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 Infection Presenting as Acute Pancreatitis

Purpose of study Introduction COVID-19 emerged at the end of 2019 as an epidemic of respiratory disease in Wuhan, China that later spread globally and was declared as pandemic. The common clinical manifestations of COVID-19 infection include fever, cough, myalgias, headache, sore throat, anosmia, nasal congestion, fatigue and chest pain. The most serious complications include bilateral multifocal pneumonia and acute respiratory distress syndrome. Acute pancreatitis is rarely reported in association with COVID-19 infection. We report a case of acute pancreatitis secondary to COVID-19 infection. Case Report: A 69-year-old man with past medical history of hyperlipidemia and seizure disorder presented with two days of epigastric pain radiating to back. The patient reported fever, malaise and dry cough for the last 3 days. Home medication included atorvastatin and carbamazepine for 10 and 15 years respectively. The patient denied smoking and alcohol use. COVID- 19 PCR was positive. Labs showed WBC of 3800/muL, hgb 11.8 g/dL, calcium 8.4 mg/dL , lipase 426 U/L, D-Dimer 179 ng/ml DDU, High sensitivity C-reactive protein 27.5 mg/L (normal <5 mg/L) ALT 26 U/L, AST 31 U/L, alkaline phosphatase 103 U/L and total bilirubin 0.3 mg/dL. Ultrasound of the right upper quadrant and CT abdomen showed normal pancreas, common bile duct and gallbladder with no evidence of gallstones. Triglyceride level was 70 mg/dL (<149 mg/dL) on the lipid panel. The patient was diagnosed with acute pancreatitis and received treatment with IV fluids and pain medication. The symptoms improved gradually and the patient was discharged home with resumption of home medications. Methods used Case Report Summary of results The common differentials for acute pancreatitis include alcohol use, gallstones, hypertriglyceridemia, viral infections like mumps and measles, hypercalcemia and medication-related, etc. Normal AST, ALT, alkaline phosphatase and total bilirubin along with absence of gallstones and normal common bile duct ruled out alcoholic and biliary pancreatitis. Normal calcium level and triglyceride level rule out hypercalcemia and hypertriglyceridemia as the cause of pancreatitis. Carbamazepine has rarely been reported to cause acute pancreatitis typically soon after the initiating the therapy or with increase in the dose. The use of carbamazepine for more than 15 years without any recent dose change makes this unlikely as the cause of pancreatitis. The onset of acute pancreatitis during the timeline of COVID-19 constitutional symptoms and absence of other risk factors suggests that COVID-19 infection is responsible for acute pancreatitis in our patient. Conclusions We report a case of acute pancreatitis secondary to COVID-19 infection. Further studies are warranted to better understand the etiology and the pathophysiology of acute pancreatitis secondary to COVID-19 infection.

Association between Interlukine-6 with Serum Ferritin, D-dimer, and Lipid Profiles as Risk Factors in Patients with Coronavirus Disease 2019

Background:The current coronavirus disease 2019 (COVID-19) pandemic, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has posed a significant public health concern throughout the world, putting millions of people at risk in an increasing number of nations.Due to the development of endothelial dysfunction, coagulopathy, cytokine storm, and plaque instability, COVID-19 is recognized as an independent risk factor for cardiovascular illnesses.The goal of this study was to look at blood levels of interleukin 6 (IL-6), lipid profiles, ferritin, C-reactive protein (CRP), D-dimer, lymphocytes, and neutrophils in COVID-19 patients, as well as the relationship between IL-6 and biochemical predictor values for COVID-19 severity. Materials andMethods: In this case-control study,total of 60 COVID 19 patients within 1 week of displaying COVID19 symptoms and SARS-CoV-2 specific RT-PCR was verified. of Nasopharyngeal (NP) swab specimen were recruited.ageranged between(30-50 years)To compare the results, (60) apparently healthy persons of the same ages and sexes were included in this study ascontrol group.All of the patents and healthy persons were made to suffer to the estimation of serume IL-6, D-Dimer, CRP, ferritin,lipid profiles, andanthropometric data were analyzed. Results:Serum IL-6 level was higher in covid-19 patients group compared to healthy control group (812.32± 147.76vs. 148.95± 51.59ng/ mLp = 0.0001). Ferritin,CRP, and D-dimer serum levels were also higher in covid-19 patients compared to control group (p = 0.0001). as well as TC,LDL-C,and VLDL-C When compared to healthy controls, COVID-19 patients exhibited a substantial reduction in the levels studied in this study. We also discovered that IL-6 levels were higher significantly associated with the serum ferritin,D-dimer,TC, LDL-C, and CRP levels. Conclusion:The level of IL-6 was shown to be the most important predictor of outcome and a useful tool for prognostic assessment. The prevalence of atherogenic dyslipidaemia during infection was linked to a poorer COVID-19 infection outcome in a robust and independent way. Low HDL cholesterol and high triglyceride levels seen in covid-19 patients are strong indicators of the disease's severity. 1.

A diagnosis erupting from within

We report a case of eruptive xanthomas in a 31 year old Caucasian man with a background history of poorly controlled Type 2 diabetes mellitus, obstructive sleep apnoea and fatty liver disease. He developed a widespread pruritic rash which started on his left arm 9 h after his first dose of the Pfizer covid vaccination which progressed to involve bilateral upper limbs, lower limbs and abdomen. However, he presented a week later with acute abdominal pain and was later admitted to ICU with pancreatitis resulting in diabetic ketoacidosis. Dermatology were consulted for management of his pruritic eruption and possible covid vaccination adverse reaction. Physical examination revealed multiple excoriated yellow to pink papules. His bloods showed a total cholesterol of 31 and triglycerides of 157. A biopsy was taken which demonstrated perivascular and periadnexal foam cells in the superficial to mid dermis consistent with eruptive xanthoma. He was commenced on fenofibrate to manage his hypertriglyceridemia and insulin to manage his diabetes. This case highlights the rarity of eruptive xanthomas and that it can go unrecognised or misdiagnosed if not considered. Clinicians should consider a biopsy to confirm the diagnosis and consider differentials of Non-Langerhans cell and Langerhans cell histiocytosis, disseminated granuloma annulare and sarcoidosis. Eruptive xanthomas are lipid deposits in the skin in the context of high triglycerides >20 mmol/L. They are characterised by firm 2-5 mm papules that commonly involve the extensor surfaces. The papules can be pruritic or tender. The xanthomas usually resolve within two weeks of normalisation of triglyceride levels, as observed in this patient. Effective treatment options include dietary modification and lipid lowering medication such as fenofibrate. In refractory cases, surgical excisions, cryotherapy and ablative lasers such as Er-YAG and CO2 have been reported . Clinical photos and histology will be presented for discussion.

Comparative evaluation of serum lipid levels in COVID-19 patients before and after therapy

Introduction: Aims of this study were to investigate the pathological alterations in LDL-cholesterol, HDLcholesterol, total cholesterol, and triglycerides in individuals with COVID-19 infection. Methods:Between February and April 2020, a total of 80 COVID-19 patients admitted to our hospital and 80 patient recovered from COVID-19 were evaluated for their LDL- and HDL-cholesterol levels. 80 age and sex matched individual were included in the study for comparision. Lipid level were compared among the COVID-19 patient, patient recovered from COVID-19 and healthy control. Results:Over eighty percent of the covid-19 patients had cholesterol levels that were much lower than the normal person. Only total cholesterol indicated significant differences between healthy controls and COVID-19. There was a considerable increase in the levels of HDL, LDL (bad), and triglyceride levels after recovery compared to the acute stage of sickness. Low density lipoprotein (LDL) cholesterol and total cholesterol had a negative relationship with C-reactive protein (CRP). It is possible that lipids such as cholesterol are important in viral multiplication, internalisation and immunological activation in COVID-19 infected individuals, according to our data. Conclusions: In addition, it is possible to use lipid abnormalities discovered during and after infection as a proxy for assessing the effectiveness of therapeutic treatment.

Necrotizing pancreatitis secondary to COVID-19

Case Report A 29-year-old male with a past medical history significant for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection presented with epigastric pain, vomiting, fever, and inability to tolerate oral intake for 1 day. The patient was diagnosed with COVID-19 six weeks prior to presentation and four weeks later was diagnosed with idiopathic acute pancreatitis. He reported initial resolution of pain, however symptoms recurred for one day prior to this admission. The patient denied a history of alcohol use disorder. He is a lifetime nonsmoker. He does not take any medications. Vital signs were stable and he was afebrile. Labs on presentation were remarkable for elevated lipase of 1,527 and leukocytosis (23,000). The patient was still positive for COVID-19. However, he maintained oxygen saturation >95% on room air with no apparent distress. On physical examination, he had severe tenderness to palpation at the epigastrium and left upper and lower quadrants. Abdominal ultrasound had no evidence of gallstones. Triglyceride levels were within normal limits. CT abdomen showed necrotizing pancreatitis. MRCP showed evidence of acute pancreatitis with peripancreatic acute necrotic collection in the pancreatic head measuring up to 8.8 cm. Intrinsic T1 signal within the peripancreatic collection compatible with hemorrhagic pancreatitis. There was about 30% pancreatic parenchymal necrosis in the pancreatic head. A nonocclusive thrombus involving the main portal vein was also seen. Autoimmune workup was negative. In the setting of hemorrhagic pancreatitis, treatment with anticoagulation was deferred. The patient was treated with supportive measures, including intravenous fluids and adequate pain control with eventual advancement of his diet. He was started on empiric antibiotics and discharged for outpatient follow-up. SARS-CoV2 is known to cause many extrapulmonary effects, including transaminitis, myocarditis and pericarditis. There have been rare cases of SARS-CoV2-induced acute pancreatitis reported in the literature. The exact mechanism behind pancreatic injury in the setting of SARS-CoV2 infection remains unclear, but it is hypothesized that it may occur secondary to the presence of SARS-CoV2 receptors on the pancreas. The main receptor used by SARS-CoV2 is angiotensin- converting enzyme 2, which is also expressed in the GI tract. The most common causes of acute pancreatitis, including alcohol abuse, gallstones, medications and autoimmune causes were ruled out in our patient. In a patient with no particular risk factors, it is likely that SARS-CoV2 precipitated his first episode of acute pancreatitis. Moreover, it is well known that acute pancreatitis can commonly lead to necrotizing pancreatitis as the initial injury and inflammation from the first attack can cause the pancreatic tissue to necrotize and later become infected. This case highlights that SARS-CoV2 can be a possible etiology of acute pancreatitis and its local complications.

A rare disease in the community hospital: Hemophagocytic lymphohistiocytosis (HLH) needs immediate local attention for early recognition and individualized treatment

Purpose: HLH is a severe hyperinflammatory syndrome characterized by highly active cytotoxic T-cells, NK-cells, and macrophages. If undiagnosed, HLH can lead to multiorgan damage and death. Conditions triggering HLH are infections, malignancies and autoimmune/-inflammatory (MAS-HLH) disorders. Immunosuppressive patients are prone to develop infection triggered HLH. The incidence in the European community hospital is unknown, as is the number of unrecorded cases. HLH-patients, diagnosed at a single communal hospital with an adjacent catchment area of 500,000 citizens, were reviewed in the context of national and international guidelines. Methods: From 08/2016 to 11/2020, 13 HLH patients were analysed retrospectively. Both HLH-2004 criteria and the web-based Hscore were used to diagnose HLH. The collected data depicts clinical presentation, underlying disease, laboratory findings, and treatment. Results: This Study includes 13 HLH-patients (10 male). Median age at diagnosis was 53, ranging from 27-80 years. Most common triggers in our cohort were infections (n=7) and malignancies(n=4). MAS-HLH (n=1) was seen in a Still's disease patient. HLH-related gene mutation was identified (n=1) with a heterozygote mutation in Perforin (PrfA91). Lymphomas of B-as well as T-cell origin (n=2) and AML (n=3) represented main cause in malignancy associated HLH. Viral infections i.e., COVID-19(n=1), RSV (n=1) and EBV (n=1), also bacterial infections like M. tuberculosis (n=1), and the attenuated strain BCG (n=2) were seen in infection associated HLH. Most patients presented with fever (n=9) and splenomegaly (n=4). HLH patients show pancytopenia, peak ferritin levels ranging 1352-185000 ng/ml (median=21600), peak soluble IL-2 receptor levels ranging 2571-21660 U/ml (median=6606), and peak triglyceride levels ranging 175-610 mg/ml (median=227). Hemophagocytosis in bone marrow was found in 6 patients. First line therapy was glucocorticoids (n=12) combined with polyvalent immunoglobulins. Etoposide (n=5) and chemotherapy (n=4) were given to malignancy triggered HLH. Rituximab was applied in EBV-triggered HLH. Anakinra (n=3) and Ruxolitinib (n=4) was given to selected patients. Two patients received cytokine-depletion using adsorption columns Cytosorb®. Multiorgan failure (n=5) was the most common cause of death. Conclusion: This data provides incidence estimation of HLH in adult patients. Institutional and national measures will be presented to prevent death due to HLH.

Clinical and anamnestic characteristics of acute coronary syndrome after suffering COVID-19

Background. COVID-19 increases the risk of developing thromboembolic complications, including acute myocardial infarction, in the acute period of the disease. The long-term consequences of COVID-19 are poorly understood. At the same time, the available data on an increased risk of acute coronary syndrome after infectious diseases allow us to make an assumption about a similar risk in COVID-19. The aim of the study was to study the anamnestic and laboratory diagnostic data in patients with acute coronary syndrome after COVID-19. Methods. The study included 185 patients with acute coronary syndrome who were admitted to the State Clinical Hospital No. 13 in Moscow in the period from May to December 2020. 2 groups were identified: group 1 - 109 patients with ACS who had previously suffered COVID-19, group 2 - 76 patients with ACS without COVID-19 in the past. The patients were collected anamnesis, including: the fact of smoking and alcohol consumption, heredity, previous diseases, including diabetes mellitus, acute myocardial infarction, previously performed PCI. Information about the COVID-19 infection has been collected (the duration of the disease, the course of the disease). A clinical and laboratory examination was conducted, including the determination of body mass index (BMI), examination for antibodies to COVID-19, determination of the lipid profile level (total cholesterol, LDL, HDL, triglycerides), blood glucose level, C-RB. The analysis was performed on automatic biochemical analyzers Hitachi-902, 912 (Roche Diagnostics, Japan). All patients underwent coronary angiography. Results. In patients with ACS with previously transferred COVID-19, the development of the disease occurred at a younger age compared to patients without transferred COVID-19. Among the patients with COVID-19, body weight was significantly lower, there were fewer smokers, concomitant type 2 diabetes mellitus and transferred ONMC were less common. In laboratory parameters, lower triglyceride levels were observed in patients with ACS with COVID-19 compared with those of patients without COVID-19. In the laboratory parameters of blood clotting in patients with ACS with COVID-19, higher APTT, thrombin time, fibrinogen level, D-dimer were noted. The indicated laboratory parameters in the groups had statistically significant differences. In ACS patients with a previous COVID-19, compared with patients without COVID-19, the lesion of 2 or more coronary vessels was more common in the anamnesis. Conclusion. According to the results of our study, it was revealed that multivessel coronary artery damage in patients after COVID-19 in comparison with patients without COVID-19 develops significantly more often, while these patients are significantly less likely to have DM and previously suffered ONMC, the level of TG is significantly lower.

Hypertrigliceridemia in children and adolescents with onset of type 1 diabetes in the pandemic COVID-19

Introduction: The rapid spread of SARS-COV2 infection has led to a pandemic affecting people of all ages. Objectives: Hypertriglyceridemia is a complication that can occur when diagnosing diabetes, especially the onset of ketoacidosis Methods: The cases of diabetes at onset during the March-October 2020 pandemic were analyzed and were compared with the same period of 2019 Results: During the pandemic there were 14 cases of type 1 diabetes at onset, compared to the same period in 2019, when there were 10 cases of type 1 diabetes. Of these, 7 (50%) had ketoacidosis at onset in 2020, compared to 2019-3 cases (30%) with ketoacidosis at onset. In 2019, 1 single patient had triglyceride levels> 500 mg/dl. 6 patients (85%) in 2020 presented triglycerides> 500 mg/dl as follows: 2 had> 2000 mg/dl, 2> 1000 mg/dl, 3> 500 mg/dl. Conclusions: Diabetic ketoacidosis is a common form of diabetes in the pediatric population. When accompanied by severe hypertriglyceridemia, it must be managed with great care by the medical team to prevent complications, thus reducing the mortality of cases of diabetic ketoacidosis.