Impact of free insulin scheme to patients with type 1 diabetes during Covid-19 pandemic

Aim: Our institute provided the required monthly insulin free to patients with type 1 diabetes, where either patients or parents became unemployed and/or economically weaker during the pandemic. Method(s): All 296 patients with type 1 diabetes were given questionnaires to assess their or their family's economic status during Covid-19. 33 patients fell below poverty line and had a Priority Household Card (with 35kgs of free rice every month) and ration cards enrolled for monthly free insulin scheme. The patients were given monthly requirements of insulin based on existing regimens. Their weight, HbA1c and episodes of ketoacidosis were measured at 3-and 6-months following initiation of the scheme. Additional financial and material support were organized from NGO's and philanthropic individuals. Measurable impact of this project was ascertained through glycaemic control through HbA1C levels prior and after, overall wellbeing and prevention of acute complications like ketoacidosis. Result(s): 33 patients enrolled for the study, 9 were less than 15 years of age, 19 between 15 and 30 years and 5 above 30 years of age. HbA1c levels fell cumulative by 0.8% by 3 months and 1.2% by six months. Weight increased by 1 kg by 3 months and 1.5 kg by six months. Few episodes of ketoacidosis were reported during six months primarily due to engagement issues issue rather than availability of insulin. Conclusion(s): There was a dramatic impact on overall wellbeing of these patients with type 1 diabetes with significant improvement on glycaemic control and on emotional by reducing the financial burden of procuring monthly doses of insulin.

Trends of the medical status of adult patients with diabetes mellitus in the Samara region for 2018-2020.

According to domestic and foreign studies, diabetes mellitus (DM) is a significant risk factor for infection with the SARS-CoV-2 vi-rus, a severe course of the disease, and an adverse outcome. Trend analysis of epidemiological and clinical characteristics of DM patients living in the Samara region in the initial period of the spread of the new coronavirus infection can help to assess the effectiveness of medical care for DM patients in a challenging epidemiological setting and to determine the directions for its improvement. Objective. To assess the trends in the prevalence, incidence, and mortality of DM patients living in the Samara region and to iden-tify the changes in the structure of vascular complications and the status of glycemic control from 2018 to 2020. Material and methods. The study of the medical and epidemiological DM indicators was performed according to the design of a continuous retrospective observational study covering the period from 2018 to 2020;the object was the adult population of the Samara region. Results. The total number of DM patients in the Samara region in 2020 was 118,623 people (3.73% of the population), of which type 1 diabetes was detected in 5.2% (6118 people) and type 2 diabetes in 94.2% (111,700 people). The trends of the prevalence of type 1 DM were 186.3->192.4/100,000 population, type 2 DM 3132.5->3153.1/100,000 population;the dynamics of primary morbidity with type 1 diabetes mellitus 8.8->6.2/100,000 population, with type 2 DM 259.1->196.4/100,000 population;mortality with type 1 diabetes mellitus 3.2->4.2/100,000 population, with type 2 diabetes mellitus 120.7->174.5/100,000 population. The most common causes of death were cardiovascular diseases: 30.3% in type 1 DM, 39.7% in type 2 DM;there is a trend towards increasing in death <<from DM>> without indicating the immediate cause of death for both types of DM;<<from COVID-19>> 3.8% with type 1 DM and 3.7% with type 2 DM. The incidence of vascular complications in type 1 and type 2 DM was 31.4% and 11.5% for reti-nopathy, and 21.4 and 11.5% for nephropathy, respectively. Trends in the proportion of patients with HbA1c <7%: 28.1%->51.1% in type 1 DM, 15.7%->62.4% in type 2 DM;with HbA1c >=9.0%: 25.4%->12.1% in type 1 DM, 39.8%->7.1% in type 2 DM. Conclusion. The study demonstrates the importance of a comparative sequential assessment of the epidemiological characteristics of diabetes mellitus and the clinical status of patients living in the Samara region in challenging epidemiological settings to assess the prospects for optimizing follow-up.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

Complex presentations in people with diabetes: Does HbA1c help or hinder?

HbA1c measurement is widely used for diagnosis/ management/remission of diabetes with international schemes certifying comparability. A) 75 year-old Chinese female with type 2 diabetes was admitted in April 2020 with Covid-19 and diabetic ketoacidosis. Glucose was 35mmol/l and HbA1c 150mmol/mol with previous HbA1c of 45mmol/mol on metformin and alogliptin. She was treated for ketoacidosis and once-daily Lantus introduced along with supportive management of viral illness. B) 68 year-old Afro-Caribbean with type 2 diabetes on metformin before admission, presented with new onset, jerky ballistic movements of high amplitude in right arm, 10-15 movements every 5 min. Admission glucose was >33mmol/l, ketones 1.8mmol/l and HbA1c >217mmol/ mol. Hemichorea-hemiballism, a hyperglycaemia related movement was diagnosed and insulin commenced. Glucose decreased to 8-20mmol/ l, reaching 5-15mmol/ l by time of discharge. Ballistic movements resolved when glycaemic control improved with HbA1c 169mmol/mol, 25 days after discharge. C) Several days before admission, a female with diabetes over 20 years required attention from paramedics on four occasions for hypoglycaemia. Months beforehand metformin was replaced by gliclazide due to chronic kidney disease with HbA1c 50mmol/mol, and she was transfused six weeks before admission for microcytic anaemia. Gliclazide was discontinued and her diet modified which prevented further hypoglycaemic episodes. Variant haemoglobin, beta-thalassaemia which can overestimate glycaemia;undetected by HbA1c HPLC method, invalidated HbA1c as did the blood transfusion. These cases highlight that inadequate understanding of HbA1c can lead to acute presentations of dysglycaemia. As HbA1c accuracy can be affected by multiple factors, clinical assessment and triangulation are key to the management of such patients.

Change in glycaemic control immediately after Covid-19 vaccination in people with type 1 diabetes: What happens after the most recent vaccination?

Aims: We have shown previously in 93 individuals with type 1 diabetes using the FreeStyle Libre flash glucose monitor that the week after their first Covid-19 vaccination, the percent 'time in target range 3.9-10mmol/ l' (%TTR) average went from 55.2%-> 52.4% (effect size -5.1%) with 58% of people recording a fall. 47 (50%) people with HbA1c < 56mmol/mol %TTR went from 69.3-> 63.5 (-8.3%) and 24 (25%) people using insulin+oral treatment 56.7%-> 50.7% (-10.1%). We have now repeated the exercise after the most recent Covid-19 vaccination. Method(s): FreeStyle Libre data and medical records of the same patients from the previous study were examined for the week before and week after their most recent Covid-19 vaccination. () in the results section show change in %TTR as % of the prior value to show effect size. TTR% results from 2 weeks before and after were also considered. Result(s): Median time between vaccines was 38 weeks IQR (37-40). After the latest vaccination average %TTR average went from 51.1%-> 49.8% (-2.5%) with a reduction found in 54% of patients. Impact on the 39 patients with HbA1c < 56mmol/mol -% TTR from 66.2%-> 61.8% (-6.5%) and the 20 (25%) patients using insulin+oral %TTR from 48.2%-> 47.1% (-2.2%). 65% of the patients whose %TTR fell previously, fell again after this vaccination. Fortnight average %TTR 53.5%-> 52.1% (-2.7%) whereas in the previous study across fortnight %TTR 55.4%-> 54.0% (-2.4%). Conclusion(s): The perturbation effect on blood glucose with 1st Covid-19 vaccination was seen again in the latest vaccination but reduced in magnitude, confirming that a significant group of type 1 diabetes individuals' glycaemic control is still being impacted by the Covid-19 vaccination.

ID: 215433 The History of Spinal Cord Stimulation to Treat Painful Diabetic Peripheral Neuropathy

Introduction: Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18. Method(s): A systematic literature review of the robust body of evidence for SCS in the treatment of painful DPN was conducted. Publications were selected for inclusion by two independent reviewers using defined selection criteria. Additional relevant publications from outside the search dates were included. Result(s): SCS was first documented as an effective treatment for DPN in three single-arm studies published between 1996 and 20122,4,5, one of which was followed-up to thirty-six months18, and another to seven-years3. These studies paved the way for two RCTs published in 20146,7, one of which was followed-up to five-years in two publications8,10, and another7 was followed-up with analyses on QoL9 and an evaluation of the effects of burst SCS17. Two meta-analyses were published in 2020 and 202111,12. A post-hoc analysis of a multi-center single-arm study on high frequency (10kHz) SCS to treat DPN was published in 202013 and followed by an RCT published in 202114 with additional 1-year follow-up15,16. Collectively these studies demonstrate that SCS is an effective therapy for patients with painful DPN by reducing pain and increasing QoL for DPN patients (Figure 1). Conclusion(s): This review of a large body of evidence shows a decades-long history of the effectiveness of SCS for symptom relief in patients suffering from painful DPN. Future research on the effectiveness of new waveforms and novel methods of energy delivery to the spinal cord are needed. The study of outcomes in addition to pain relief is also needed, which may better illustrate the breadth of effects of SCS therapy on the underlying disease factors. Increasing awareness of the current evidence is essential to increasing therapy adoption by expanding payer support and influencing referring health care provider behavior. Disclosure: Eric Grigsby, MD: AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Medtronic: Consulting Fee: Self, SPR Therapeutics: Consultant: Self, Tenex Health: Consultant: Self, Voyager Therapeutics: Consultant: Self, Xalud: Consulting Fee: Self, AE Mann Foundation: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Bioness Inc.: N/A: Self, Medallion Therapeutics: N/A: Self, SPR Therapeutics: N/A: Self, Abbott / St. Jude Medical: N/A: Self, Tenex: N/A: Self, Vertos: N/A: Self, Xalud: N/A: Self, AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medtronic, Inc.: N/A: Self, Collegium Pharmaceutical, Inc.: Trustee: Self, Flowonix Medical: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Trustee: Self, Spinal Restoration, Inc.: Trustee: Self, Jazz Pharmaceuticals: N/A: Self, Alfred Mann Foundation: N/A: Self, Boston Scientific: N/A: Self, CNS Therapeutics: N/A: Self, Collegium Pharmaceutical, Inc.: N/A: Self, Flowonix Medical: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: N/A: Self, Myoscience: N/A: Self, NeurAxon Inc.: N/A: Self, Spinal Restoration, Inc.: N/A: Self, St. Jude Medical, Inc.: N/A: Self, Abbott Laboratories: Consultant: Self, Alfred Mann Foundation: Consulting Fee: Self, Cervel Neurotech, Inc.: Consultant: Self, CNS Therapeutics: Consultant: Self, Covidien: Consultant: Self, Cumberland Pharmaceuticals, Inc.: Consultant: Self, Flowonix Medical: Consultant: Self, Jazz Pharmaceuticals: Consultant: Self, Mainstay Medical: Consultant: Self, Medtronic, Inc.: Consultant: Self, Myoscience: Consultant: Self, NeuroPhage Pharmaceuticals: Consultant: Self, Nevro Corp: Consultant: Self, Palyon: Consultant: Self, Spinal Modulation: Consultant: Self, SPR Therapeutics: Consultant: Self, St. Jude Medical, Inc.: Consultant: Self, Tenex Health, Inc.: Consultant: Self, VertiFlex Inc.: Consultant: Self, Vertos Medical, Inc.: Consultant: Self, Xalud Therapeutics, Inc.: Contracted Research: Self, Medtronic, Inc.: Served on speakers' bureau: Self, Flowonix Medical: Served on advisory board: Self, Medtronic, Inc.: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Nevro Corp: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Rachel Slangen, PhD: None, Lisa Johanek, PhD: Medtronic: Salary/Employee: Self, Maddie LaRue, PHD: Medtronic: Employee:, Cecile de Vos, PhD: None, Melissa Murphy: Medtronic: Consulting Fee:, Relievant: Consulting Fee:Copyright © 2023

Comparative effectiveness and safety of a pharmacist-managed protocol for the transition from intravenous to subcutaneous insulin

Purpose: To evaluate the effectiveness and safety of a pharmacist-managed protocol for transitioning critically ill patients from intravenous (iv) to subcutaneous insulin compared with a provider-managed process. Method(s): This single-center, retrospective, observational study included patients admitted to the medical or surgical/trauma intensive care unit who received a continuous infusion of iv insulin from January 2019 to April 2021. Patients were excluded if they were less than 18 years of age, pregnant, incarcerated, or received iv insulin for the diagnosis of diabetic ketoacidosis, hyperglycemic hyperosmolar state, calcium channel blocker or beta blocker overdose, or hypertriglyceridemia. The primary outcome was the percentage of blood glucose (BG) concentrations within the target range of 70-150 mg/dL from 0 to 48 h following transition to subcutaneous insulin. Secondary outcomes included percentage of BG concentrations within goal range following transition at 0-12 h and 12-24 h, incidence of hypo- and hyperglycemia, and percentage of patients requiring dose adjustments after initial transition. Result(s): A total of 110 unique patients were included with 70 patients in the provider-managed group and 40 patients in the pharmacist-managed group. On average, pharmacists transitioned patients to 63% basal insulin based on their 24-h total day dose of insulin. The pharmacist-managed group achieved glycemic control in 53% of transitions at 12 h, 40% at 24 h, and 47% from 0 to 48 h, while the provider group achieved glycemic control in 25% of transitions at 12 h, 12% at 24 h, and 18% from 0 to 48 h (p < 0.001 for all time points). As for safety end points, the pharmacist-managed group demonstrated lower rates of hypoglycemia (p = 0.001), severe hypoglycemia (p = 0.332), hyperglycemia (p < 0.001), and severe hyperglycemia (p < 0.001) compared with the provider-managed group. Conclusion(s): Pharmacists can effectively and safely transition critically ill patients from iv to subcutaneous insulin utilizing a standardized protocol.Copyright © 2023 Pharmacotherapy Publications, Inc.

The intersection of technology, ethnicity, deprivation, and the covid-19 pandemic: Lessons from the National Diabetes Audit

Introduction: The aim was to investigate access to and the effect of intermittency scanned flash glucose monitoring (isCGM) on glycaemic control during the Covid-19 pandemic. Method(s): Data from the National Diabetes Audit from 2019 to 2021 was stratified into those who were already using isCGM on 1st April 2020 (A), those who started isCGM on or after 1st April 2020 (B), and those who did not receive isCGM (C). Logistic regression investigated the independent effects of ethnicity and deprivation on access to isCGM after adjustment for baseline covariates (age, gender, BMI, duration of diabetes, and baseline HbA1c). Ethnicity was categorized as White, Asian, Black, Mixed, and not reported. The Index of Multiple Deprivation (IMD) was divided into quintiles. Result(s): 251,620 people were identified with type 1 diabetes;88,910 (35%) had isCGM prescribed at 1st April 2020. The mean follow-up post-isCGM initiation was six months. Mean HbA1c at baseline was 67.4mmol/mol in (A), 73.6mmol/mol in (B) and 69.7mmol/mol in (C). Mean HbA1c at follow-up was 64.9mmol/mol (A) (p < 0.001), 65.5mmol/mol (p < 0.001) (B). After adjustment for age, sex, duration of diagnosis, baseline HbA1c, and BMI people with White ethnicity (OR = 1.79 p < 0.001) or in the least deprived quintile (OR = 1.54, p < 0.001) were more likely to be initiated on isCGM as compared to the black and most deprived groups. Conclusion(s): Initiating isCGM during the Covid-19 pandemic was associated with improved glycaemic control. Ethnic and socioeconomic disparities in access to isCGM were observed even during the pandemic. Ongoing work is investigating the effect of isCGM on diabetes-related hospital admissions during the pandemic.

Primary care network (PCN) based 'type 2 diabetes optimisation clinics' run by primary care clinicians are a cost effective and efficient way of improving treatment targets for patients with poorly controlled diabetes, despite the constraints of the Covid-19 pandemic

Background: Approximately 10% of people living with type 2 diabetes in Waltham Forest (WF) who are treated with oral hypoglycaemic agents (OHA) alone and not under specialist care have an HbA1c > 75mmol/mol. No optimisation clinic exists at PCN level in WF, despite maximum capacity reached in specialist community and secondary care clinics. Aim(s): To establish a remote PCN based optimisation clinic during the Covid-19 pandemic, using motivational and patient empowerment interviewing techniques. Improvement in HbA1c, blood pressure and lipid profile underpinned the study. The 'behaviour change model' was also used to assess patient engagement. Method(s): We identified and consulted with 43 patients using an extended consultation of 25 min. Engagement and recall after 3 months were facilitated by a dedicated administrator and optimal care was ensured via monthly remote consultant input. Result(s): 38 patients were optimised with oral hypoglycaemic agents (OHA) alone and completed the pilot. 31/38 patients had an HbA1c reduction of more than 11mmol/ mol, with a significant overall median reduction across the whole cohort (pre 88mmol/mol vs 70mmol/mol, p < 0.0001). There was also a significant median reduction in triglyceride level (pre 1.56mmol/l vs 1.20mmol/l, p = 0.0247). In terms of behaviour change, all but one patient improved their behaviour towards their diabetes significantly. The approximate cost of the pilot per patient was 263 (excluding medication). Conclusion(s): A PCN based optimisation clinic using active recall is a cost effective and efficient method for significantly improving glycaemic control in people living with type 2 diabetes.

COVID-19 among Hospitalized Patients with Diabetes in Karachi: A Single Centre Study

Aim: To evaluate the clinical characteristics, severity, and outcomes of local COVID-19 patients with diabetes. Study Design: Case series Place and duration of study: Orthopedic Medical Institute Hospital, Karachi from 1st September 2020 to 28th February 2021. Method(s): One hundred and forty seven COVID-19 positive patients with diabetes and pre-diabetes were enrolled. The patients' demographic and clinical information specific to COVID-19 and diabetes was collected and analyzed. Result(s): The mean age of 64.03+/-11.56 years. The ischemic heart disease (39.9%) and hypertension (74.3%) were the two most prevalent comorbid conditions. The overall mortality rate of 20.3%. Between patients with diabetes receiving steroids and those receiving no steroids, the mean fasting (FBG) and random blood glucose (RBG) were relatively elevated. Glycemic control had no discernible impact on the severity, results, or length of the COVID-19 hospital stay (p>0.05). Conclusion(s): No significant effect of diabetes millitus control on COVID severity and outcomes, but the altered blood glucose levels suggest a need to define specific targeted intervention for COVID-19 patients with comorbidities, specifically diabetes mellitus.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.

Glycemic Control in Type 1 Diabetes Mellitus and COVID-19: What We Learned From the Lockdown Experience.

INTRODUCTION: Confinement measures that were imposed during the COVID-19 pandemic drastically changed the routines of the population. Some studies on the impact of confinement on glycemic control suggest a reduction of 0.1 to 0.5% in glycated hemoglobin. The objective of this study was to evaluate the impact of the COVID-19 pandemic lockdown on glycemic control in adult patients with type 1 diabetes mellitus. METHODS: An observational retrospective cohort study of patients with type 1 diabetes mellitus followed in a Diabetes Unit was performed. The study compared the metabolic control of these patients before (between January 1st and March 18th, 2020) and after (between May 3rd and July 31st, 2020) the lockdown. RESULTS: The study included 102 patients with type 1 diabetes mellitus (51% females), with a median age of 36 years (interquartile range 18.75, (24.25-43)) and a median duration of diabetes of 15 years (interquartile range 13, (8-21)). After lockdown, a significant decrease of 0.28±0.71% in glycated hemoglobin was observed (7.88±1.33% vs 7.59±1.23%, p=<0.001). In patients using continuous glucose monitoring a significant improvement in time in range was also noted (47.25±17.33% vs 49.97±18.61%, p=0.008). CONCLUSIONS: This study demonstrated an improvement in glycemic control after the lockdown. This might be explained by the positive impact of stable schedules, healthy meals and greater availability to make therapeutic adjustments to glycemic control. The fact that diabetes was considered a risk factor for the development of severe COVID-19 disease might also influence patients to increase their efforts to optimize their glycemic control.

Poor glycemic control: a public health challenge prepandemic and pandemic

Objective. To compare glycemic control in patients with type 2 diabetes mellitus who attended primary healthcare units in Mexico City, prepandemic and during the COVID-19 pandemic. Materials and methods. Records of 23 912 diabetes patients were analyzed;78.7% were from the prepandemic group (2016 to 2020) and 21.3% from the pandemic group (March 2020 to July 2021). Central tendency and dispersion measures were calculated, Student's t-test and multiple logistic regression model were performed. Results. Patients with diabetes were mainly women (66.6 and 62.6%) with an average age of 59 and 58 years, respectively. Glycosylated hemoglobin (HbA1) levels were 7.7 in the prepandemic group and (8.0) in the pandemic group. The variables associated with poor glycemic control included period, HbA1 level, overweight, obesity, history of parents with diabetes, number of medications and type of insulin. Conclusions. Most patients with diabetes continued to have poor glycemic control in both groups. Patients in the pandemic group had poor glycemic control compared to the prepandemic group.After medical intervention, patients improved their glycemic control in both groups © 2023,Salud Publica de Mexico. All Rights Reserved.

Comparison of HbA1c measurement in remotely prepared capillary versus standard venous blood samples

Background The COVID-19 pandemic has disrupted routine HbA1c testing. This has led to difficulties in monitoring glycaemic control and identifying people with suboptimal glycaemia. Delayed diagnosis of diabetes and suboptimal glycaemic control over extended periods can increase the risk of developing long-term complications of diabetes. The self-collection of capillary blood remotely (at home) for routine HbA1c testing can facilitate monitoring of glycaemic control whilst supporting virtual consultations. The aimof this study was to assess the clinical performance and user acceptance of capillary blood samples prepared remotely using the MiniCollect capillary blood collection device as an alternative to standard venous blood collection for HbA1c analysis. Methods Adult men and women with any type of diabetes were recruited. Following informed written consent, eligible participants provided a venous blood sample at their routine clinic appointment and subsequently prepared a capillary blood sample remotely. Participants also completed a bespoke usability questionnaire. Results Of 84 participants recruited, 62 capillary samples returned to the laboratory, with 41 having a paired venous sample for HbA1c analysis. HbA1c results using both collection methods demonstrated good agreement;Passing-Bablok Regression analysis, y=0 + 1x;R=0.986, Bland-Altman Difference Plot providing a mean difference of 0.3 mmol/mol. Conclusions Over half of participants found the MiniCollect device easy to use. The majority were in favour of the remote capillary blood collection service and would use it if routinely available. The remote self-collection of capillary blood for HbA1c is a convenient alternative for people with diabetes living and working in rural or urban settings ensuring optimal continuance of care.

Metformin in COVID-19: Is There a Role Beyond Glycemic Control?

Context: The coronavirus disease 2019 (COVID-19) pandemic is still a cause of worldwide health concern. Diabetes and its associated comorbidities are risk factors for mortality and morbidity in COVID-19. Selecting the right antidiabetic drug to achieve optimal glycemic control might mitigate some of the negative impacts of diabetes. Metformin continues to be the most widely administered antidiabetic agent. There is evidence of its beneficial outcome in COVID-19 independent of its glucose-lowering effect. Evidence Acquisition: A thorough literature search was conducted in PubMed, Google Scholar, Scopus, and Web of Science to identify studies investigating metformin in COVID-19. Result(s): Several overlapping mechanisms have been proposed to explain its antiviral properties. It could bring about conformational changes in the angiotensin-converting enzyme-2 receptor and decrease viral entry. The effects on the mammalian target of the rapamycin pathway and cellular pH have been proposed to reduce viral protein synthesis and replication. The immunomodulatory effects of metformin might counter the detrimental effects of hyperinflammation associated with COVID-19. Conclusion(s): These findings call for broader metformin usage to manage hyperglycemia in COVID-19.Copyright © 2023, International Journal of Endocrinology and Metabolism.

Dysglycemias in patients admitted to ICUs with severe acute respiratory syndrome due to COVID-19 versus other causes - a cohort study.

BACKGROUND: Dysglycemias have been associated with worse prognosis in critically ill patients with COVID-19, but data on the association of dysglycemia with COVID-19 in comparison with other forms of severe acute respiratory syndrome are lacking. This study aimed to compare the occurrence of different glycemic abnormalities in patients with severe acute respiratory syndrome and COVID-19 admitted to intensive care units versus glycemic abnormalities in patients with severe acute respiratory syndrome from other causes, to evaluate the adjusted attributable risk associated with COVID-19 and dysglycemia and to assess the influence of these dysglycemias on mortality. METHODS: We conducted a retrospective cohort of consecutive patients with severe acute respiratory syndrome and suspected COVID-19 hospitalized in intensive care units between March 11 and September 13, 2020, across eight hospitals in Curitiba-Brazil. The primary outcome was the influence of COVID-19 on the variation of the following parameters of dysglycemia: highest glucose level at admission, mean and highest glucose levels during ICU stay, mean glucose variability, percentage of days with hyperglycemia, and hypoglycemia during ICU stay. The secondary outcome was the influence of COVID-19 and each of the six parameters of dysglycemia on hospital mortality within 30 days from ICU admission. RESULTS: The sample consisted of 841 patients, of whom 703 with and 138 without COVID-19. Comparing patients with and without COVID-19, those with COVID-19 had significantly higher glucose peaks at admission (165 mg/dL vs. 146 mg/dL; p = 0.002) and during ICU stay (242 mg/dL vs. 187md/dL; p < 0.001); higher mean daily glucose (149.7 mg/dL vs. 132.6 mg/dL; p < 0.001); higher percentage of days with hyperglycemia during ICU stay (42.9% vs. 11.1%; p < 0.001); and greater mean glucose variability (28.1 mg/dL vs. 25.0 mg/dL; p = 0.013). However, these associations were no longer statistically significant after adjustment for Acute Physiology and Chronic Health Evaluation II scores, Sequential Organ Failure Assessment scores, and C-reactive protein level, corticosteroid use and nosocomial infection. Dysglycemia and COVID-19 were each independent risk factors for mortality. The occurrence of hypoglycemia (< 70 mg/dL) during ICU stay was not associated with COVID-19. CONCLUSION: Patients with severe acute respiratory syndrome due to COVID-19 had higher mortality and more frequent dysglycemia than patients with severe acute respiratory syndrome due to other causes. However, this association did not seem to be directly related to the SARS-CoV-2 infection.

The First Reported Case of Lorlatinib-Associated Diabetic Ketoacidosis

Introduction: Lorlatinib is a third-generation tyrosine kinase inhibitor that inhibits anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1). Although 2-10% of patients with non-small cell lung cancer developed hyperglycemia in phase 2 and 3 studies of lorlatinib, only one case has subsequently reported hyperglycemia >500 mg/dL, and no cases of diabetic ketoacidosis (DKA) have been previously reported. Phase 1 trials in neuroblastoma are ongoing. Case Description: A 34-year-old woman with ALK-mutated paraspinal neuroblastoma presented with DKA 14 months after initiation of lorlatinib. Prior to starting lorlatinib, her hemoglobin A1c had been 5.0% (n: < 5.7%). After 12 months of therapy, her A1c increased to 7.8%, prompting the initiation of metformin 500 mg daily. However, two months later she was admitted for DKA with a blood glucose of 591 mg/dL (n: 65-99 mg/dL), CO2 17 mmol/L (n: 20-30 mmol/L), anion gap 18 (n: 8-12), moderate serum ketones, and 3+ ketonuria. Her A1c was 14.8%, C-peptide was 1.2 ng/mL (n: 1.1-4.3 ng/mL), and her glutamic acid decarboxylase-65 and islet antigen-2 autoantibodies were negative. She was also found to be incidentally positive for COVID-19 but was asymptomatic without any oxygen requirement. The patient's DKA was successfully treated with IV insulin infusion, and she was discharged after 3 days with insulin glargine 27 units twice daily and insulin aspart 16 units with meals. One month later, her hemoglobin A1c had improved to 9.4%, and the patient's oncologist discontinued lorlatinib due to sustained remission of her neuroblastoma and her complication of DKA. After stopping lorlatinib, her blood glucose rapidly improved, and she self-discontinued all her insulin in the following 3 weeks. One month later, she was seen in endocrine clinic only taking metformin 500 mg twice daily with fasting and post-prandial blood glucose ranging 86-107 mg/dL. Discussion(s): This is the first reported case of DKA associated with lorlatinib. This case highlights the importance of close glucose monitoring and the risk of severe hyperglycemia and DKA while on lorlatinib therapy. Discontinuation of lorlatinib results in rapid improvement of glycemic control, and glucose-lowering treatments should be promptly deescalated to avoid hypoglycemia.Copyright © 2023

The Effect of the Different Waves of COVID-19 Pandemic on the Outcome of Diabetic Foot Ulcers

Objective: Diabetic foot ulcers (DFUs) are complications of diabetes mellitus. COVID-19 pandemic has massively impacted human health. We studied effect of COVID-19 on outcome of DFUs. Method(s): We recruited 483 people with DFU from June 2020-April 2022 (pandemic group) together with a matched group of 227 people with DFU from March 2019-March 2020 (pre-pandemic group). Matching was done with respect to glycemic control (Average HbA1c in pandemic group 9.15%;pre-pandemic group 8.92%), and renal status. Primary endpoint was outcome of ulcers- healed or undergone amputation. Primary outcome was further sub analyzed in the 3 waves of COVID-19 Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data with site, nature and Wegner's grading of DFUs were collected. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ABI. Standardized treatment protocol including glycemic control, infection control, debridement, dressing, offloading was provided. All patients were monitored for >6 months. Result(s): In pandemic cohort of 483 patients 323(66.9%) patients had healed ulcers, 70(14.5%) had minor amputation, 11(2,2%) had major amputation, 29(6%) lost to follow up, 22(4.6%) had not healed and 28 are in follow up (5.8%). Rate of healing of DFU in pandemic group was higher (66.9%) than control group (53.5%). Similarly, rate of amputation in pandemic group was less (16.7%) than pre-pandemic group (23.4%). Among healed ulcers in pandemic group, non-infected neuropathic ulcers healed better (77.8%;199/256) than other types (54.6%;124/227) [p< 0.00001]. Similarly, rate of amputation (major/minor) in ischemic and neuroischemic ulcers in pandemic group was more (32.3%;11/34) than other types (15.6%;70/449) [p= 0.011]. Rate of healing of foot ulcers in 1st wave was 65.4% (53/81), 2nd wave 75.2% (158/210), 3rd wave 58.3% (112/192). Neuropathic ulcers though less prevalent in first two waves (49.8%;145/291) than 3rd wave (57.8%;111/192) healing rate was more in first two (79.3%;115/145 vs 75.6%;84/111). [p=0.488 (statistically not significant]. Ischemic and neuroischemic ulcers were more in 3rd wave (7.8%;15/192) than first two waves (6.5%;19/291) and undergone more amputation (46.7%;7/15 vs 15.7%;3/19). [p=0.58 (statistically not significant;due to small sample size]. Discussion/Conclusion: COVID-19 pandemic (mainly first two waves) accounted for travel restrictions contributing to better healing of neuropathic ulcers whereas ischemic and neuroischemic ulcers worsened and underwent more amputation as patients could not seek intervention. Conversely, in third wave withdrawal of COVID restrictions lead to worsening of DFUs leading to less healing and more amputation.Copyright © 2023

Racial and Ethnic Disparities in the Use of Live Video Telemedicine

Purpose of Study As a result of the coronavirus disease 2019 (COVID-19) pandemic and physical distancing, telehealth has been scaled up as a key strategy to address the need for virtual access to medical services. Previous studies have examined use of web-portals for accessing health information, but data on the use of live video telemedicine for disease management across different ethnicities is limited. The objective of this study is to determine if disparities exist among different ethnic groups in accessing live video telemedicine services. Methods Used A literature review was conducted using databases such as PubMed and Google Scholar. Key search terms included: telehealth, telemedicine, ethnicity, and disparities. Studies were included if a) they were conducted in the United States, b) patients used a live video telehealth service with a provider, c) focused on telemedicine use across different racial and ethnic groups, and d) investigated completed access to live video telemedicine at the individual level, and not potential access at the aggregate level. Summary of Results Of 25 articles found, 5 met our inclusion criteria. Overall, white patients had higher rates of telehealth visit completion and video telehealth use than non-white patients. Studies that used telehealth visits for diabetes education and glycemic control showed that self-care improved in all ethnic groups, but despite tailored intervention, minority groups never achieved the same level of self-care as whites. Conclusions Our review suggests that overall white patients have better access to live video telemedicine, and use the services at higher rates compared to non-white patients. However, since this trend was not seen in every study, it is likely that other factors beyond race and ethnicity play a role in access to telemedicine. Effective strategies are needed to mitigate disparities to ensure equitable telemedicine access.

Glycemic Control Improvement amongst Patients with Diabetes Mellitus during a COVID-19 Lockdown in Jordan

Aims: The purpose of this study is to evaluate the effects of lockdown measures by the Jordanian government to contain the spread of the novel corona virus (COVID-19) on glycemic control of patients with diabetes mellitus. Method(s): This cross-sectional study was conducted in Jordan University Hospital. A total of 264 patients with type 2 or type 1 diabetes mellitus were sampled. The authors evaluated the extent of glycemic control reached by patients with type 2 or type 1 diabetes mellitus by measuring change in glycosylated hemoglobin (A1C) values, in addition to the number of hypoglycemic episodes experienced by patients during lockdown. The authors conducted a questionnaire via telephone interviews to record information about drug adherence and availability, diet, physical activity, and telephone consultations. A paired sample t-test was used to compare values before and after lockdown. Result(s): A significant reduction in HbA1C values was found during lockdown (p=0.038), with only 33.6% of patients experiencing one or more hypoglycemic episodes;both factors suggest controlled blood glucose levels. Medication adherence was found to be the main reason for improvement, with 74.8% of our population being strongly adherent to their medications. Conclusion(s): In Jordanian patients with diabetes mellitus, glycemic control was significantly improved during COVID-19 lockdown and this was found to be associated with strong medication adherence.Copyright © 2023 University of Jordan,Deanship of Scientific Research. All rights reserved.

Performance of a Computerized Insulin Infusion Protocol in 359 Critically Ill Patients with COVID-19

Objective: People with diabetes and uncontrolled hyperglycemia are at high risk of COVID-19 complications and as such, many patients admitted to the ICU with COVID-19 have diabetes or stress hyperglycemia. It is suggested that quick and adequate control of hyperglycemia without increasing the risk of hypoglycemia is imperative to improve outcomes in these patients. Control of wide fluctuations of glycemic variances in these patients may often require modifications of existing strategies of glycemic management. Use of a computerized insulin infusion protocol (CIIP) in these settings could be largely beneficial in getting early and sustained glycemic control. We report our experience with the Lalani Insulin Infusion Protocol (LIIP), a novel CIIP with dynamic and adaptive glycemic targets in accordance with the patient's glycemic state, in critically ill COVID-19 patients with hyperglycemia treated with IV insulin. Method(s): We conducted a retrospective analysis of 359 critically-ill COVID-19 patients in whom LIIP was used (8/18/2020 to 08/31/2022) at six HonorHealth Hospitals in the Phoenix metropolitan area. Primary endpoints of the analysis included Time to Euglycemia (min), % of time in euglycemia (70-180 mg/dl), % of time in hyperglycemia (>180 mg/dl), and % of time in hypoglycemia (<70 mg/dl). We also report the average length of stay (ALOS) in the hospital and ICU as well as the discharge dispositions of these patients. Result(s): Of the 359 critically ill COVID-19 patients who received IV insulin directed by LIIP, 167 patients had diabetes, 266 patients were treated with steroids, 226 patients had compromised renal function (eGFR< 60), 40 patients had sepsis, and 5 patients had cardiovascular comorbidities. The following glucometrics were observed: average Time to Euglycemia from baseline glucose values was 278 minutes, average % time in euglycemia was 83.01%, average % time in hyperglycemia was 16.77%, and average % time in hypoglycemia was 0.22%. Of the 359 patients, there were 166 deaths (46.2%), 91 patients were discharged to home (25.4%), and 102 patients were discharged to an interim facility (28.4%). The hospital ALOS was 15.02 days and ICU ALOS was 9.50 days. Discussion/Conclusion: For HonorHealth hospitals, LIIP was a safe and effective method of quickly achieving and maintaining euglycemia in critically ill patients with COVID-19, while maintaining low hypoglycemia incidence. Herein the patients reported had varying degrees of comorbidities and treatments, including steroids and vasopressors;however, no modifications in glycemic management strategy or nursing workflow were necessary during the use of LIIP due to its adaptive formula which individualizes IV insulin rates for each patient.Copyright © 2023

Diabetes mellitus and COVID-19: A bidirectional relationship?.

The COVID-19 pandemic has generated a public health emergency around the world. The risk, severity, and mortality of the disease has been associated to chronic diseases, such as diabetes mellitus. There are multiple patho-physiological explanations that relate these two entities. The possibility of a bidirectional relationship between COVID-19 and diabetes mellitus type 1 and 2 has been raised. Most studies agree that diabetes mellitus of any etiology is associated with a negative outcome of the infection. Also, CO-VID-19 can cause a worsening of glycemic control and can be a trigger for the development of diabetes mellitus type 1.Copyright © 2023 Universidad de Antioquia.