Sons.

Telemedizinische Anwendungen in der diabetologischen Schwerpunktpraxis

ZusammenfassungDie digitale Sprechstunde und Onlineschulung entwickelten sich seit den COVID-Pandemie-bedingten (COVID: „coronavirus disease") Einschränkungen zu einem festen Bestandteil in der Versorgung von Menschen mit Diabetes in den ambulanten und auch stationären Diabetesschwerpunkteinrichtungen. Trotz fortschreitender Digitalisierung und Anwendung moderner Diabetestechnik nutzten zuvor nur einige wenige Modellprojekte und Schwerpunktpraxen mit engagiertem Diabetesteam diese neuen Kommunikationsmöglichkeiten. Mit Verbesserung der Technik, der Rahmenbedingungen, dem Ausbau der IT-Infrastruktur (IT: Informationstechnologie) und v. a. den Erwartungen der Patienten ist auch nach COVID die digitale Sprechstunde eine gute und sinnvolle Ergänzung und Alternative zur Präsenzsprechstunde. Der Start in die digitale Sprechstunde erfordert eine sorgfältige Vorbereitung. Neben persönlicher Bereitschaft zur Erweiterung der Patientenkommunikation sind eine entsprechende Struktur- und Prozessqualität in der Praxis notwendig. Gesetzliche Vorgaben und technische Voraussetzungen sowie Integration in den bisherigen Praxisablauf müssen umgesetzt werden. Die demografische Entwicklung, die steigende Prävalenz des Diabetes, weniger Behandlungseinrichtungen, Diabetologen und Diabetesteams, ortsunabhängige Konsultation und nicht zuletzt die Erwartungen unserer Patienten fördern die Umsetzung digitaler Sprechstunden im Praxisalltag. Die zwar noch nicht optimale, aber deutlich verbesserte Honorierung ist ebenso ein Anreiz für die neuen Wege der Kommunikation. Die Behandlungsstrukturen in der diabetologischen Praxis und der Behandlungserfolg werden durch digitale Sprechstunden verbessert.

Hypothalamo-pituitary adrenal axis in survivors of Sars Cov-2 infection- 3 months after acute infection

Introduction: Coronavirus disease 2019 (COVID-19) mainly involves the lungs;it also affects the endocrine system including the hypothalamic-pituitary adrenal axis (HPA). Aims: To assess and compare the changes in the HPA axis in survivors of SARS CoV-2 infection 3 months after recovery. Methods: A cross-sectional, descriptive study was undertaken at JIPMER, including 69 patients 318 years of age, after 3 months after the diagnosis of COVID-19. At baseline, a fasting sample was collected for basal cortisol, thyroid function, and biochemical investigations between 8.00-9.00 AM. A low dose Synacthen test (1 mg) was performed in all patient's blood samples for serum cortisol collected after 30 and 60 minutes of intravenous administration. Results: The mean age (SD) was 49.74 ± 12.05 years, 24 (34.78%) were female and 45 (65.2%) were male patients. 20 (28.98%) patients had mild, 10 (14.4%) had moderate and 39 (56.52%) patients had severe COVID-19 infection. 62 (89.85%) patients had post covid symptoms. Out of the sixty-nine patients with COVID-19, nine patients (9/69, 13.04%) had peak serum cortisol <18 mg/dL suggestive of secondary adrenal insufficiency. Peak serum cortisol did not differ according to disease severity [Mild, (13.03 ± 4.08 mg/dL) vs moderate, [(11.52 ± 2.40 mg/dL) vs severe, (13.70 ± 1.43 mg/dL), P = 0.67]. In addition, there was no difference in peak serum cortisol in patients with or without adrenal insufficiency [(12.99 ± 2.54 mg/dL) vs (22.44±5.52 mg/dL), P = 0.09 respectively. Conclusion: HPA axis is affected in 13.04% of patients 3 months after presentation with COVID-19. These findings have important implications for the clinical care and long-term follow-up of patients after COVID-19.

A rare case of central diabetes insipidus unmasked after renal transplantation in a young male

Background: The diagnosis of central Diabetes insipidus (DI) requires intact renal function to manifest polyuria. Therefore, it may not become evident in patients with oliguric or anuric renal failure such as in chronic kidney disease (CKD) or end stage renal disease (ESRD). This might get manifested after renal transplantation, however there are only 5 cases reported so far of Central DI post renal transplantation. Here we report a case of central DI that was unmasked in a patient with CKD after kidney transplantation leading to polyuria. Case Report: RV, 26-year-old male had one episode of febrile illness with hematuria at age of 20 years and was diagnosed IgA nephropathy by renal biopsy following which he recovered completely. Hypertension was detected in Feb 2021, and he has been on Cilnidipine 10 mg OD, Clonidine 0.1 mg TDS, Metoprolol XL 40 mg OD. At age of 25 years, he had covid illness and his kidney function deteriorated to ESRD for which he was started on twice weekly hemodialysis for 8 months and then underwent live donor renal transplantation in October 2021. Two months later, he was admitted for polyuria, polydipsia, and nocturia. After renal transplantation, his urine volume increased to 9-10 L/ d, while it had been less than 500 mL/day before the transplantation. His serum creatinine level improved from 3.2 mg/dL prior to transplant to 0.8 mg/dL after transplant. He had not been diagnosed with diabetes before, and his blood glucose levels were within the normal range. He showed no symptoms of polyuria or polydipsia before transplantation and had no history of head trauma or neurosurgery. Diagnosed to have primary hypothyroidism in Feb 2021 during pre-transplant workup, for which he was started on levothyroxine 50 ug and was euthyroid. The patient received prednisolone, tacrolimus, mycophenolate mofetil, and sulfamethoxazole/trimethoprim after the transplantation. During evaluation for polyuria, urine volume was >100 ml/kg in 24 Hour. Serum osmolality of 295 mOsm/kg, urine osmolality of 101 mOsm/kg, and serum sodium of 138 mEq/L, RBS 86 mg/dl, Urea 24 mg/dl. Anterior pituitary hormone profile workup was normal. To evaluate the cause of polyuria, water deprivation test was performed which confirmed complete central diabetes insipidus. He was started on oral desmopressin 120 ug in divided doses. His urine output subsequently decreased to about 2.5 L/d with resolution of excessive thirst and nocturia. MRI sella revealed normal anterior pituitary, infundibulum and diminished posterior pituitary bright spot in the T1-weighted image. Patient is continued on desmopressin therapy at 6 months with marked improvement in symptoms. Conclusion: In this case, the water deprivation test and diminished posterior pituitary bright spot-on MRI and the responsiveness to desmopressin therapy confirm the diagnosis of central DI. Hence, any case of polyuria after renal transplantation must be evaluated for Central Diabetes Insipidus.

Hypogonadism in male covid 19 survivors – A prospective study

Introduction and Aims: Covid 19 can invade the testes directly by through the ACE2 receptors. It can also affect the hypothalamus and pituitary gland, thus disrupting the HPG axis. We aimed to assess the HPG axis in male survivors of Covid 19 about 3-5 months after recovery from Covid 19 infection. Methods: This was a prospective study conducted at a tertiary centre in southern India. Adult male patients were enrolled for the study 3-5 months after recovery from Covid 19 infection. Hypogonadism was defined as low testosterone (total testosterone <241 ng/dl) or borderline low testosterone (total testosterone 241-317 ng/dl) with low free testosterone (<6.3 ng/dl). Primary hypogonadism was defined as hypogonadism with LH 39.4 mIU/ml and secondary with LH <9.4 mIU/ml. Results: We recruited a total of 85 subjects. The mean age of our study population was 49.50 ± 12.73 years. 24 (28.24%), 21 (24.71%), and 40 (47.06%) patients had mild, moderate and severe Covid 19 infection. Hypogonadism was seen in 21 (24.7%) study subjects. The predominant pattern of hypogonadism was secondary seen in 20 subjects (95%). Younger age, higher BMI and use of remdesivir were significantly associated with hypogonadism. The prevalence of hypogonadism was not associated with severity of illness, the extent of pulmonary involvement or the duration of hospitalisation. Conclusion: We found a high prevalence of hypogonadism in male subjects 3-5 months after acute infection. Male Covid 19 patients should be followed after acute infection for symptoms suggestive of hypogonadism. Future studies are needed to improve our knowledge regarding the sexual dysfunction seen in post covid phase.

Changes in long term glycaemic control post Covid infection -An obsevational study

Background: The world continues to face the ongoing COVID 19 pandemic, which has affected multiple organ systems. Diabetes is a slow growing pandemic, affecting an individual in multiple ways. Both these disease conditions have impacted each other in terms of clinical progression and outcome. To date, acute hyperglycaemic effects of Covid and new onset diabetes post covid have been established. How long this glycaemic effect persists, is yet to be established. In our study, we aimed to look at the glycaemic changes over 6 months post covid-19 infection, among previously diagnosed type 2 diabetic subjects having good to modestly good control of diabetes. Methods: Type 2 diabetic individuals who met the eligibility criteria and visited the Endocrinology outpatient department with a history of covid infection, were included. The severity of covid infection and steroid usage data was collected retrospectively from discharge summary, and patient history. HbA1c, fasting and postprandial glucose values prior to covid-19 infection were collected from previous outpatient records. Diet, physical activity and drug compliance history were collected by oral questionnaires. These individuals were called back for follow-up at 3 months. Those with poor glycaemic control were followed-up at monthly intervals, for drug titration. Data collected over six months period was analysed for significance of change in glycatedhaemoglobin, fasting and prandial glucose values. The confounding effects of poor dietary compliance, lack of physical activity, steroid use during covid was also studied after adjusting the data.{Table 1} Results: Among 1856 patients screened, 256 subjects were included in the study after meeting eligibility criteria. Among them 36.5% (96) were females and 62.5% (160) were males. More than half of the subjects (135) were aged greater than 60 years. The mean duration of diabetes was 8.2 years. In majority (183), duration of diabetes was less than 10 years. The severity of Covid infection was found to be parallel with prior diabetic control. The mean glycatedhaemoglobin level before covid was 7.2%. On follow up at three months it had raised to 8.6% (p < 0.001). At six months, the mean glycatedhaemoglobin was at higher level of 7.9% (p < 0.001) in spite of dose titration in 72% of subjects. The change is equally driven by both fasting and prandial glucose levels (all p < 0.001). When data was adjusted to the use of steroids, still significant changes in all three variables-glycatedhaemoglobin, fasting and prandial glucose levels persisted. When confounding effects of both steroid use and lack of physical activity were excluded, the glycatedhaemoglobin changes at three and six months was significant at p < 0.0001 and p < 0.02 respectively. Though the change in fasting and prandial glucose values at three months was significant (p < 0.001), it was not significant at six months (p = 0.08). The changes in glycaemic control were affected by severity of Covid infection, with poor glycaemic control in those having severe infection. Conclusions: Covid 19 infection impairs glycaemic control in long term. Thus, frequent monitoring and timely drug titration is necessary for appropriate management of diabetes post Covid.

COVID-19 vaccine side effects in Type 1 diabetes mellitus patients as compared to healthy controls: Results from the COVAD study

Background: COVID-19 vaccinations have been proven to be generally safe in healthy populations. However, the data on the vaccine safety in patients with Type 1 Diabetes Mellitus (T1DM) is inadequate. The study aimed to evaluate the frequency and severity of the adverse vaccination effects (ADEs) and their risk factors among T1DM patients. Methods: This study analyzed data from the COVID-19 vaccination in Autoimmune Diseases (COVAD) survey database (May-Dec 2021;110 collaborators, 94 countries), comparing COVID-19 vaccine adverse drug events among T1DM patients and healthy controls (HCs). The study was designed to assess post-COVID-19 vaccination ADE in patients with autoimmune diseases. Descriptive and comparative analysis was performed based on data distribution and variable types. Results: We included 5480 completed responses in this study. Of all responses, 5408 were HCs, and 72 were T1DM patients (43 females, 48.0% Caucasians). The majority of the respondents had received Pfizer vaccines (p < 0.001). 4052/5480 (73.9%) respondents had received 2 vaccine doses, rest had received 1 vaccine dose. The most common ADE reported was injection site pain (50.0%), with T1DM patients reporting significantly lower frequency of injection site pain than HCs [OR 0.6 (0.3-0.9), p = 0.045]. Multivariate analysis showed that T1DM respondents had higher frequency of severe skin rashes [OR = 8.0 (1.7-36.0), p = 0.007] than HCs. However, overall ADEs, major ADEs, minor ADE and hospitalization frequency remained similar between T1DM and HCs. Conclusions: COVID-19 vaccination was largely safe and well tolerated in patients with T1DM with similar ADE profile compared to HCs, except for increased frequency of skin rashes in them.

To study the effect of six months of combined estrogen and progestin treatment on anti-mullerian hormone in polycystic ovary syndrome patients

Background: Anti-Mullerian hormone (AMH) is secreted by small antral follicles and is elevated in PCOS. Unlike serum total testosterone, its value remains constant irrespective of the phase of menstrual cycle. Serum AMH could prove to be a promising marker of disease activity and response to therapy. Combined estrogen-progestin (CEP) pills are considered treatment of choice in PCOS, but their effect on serum AMH has not been widely studied. Objective: To study the effect of six months of CEP pills on serum AMH and testosterone in PCOS patients. Methods: 55 consecutive females, above 18 years and diagnosed with PCOSby Rotterdam Criteria, who attended our outpatient clinic from July 2020 to April 2021, were enrolled. Hirsutism was assessed by modified Ferriman-Gallwey Scoring (mFGS). Serum AMH and total testosterone were measured at baseline, and all the patients were initiated on combination of ethinyl estradiol (35 mcg) with cyproterone acetate (2 mg), to be taken orally for 21 days every month for a period of 6 months. Serum AMH and total testosterone were reassessed again after 6 months of CEP therapy. Out of total 55 patients, 14 were lost to follow up due to Covid-19 pandemic. A total of 24 patients completed 6 months of CEP therapy, while remaining discontinued the treatment after a mean period of 2 months because of perceived adverse effects. Results: Mean age of study population was 22.8 ± 4.4 years. At baseline, hyperandrogenic features like acne, hirsutism and hair fall were present in 41 (74.5%), 35 (63.6%) and 42 (76.4%) females, respectively. Mean mFGS was 5.6 ± 2.8. Oligomenorrhoea was reported by38 (69.1%) females. Mean AMH levels and testosterone were 12.1 ± 7.1 ng/ml and 46.6 ± 20.1 ng/dl, respectively. There were 17 (30.9%) patients who had testosterone 360 ng/dl, while 42 females (76.3%) had high AMH levels (36.8 ng/ml). Baseline AMH positively correlated with BMI and serum LH level. Post-treatment, there was significant decrease inacne, hirsutism and hair fall (P < 0.001 for all). Mean mFGS (5.6 ± 2.8 vs 4.2 ± 2, P < 0.001) and mean serum AMH levels (12.1 ± 7.1 ng/ml vs 10.4 ± 7 ng/ml, P = 0.002) demonstrated a significant improvement. Serum testosterone levels decreased post therapy (46.6 ± 20.1 vs 42.3 ± 17.4 ng/dl, P = 0.08), but did not reach statistical significance (table 1). Testosterone and AMH levels did not show any correlation (R = 0.054, P = 0.7). Conclusions: AMH levels show a significant decline after 6 months of treatment, corresponding to improvement in hyperandrogenic symptoms and mFGS. AMH can prove to be a promising marker of disease activity in PCOS. The major limitation of the study was its small sample size, and more robust studies are needed.

Endocrine dysfunction in Covid-19 recovered individuals

Background: Involvement of the endocrine system has been well characterized in the acute stage of COVID-19. Long-term sequelae of COVID-19 involving various systems with a negative impact on mental health, well-being, and quality of life have been reported. Observational studies from different populations revealed a variable proportion of endocrine dysfunction following SARS-CoV-2 infection. The spectrum ranges from normal function to the persistence or emergence of new dysfunction up to 12 weeks post-COVID. Objective: To determine the spectrum of endocrine dysfunction in COVID-19-recovered individuals. Methods: Patients were recruited 8-20 weeks following recovery from COVID-19. They were further stratified according to disease severity as defined by the ICMR criteria. Demographic and clinical details, physical examination, basal and stimulated cortisol, DHEAS, ACTH, TSH, fT4, fT3, LH, FSH, Testosterone, SHBG, AMH, prolactin, fasting blood glucose (FBG), Hba1c, insulin, c-peptide levels with calculated HOMA-IR and HOMA-beta were done. Results: Eighty-three subjects were recruited of which 33 (39.7%) and 50 (60.3%) belonged to mild and moderate to severe COVID respectively. There were 50 male and 33 female subjects. The mean duration after recovery was 14.7 weeks. Sixty-nine subjects (83%) had new or persistent symptoms. Thirty-seven subjects (44.6%) had some form of endocrine dysfunction. Thyroid function abnormalities were observed in 18 subjects (21.6%) [Subclinical hypothyroidism (18.1%), overt hypothyroidism (1.2%), Central hypothyroidism (2.4%)]. Primary and Secondary adrenal insufficiency was documented in 1 (1.2%) and 15 (18.1%) subjects respectively. A higher prevalence of adrenal insufficiency was noted among those who received steroids (62.5% vs. 37.5%). Hypogonadism was observed in 10 males [Primary 2 (4%) and Secondary 8 (16%)]. Central endocrine dysfunction involving two axes was noted in 3 patients. There was no association was between the severity of COVID and any of these endocrine dysfunctions. Among 67 patients with no history of Diabetes Mellitus (DM), 6 (9%) patients had dysglycemia [3 new-onset DM and 3 Pre DM]. Significant differences were also noted between the means of waist circumference (p = 0.003), FBS (p = 0.02), HOMA IR by insulin (p = 0.04) and c-peptide (p = 0.001) among non-DM patients when compared for disease severity [mild (n = 29) vs. moderate-severe (n = 38)]. Conclusion: Our study highlights that endocrine dysfunction involving different endocrine axis can be seen up to 20 weeks post-COVID in patients with no prior history of endocrine disorder. The most common dysfunction observed was of the thyroid followed by the adrenal axis.

Insulin autoimmune syndrome: Experience at a tertiary care centre

Introduction: Insulin autoimmune syndrome (Hirata's disease) is a rare cause of hypoglycemia characterised by recurrent hypoglycemic episodes due to insulin autoantibodies, without any prior exposure to insulin. Method: Retrospective review of patients with hyperinsulinemichypoglycemiawas done. 10 patients (8 females), aged between 7 to 60 years (mean 42.9 years), from year 2005 to 2021 were assessed. Results: Four patients presented with fasting hypoglycemia, while all of them had post-absorptive hypoglycemic episodes. Four (40%) patients had evidence of other autoimmune conditions (three Hashimoto's thyroiditis & one autoimmune cholangiopathy). Mean insulin was 2782uIU/mL (61-14,332), and mean C-peptide was 12.9 ng/dL (3.6-37.6). Mean anti insulin antibody level was 77.8% (13.6-98.82) in samples evaluated by RIA (till 2015), and 84.7 u/mL by ELISA (2016 onwards). Three (30%) patients had positive history of offending drug usage (clopidpgrel, torsemide and pantoprazole). One of the patients had history of Covid-19 infection three months prior. Treatment with low carbohydrate diet, alpha glucosidase inhibitor & /or prednisolone was effective in all symptomatically. Conclusion: In hyperinsulinemichypoglycemia, when insulin is markedly elevated, but C-peptide is only moderately elevated, insulin autoimmune syndrome should be suspected and insulin in dilution and anti-insulin antibody should be checked. Also, history of other autoimmune conditions, and history of any offending drug usage should be diligently investigated in these patients.

Patterns, determinants and long term outcomes of hyperglycemia among subjects recovering from COVID 19 illness

Objectives: While presence of diabetes has been frequently associated with severe Corona virus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARSCoV-2), new onset hyperglycemia had been common phenomenon seen in these patients and associated with poor outcomes. Less is known about determinants of this and its long-term outcomes. Materials and Methods: This were a retrospective and prospective hospital based;observational study and a total of 302 patients who suffered from COVID 19 illness from January 2021 to January, 2022 were included after fulfilling inclusion criteria and procuring informed consent. Patients with diabetes mellitus were excluded from the study. Hyperglycemia was defined as BGF 3 126 mg/dl or BGR 3 200 mg/dl or Hba1c 36.5% on admission or anytime during hospital stay. Results: Average age of study population was 51.82 ± 18.33 years and male to female ratio was 1.7:1. Out of 302 patients, 40 had mild disease and 262 had moderate to severe disease. 27 patients developed hyperglycemia during their admission and all the patients had suffered severe COVID 19 illness. They were managed with Insulin therapy. One patient had presented with Diabetic ketoacidosis and later diagnosed with Type 1 diabetes mellitus. The major determinants of hyperglycemia were age, BMI, Severity of illness, use of steroids especially methylprednisolone and family history of diabetes. On follow up at 1 year, no new appearance of hyperglycemia was seen in euglycemic subjects and 6 out of 27 patients persisted with diabetes and were managed with oral antidiabetics. Conclusion: The incidence of new onset diabetes is increased in patients with COVID 19 however, the mechanism of how SARS-CoV-2 might lead to incident diabetes is likely complex and could differ by type 1 and type 2 diabetes. Monitoring of long-term metabolic consequences of COVID 19 illness including Diabetes mellitus is required.

Using Age-Specific Checklists to Help Transition Adolescents With Type 1 Diabetes to Adult Care

Aim 3: Attaining Pediatric Endocrinology Clinician SatisfactionPediatric endocrinology clinician and nurse feedback was collected before each pilot round of checklist distribution. Pediatric endocrinology clinicians and nurses were encouraged to give the project team their suggestions and potential topic additions for each of the transition checklists. Team members' feedback and input were highly valued and used during each checklist revision before the finalized versions were introduced. Moreover, it was believed that by maintaining staff involvement throughout the project, the team would be more inclined to want to use the checklists with their patients. Thus, their feedback was incorporated directly into the finalized checklists.Feedback was sought through a series of staff surveys throughout the project during the following times: before implementation of the transition checklists, during implementation, and after implementation. Effectiveness measurement occurred at multiple points of the project and of the patient encounter cycle. This was performed through surveys with Likert scales and free-text questions. These surveys occurred before project implementation, after a 4-week trial, and after another 4-week cycle.It is important to note that the first 2 staff surveys (ie, before implementation and during the implementation) asked a uniform set of questions, whereas the postimplementation survey asked unique, specific questions pertaining to each age-related checklist. These 3 sets of staff surveys were vital to assess staff feedback and to track areas of improvement. Staff were able to voice their areas of concern and provide recommendations for the checklists.ResultsResults were centered on staff perception of inclusivity, program usefulness, and effectiveness. Before and during implementation, a total of 3 rounds of staff surveys were completed. The first staff survey was administered during the week of January 5, 2020. A total of 17 staff surveys were distributed to the provider team. A response rate of 76% (13/17) was obtained.Regarding Aim 1, the majority of individuals surveyed (94%;16/17) strongly agreed that transition management should begin in middle adolescence, that it was important to the practice, and that the pediatric endocrinology clinic's current self-management and transition screening process was lacking. The majority of nurses and providers (77%;13/17) strongly agreed that there was ease of use with the checklist process. These positive results aligned with the first aim of the project—to assist pediatric endocrinology clinicians in assessing the responsibility of T1D care.Aim 2 of this project was to integrate evidence-based checklists into daily use. Prior to the start of implementation, staff strongly agreed that the checklists were easy to use (92%;12/13), and the majority of individuals surveyed (69%;9/13) agreed strongly that they would adopt the checklists as a standard of care. Throughout the project, time was the main issue that pediatric endocrinology clinicians expressed concern with checklist integration. Although most staff had no concerns for additional time requirements, over a quarter (31%;4/9) were unsure if the checklists would ultimately extend pediatric endocrinology clinic visits and provider schedules (see Figure 5).The second survey was administered the week of February 2, 2020, with a good response rate (86%;6/7). As evidenced in Figure 6, pediatric endocrinology clinic nurses showed increasing support for use of the checklists during the intake portion of the visit in February compared to preintervention data. After 1 month of a PDSA pilot, nurses also unanimously agreed that they would be willing to integrate the checklist model and transition education into their daily practice with patients.Aim 3 of this project was to attain pediatric endocrinology clinician satisfaction in a manageable and attainable new intake process. After an initial PDSA cycle, a second staff survey was slightly modified to only include nurse feedback;the nurses were the staf mem ers who were directly involved with the distribution, collection, and tracking of the transition checklists. There was also a decrease in staff perception as to whether it was useful for patients and whether the educational handouts were beneficial (see Figure 7).However, staff were split as to whether they believed both parents and adolescents thought the process was equally beneficial. As Figure 8 shows, nurses were satisfied with the level of parental support they had witnessed both during checklist administration and while providing education to teens and families. Over half of nurses (53%;7/13) felt that the same support existed among adolescent patients.DiscussionPediatric care providers, particularly nursing staff, have an integral role in helping adolescents with T1D transition to adult care. In outpatient settings, pediatric nurses proactively manage patients and outcomes in between follow-up visits. It is extremely important to attain the interest and involvement of pediatric nurses, advanced practice pediatric endocrinology clinicians, and physicians prior to starting a care management and transition program. Within the context of T1D, research has shown that young adults are not confident in their self-management and may also display higher levels of depression and risk-taking behaviors (Gutierrez-Colina et al 2020). A coordinated and enthusiastic team approach is necessary to approach care management for patients on physical, mental, and emotional levels.Involving pediatric endocrinology clinic care providers early and throughout the project may have contributed to sustained support for the implementation of the checklists. Staff were involved during every round of the checklist revisions in which their feedback and suggestions were continually welcomed. Nurses and NPs were shadowed prior to implementation to assess daily activities, pediatric endocrinology clinic flow, and the feasibility of integrating new duties into appointments and charting duties. New patient support and insulin pump classes, hosted by dual pediatric nurses and certified diabetes care and education specialists, were also attended to assess the responsibilities of pediatric endocrinology clinic staff. In consideration of the literature, involvement of providers was extremely important through the self-management evaluation (Garvey et al 2017). It was extremely important for our team to integrate interventions that were manageable and sustainable for nurses and providers. We sought approval from physicians, advanced practice providers, nurses, and the pediatric endocrinology clinic dietitian for every checklist and proposed educational intervention. Involving pediatric endocrinology clinic care providers early and throughout the project may have contributed to sustained support for the implementation of the checklists.A nurse champion was identified and assigned to help coordinate patient selection, distribution of checklists, and staff education. Having a champion was critical to implementation of the project, even when it was noted to cause additional time in patient intake. The champion spearheaded meetings with facility technology liaisons, which was helpful because the DNP students on the team were not employees of the health system. The nurse champion was a BSN-prepared certified diabetes educator, and her expertise supported the project both before and during COVID-19. This individual is expected to assist with the sustainability of the project.Nursing staff routinely provided feedback that the checklist process would need to be integrated into the electronic medical record (EMR) for it to be sustainable after the end of the trial period. While awaiting coordination with the facility's EMR team, the pediatric endocrinology clinic's medical assistants provided the checklist to patients and parents during the check-in process. Meetings occurred every Friday with nurses and a lead medical assistant to identify next week's patients who would need assessment of self-management and transition readiness. Patients were identi ied and mar ed with the date and time of appointment, provider name, and team nurse. At this preweekly screening, patients' health history was assessed to ensure the adolescent was an appropriate candidate for self-management discussion.Throughout the project, pediatric endocrinology clinical staff support and buy-in for the transition of care readiness checklists remained above average or high. For instance, it was found in the first survey that 92% of the staff strongly believed that transition of care management is important and relevant to their practice. Interdisciplinary coordination and buy-in of a transition of care program has been viewed as important to the success of transition (Pierce et al 2017). Perhaps a potential reason for such high, sustained pediatric endocrinology clinical support could be explained by the fact that the pediatric endocrinology clinic did not have any prior transition of care process in place. They were eager for us to begin working on a structured process for the staff and patients. Evaluation of the contextual setting and implementing evidence into practice assisted with implementation and continuing momentum on the project (Seers et al 2012).The final versions of the checklists support a developmentally appropriate and systematic process that can assist pediatric endocrinology clinics to prepare adolescents with T1D for a safe transition to adult care. Most children are diagnosed at a young age, and teaching is focused on parent understanding. Therefore, transition to adult care requires a comprehensive and logical approach to assess adolescent understanding. Starting with an independent environment in high school and the need to correctly count carbohydrates and dose insulin and progressing on to the ability to refill prescriptions anddeal with insurance questions is crucial. The final versions of the checklists support a developmentally appropriate and systematic process that can assist pediatric endocrinology clinics to prepare adolescents with T1D for a safe transition to adult care.LimitationsBarriers identified included the size of data collection during initial cycles, time needed for checklist completion, and integration into the EMR. A major limitation of our project was the small sample size of pediatric endocrinology clinical staff who were surveyed. A total of 17 clinical staff members, 16 of whom provided feedback during survey 1. Of the 7 nurses who were surveyed in surveys 2 and 3, 6 provided feedback during survey 2, and 7 provided feedback during survey 3. Another limitation is that the pediatric endocrinology clinical site for the project resides in a large, suburban area and cannot be assumed to be representative of the entire adolescent T1D population at large. Moreover, our data only come from a single pediatric endocrinology clinic.Another area where the data were not as persuasive compared to the pediatric endocrinology clinical staff support for the checklists was in terms of staff feedback involving the length of time required to complete the checklists. A resounding theme with staff was their concern with how much time would be added on to the intake process for patients. Due to the nature of the pediatric endocrinology clinic, nurses had approximately 5 to 10 minutes to room patients and prepare them for a visit with the provider. The initial rollout of the project consisted of patients being presented with the survey upon check in. If deficiencies in care management were identified, the nurse would provide education and an issue-specific handout. This handout had to be retrieved from the provider office, which added an extra 3 to 5 minutes of walking and coordination.Additionally, the decrease in the percentage who strongly disagreed could potentially be attributed to not having the checklists uploaded into the EMR. This action could decrease the amount of time that staff would need to chart on the patient's progress. We might expect more favorable responses for this category once a more finalized pediatric endocrinology clinical workflow process is established. How ver, this is largely reliant on when the checklists become uploaded by the health IT department into the EMR.Using paper checklists and handouts, rather than technology, was the largest impediment to our aims. During the phase of our project where we sought staff feedback, it would have been useful to engage with the facility's IT department early in the process. This would have assisted with concurrent project and EMR rollout, rather than initiating the project using hard copies of checklists and educational handouts. Integration of the project into daily use is intended to be done by using the EMR. The team expected to lay the groundwork for the aim in spring 2020 and create a plan with IT to facilitate a unique note within the EMR. Transition of the pediatric endocrinology clinic from regular to COVID-19 operations put this aim on hold. The next direction of this project is a nurse-led program to integrate the checklists as part of a routine template within the medical record. Using paper checklists and handouts, rather than technology, was the largest impediment to our aims.RecommendationsIt is important to note that while the use of checklists can be a helpful mechanism to track a patient's progression in their self-care and to prepare them to be able to self-manage their diabetes, it may not be the best format to use for all patients. Some patients may require multiple transitions of care strategies. We recommend a targeted approach to each patient's unique situation.We also recommend that the transition process begins earlier rather than later. Current literature supports assessing readiness of emerging adults with diabetes to transition to adult care at 15 years of age (Kamoun et al 2022). Our staff noted that adolescents are required to independently manage their diabetes when starting high school at 14 years of age. Therefore, we recommend starting the transition process as early as age 14 to begin assessing the patient's needs and self-care abilities. This is in contrast to many larger diabetes authorities, such as the American Diabetes Association (ADA), who largely recommend beginning the transition of care process approximately 1 year prior to transition. Our approach offers more time to prepare and home in on the important self-care skills.We further recommend that staff administer the transition of care checklists at least 1 to 2 times per year starting at age 14 until the transition. Because most patients are seen in the pediatric endocrinology clinic at least every 3 months for follow-up, we recommend incorporating the checklists into the routine 3-month visit workflow to maintain tight tracking of the patient's progression in their disease self-management.It is also important to keep in mind the practicality of integrating a checklist system into a busy pediatric endocrinology clinic day of approximately 10 to 15 patients per provider. Most pediatric endocrinology clinic visits are fairly short and may only last 15 to 30 minutes, making it at times seem cumbersome to administer the checklists. This is why we recommend continuing to have patients complete the checklist form while they are in the waiting area before their appointment and to supply them with the corresponding education at the end of the appointment should they feel unsure about a particular disease topic. This way, filling out the checklists would not impede the overall flow of the visit.

Diabetes-Related Excess Mortality in Mexico: A Comparative Analysis of National Death Registries Between 2017–2019 and 2020

OBJECTIVE To estimate diabetes-related mortality in Mexico in 2020 compared with 2017–2019 after the onset of the coronavirus disease 2019 (COVID-19) pandemic. RESEARCH DESIGN AND METHODS This retrospective, state-level study used national death registries of Mexican adults aged ≥20 years for the 2017–2020 period. Diabetes-related death was defined using ICD-10 codes listing diabetes as the primary cause of death, excluding certificates with COVID-19 as the primary cause of death. Spatial and negative binomial regression models were used to characterize the geographic distribution and sociodemographic and epidemiologic correlates of diabetes-related excess mortality, estimated as increases in diabetes-related mortality in 2020 compared with average 2017–2019 rates. RESULTS We identified 148,437 diabetes-related deaths in 2020 (177 per 100,000 inhabitants) vs. an average of 101,496 deaths in 2017–2019 (125 per 100,000 inhabitants). In-hospital diabetes-related deaths decreased by 17.8% in 2020 versus 2017–2019, whereas out-of-hospital deaths increased by 89.4%. Most deaths were attributable to type 2 diabetes (130 per 100,000 inhabitants). Compared with 2018–2019 data, hyperglycemic hyperosmolar state and diabetic ketoacidosis were the two contributing causes with the highest increase in mortality (128% and 116% increase, respectively). Diabetes-related excess mortality clustered in southern Mexico and was highest in states with higher social lag, rates of COVID-19 hospitalization, and prevalence of HbA1c ≥7.5%. CONCLUSIONS Diabetes-related deaths increased among Mexican adults by 41.6% in 2020 after the onset of the COVID-19 pandemic, occurred disproportionately outside the hospital, and were largely attributable to type 2 diabetes and hyperglycemic emergencies. Disruptions in diabetes care and strained hospital capacity may have contributed to diabetes-related excess mortality in Mexico during 2020.

Summary Report of the ADCES 2021 Insulin Initiation and Titration Survey

The intent of the IITS is to assess the current practice of insulin management and education including initiation, intensification, and technology integration.ADCES administers the Insulin Initiation and Titration Survey (IITS) to its members on a periodic basis. The intent of the IITS is to assess the current practice of insulin management and education including initiation, intensification, and technology integration. The survey consists of 49 questions inquiring about practice involvement and setting, the education and management of patients requiring insulin initiation and intensification, use of diabetes technology, and cause/impact of therapeutic inertia. The last survey prior to the one reported in this article was performed in 2016, and the results were published in 2017.1For the 2021 survey, approximately 12 429 emails were sent inviting members to participate. Of those, 473 were undeliverable, and 6 individuals opted out. Out of the 11 950 email invitations delivered, 633 surveys were completed. This resulted in a 5.3% response rate. The 80% of respondents that said they had the Certified Diabetes Care and Education Specialist (CDCES) credential were mostly nurses and dietitians.There were 11% with the Board Certified- Advanced Diabetes Manager (BC-ADM) credential, and most of them were pharmacists. Advanced Practice Nurses were more likely to hold both certifications.Most respondents worked in hospital outpatient/clinic settings, followed by inpatient and then private practice. Not surprisingly, there was a 12% increase in the use of telehealth as compared to the 2016 survey, likely because of the COVID-19 pandemic. Both the 2016 and the 2021 surveys showed that diabetes care and education specialists working in an accredited, recognized program are more likely to provide one-on-one education.The authority of the respondents to initiate insulin in their current positions, either without restriction, under supervision, or with a preapproved protocol, did not change much from the previous survey to the current one and ranged from 12% to 39%. There were 42% who said they did not have the authority to initiate insulin. More of them reported titrating insulin either using a standing order (22%) or with a physician’s orders (41%) than in the previous survey (14% and 34%, respectively).

Are those with diabetes more willing to adhere to COVID‐19 guidance?

Background: Those with diabetes were at a higher risk of experiencing severe illness in the event of contracting COVID‐19. Did they therefore act more cautiously?Method: The Imperial ‘COVID‐19 Behavioural Tracker’ details the results of regular surveying on attitudes surrounding COVID‐19 guidance. Results from UK participants to questions reflecting willingness to adhere to important recommendations regarding everyday behaviour were examined. Responses from those with diabetes were compared to those stating none of a list of pre‐existing health conditions. The effect of gender and age was examined.Results: Respondents with diabetes showed higher willingness to follow guidance than those with no health conditions. Compliance varied over time;willingness to self‐isolate remained high throughout, while willingness to avoid shopping, avoid going out, or avoid large gatherings rose in winter months. Greater adherence was seen in older age ranges, and in females, for both those with diabetes and healthy respondents. A logistic regression underlined the influence of gender, showing it as the most important variable influencing willingness to follow guidance.Discussion: The results underline that interrelating factors influence health behaviour decisions. The results suggest that those with diabetes are likely to listen to advice provided to them by health care professionals. Copyright © 2022 John Wiley & Sons.