Diagnosing gestational diabetes during the Covid-19 pandemic using HbA1c rather than oral glucose tolerance test (OGTT)

The Royal College of Obstetrics and Gynaecology advocated replacing OGTT with HbA1c for gestational diabetes (GDM) screening for women with risk factors during the Covid-19 pandemic. HbA1c >=48mmol/mol/random plasma glucose (RPG) >=11.1mmol/l at booking indicated diabetes, and 41-47mmol/ mol/9-11mmol/ l prediabetes or possible GDM. Testing was repeated at 26 weeks if normal previously, with HbA1c >=39mmol/mol, fasting PG >=5.6mmol/l, or RPG >=9mmol/l diagnostic for GDM. A) At her clinic booking visit at 10 weeks gestation, 36 year-old South Asian female had HbA1c 55mmol/mol/RPG 9.5mmol/l suggesting undiagnosed type 2 diabetes. Initially managed with dietary advice and home blood glucose monitoring, metformin was added when self-monitored glucose above pregnancy targets (fasting and pre-meal <5.3mmol/l or 1 h post meal <7.8mmol/l) but insulin was required later. Metformin and insulin were stopped after delivery at 38 weeks with HbA1c 50mmol/mol three months postpartum, supporting the earlier diagnosis of type 2 diabetes. B) 32 year-old White Caucasian female was screened for GDM on booking at 11 weeks as BMI 38 kg/m2. HbA1c 44mmol/mol and RPG 6.9mmol/l confirmed GDM which was managed by dietary/lifestyle changes with glucose and pregnancy targets achieved until 28 weeks when metformin added. Normal delivery at 40 weeks with HbA1c 40mmol/mol three months postpartum triggered advice on long-term dietary/lifestyle changes and annual HbA1c checks. HbA1c was useful during the pandemic but most centres reverted to OGTT for GDM screening due to a significant fall in diagnoses using HbA1c >=39mmol/mol at 26 weeks. But, HbA1c testing was advantageous at booking to diagnose type 2 diabetes earlier.

GDM diagnosis criteria: Standard and Covid-19 criteria

Aim: Standard diagnosis of gestational diabetes (GDM) is based on the Oral Glucose Tolerance test (OGTT). During the Covid-19 outbreak, due to Covid restrictions, criteria were modified i.e Fasting Blood Glucose >=5.3 and/ or HbA1c >= 39 for diagnosis of GDM. After the lifting of the Covid restrictions, the standard criteria were reimplemented and on analyzing the data, it was highlighted that some of the patients could have tested negative for GDM based on Covid Criteria. Method(s): We analyzed the data of 43 patients based on standard criteria (OGTT and HbA1c) after Covid restrictions, with the following results. Result(s): 11/43(28%) patients who were diagnosed on the basis of standard criteria could have been missed based on Covid criteria. Out of 11 deliveries, 2 babies with weight above 4 kg. There were no admissions to NICU. One patient had postpartum hemorrhage with 670 mL of blood loss. Conclusion(s): This was a retrospective study in which we analyzed the data of 45 pregnant females diagnosed with GDM based on testing using the Covid criteria and compared this to 43 pregnant females who were diagnosed with GDM on the basis of OGTT based on GOLD standard NICE criteria. In addition, we also examined maternal and obstetric outcomes in both groups such as the mode of delivery, the baby's birth weight, the incidence of shoulder dystocia, mean blood loss (MBL), and NICU admission. We understand that Covid GDM diagnosis was a necessity of time. In this study, we want to learn what could have been missed with that diagnostic criteria. For future pandemics, we need to revise our diagnostic criteria to avoid the risk of underdiagnosing GDM and associated complications.

Optimal continuous glucose monitoring metrics for identification of women with gestational diabetes

Aims: Continuous glucose monitoring (CGM) is widely used in pregnant women with pre-gestational diabetes, but optimal targets have not been defined in gestational diabetes. Previous work identified mild hyperglycaemia in pregnant women without gestational diabetes, but with risk factors such as obesity. We aimed to examine CGM metrics and patterns of glycaemia in women with gestational diabetes compared to healthy pregnant women with comparable risk factors. Method(s): We recruited 73 healthy women with >1 risk factor (gestational diabetes excluded using Covid-19 criteria, OGTT) and 200 women with gestational diabetes (NICE and interim-Covid- 19 criteria) from antenatal clinics at 28 weeks' gestation. A Dexcom G6 CGM device was cited on the non-dominant upper arm. Result(s): Women with gestational diabetes had significantly higher weight (mean +/- SEM 95.7 kg +/- 1.3 Vs 85.4 kg +/- 2.2) and BMI (36.0 +/- 0.5 Vs 31.3 +/- 0.7) compared to healthy pregnant women (p < 0.01). Women with gestational diabetes had significantly higher mean CGM-glucose (mean +/- SEM 5.6 +/- 0.01 Vs 5.4 +/- 0.01mmol/l;p < 0.01), significantly altered time-below- range (median(IQR);1.0% (0.2-2.9) vs 2.5% (0.7-5.5);p < 0.05) and time-in- range (95.0% (91.1-97.9) vs 94.5% (87.9-96.2);p < 0.05) but comparable time-above- range to healthy women with risk factors. Diurnal glucose profiles in women with gestational diabetes were comparable to healthy women between 14:00 and 18:00, but demonstrated significant increases in glucose at all other time points during the 24-h cycle (p < 0.01). Conclusion(s): Mean CGM glucose is the most reliable CGM metric to distinguish women with gestational diabetes from healthy pregnant women with risk factors.

Was the diagnosis of gestational diabetes from 34 weeks gestation of pregnancy more prevalent during Covid-19 due to the change in how gestational diabetes was diagnosed?

Aim: During Covid we noticed that more women were being diagnosed with Gestational Diabetes (GDM) from 34 weeks gestation than prior to Covid. It was suspected that this was due to how GDM was diagnosed, from Oral Glucose Tolerance Test (OGTT) prior to Covid to HbA1c with Fasting or Random Blood Glucose (RBG) during Covid. Method(s): An audit of our GDM database was performed, looking at rates of late GDM diagnosis from 2018-present. Result(s): Prior to Covid the late diagnosis rate was 14-15%. In 2020 and 2021 this increased to 27.7%. This year diagnosis is only by OGTT, and the rate has dropped to 21%. There was also a significant rise in the number of women who were being diagnosed from 34 weeks gestation whom had previously been tested for GDM earlier in their pregnancy. In 2018 and 2019 52-56% of these women had previously been tested. In 2020 this increased up to 84% and fell to 74% in 2021. This year the rate has fallen to 67%. In 2018 and 2019 all women had been diagnosed using OGTT's. In 2020 61% of women had previously been tested for GDM by HbA1c and RBG, with this increasing to 84% in 2021. This year only 10% had previously been tested using HbA1 and RBG. Conclusion(s): The sharp increase in late diagnosis of GDM during the Covid seems to be related to the change in diagnostic testing and shows that OGTT is the more accurate way to diagnose GDM and not HbA1c with RBG.

Prevalence of Hyperglycemia in Pregnancy and Related Screening Practices in Rural Dehradun: The First Population-Based Study from Uttarakhand (PGDRD-1).

Aims: Phase I of the Prevalence of Gestational Diabetes Mellitus in Rural Dehradun (PGDRD) project estimates hyperglycemia in pregnancy (HIP) prevalence and identifies gaps in the utilization of community-related services in rural areas of the Dehradun district (western Uttarakhand); a state where notably no prior population-based study has ever been conducted despite being an Empowered Action Group state for more than two decades. Methods: Using a multistage random sampling technique, 1,223 pregnant women locally registered in the rural field practice area of a block were identified. Those requiring HIP screening were subjected to a 2-h 75 g oral glucose tolerance test during the house visit irrespective of their period-of-gestation and last meal timings, diagnosed using the Diabetes in Pregnancy Study Group India (DIPSI) criterion (when indicated). Data were collected by personal interviews using a pretested data collection tool. Statistical Package for Social Sciences version 20.0 was used for analysis. Results: The overall HIP prevalence recorded was 9.7% (95% CI: 8.1-11.5%); the majority (95.8%) were GDM followed by overt DIP (4.2%). Less than 1% of the subjects (0.7%) self-reported pre-GDM. Despite this burden, more than three-fourths were never screened for HIP in their pregnancy. Of those tested, the majority availed secondary healthcare facilities. Few even had to bear expenses in private with a very handful being tested free-of-cost by ANM in the community; findings that altogether sharply contrast to those recommended by national protocols. Conclusion: Despite the high HIP burden, beneficiaries are unable to utilize community-related universal screening protocols as desired.

Improving screening for cystic fibrosis-related diabetes in a pediatric cystic fibrosis clinic

Background: Cystic fibrosis-related diabetes (CFRD) is the most common comorbidity in people with cystic fibrosis (CF), affecting approximately 20% of adolescents and 40% to 50% of adults [1]. CF care guidelines recommend screening for CFRD using the 75-gram 2-hour oral glucose tolerance test (OGTT) yearly beginning at 10 years old. Our CF center had a below-average percentage of eligible patients adequately screened for CFRD (65% total screened [only 36% with recommended OGTT] vs ~63% nationally) because of use of a non-preferred screening method and a wide clinic catchment area.We initiated a quality improvement project to increase the percentage of eligible people with CF appropriately screened according to recommended CF care guidelines. Method(s): We began in 2019 by reviewing current data and processes to understand our baseline, goals, and anticipated barriers. We then established the goals of our project with proposed interventions and obtained institutional reviewboard approval. The three goals of our project were to fully eliminate use of the non-preferred screening method by the end of 2020, streamline local OGTT location options for families that live far from our CF center, and increase the percentage of eligible patients screened via OGTT by 20% by the end of 2020.We accomplished these goals by educating families regarding the recommended CFRD screening by OGTT in our CF newsletter;surveying families on how, when, and where they would like to complete their OGTT;and creating an OGTT informational brochure including three selected locations across our clinic geographical coverage area where OGTT can be reliably obtained. An additional goal was added in January 2022 because our percentage of appropriately screened patients dropped in 2021.We aimed to increase our percentage of eligible patients screened by 10% for the year. We are doing this by changing the location of an outlying OGTT facility after receiving negative feedback from our patients. Result(s):We fully eliminated use of the non-preferred screening method by 2020;all patients screened in 2020 were done by OGTT. We increased our total screening percentage from 65% in 2019 to 86% percent in 2020, despite difficulties created by the COVID pandemic. Our screening percentage dropped to 78% in 2021, but we have worked to offer OGTT at one of our associated pediatric clinic locations to better serve families. Conclusion(s): Using traditional quality improvement methods and processes, we eliminated use of a non-preferred CFRD screening method in our pediatric CF clinic. We have increased our screening rates to above the national average and continue to work on improving the CFRD screening process for our patients and families.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Changes in Diagnosis of Gestational Diabetes Mellitus during the Covid-19 Pandemic at a large Maternity Hospital in Southwest Ireland

Background Targeted screening for Gestational Diabetes Mellitus (GDM) occurs routinely at 24-28 weeks gestation using the oral glucose tolerance test (OGTT). During the COVID-19 pandemic, the Health Service Executive (HSE) and the Royal College of Obstetricians and Gynaecologists recommended discontinuing the OGTT to minimise hospital visits. Fasting plasma glucose (FPG), random plasma glucose (RPG), and glycated haemoglobin (HbA1c) were instead proposed for diagnosing GDM. This study retrospectively compared testing patterns and putative diagnostic rates for GDM in pregnancies using the HSE guidelines pre- and post-pandemic. Methods Pregnancies with complete gestation in the 18 months before (Group1) or 18 months after (Group2) adoption of revised HSE guidance at CUMH (01/05/2020) were included. Women with pre-existing diabetes mellitus were excluded. Results were extracted from databases at the Departments of Clinical Biochemistry and Haematology at CUH. Diagnostic cut-offs for GDM were: OGTT (FPG >=5.1 mmol/L or 2-h plasma glucose >=8.5 mmol/L), FPG (>=5.1 mmol/L), RPG (>=9 mmol/L), and HbA1c (>=39 mmol/mol). Diagnostic rates were compared using Chi-square analysis. The study was approved by the Cork Teaching Hospitals Clinical Research Ethics Committee. Results In Group1, 43.8% of 6,737 pregnancies had an OGTT, compared with 20.5% of 6,743 pregnancies in Group2. After implementing the revised guidelines, OGTT requests were 34.5% and 79.7% lower for primary and secondary care, respectively. Comparing Group1 with Group2, FPG was measured in 46.9 vs 49.8%, RPG in 13.3 vs 11.8%, and HbA1c in 23.7 vs 51.9%. The positive rate for GDM testing was 15.9% in Group1 and 22.0% in Group2 (p<0.00001). Conclusions OGTT use fell significantly with revised HSE guidelines, although only a modest reduction was observed in primary care. HbA1c use in pregnancy doubled during the pandemic. The proportion of pregnancies with biomarkers positive for GDM showed a small but significant increase upon adopting the new diagnostic guidelines.

A Clinical Case of Pheochromocytoma Presenting with Decompensated Diabetes Mellitus and Paroxysmal Hypertension

Introduction: Pheochromocytoma is a rare neuroendocrine tumor that originates from the adrenal medulla, less commonly from extraadrenal chromaffin cells (paraganglioma). In about 90% of cases, the tumor produces abnormal amounts of catecholamines. Pheochromocytomas are usually benign, but in rare cases can be malignant. Typical clinical manifestations are the result of the haemodynamic and metabolic effects of catecholamines and usually include paroxysmal hypertension with the classic triad (headache, excessive sweating, palpitations), carbohydrate disorders, etc. Elevated levels of catecholamine metabolites (metanephrine and normetanephrine) tested in plasma or in 24-hour urine confirm the diagnosis. Surgical removal of the tumor is the only radical treatment. Follow-up of patients postoperatively should be lifelong and performed by a multidisciplinary team in a specialized center of expertise. Case report: A 36-year-old female patient referred to the clinic for decompensated diabetes mellitus. Detailed history revealed paroxysmal hypertension and the classic triad of pheochromocytoma. The diagnosis was confirmed by high urinary metanephrine levels and an abdominal CT scan, showing a tumor in the right adrenal gland with features typical of pheochromocytoma. Surgical removal of the pheochromocytoma and normalization of catecholamine levels led to normalization of blood pressure and reversal of diabetes mellitus. Conclusion(s): Pheochromocytoma is a difficult diagnosis in endocrinology practice as it can mimic many other diseases. Early detection and surgical removal of the tumor are crucial to avoid complications caused by elevated serum catecholamine levels.Copyright © 2022 Medical Information Center. All rights reserved.

IDF2022-0635 Can COVID-19 infection provoke new-onset A-beta+ KPD (ketosis-prone diabetes)? - Insights from an Indian prospective study

Background COVID-19 as a trigger for A-beta+ ketosis-prone diabetes (KPD) [1,2] in previously normoglycemic individuals presenting with new-onset DKA, has been sparsely studied. Aim To study prospective changes in insulin secretion and insulin resistance in suspected A-beta+ KPD patients presenting with COVID-associated new-onset DKA. Method 22 previously non-diabetic, antibody-negative patients with new-onset DKA and RT-PCR positive COVID-19 (suspected A-beta + KPD), were followed up for one year. They were compared with 20 Type 1A and 18 Type 2 DM patients, with serial assessments (0,6 and 12 months) of insulin secretion rates (ISR) and multi-tissue insulin resistance (IR). 75-g OGTT with serial glucose, insulin and C-peptide estimation (0,15, 30,45, 60,90,120, 150 and 180 minutes) was used to derive IS, while hepatic and peripheral IR was calculated based on study by Ghani et al. [3]. Results At baseline, ISR in suspected KPD (n = 22) was significantly reduced but similar to Type 1A DM(p = 0.15). Serial ISR demonstrated complete recovery in 17 (77%) patients who became insulin independent at one-year follow-up (remission), while 5(23%) patients continued to require insulin (non-remission). KPD patients showed significant hepatic and peripheral IR at baseline compared to Type 1A DM (p < 0.05). The remission group (n = 17) showed significantly enhanced recovery of hepatic and peripheral insulin sensitivity at 6 and 12 months follow-up (all p < 0.01) compared to the non-remission (n = 5) group, with IR in the latter being comparable to Type 2 DM at follow-up (all p > 0.05). Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were factors associated with poorer recovery of beta-cell secretion amongst the KPD patients. Conclusion This is the first prospective study to demonstrate progressive recovery of p-cell secretion in new-onset A-beta + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM.Copyright © 2023 Elsevier B.V.

Improving cystic fibrosis-related diabetes annual screening in adults with cystic fibrosis

Background: Cystic fibrosis (CF)-related diabetes (CFRD) is associated with decline in lung function and nutritional status. Cystic Fibrosis Foundation (CFF) guidelines recommend annual CFRD screening in patients starting at age 10. A review of our adult program data showed a decline in screening during 2020. We identified barriers, in addition to the COVID pandemic, that contributed to a decline in adherence. In July 2020, our clinic moved to a new location and began offering morning visits. After a quality improvement review, we began offering annual oral glucose tolerance testing (OGTT) within a routine clinic visit along with annual routine labs. Our objective was to use this multidisciplinary approach to increase OGTT screening to 50% within the first year of moving to our new location. Method(s): The CFF Patient Registry was used to compile a list of our nondiabetic patients overdue for annual OGTT. The list was reviewed during our multidisciplinary preclinic conference to identify patients who needed testing. Each patient was re-educated during clinic, and barriers to testing identified through patient interview and questionnaires. Common barriers to testing adherencewere length of testing time, time missed from work, COVID concerns, and needle phobia. The nurse and nurse coordinators made follow-up appointments, incorporating OGTT into next clinic appointment to increase adherence. Patients received phone call reminders for these appointments and the fasting criteria for testing. Result(s): CFF Registry Report data showed a decline in OGTT screening from 26% in 2019 to 21% in 2020.We identified 76 eligible patients who needed OGTT in 2021. Patient interviews were conducted during clinic visits and barriers identified. We offered routine clinic appointments in conjunction with lab appointments to increase screening adherence. We were able to capture seven patients in the first 6 months and 14 in the second 6 months, increasing our OGTT screening rate to 28%. Conclusion(s): Using a multimodal approach in a multidisciplinary team,we increased our OGTT annual screening rate by 7 percentage points. The ability to incorporate recommended screening into routine clinic visits supported adherence and patient satisfaction. Limitations to OGTT screening include continued COVID concerns and transportation to clinic.We plan to continue this quality improvement approach to increase adherence to 50% within this next year by continued consolidation of lab work and OGTT with visits and assisting patients with scheduling lab appointments and transportation to the clinic Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Gestational Diabetes during the Pandemic: Screening Methods and Outcomes in First-time GDM

Objective: To study the impact of national recommendations on the method of screening used for GDM during the COVID-19 pandemic, and evaluate differences in maternal and fetal outcomes among women with first-time GDM (ftGDM). Design: A retrospective observational study in a single Tertiary London Hospital. During the pandemic, the RCOG recommended an amended GDM screening protocol to reduce hospital attendance and risk of virus transmission (fasting blood glucose level ≥5.3 and/or HbA1c ≥39 at 28 weeks of gestation). Our Trust did not adopt this due to concerns regarding its sensitivity. We adopt a 2-step approach to universal GDM screening using a 50g glucose challenge test, and refer those screening positive for a full oral glucose tolerance test. Method: Outcomes were reviewed for women with ftGDM delivering a singleton at ≥24 weeks gestation between 01/04/20 -28/ 5/21. Our primary aim was to determine the impact of the change in COVID-19 GDM screening policy, had it been implemented. Our secondary outcomes included GDM management method, maternal and perinatal complications. We excluded women with a booking HbA1c ≥42 (indicative of pre-diabetes) and those who had bariatric surgery. Demographic and outcome data were obtained from electronic databases. Results: 247 women were diagnosed with ftGDM using local screening methods. Only 23 of these women had a HbA1c ≥39 at time of diagnosis and a further 12 had FBG ≥5.3. There was no significant difference in age or ethnicity between the two groups. The locally diagnosed group had a statistically significantly lower booking BMI (P<0.001) and were less likely to require pharmacological management of GDM (P<0.001). There were no significant differences in rates of induction of labour, gestation at delivery, birth weight or any perinatal adverse outcome. However, the women in the Covid-19 GDM screening group were significantly more likely to be delivered by Emergency Caesarean Section (p = 0.03) and have gestational hypertensive disease (p = 0.025). Conclusions: If we had implemented RCOG HbA1c screening, we would have not diagnosed 207 women with GDM, 41% of whom required pharmacological treatment. It is not surprising that women with higher HbA1c values had higher rates of maternal complications, due to the well-established association between maternal hyperglycaemia and adverse obstetric outcomes. As such, it is imperative that more sensitive screening protocols such as the 50g screen are considered in any future pandemics, such that women with GDM can be identified and maternal hyperglycaemia treated to benefit in-utero fetal programming.

Association of Maternal Nutritional Status with COVID-19 Infection and its Effects on Pregnancy Outcomes- A Retrospective Study

Introduction: Need is felt to perform research for assessing the impact of maternal nutrition status on severity of Coronavirus Disease 2019 (COVID-19) in pregnancy and effect of COVID-19 on maternal outcomes as it has not been established. Aim: To evaluate association of maternal nutritional status and pregnancy outcomes with COVID-19 infection in pregnancy. Materials And Methods: A retrospective study was conducted among 260 antenatal patients admitted in COVID-19 level 3 hospital (Teerthanker Mahaveer Medical College and Research Centre), Moradabad, Uttar Pradesh, India, from April 2020 to May 2021 with COVID-19 infection. Records were studied for the effect of maternal nutrition status along with COVID-19 and outcome of pregnancy in terms of anthropometric markers (body mass index), nutritional markers (haemoglobin, total serum proteins) and biochemical markers (oral glucose tolerance test, vitamin D). Pregnancy outcomes were assessed in terms of severity of symptoms, Intensive Care Unit (ICU) admission, labor outcome and obstetric complications. Data were tabulated and examined using the Statistical Package for Social Sciences (SPSS) version 20.0. Results: Mean age of the patients enrolled was 21.4±5.6 years. A statistically significant association was seen with high body mass index (88.24%), hyperglycaemia (82.35%), hypoproteinaemia (6.01±0.47) and hypoalbuminaemia (0.93±0.24). Statistically significant association between adverse pregnancy outcomes in terms of bleeding per vaginum (11.76%), preterm labour (54.92%), gestational diabetes mellitus (82.35%), hypertension (29.41%), Intrauterine Device (IUD) baby (35.29%) with increasing severity of COVID-19 infections. C onclusion: COVID-19 adversely affects the maternal obstetric outcome. Maternal nutrition status factors associated with severity of COVID-19 were body mass index, deranged blood sugar levels and protein levels.

Service evaluation to determine the reason for increased gestational diabetes (GDM) referrals following SARS-CoV- 2 pandemic

Aims: England and Wales report on average, 700,000 annual pregnancies. From these 5% are complicated with hyperglycaemia with 87.5% of these Gestational diabetes (GDM). Pregnant women living with obesity are at higher risk of developing GDM. There is a linear relationship between glucose and adverse pregnancy outcomes. We noted a marked increase in the number of referrals with GDM to our service in 2021. The aim of this study was to compare the incidence of GDM and the characteristics of women under our service in 2021 to the pre-pandemic data from 2019. Methods: Data were collected retrospectively, analysing the data of women with GDM during the time period of 1st May to 31st July 2019 and compared to the same period from 2021. Results: The number of positive OGTT results increased by 209% in 2021 (n = 107 vs 51). In 2021 there was a 66% increase in the number women with GDM with a Body Mass Index (BMI)≥30kgm2 (36 to 60). The average BMI of this group increased from 34.9kg/m2 in 2019 to 36.5 in 2021 although this failed to reach statistical significance. Conclusion: The local incidence of GDM is higher in 2021 compared to 2019. This is driven by an increase in the number of women diagnosed with GDM with a BMI≥30. We hypothesize that this may be a result of sedentary lifestyle brought on by the lock downs because of the pandemic. Further work may be warranted in this area using a larger sample size derived nationally.

Prevalence of Diabetes Mellitus and Impaired Glucose Tolerance in Patients with Covid-19

Objective: The aim of this study is to determine the prevalence of diabetes mellitus and impaired glucose tolerance in patients with COVID-19. Study Design:Cross-sectional study Place and Duration:Conducted at department of Medicine, Khyber Teaching Hospital (KTH),Peshawer and Avicenna Teaching Hospital, Lahorefor the duration from July 2020 to December 2020. Methods: There were one hundred and fifteen patients of both genders had coronavirus disease were included in this study.Patients ranged in age from 25 to 80 years.After obtaining informed written permission, we collected detailed demographic information on all of the registered patients, including their age, gender, BMI, educational attainment and place of residence. All of the patients had their blood tested for corona disease using RT-PCR. After screening positive (fasting capillary glucose >100 mg/dl and 200 mg/dl) and each sixth consecutive negative (fasting capillary glucose <100 mg/dl) subjects, the 75-g oral glucose tolerance test was administered. The SPSS 23.0 software was used for analyzing of data. Results:Included patients had mean age 59.4±12.55 years with mean body mass index 29.12±11.76 kg/m2. There were 70 (60.9%) male patients and 45 (38.1%) females. Majority of the patients were illiterate 65 (56.5%) and 49 (42.6%) patients were from urban areas. Most common co-morbidities were hypertension, hyperlipidemia, chronic kidney disease and coronary artery disease. We found 62 (53.9%) patients had diabetes mellitus in which majority of the cases were pre-existing. Frequency of impaired glucose tolerance was found among 26 (22.6%) cases in which majority of the cases had pancreatic cancer. 28 (24.4%) cases had intubation. Overall mortality was found among 18 (15.3%) cases. Conclusion:This research found that people with diabetes and poor glucose metabolism are more likely to have severe Covid-19. A previously undiagnosed symptom of primary infection has been linked to a disorder in glucose metabolism. Pathways through which SARS-CoV-2 affects glucose metabolism must be investigated if disease aetiology is to be fully understood.

Gestational diabetes is associated with SARS-CoV-2 infection during pregnancy: A casecontrol study

Introduction Diabetes mellitus has been identified as a risk factor for a severe course of COVID-19 in pregnant women. In addition, it has been suggested that SARS-CoV-2 infection may trigger the development of diabetes mellitus through direct destruction of the pancreatic Langerhans cells. Until now, little data regarding an association between gestational diabetes (GDM) and risk of SARS-CoV-2 infection during pregnancy is available. The aim of our study was to investigate this possible association in our population using a case-control model. Material and methods We included 85 pregnant women with symptomatic or asymptomatic SARS-CoV-2 infection in our study, who were managed at our institution starting with May 2020 to date. We matched these cases 1:2 with a cohort of women managed at our hospital between before 30.10.2019 based on parity, BMI and ethnicity. Screening for gestational diabetes by a 75 mg oral glucose tolerance test (OGTT) was performed at 26 weeks' gestation in all women. Clinical data on pregnancy outcomes were collected. Results Of the 85 women included in the case group, OGTT was available in 75 cases. Diagnosis of gestational diabetes was made in 23 women in the case group (30.66%), vs. 20 in the control group (13.42%). This difference was statistically highly significant (p 0.0036 through two-sided Fisher's exact test, where p<0.05 was considered as significant) . Mean age was 30.42 years old (SD±4.65) in the case group and 30.39 years old (SD±4.77) in the cohort group. Mean BMI was 26.10 (SD±5.13) in the case and 25.67 in the control group (SD±5.10) When classifying patients into not-overweight (BMI<25 kg/m2) vs. overweight (BMI≥25 kg/m2), 60.86% of the women with GDM in the case group were overweight vs. 80% in the control group. This difference was statistically significant. According to the WHO classification of the severity of COVID19, most women presented with mild or moderate course of the disease. In four women, hospitalization was necessary because of severe COVID-19 infection. Of these, two (50%) suffered from GDM. Discussion The main finding in our study is a significantly higher rate of GDM among women with SARS-CoV-2 infection during pregnancy, when compared to a control group. We speculate that GDM increases the risk of SARS-CoV-2 infection in pregnant women. On the other hand, the infection might increase the risk of developing GDM. Interestingly, in the women who developed GDM in the control group, significantly more patients with overweight were found than in the case group (80 vs. 60.86%). It remains open, if SARS-CoV-2 acted as an additional 'promoter' for developing GDM in these women. To our knowledge, this is the first study showing a possible correlation between GDM and SARS-CoV-2 infection. Further studies are needed to confirm this association and the potential mechanism behind it.

Detection of cystic fibrosis related diabetes through analysis of voice characteristics in telemedicine clinics

Purpose of Study Cystic fibrosis-related diabetes (CFRD) is one of many extrapulmonary co-morbidities associated with cystic fibrosis (CF), affecting an estimated 50% of all adults with the condition [1,2]. The standard test recommended by the CF Foundation for screening of CFRD is the oral glucose tolerance test (OGTT) [5]. Requiring a complex in-person clinic visit, the OGTT can be cumbersome to schedule, and for these reasons, may lead to a delayed diagnosis of CFRD. We are interested in developing a novel technique to detect changes in glucose levels by analyzing characteristics of the voice, specifically a method to capture voice recordings that requires no face-to-face interaction as restricted by the ongoing COVID-19 Pandemic. We hypothesized that high blood glucose levels may cause laryngeal soft tissue swelling and lead to changes in voice characteristics. The purpose of this study is to examine if changes in voice can distinguish patients with CFRD from patients without CFRD. Methods Used A prospective cross-sectional study was performed in adult CF patients recruited from the CF Telemedicine Clinic at Emory Healthcare from March to September 2021. We recorded 5-second voice samples of a sustained/a/ vowel via an electronic submission form to allow patients to submit recordings directly from a link sent to their smartphone. Voice parameters listed in Table 1 were analyzed using a Computerized Speech Lab with the Multi-Dimensional Voice Program. Summary of Results 5 patients with CFRD and 9 patients with CF alone were included in this study. Patients with CFRD had a similar mean age to patients without CFRD (39 ± 15 vs 33 ± 12 years old, p=0.948). Male CFRD patients were excluded due to low sample size. An acoustic parameter analysis categorized by sex showed vF0 in female patients who have CFRD was significantly higher compared with female patients with CF alone. FTRI was also significantly higher in CFRD individuals. Conclusions With a significant voice character distinction between CFRD and CF alone patients, we present a novel screening tool for diabetes that may have potential use in the CF community. This study is ongoing and will collect additional data on males with CFRD. The results indicate great potential for this technology to be used as a noninvasive test for earlier detection of undiagnosed CFRD. Studies in patients with diabetes without CF have also demonstrated a potential use of this technology [7].

Extended follow-up results from a prospective rct for transcatheter bariatric embolotherapy for weight loss in obese subjects

Introduction: Obesity is an important risk factor associated with poor cardiovascular outcomes. Lifestyle modification, pharmaceutical, and intragastric balloons weight loss therapy are often unsuccessful, unsustainable, or accompanied by risks. Transcatheter bariatric embolotherapy (TBE) is a promising therapy in which the left gastric artery is embolized to reduce the expression of “hunger” hormones from the gastric fundus. Despite several early clinical trials, long-term safety or efficacy has yet to be studied. We originally studied TBE in a double-blind, sham procedure, first in human RCT of 40 obese patients (pts) (NCT03185949). Complete details regarding the initial RCT were previously published, briefly the study demonstrated up to 9.3% TBWL at 1-year post-TBE. Following completion of the initial study at 1 year followup, we asked subjects to return for long-term evaluation. Methods: Subjects who previously completed the RCT with no major protocol deviations were asked to return for SOC follow-up visits at 2-, 2.5-, and 3-years post-embolization for further evaluation on weight loss, blood pressure, pre-diabetic clinical status, satiety, and Quality of Life (QoL). Given the evolving situation of the COVID-19 pandemic, the study site was unable to complete all planned study visits. Results: Between 2-3 years post-TBE subjects (n=11) demonstrated a mean 9% TBWL and 25% EBWL. This cohort of patients demonstrated a long-term weight loss maintenance, with previously reported weight loss of 8% TBWL at 1-year post-embolization. Overall QoL at 2 years postTBE increased by approximately 22%. The volume to achieve satiety was reduced by 33% in long-term follow-up. Oral Disposition Index increased from 1.89 mM at 6 months post-TBE to 4.41 mM 2 years postTBE. 1-hr Oral Glucose Tolerance Test (OGTT) C-Peptide levels decreased from 3.22 nmol/L at 6 months to 2.53 nmol/L at 2 years post-TBE. 2-hr OGTT C-Peptide levels also showed a decrease from 2.95 nmol/L at 6 months to 1.78 nmol/L at 2 years post-TBE, possibly indicating an improvement in pre-diabetic status. Conclusions: Bariatric embolization is safe and when used along with lifestyle therapy, results in clinically significant and sustained weight loss up to 2-3 years post-TBE.

Intermittent dual vagus neuromodulation improved glycemic control in swine model of type 2 diabetes

Background: Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Post COVID-19 with an increased rate of obesity, there is a growing need for treatments providing improved efficacy and compliance. Modulation of nerves innervating organs that regulate plasma glucose (PG) may be a novel method for treating T2DM. Standalone stimulation of the vagus nerve or vagotomy/treatments has mixed/undesirable results. Long term/4 hrs dual neuromodulation consisting of simulation of celiac fibers innervating the pancreas (increasing insulin release) w/ simultaneous reversible electrical blockade of neuronal hepatic fibers innervating the liver (preventing glucose release) in obese T2DM animal models enhanced glycemic control superior to standalone treatments. This long term neuromodulation requires considerable amount of energy. Here we tested if glycemic control could be preserved w/ intermittent short-term neuromodulation. Methods: We used a proprietary bio-electronic device & algorithm developed by ReShape Lifesciences Inc. comprising Stimulation (Stim) of the celiac nerve w/ a simultaneous reversible high frequency alternating current (HFAC)-induced blockade of the hepatic nerve. Experiments were conducted in an Alloxan treated swine model of T2DM. Area under the curve (area units = AU) of Oral Glucose Tolerance Tests (OGTTs) was used to quantify glycemic control. Results: 30 min of HFAC/Stim @ OGTT initiation increased glycemic control (Sham = 6711 ± 1442 AU, HFAC/Stim = 545 ± 1632 AU, p < 0.05). During OGTT in Sham there was a 36 ± 7 mg/dL & 35 ± 9 mg/dL increase in PG @ 30 & 60 min w/ 9 ± 9 mg/dL @ 4 hrs. W/ 30 min of HFAC/Stim the PG was -5 ± 11 mg/dL & 3 ± 20 mg/dL relative to baseline @ 30 & 60 min & -7 ± 8 mg/dL @ 4 hrs. Interestingly, fasting PG remained suppressed by 34 ± 7 mg/dL following cessation of HFAC/Stim for 48 hrs. Histopathology demonstrated healthy tissues. Conclusions: These studies suggest a novel, reversible & intermittent energy efficient neuromodulation for the treatment of T2DM.

Self-administered oral glucose tolerance test with capillary glucose measurements for the screening of diabetes mellitus in high-risk adults: a feasibility study.

INTRODUCTION: Early diagnosis of prediabetes based on blood sampling for the oral glucose tolerance test (OGTT) is crucial for intervention but multiple barriers hinder its uptake. This study aimed to assess the feasibility and precision of a self-administered capillary OGTT for type-2 diabetes mellitus (T2DM) in high-risk individuals. RESEARCH DESIGN AND METHODS: Participants with history of gestational diabetes or prediabetes were recruited in primary care. Due to their prediabetic status and previous diagnosis of gestational diabetes mellitus, a proportion of participants had previous experience doing OGTT. They self-administered the capillary OGTT and concurrently their venous glucose samples were obtained. They filled a questionnaire to collect their demographic information, views of their capillary OGTT, and their preferred site of the test. RESULTS: Among 30 participants enrolled in this feasibility study, 93.3% of them felt confident of performing the capillary OGTT themselves, and 70.0% preferred the test at home. Older, less educated participants found it less acceptable. Mean capillary glucose values were significantly higher than venous glucose values, with mean difference at 0.31 mmol/L (95% CI 0.13 to 0.49) at fasting, and 0.47 mmol/L (95% CI 0.12 to 0.92) 2 hours post-OGTT. Capillary and venous glucose measurements were correlated for fasting (r=0.95; p<0.001) and 2-hour-post-OGTT (r=0.95;p<0.001). The Fleiss-Kappa Score (0.79, p<0.0001) indicated fair agreement between the two methods. The capillary OGTT had excellent sensitivity (94.1%) and negative predictive value (NPV=91.7%) in identifying prediabetes or T2DM status, vis-a-vis to venous glucose samples. CONCLUSION: Self-administered capillary OGTT is feasible and acceptable, especially among younger adults, with excellent sensitivity and NPV compared with plasma-based OGTT.

Postpartum Diabetes Screening: Compliance in the COVID Era

Objective: Most women with gestational diabetes (GDM) will not undergo recommended postpartum screening, and it is unknown if COVID has impacted these low rates of follow-up. The objective of this study was to determine the rate at which patients completed their recommended postpartum diabetes screening and compare compliance prior to and during the COVID pandemic. Study Design: This was a retrospective review of patients diagnosed with GDM who delivered at a single institution from April 1, 2019 – March 31, 2021. The main outcome was difference in compliance with recommended 2-hour oral glucose tolerance test prior to and during the COVID pandemic. For the purpose of this study, compliance was defined as completion from 4 weeks to 6 months postpartum. Secondary outcomes were maternal and neonatal outcomes and the prevalence of impaired glucose tolerance postpartum among women who completed the screening. Univariate analysis was performed to compare the two populations. Results: During the study period, 220 patients met inclusion criteria. Among these patient, 104/220 (47.3%) were considered pre-COVID deliveries, defined as delivery prior to March 1, 2020. Baseline characteristics including age, parity, and ethnicity were similar between the two groups (p > 0.05). Diet-controlled diabetes was more prevalent during the COVID pandemic (74.1% versus 61.5%, p = 0.045). During the COVID pandemic, providers more frequently ordered postpartum screening (92.2% vs 81.7%, p = 0.020). Among the patients with screening tests ordered, approximately one third of patients completed recommended postpartum screening in both groups (p > 0.05) and similar rates of prediabetes and diabetes were observed (25.0% versus 37.5% during COVID and prior to the COVID pandemic, respectively, p > 0.05). Conclusion: Overall, the rate of postpartum diabetes screening is poor and remained stable prior to and during the COVID pandemic. Alternative strategies such as inpatient testing prior to hospital discharge may need to be considered.