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.

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.

Duration of MERS - Coronavirus antibodies in a small closed dromedary camel herd in Dubai

This investigation shows that MERS-CoV ELISA antibodies remain in dromedary camels at least for 9 years, most probably lifelong. The viral infection was most likely acquired at a young age when maternal antibodies have receded between 4 to 8 month of age. Additionally, in the investigated herd, the 4 ELISA antibody negative dromedary camels remained negative also for 9 years, indicating, that no MERS-CoV was circulating in the herd. Until today, the specific source of MERS-CoV infection for young dromedaries remains unknown.

Detecting Primary Hyperparathyroidism with Image Discordant Findings

Introduction: Primary hyperparathyroidism is a common cause of hypercalcemia, with 80-85% of cases being due to a single gland adenoma. The sensitivity of imaging modalities varies, with ultrasound at 76%, sestamibi scintigraphy at 63%, and 4-dimensional computed tomography (CT) scan at 89%. Clinical Case: A 48-year-old woman with a remote history of iron deficiency anemia presented with 2 weeks of dry cough. She reported associated body aches and fatigue, but review of systems was otherwise negative. Family history was notable for a maternal grandmother with an unknown thyroid disease. On presentation, her blood pressure was 115/74 mm Hg, temperature was 37.1 Celsius, pulse was 64 beats per minute, with a respiratory rate of 16 breaths per minute, and oxygen saturation of 100 percent on room air. On exam, there was no thyromegaly, and there were decreased breath sounds. Initial labs were notable for calcium of 11.4 mg/dL (reference range: 8.4-10.2 mg/dL). Her rapid Covid antigen test was negative. A chest x-ray showed bilateral opacifications, suggestive of community acquired pneumonia. She was started on isotonic intravenous (IV) fluids, as well as ceftriaxone and azithromycin. The calcium remained persistently elevated and peaked at 12.6 mg/dL. Creatinine levels remained between 0.7-1. 0 mg/dL (reference range: 0.5-1. 0 mg/dL). Phosphorus level was 3.6 mg/dL (reference range: 2.5-4.5 mg/dL). Parathyroid hormone level was 174.6 pg/mL (reference range: 37.87-83.87 pg/mL). 24-hour urinary calcium was 660 mg (reference range: 0-320 mg). Ultrasound of the neck showed multiple mildly suspicious thyroid nodules, but no notable findings for the parathyroid gland. Subsequent nuclear medicine sestamibi scan revealed no discrete parathyroid adenomas. The 4-dimensional CT scan did not mention parathyroid pathology on the report. However upon review by a head and neck surgeon, a suspicious lesion was identified adjacent to the right thyroid lobe. Intervention was indicated given her age (<50), serum calcium > 1 mg/dL above the upper limit of normal, and 24-hour urinary calcium > 400 mg. The patient underwent a right neck exploration, and a right superior parathyroidectomy was performed. Conclusion: The patient met the criteria for primary hyperparathyroidism based on her normal kidney function, elevated serum calcium, and elevated parathyroid hormone. While imaging is frequently ordered, it is important to note that it does not have a role in confirming or ruling out the diagnosis of primary hyperparathyroidism. It should instead be used to localize abnormal parathyroid glands for operative planning. This case highlights the importance of surgical consultation in primary hyperparathyroidism, especially in the setting of negative or conflicting imaging results.Presentation: No date and time listed

A global perspective on the influence of the COVID-19 pandemic on freshwater fish biodiversity. (Special Issue: Conservation and ecological impacts of the COVID-19 pandemic.)

The COVID-19 global pandemic and resulting effects on the economy and society (e.g., sheltering-in-place, alterations in transportation, changes in consumer behaviour, loss of employment) have yielded some benefits and risks to biodiversity. Here, we considered the ways the COVID-19 pandemic has influenced (or may influence) freshwater fish biodiversity (e.g., richness, abundance). In many cases, we could only consider potential impacts using documented examples (often from the media) of likely changes, because anecdotal observations are still emerging and data-driven studies are yet to be completed or even undertaken. We evaluated the potential for the pandemic to either mitigate or amplify widely acknowledged, pre-existing threats to freshwater fish biodiversity (i.e., invasive species, pollution, fragmentation, flow alteration, habitat loss and alteration, climate change, exploitation). Indeed, we identified examples spanning the extremes of positive and negative outcomes for almost all known threats. We also considered the pandemic's impact on freshwater fisheries demand, assessment, research, compliance monitoring, and management interventions (e.g., restoration), with disruptions being experienced in all domains. Importantly, we provide a forward-looking synthesis that considers the potential mechanisms and pathways by which the consequences of the pandemic may positively and negatively impact freshwater fishes over the longer term. We conclude with a candid assessment of the current management and policy responses and the extent to which they ensure freshwater fish populations and biodiversity are conserved for human and aquatic ecosystem benefits in perpetuity.