Molecular Assays Versus Mycological Methods for Diagnosis of Rhino Orbital Mucormycosis: Analysis of 120 Clinical Specimens from COVID-19 Patients

BACKGROUND

Mucormycosis, a fungal emergency, poses a serious threat to both COVID-19 and non-COVID-19 individuals due to its invasive nature, rapid progression, and high rates of morbidity and mortality. This underscores the crucial need for timely detection and management. In this study, we investigated the utility of real-time PCR (RT-qPCR) assays for detecting Mucorales in clinical specimens, and assessed the performance of both SYBR Green and TaqMan probe RT-qPCR in amplifying Mucorales-specific 18S rDNA genes. We conducted accuracy analyses using direct examination with KOH as a standard for the laboratory diagnosis of mucormycosis. Additionally, we compared the results with culture and duplex PCR.

PATIENTS/METHODS

Both SYBR Green and TaqMan RT-qPCR were optimized using Mucorales-specific oligonucleotides to amplify the conserved 18S rDNA targets. DNAs extracted from 120 rhino sinus specimens, which all were collected from COVID-19 patients upon suspicion of invasive fungal infections, were used for molecular diagnosis. The results of both RT-qPCR assays were compared with the result of direct microscopy, culture, and duplex Mucorales-specific PCR assay.

RESULTS

SYBR Green real-time PCR produced a distinct melting temperature (Tm) pattern (80.24 ± 0.70 °C) and detected Mucorales in 51 out of 120 clinical samples. When compared to direct examination with KOH, the standard method for diagnosing mucormycosis, SYBR Green PCR demonstrated a sensitivity of 91.67% (95% confidence interval (CI): 86.7-96.5%) and a specificity of 90.28% (95% CI: 84.9-95.5%). In contrast, TaqMan-probe PCR identified Mucorales in 34 out of 120 samples, with a sensitivity of 64.58% (95% CI: 56-73.1%) and a specificity of 95.83% (95% CI: 92.26-99.39%).

CONCLUSION

SYBR Green-based PCR can be used as a reliable confirmatory test for diagnosing mucormycosis, particularly in cases with atypical hyphae, mixed infections (featuring both septate and non-septate hyphae), or when the direct examination is positive but culture results are negative. The lower sensitivity of the TaqMan-probe PCR may be attributed to factors such as using a degenerate probe, which can lead to false-negative results.

Combination of Glucagon-Like Peptide 1 Receptor Agonist and Thiazolidinedione for Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes

Importance

Combination therapy has emerged as a critical area of interest in managing diabetes; however, the association of combination therapy with a glucagon-like peptide 1 receptor agonist (GLP-1RA) and thiazolidinedione and the risk of diabetes-related complications remains incompletely understood.

Objective

To compare the hazards of cardiovascular-related morbidities and mortality among patients with type 2 diabetes receiving combination therapy with a GLP-1RA plus thiazolidinedione, those receiving monotherapy with a GLP-1RA or thiazolidinedione, and nonusers.

Design, Setting, and Participants

This retrospective cohort study used nationwide data obtained from Taiwan's National Health Insurance Research Database. Patients older than 20 years with type 2 diabetes who received a GLP-1RA or thiazolidinedione between January 1, 2011, and December 31, 2020, were enrolled. The data analysis was performed from May 1 to May 22, 2024.

Main Outcomes and Measures

This study investigated the hazards of all-cause mortality, major adverse cardiovascular events, cardiovascular mortality, cardiovascular complications, and hypoglycemia in GLP-1RA and thiazolidinedione combination or monotherapy users compared with nonusers.

Results

A total of 110 411 patients were enrolled (mean [SD] age, 58.3 [11.9] years; 45.5% female; 47 526 GLP-1RA users, 32 203 thiazolidinedione users, and 30 682 GLP-1RA plus thiazolidinedione users), along with a propensity score-matched group of patients who did not use a GLP-1RA or thiazolidinedione, for a total cohort size of 220 822. Patients receiving GLP-1RA and thiazolidinedione dual therapy had significantly lower risk of all-cause mortality (adjusted hazard ratio [AHR], 0.20; 95% CI, 0.19-0.21; P < .001), major adverse cardiovascular events (AHR, 0.85; 95% CI, 0.82-0.89; P < .001), and cardiovascular mortality (AHR, 0.20; 95% CI, 0.18-0.23; P < .001) than those who did not receive a GLP-1RA or thiazolidinedione. However, a higher risk of hypoglycemia was seen in those receiving combination therapy (AHR, 1.61; 95% CI, 1.43-1.82; P < .001) and those receiving thiazolidinedione monotherapy (AHR, 1.69; 95% CI, 1.51-1.90; P < .001) compared with nonuse. This risk was mitigated with prolonged use. Thiazolidinedione monotherapy users had a significantly higher risk of all-cause mortality (AHR, 1.29; 95% CI, 1.24-1.34; P < .001) and cardiovascular mortality (AHR, 1.28; 95% CI, 1.13-1.45; P < .001) than GLP-1RA monotherapy users. Several sensitivity analyses further supported the robustness of these findings.

Conclusions and Relevance

In this cohort study of patients with type 2 diabetes, combination therapy with a GLP-1RA plus thiazolidinedione was associated with significantly lower hazards of mortality and cardiovascular complications compared with nonuse. The findings suggest that GLP-1RAs may mitigate the adverse cardiovascular effects of thiazolidinedione.

Association of long-term weight management pharmacotherapy with multiple health outcomes: an umbrella review and evidence map

BACKGROUND

Multiple meta-analyses (MAs) have demonstrated that six pharmacotherapies, including orlistat, liraglutide, phentermine/topiramate, naltrexone/bupropion, semaglutide, and tirzepatide, improve weight loss and weight maintenance. However, few studies have synthesized and evaluated the quality of this evidence.

OBJECTIVE

To identify the relevant MAs of randomized clinical trials (RCTs) that explored the association between the six pharmacotherapies and obesity-related health outcomes and adverse events (AEs).

METHODS

A comprehensive search was conducted across PubMed, Embase, Cochrane Library, and Web of Science from database inception up to January 2024. We calculated the effect size as the mean difference and risk ratio using the random-effects model. The quality of MAs was evaluated using "A Measurement Tool to Assess Systematic Reviews 2".

RESULTS

Sixteen MAs comprising 235 RCTs that described 115 unique associations between the six pharmacotherapies and various health outcomes were included. Overall, 101 statistically significant associations (88%) had beneficial outcomes on body weight, weight loss, waist circumference, body mass index, total cholesterol, triglycerides, both low-density and high-density lipoprotein cholesterol, blood pressure, and glycemic profile. The pharmacotherapies were associated with significant weight loss and partial improvements in the lipid profile, blood pressure, and glycemic control among individuals with overweight or obesity. Notable AEs were associated with liraglutide, naltrexone/bupropion, semaglutide, and orlistat. The methodological quality of the included MAs requires improvement.

CONCLUSIONS

This umbrella review identified significant beneficial associations between pharmacotherapies and anthropometric measures, lipid profile, blood pressure, glycemic profile, and quality-of-life outcomes in individuals with overweight or obesity. In addition, the umbrella review highlighted safety considerations. The findings affirm the efficacy of the six pharmacotherapies in promoting weight loss in this demographic. Further clinical trials with long-term follow-up are essential to evaluate the effects of these pharmacotherapies on clinical outcomes, including cancer, cardiovascular events, and mortality.

A Case Report of Acute Lymphoblastic Leukemia Complicated by Naso-Ophthalmic Mucormycosis

Rhinocerebral mucormycosis, an invasive fungal infection caused by Mucorales species, typically involves the paranasal sinuses, orbits, and central nervous system. Known for its aggressive nature, the infection often leads to severe complications and a high risk of mortality. Common risk factors include uncontrolled diabetes mellitus, immunosuppression, prolonged use of glucocorticoids, and hematologic malignancies. Patients with hematologic malignancies are particularly susceptible to this infection due to compromised immune function. This case report details an instance of acute lymphoblastic leukemia complicated by naso-ocular encephalomycosis, providing a comprehensive overview of its clinical presentation, diagnostic approach, therapeutic management, and prognosis. Additionally, preventive measures and early diagnosis are important in patients with hematologic malignancies.

Icodec ONWARDS: A review of the first once-weekly diabetes treatment for nurse practitioners and physician assistants

BACKGROUND

Diabetes management is challenged by the complexity of treatment regimens and the need for frequent injections, affecting patient adherence and quality of life. Insulin icodec, a once-weekly basal insulin analog, represents a significant innovation, potentially simplifying diabetes care and improving outcomes.

OBJECTIVES

This review aims to evaluate the safety, efficacy, and clinical implications of insulin icodec for individuals with type 1 and type 2 diabetes, highlighting its potential to affect current treatment paradigms.

DATA SOURCES

A review was conducted comparing once-weekly insulin icodec with daily basal insulin analogs using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to ensure transparent reporting of systematic reviews. A search was performed in the following databases: PubMed, Google Scholar, Embase, and ClinicalTrials.gov , focusing on efficacy and safety outcomes.

CONCLUSIONS

Insulin icodec has demonstrated effective glycemic management and a safety profile comparable to daily basal insulins. Its extended half-life and steady-state glucose-lowering effect have the potential to reduce the burden of daily injections and improve patient adherence.

IMPLICATIONS FOR PRACTICE

The introduction of once-weekly insulin icodec represents an advancement in diabetes care. For front-line clinicians, this innovation aligns with the need for more straightforward medication regimens. Coupled with continuous glucose monitoring systems, it enables a more personalized and efficient approach to diabetes management, with the potential to improve patient satisfaction and clinical outcomes. This underscores the impact of integrating such advancements into practice, highlighting the role of nurse practitioners and physician assistants in adopting these innovations to optimize patient care.

Clinical utility of anti-Müllerian hormone in female children and adolescents

Anti-Müllerian hormone (AMH) is a dimeric glycoprotein that belongs to the transforming growth factor beta superfamily and plays essential roles in sexual differentiation and folliculogenesis. In the male embryo, AMH is produced by the Sertoli cells and induces the involution of the Müllerian ducts. In females, AMH is predominately produced by the granulosa cells of growing preantral and small antral follicles and regulates follicular maturation. Many recent studies have highlighted the significant role of this hormone in the diagnostic approach to female children and adolescents with various disorders that affect ovarian development and function. AMH is considered a valuable diagnostic tool in the management of female pediatric patients with conditions such as polycystic ovary syndrome, precocious puberty, ovarian tumors, differences in sex development, and premature ovarian insufficiency. Standardization of AMH assays, internationally approved reference values based on age and pubertal stage, and widespread availability of the test could further upgrade the clinical utility of AMH, rendering it a valuable tool in the armamentarium of physicians involved in the care of female children and adolescents, and promote future research.

Rhino-Orbital Mucormycosis in a Postpartum Diabetic Patient: An Atypical Presentation of Oral Ulcers and Facial Swelling

Mucormycosis is a rare, life-threatening fungal infection primarily affecting immunocompromised individuals, particularly those with poorly controlled diabetes mellitus. This case report presents a 40-year-old female with a decade-long history of uncontrolled type 2 diabetes who developed progressively worsening oral ulcers, facial swelling, and vomiting, following a recent stillbirth. The patient exhibited extensive necrotic lesions involving the nose, oropharynx, and soft palate, leading to a high suspicion of invasive fungal infection. Diagnostic imaging with magnetic resonance imaging (MRI) revealed extensive sinus and orbital involvement, while histopathological examination confirmed rhino-orbital mucormycosis. The patient was managed with liposomal amphotericin B, strict glycemic control, and surgical debridement to remove necrotic tissue. This case underscores the importance of early recognition and multidisciplinary management of mucormycosis, particularly in atypical presentations involving postpartum immunosuppression. Given the rising incidence of invasive fungal infections, clinicians must maintain a high index of suspicion in high-risk patients, especially those with uncontrolled diabetes. Awareness of mucormycosis and its varied clinical presentations can aid in timely diagnosis and improve patient outcomes. The report highlights a unique presentation in a postpartum female, suggesting a potential link between obstetric complications and invasive fungal infections, warranting further research into postpartum-related immunosuppression as a risk factor.

Sex Differences in the Efficacy of Glucagon-Like Peptide-1 Receptor Agonists for Weight Reduction: A Systematic Review and Meta-Analysis

AIM

To verify sex differences of GLP-1RAs for weight reduction.

METHODS

We searched RCTs reporting weight change by sex from PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials registries. Meta-regression was performed to evaluate the association between weight reduction and sex differences. Subgroup analyses were stratified by individual GLP-1RA medications, dose, treatment duration, indication, type of control, background treatment, and baseline weight. The study protocol was registered (CRD42023480167).

RESULTS

Fourteen studies covering dulaglutide, exenatide, liraglutide, semaglutide, and retatrutide were included in this study. The meta-analysis showed that females lost more weight than males (MD 1.04 kg [95% CIs 0.70-1.38]; MD 1.69% [95% CI 0.78-2.61]). The pooled results of GLP-1RAs indicated similar results (MD 0.88 kg [95% CIs 0.67-1.09]). Meta-regression illustrated that substantial weight reduction was significantly relevant to greater gender differences (β = -0.19 [95% CIs -0.29 to -0.09]). Subgroup analysis demonstrated that indications for weight reduction increased the gender difference in weight reduction (MD 4.21 kg [95% CIs 1.75-6.67]). Background treatment, dose, duration of treatment, baseline weight, and type of control had no subgroup differences in the sex difference in weight reduction of GLP-1RAs. Dulaglutide (MD 0.88 kg [95% CIs 0.63-1.12]) and semaglutide (MD 1.04 kg [95% CIs 0.45-1.63]) showed statistically significant differences in weight reduction between males and females. No gender difference was observed in the exenatide subgroup analysis.

CONCLUSIONS

Females lost more weight than males when treated with GLP-1RAs for weight reduction. The sex difference in weight reduction became more pronounced as the degree of weight reduction increased. Indications for obesity could magnify this sex difference.

Outcomes of COVID-19-associated mucormycosis epidemic in India: A prospective 2-year follow-up study

Objectives

The objective of this study was to study the various outcomes among coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) in terms of morbidity and mortality.

Methods

A prospective study was done on 107 patients (60 male, 47 female) in the Department of Otolaryngology and Head and Neck Surgery, Government Medical College, Patiala, India, diagnosed with CAM from April 2021 to August 2021. The patients were managed both medically and surgically. The follow-up was done up to 2 years to assess the various outcomes.

Results

Out of 107 patients, short-term (3 months) survival was 68.22%, and long-term (2 years) survival was 52.34%. Overall mortality was 47.66%, with short-term mortality of 31.77% and long-term mortality of 15.89%. Eye loss was seen in 17 patients, residual ophthalmoplegia in 12, palatal loss in 15, depression in 56, cerebrospinal fluid rhinorrhea in two, and recurrence in two patients.

Conclusions

In conclusion, despite early management and successful initial outcome, the patients are still haunted by the after-effects of CAM like residual morbidity in terms of eye and palate loss, ophthalmoplegia, and depression. Delayed mortality has also been noticed over 2 years of follow-up.

Effect of Comorbidities on the Mortality of Patients With COVID-19: A Systematic Review of Reviews and Meta-Analyses

Studies with strong scientific evidence have demonstrated that comorbidities are associated with fatal outcomes in patients with SARS-CoV-2 infection. To aggregate the findings of these studies and assess the magnitude of the effect of different chronic diseases on COVID-19 mortality, we conducted a systematic review of reviews and meta-analysis. Six databases were searched to retrieve systematic reviews with meta-analysis published during the early years of the pandemic. Statistical analysis was performed using Stata v.12.0 software, and the risk ratio (RR) and odds ratio (OR), with a confidence interval of 95% (95% CI), were calculated. We selected 15 publications with 476 original articles and 2,135,888 patients. Our results indicated the following risk factors for COVID-19 mortality: diabetes mellitus (RR = 1.95; 95% CI:1.41-2.49); hypertension (RR = 1.88; 95% CI:1.51-2.26); cancer (RR = 1.84; 95% CI:1.24-2.43); cardiovascular (RR = 2.14; 95% CI:1.66-2.63), cerebrovascular (RR = 2.43; 95% CI:2.15-2.72), kidney (RR = 2.39; 95% CI:1.36-3.42), pulmonary (RR = 1.98; 95% CI:1.48-2.47) and liver diseases (OR = 1.56; 95% CI:1.18-1.94); obesity (OR = 1.15; 95% CI:1.04-1.26); smoking habits (OR = 1.18; 95% CI:1.13-1.22); and the male sex (OR = 1.69; 95% CI:1.65-1.73). Evidence has confirmed that underlying chronic conditions, which involve an imbalance in the immune response, significantly increase the risk of COVID-19 deaths.

Managing Ifosfamide-Induced Arginine Vasopressin Resistance: Diagnostic and Treatment Strategies

The early recognition of ifosfamide-related renal dysfunction, including arginine vasopressin resistance (previously referred to as diabetes insipidus), which is characterized by polyuria due to the inability of the collecting duct to concentrate urine, as well as direct proximal tubular injury, which is characterized by numerous metabolic disturbances including hypophosphatemia, metabolic acidosis, hypokalemia, and glucosuria, is paramount to timely initiation of treatment and titration of desmopressin. In this report, we present a case of a 42-year-old female with a history of spindle cell carcinoma of the left thigh, who was referred to the inpatient nephrology consult service for acute kidney injury, polyuria, and metabolic derangements following her sixth cycle of doxorubicin-ifosfamide chemotherapy. The patient was treated with supratherapeutic doses of desmopressin, with successful improvement of her polyuria. We review the pathophysiology of different forms of ifosfamide-associated nephrotoxicity, including arginine vasopressin resistance, the challenges of diagnosing arginine vasopressin disorders, and the utility of desmopressin in the management of arginine vasopressin resistance. This case also highlights the clinical implications of using copeptin in the diagnosis of arginine vasopressin resistance, leading to effective treatment and improving patient outcomes.

Have SGLT-2 inhibitors DELIVERed an EMPhatic win in heart failure and chronic kidney disease?

INTRODUCTION

Major global guidelines currently recommend sodium-glucose co-transporter-2 inhibitors (SGLT-2i) as the first-line agent in people with type 2 diabetes (T2D) who have either established cardiovascular disease (eCVD), heart failure (HF), or chronic kidney disease (CKD), regardless of baseline glycated hemoglobin (HbA1c). Moreover, SGLT-2i are currently included in guideline-directed medical therapy as one of the pillars for people with HF and CKD, regardless of T2D. These recommendations are based on positive cardio-renal outcomes from several randomized controlled trials (RCTs).

AREAS COVERED

Following an extensive search in electronic databases of PubMed, Google Scholar, and clinicaltrials.gov, we critically analyzed the RCTs that assessed cardio-renal outcome trials of SGLT-2i and put a perspective on how SGLT-2i delivered an emphatic win for people with HF and CKD, with or without T2D.

EXPERT OPINION

From thirteen high-quality RCTs, including five cardiovascular outcome trials, five HF outcome trials, three renal outcome trials, and a pooled meta-analysis, it is evident that SGLT-2i has delivered an emphatic win in people with HF and CKD, with or without T2D, with an acceptable safety profile. Ongoing RCTs shall further enlighten whether SGLT-2i will be effective in polycystic kidney disease, lupus nephritis, vasculitis, end-stage CKD with or without hemodialysis, and renal transplant.

Bio-standardization and development of a unique polyherbal formulation with dipeptidyl peptidase -IV inhibitory activity for type 2 diabetes mellitus

Medicinal herbs may provide an alternative source of Dipeptidyl peptidase -IV (DPP-IV) Inhibitors, particularly in light of mounting evidence of high costs and adverse drug reactions associated with synthetic DPP-IV Inhibitors. DPP-IV inhibitory activity of medicinal plants Commiphora mukul, Terminalia arjuna and Phyllanthus emblica was elucidated in previous investigations from our lab. The goal of this work was to develop a polyherbal tablet including these medicinal plants with DPP-IV inhibitory action, conduct bio-standardization investigations, and test its anti-diabetic benefits in the streptozotocin model of Type 2 diabetes. A high-performance thin-layer chromatography technique was developed and validated in terms of linearity, accuracy, precision, repeatability, the limit of detection, and the limit of quantification for the bio-standardization of polyherbal combinations. Polyherbal combination's demonstrated significant DPP-IV inhibitory activity. It was interesting to note that in the Type II diabetes experimental model, the polyherbal combination showed antidiabetic efficacy equivalent to that of the synthetic DPP-IV inhibitor Vildagliptin, which is used in clinical settings.

A syndemic approach to the study of Covid-19-related death: a cohort study using UK Biobank data

BACKGROUND

The Covid-19 pandemic showed higher infection, severity and death rates among those living in poorer socioeconomic conditions. We use syndemic theory to guide the analyses to investigate the impact of social adversity and multiple long-term conditions (MLTC) on Covid-19 mortality.

METHODS

The study sample comprised 154 725 UK Biobank participants. Structural equation modeling was used to investigate pathways between traumatic events, economic deprivation, unhealthy behaviors, MLTC, for Covid-19 mortality. Cox regression analysis was used to investigate MLTC and Covid-19 mortality. We also tested effect modification by traumatic events, economic deprivation and unhealthy behaviors.

RESULTS

Covid-19 mortality (n = 186) was directly explained by overall level of MLTC. Economic deprivation and unhealthy behaviors contributed to Covid-19 death indirectly via their negative impact on MLTC. The risk for Covid-19 mortality grew exponentially for every quintile of predicted scores of MLTC. The presence of traumatic events, economic deprivation or unhealthy behaviors did not modify the impact of MLTC on Covid-19 mortality.

CONCLUSIONS

Results suggest a serially causal pathway between economic deprivation and unhealthy behaviors leading to MLTC, which increased the risk of Covid-19 mortality. Policies to tackle the social determinants of health and to mitigate the negative impact of multimorbidity are needed.

The Impact of SARS-CoV-2 Infection on Glucose Homeostasis in Hospitalized Patients with Pulmonary Impairment

Background and Objectives: We conducted a retrospective observational study to evaluate the impact of elevated blood glucose levels in patients with SARS-CoV-2 infection and a prior diagnosis of diabetes mellitus (DM) or newly diagnosed hyperglycemia. Materials and Methods: This study analyzed 6065 patients admitted to the COVID-19 departments of the "Marius Nasta" National Institute of Pulmonology in Bucharest, Romania, between 26 October 2020 and 5 January 2023. Of these, 813 patients (13.40%) were selected for analysis due to either a pre-existing diagnosis of DM or hyperglycemia at the time of hospital admission. Results: The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were elevated in patients with blood glucose levels exceeding 300 mg/dL. These elevations correlated with the presence of respiratory failure and increased mortality rates. Additionally, oxygen requirements were significantly higher at elevated blood glucose levels (p < 0.001), with a direct relationship between glycemia and oxygen demand. This was accompanied by lower oxygen saturation levels (p < 0.001). Maximum blood glucose levels were associated with the severity of respiratory failure (AUC 0.6, 95% CI: 0.56-0.63, p < 0.001). We identified cut-off values for blood glucose at admission (217.5 mg/dL) and maximum blood glucose during hospitalization (257.5 mg/dL), both of which were associated with disease severity and identified as risk factors for increased mortality. Conclusions: High blood glucose levels, both at admission and during hospitalization, were identified as risk factors for poor prognosis and increased mortality in patients with SARS-CoV-2 infection, regardless of whether the hyperglycemia was due to a prior diagnosis of DM or was newly developed during the hospital stay. These findings underscore the importance of glycemic control in the management of hospitalized COVID-19 patients.

Apple peel flour instead of sugar in sponge cake: Nutritional, sensory, physical, and microbiological evaluation

Apple peels are considered "inedible parts," however, they can be dehydrated and ground to use as an ingredient in bakery products. The present study aims to evaluate the replacement of 25% and 50% sugar in sponge cakes for apple peel flour (APF) cakes by comparing their nutritional composition, sugar profile, microbial development, sensory preference and acceptability, color, and specific volume. The results showed that by incorporating APF into sponge cakes, the dietary fiber content increases, and the concentration of total sugars and energy intake significantly decrease. As disadvantages, it is revealed that APF does not inhibit microbial development and the specific volume decreases when incorporating APF. The sample with the greatest preference and sensory acceptability corresponds to the 25% sugar replacement with APF.

Effect of obesity on the acute response to SARS-CoV-2 infection and development of post-acute sequelae of COVID-19 (PASC) in nonhuman primates

Long-term adverse consequences of SARS-CoV-2 infection, termed "long COVID" or post-acute sequelae of COVID (PASC), are a major component of overall COVID-19 disease burden. Prior obesity and metabolic disease increase the severity of acute disease, but SARS-CoV-2 infection also contributes to the development of new-onset metabolic disease. Since the COVID pandemic occurred in the context of the global obesity epidemic, an important question is the extent to which pre-existing obesity modifies long-term responses to SARS-CoV-2 infection. We utilized a nonhuman primate model to compare the effects of infection with the SARS-CoV-2 delta variant in lean and obese/insulin-resistant adult male rhesus macaques over a 6-month time course. While some longitudinal responses to SARS-CoV-2 infection, including overall viral dynamics, SARS-CoV-2-specific IgG induction, cytokine profiles, and tissue persistence of viral RNA, did not appreciably differ between lean and obese animals, other responses, including neutralizing Ab dynamics, lung pathology, body weight, degree of insulin sensitivity, adipocytokine profiles, body temperature, and nighttime activity levels were significantly different in lean versus obese animals. Furthermore, several parameters in lean animals were altered following SARS-CoV-2 infection to resemble those in obese animals. Notably, persistent changes in multiple parameters were present in most animals, suggesting that PASC may be more prevalent than estimated from self-reported symptoms in human studies.

SGLT2 Inhibitors in COVID-19: Umbrella Review, Meta-Analysis, and Bayesian Sensitivity Assessment

BACKGROUND

Several studies have reported a reduced risk of COVID-19-related mortality in patients taking antidiabetic medications. This is an umbrella review, meta-analysis, and Bayesian sensitivity assessment of SGLT2 inhibitors (SGLT2is) in COVID-19 patients with type 2 diabetes mellitus (T2DM).

METHODS

A search was conducted on the MEDLINE (PubMed), EMBASE, Cochrane, and ClinicalTrials.gov databases on 5/12/2023. We performed an umbrella review of systematic reviews and meta-analyses on the effects of SGLT2is in T2DM patients with COVID-19 and critically appraised them using AMSTAR 2.0. Trials investigating SGLT2i use in COVID-19 patients post-hospitalisation and observational studies on prior SGLT2i use among COVID-19 patients were included in the meta-analysis, adhering to the PRISMA guidelines.

RESULTS

SGLT2is exhibited significantly lower odds of mortality (OR 0.67, 95% CI 0.53-0.84) and hospitalisation (OR 0.84, 0.75-0.94) in COVID-19 patients with T2DM. Bayesian sensitivity analyses corroborated most of the findings, with differences observed in hospitalisation and mortality outcomes. SGLT-2 inhibitors showed an OR of 1.20 (95% CI 0.64-2.27) for diabetic ketoacidosis. Publication bias was observed for hospitalisation, but not for mortality. The GRADE assessment indicated a low to very low quality of evidence because of the observational studies included.

CONCLUSIONS

The prophylactic use of SGLT2is reduces mortality and hospitalisation among COVID-19 patients, particularly in patients with diabetes. The utility of SGLT2is after hospitalisation is uncertain and warrants further investigation. A limited efficacy has been observed under critical conditions. Individualised assessment is crucial before integration into COVID-19 management.

Genome analysis of a newly isolated Lysinibacillus fusiformis-YC01 for biodegrading inosine and guanosine

Hyperuricemia (HUA) caused by high serum uric acid (UA) level can lead to a range of metabolic diseases, such as gout, cardiovascular disease and diabetes. The reduction of crucial UA precursors of both inosine and guanosine is a potential method to control HUA. Here a promising bacterial strain for biodegrading both inosine and guanosine were successfully isolated from Baijiu cellar mud and identified as Lysinibacillus fusiformis-YC01 by ANI analysis. Initial 490 mg/L of inosine and 612 mg/L of guanosine were completely biodegraded by YC01 within 18 h at 38 °C. In addition, the initial 357 mg/L of inosine and 365 mg/L of guanosine were also removed by the cell-free extracts of YC01 at a protein concentration of 0.13 mg/mL within 16 h. Furthermore, the whole genome analysis of YC01 revealed that purine nucleoside phosphorylase and purine nucleosidase played key roles in the biodegradation of inosine and guanosine, which encoded by gene deoD and gene iunH. These findings indicated that YC01 could biodegrade inosine and guanosine, and provided the new valuable insights into microbial removal of UA precursors for the amelioration of HUA.

The Many Facets of PPAR-γ Agonism in Obesity and Associated Comorbidities: Benefits, Risks, Challenges, and Future Directions

PURPOSE OF REVIEW

Obesity is strongly associated with cardiometabolic disorders and certain malignancies, emphasizing the key role of adipose tissue in human health. While incretin mimetics have shown effectiveness in glycemic control and weight loss, a holistic strategy for combating obesity and associated comorbidities remains elusive. This review explores peroxisome proliferator-activated receptor gamma (PPAR-γ) agonism as a potential therapeutic approach, highlighting its benefits, addressing its limitations, and outlining future directions for developing more effective treatment strategies.

RECENT FINDINGS

Both natural and synthetic PPAR-γ agonists hold significant therapeutic potential as insulin sensitizers, while also demonstrating anti-inflammatory properties and playing a critical role in regulating lipid metabolism. However, the clinical use of natural agonists is limited by poor bioavailability, while synthetic agents like thiazolidinediones are associated with adverse effects, including fluid retention, weight gain, and bone loss. Current research is focused on developing modified, tissue-specific PPAR-γ agonists, as well as dual PPAR-α/PPAR-γ agonists, with improved safety profiles to mitigate these side effects. Nanotechnology-based drug delivery systems also hold promise for enhancing bioavailability and therapeutic efficacy. Furthermore, the transformative potential of machine learning and artificial intelligence offers opportunities to accelerate advancements in this field. PPAR-γ agonists exhibit significant potential in addressing metabolic syndrome, cardiovascular disease, and cancer. However, their clinical use is restricted by safety concerns and suboptimal pharmacokinetics. Innovations in modified PPAR-γ agonists, nanotechnology-based delivery systems, and computational tools hold promise for creating safer and more effective therapeutic options for obesity and its associated disorders.

New insights in the treatment of DKD: recent advances and future prospects

Diabetic kidney disease (DKD) represents the predominant and severe microvascular complication associated with diabetes, frequently culminating in End-Stage Kidney Disease (ESKD). The escalating prevalence of diabetes has correspondingly led to a rise in DKD incidence, imposing significant challenges on both individuals and society. The etiology of DKD is multifaceted and remains devoid of definitive therapeutic interventions. This article examines the pharmacological actions and mechanisms of different drugs used for the prevention and treatment of DKD that are currently in clinical use or undergoing development. The goal is to offer insights for early intervention based on therapeutic combinations to potentially slow kidney disease progression.

Organic Micropollutants in Waterways of a Large-Scale Water Diversion Project: Insights from Nontarget Screening and "Community" Analysis

Large-scale water diversion projects are essential for meeting the needs of water-stressed regions, necessitating an evaluation of their impact on water quality and aquatic ecosystems. This study provides the first snapshots of organic micropollutants (OMPs) along the 1466 km Eastern Route of China's South-to-North Water Diversion Project. Using nontarget analysis with ultrahigh-performance liquid chromatography and high-resolution mass spectrometry, we identified and quantified 357 OMPs from water samples collected during the water diversion period (WDP) and the nonwater diversion period (NWDP). The OMPs included 136 household compounds, 112 agricultural compounds, 102 industrial compounds, and 7 traffic markers. Significant regional variations in OMP concentrations and compositions were observed during the NWDP due to diverse local pollution sources along the route. However, such differences were reduced during the WDP, likely due to water transfer. OMP diversity varied substantially during the NWDP but was more stable with less distance decay during the WDP. Network analysis indicated closer relationships between the OMPs during the WDP, suggesting a more consistent spatial distribution. The source water overwhelmingly influenced the water quality along the diversion route. These findings underscore the need for ongoing assessments of the impact of water diversion on regional water quality and ecosystems.

Impact of Prior Chronic Kidney Disease and Newly Detected eGFR Impairment at Admission on Outcomes and Prognosis of Hospitalized COVID-19 Patients - A Single-Center Cohort Study

Background and Hypothesis

Chronic kidney disease (CKD) is a major prognostic factor in COVID-19. Little is known about the significance of newly detected renal impairment (RI) for COVID-19 patient outcomes. This study assessed the effect of prior CKD and RI at admission on in-hospital mortality in COVID-19 patients.

Methods

A total of 5191 consecutive patients with COVID-19 admitted between March 6, 2020 and May 31, 2021, to the University Hospital in Krakow were analyzed. The main outcome was in-hospital death from any cause compared between the three study groups - patients with a prior history of CKD (group A), no history of CKD and eGFR on admission <60 mL/min/1,73 m2 (group B), and no history of CKD and eGFR on admission >60 mL/min/1,73 m2 (group C).

Results

Of 5191 patients, 2348 (45.2%) were women and 2409 (46.4%) were older than 65 years (mean age of 61.98±16.66 years). There were 483 (9.3%) patients in group A, 1009 (22.2%) in group B and 3699 (68.5%) in group C. Groups A and B were older and had higher cardiometabolic burden compared to group C. Multivariable logistic regression showed that older age, higher CRP, WBC, D-dimer levels, HF, and being in groups A or B were associated with higher in-hospital mortality. Group B had the highest risk (OR 3.003, CI 2.298-3.926) compared to group A (OR 2.020, CI 1.636-2.494) and group C (reference).

Conclusion

COVID-19 patients with prior CKD and newly detected RI have higher odds of in-hospital death compared to those with normal kidney function. Special attention is needed for newly detected RI cases in COVID-19 patients.

Metformin in gestational diabetes: physiological actions and clinical applications

Metformin is an effective oral hypoglycaemic agent used in the treatment of type 2 diabetes mellitus; however, its use in pregnancy for the treatment of gestational diabetes mellitus (GDM) remains controversial owing to concerns around safety and efficacy. This comprehensive review outlines the physiological metabolic functions of metformin and synthesizes existing literature and key knowledge gaps pertaining to the use of metformin in pregnancy across various end points in women with GDM. On the basis of current evidence, metformin reduces gestational weight gain, neonatal hypoglycaemia and macrosomia and increases insulin sensitivity. However, considerable heterogeneity between existing studies and the grouping of aggregate and often inharmonious data within meta-analyses has led to disparate findings regarding the efficacy of metformin in treating hyperglycaemia in GDM. Innovative analytical approaches with stratification by individual-level characteristics (for example, obesity, ethnicity, GDM severity and so on) and treatment regimens (diagnostic criteria, treatment timing and follow-up duration) are needed to establish efficacy across a range of end points and to identify which, if any, subgroups might benefit from metformin treatment during pregnancy.

One or two? Comparison of the cardiorenal effects between combination therapy and monotherapy with SGLT2i or GLP1RA

OBJECTIVE

This study aimed to evaluate the cardiorenal effect of combining sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) when compared with monotherapy of either agent in patients with type 2 diabetes (T2D).

METHODS

PubMed, Web of Science, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrial.gov were systematically searched from inception to June 2024. Eligible studies included randomised controlled trials and observational studies assessing that compared with SGLT2i or GLP-1RA monotherapy, the risk of cardiorenal outcomes in patients with T2D who treated with combination therapy. Pooled relative risk (RR) and 95% confidence intervals (CIs) were computed in random-effects model.

RESULTS

In all, five RCTs, 10 post hoc analyses and one observational study were included. The reduced risk of the composite cardiovascular outcome was observed in patients receiving combination therapy of SGLT2i and GLP-1RA when compared with SGLT2i monotherapy (RR = 0.57, 95% CI 0.38-0.86, p = 0.008) or GLP-1RA monotherapy (RR = 0.77, 95% CI 0.65-0.91, p = 0.002). Likewise, the composite renal adverse events were less frequent in patients receiving combination therapy of SGLT2i and GLP-1RA when compared with SGLT2i monotherapy (RR = 0.69, 95% CI 0.59-0.82, p < 0.001) or GLP-1RA monotherapy (RR = 0.66, 95% CI 0.53-0.83, p < 0.001). Compared with GLP-1RA monotherapy, the combination therapy of SGLT2i and GLP-1RA was associated with lower risks of heart failure-related outcomes (RR = 0.63, 95% CI 0.51-0.77, p < 0.001) and all-cause mortality (RR = 0.66, 95% CI 0.50-0.88, p = 0.004) in patients with T2D.

CONCLUSION

The cardiorenal benefits might be magnified with the combination therapy of SGLT2i and GLP-1RA when compared with monotherapy of either agent. Further investigations are needed to validate the findings.

A Critical Review on the Long-Term COVID-19 Impacts on Patients With Diabetes

BACKGROUND

The world is currently grappling with the potentially life-threatening coronavirus disease 2019 (COVID-19), marking it as the most severe health crisis in the modern era. COVID-19 has led to a pandemic, with the World Health Organization (WHO) predicting that individuals with diabetes are at a higher risk of contracting the virus compared to the general population. This review aims to provide a practical summary of the long-term impacts of COVID-19 on patients with diabetes. Specifically, it focuses on the effects of SARS-CoV-2 on different types of diabetic patients, the associated mortality rate, the underlying mechanisms, related complications, and the role of vitamin D and zinc in therapeutic and preventive approaches.

METHODS

Relevant literature was identified through searches on PubMed, Web of Science, and Science Direct in English, up to April 2023.

RESULTS

COVID-19 can lead to distressing symptoms and pose a significant challenge for individuals living with diabetes. Older individuals and those with pre-existing conditions such as diabetes, coronary illness, and asthma are more susceptible to COVID-19 infection. Managing COVID-19 in individuals with diabetes presents challenges, as it not only complicates the fight against the infection but also potentially prolongs the recovery time. Moreover, the virus may thrive in individuals with high blood glucose levels. Various therapeutic approaches, including antidiabetic drugs, are available to help prevent COVID-19 in diabetic patients.

CONCLUSIONS

Diabetes increases the morbidity and mortality risk for patients with COVID-19. Efforts are globally underway to explore therapeutic interventions aimed at reducing the impact of diabetes on COVID-19.

Type 2 Diabetes Mellitus: A Comprehensive Review of Pathophysiology, Comorbidities, and Emerging Therapies

Humans are perhaps evolutionarily engineered to get deeply addicted to sugar, as it not only provides energy but also helps in storing fats, which helps in survival during starvation. Additionally, sugars (glucose and fructose) stimulate the feel-good factor, as they trigger the secretion of serotonin and dopamine in the brain, associated with the reward sensation, uplifting the mood in general. However, when consumed in excess, it contributes to energy imbalance, weight gain, and obesity, leading to the onset of a complex metabolic disorder, generally referred to as diabetes. Type 2 diabetes mellitus (T2DM) is one of the most prevalent forms of diabetes, nearly affecting all age groups. T2DM is clinically diagnosed with a cardinal sign of chronic hyperglycemia (excessive sugar in the blood). Chronic hyperglycemia, coupled with dysfunctions of pancreatic β-cells, insulin resistance, and immune inflammation, further exacerbate the pathology of T2DM. Uncontrolled T2DM, a major public health concern, also contributes significantly toward the onset and progression of several micro- and macrovascular diseases, such as diabetic retinopathy, nephropathy, neuropathy, atherosclerosis, and cardiovascular diseases, including cancer. The current review discusses the epidemiology, causative factors, pathophysiology, and associated comorbidities, including the existing and emerging therapies related to T2DM. It also provides a future roadmap for alternative drug discovery for the management of T2DM.

Endocrine Complications in Hepatic Glycogen Storage Diseases: A Long-term Perspective

Patients with a hepatic type of glycogen storage diseases (GSDs) can manifest endocrine features such as hypoglycemia, dyslipidemia, or osteoporosis. This study aimed to investigate the long-term endocrine consequences in patients with hepatic GSDs.This study included 64 patients from 52 families with hepatic GSDs including GSD type Ia (41 patients from 37 families), Ib (3 unrelated), III (8 from 6 families), IV (1 patient), and IX (11 from 5 families). All patients were genetically confirmed. Clinical and endocrine findings were retrospectively analyzed.The median age at diagnosis and current age were 2.4 years (range, 0.1-42.4 years) and 17.6 years (range, 1.0-47.8 years), respectively. The mean height SDS at diagnosis was -3.5±1.4, and short stature was observed in 35.6% of patients. Patients diagnosed after the age of 3.4 years exhibited a high risk of short stature (OR=36.1; P-value<0.001). Among 33 patients who reached the final height, 23 (69.7%) showed delayed puberty. Hypertriglyceridemia was observed in 46 patients (71.9%), whereas 25 patients (39%) had elevated low-density lipoprotein cholesterol levels during the follow-up period. Among 24 patients who underwent dual-energy X-ray absorptiometry, 22 showed a low bone mineral density Z-score of -3.0±1.3 at the L-spine.This study described the long-term endocrine consequences in patients with hepatic GSDs. Pediatric endocrinologists should be aware of the presenting features and long-term endocrine sequelae of GSDs to provide proper management and decrease its morbidities.

Efficacy of Dapagliflozin + Sitagliptin + Metformin Versus Sitagliptin + Metformin in T2DM Inadequately Controlled on Metformin Monotherapy: A Multicentric Randomized Trial

INTRODUCTION

A slower adoption rate of fixed dose combinations (FDC) in diabetes management is partly due to insufficient data. This study evaluates the safety and efficacy of an FDC of dapagliflozin + sitagliptin + metformin hydrochloride extended release (XR), compared to a dual FDC of sitagliptin + metformin hydrochloride XR among patients with type 2 diabetes mellitus (T2DM) with poor glycemic control when treated with metformin monotherapy.

METHODS

A total of 274 patients with T2DM were randomized (1:1) to either arm X, receiving FDC of dapagliflozin (10 mg) + sitagliptin (100 mg) + metformin hydrochloride XR (1000 mg) (Dapa + Sita + Met) tablets, or arm Y, receiving sitagliptin phosphate (100 mg) + metformin hydrochloride XR (1000 mg) (Sita + Met) tablets, and treated for 16 weeks. The outcome measures included changes in hemoglobin A1c (HbA1c)(%), fasting plasma glucose (FPG), 2-h post-prandial glucose (PPG), weight, and the proportion of patients achieving target HbA1c levels of < 7.0% by week 16 of the study period.

RESULTS

The reduction in HbA1c at week 16 was significantly higher in arm X than in arm Y [estimated treatment difference (ETD), - 0.65% (95% CI - 0.76 to - 0.53; P < 0.0001)]. Arm X showed a marked decrease in FPG [ETD - 15.42 mg/dl; 95% CI (17.63, 13.22; P < 0.0001)], PPG [ETD - 30.39 mg/dl; 95% CI (35.59, 25.19; P < 0.0001)], and weight [ETD - 1.47 kg; 95% CI (1.59, 1.28; P < 0.0001)] after 16 weeks. In arm X, 54% of patients reached HbA1c < 7.0% compared to 29.9% in arm Y. The incidence of adverse events was comparable [13.14% (arm X) vs 12.4% (arm Y)]. There was no severe hypoglycemia-led treatment discontinuation.

CONCLUSION

Among patients with T2DM who have poor glycemic control with metformin monotherapy, triple FDC (Dapa + Sita + Met) effectively helped achieve better glycemic response compared to dual FDC (Sita + Met), with a comparable safety and tolerability profile.

TRIAL REGISTRATION

CTRI/2022/01/039857.

Safety, Tolerability, and Pharmacokinetics of a Novel Anti-obesity Agent, S-309309, in Healthy Adults with or Without Obesity

BACKGROUND

Anti-obesity medications are recommended for patients who do not achieve and maintain weight loss despite lifestyle interventions. S-309309 is a novel oral inhibitor of monoacylglycerol O-acyltransferase 2 being developed as a treatment for obesity.

OBJECTIVE

The objective of the study was to investigate the safety, clinical pharmacology, pharmacokinetics and pharmacodynamic biomarker of S-309309.

METHODS

A phase I, single-center, two-part, randomized, double-blind, placebo-controlled study of S-309309 following oral administration of a single-ascending dose (part 1) and a multiple dose (part 2) in healthy adults with or without obesity was conducted. We also assessed the effect of food on the pharmacokinetics of S-309309 and the effect of S-309309 on electrocardiogram parameters, the pharmacokinetics of midazolam (a cytochrome P450 3A substrate), and the pharmacodynamic biomarker of monoacylglycerol O-acyltransferase 2 inhibition.

RESULTS

In part 1 (N = 50), a single-ascending dose of S-309309 in healthy adults demonstrated dose proportionality and comparable exposure of S-309309 between the fasted and fed states. In part 2 (N = 24), no clinically meaningful difference was observed in the pharmacokinetics of multiple doses between healthy adults with or without obesity. S-309309 did not affect the pharmacokinetics of the cytochrome P450 3A substrate. The pharmacodynamic biomarker of monoacylglycerol O-acyltransferase 2 inhibition, dicarboxylic acid (18:1), was significantly increased after S-309309 administration in healthy adults with or without obesity. Overall, S-309309 demonstrated acceptable safety and tolerability without any serious adverse events or discontinuations because of adverse events, and did not have a clinically relevant effect on the heart rate or cardiac conduction. An effect on the placebo-corrected change-from-baseline corrected QT interval, corrected for heart rate using the Fridericia method, exceeding 10 ms can be excluded.

CONCLUSIONS

S-309309 was well tolerated as single-dose (up to 300 mg) and multiple-dose (50 mg once daily for 14 days) oral administration. The pharmacokinetic characteristics remained unaffected by obesity and food intake. S-309309 did not affect the pharmacokinetics of the cytochrome P450 3A substrate. Overall, S-309309 had an acceptable safety profile and favorable pharmacokinetic and pharmacodynamic characteristics.

CLINICAL TRIAL REGISTRATION

NCT05247970, date of registration: 8 February, 2022.

Redefining Diagnostic Cut-Offs for the Indirect Water Deprivation Test

OBJECTIVE

An incorrect diagnosis of arginine vasopressin deficiency and resistance (AVP-D and AVP-R) results in the potentially dangerous use of desmopressin in healthy individuals. The water deprivation test is a central diagnostic test in patients with polydipsia polyuria syndrome (PPS). This study aims to determine the effectiveness of the current interpretation of reference ranges.

METHODS

This is a retrospective analysis of 135 patients who underwent a water deprivation test between August 2014 and August 2023. All patient diagnoses were reviewed, and variability and receiver operating characteristic (ROC) curves were determined for serum osmolality, serum sodium and urine osmolality.

RESULTS

Serum sodium demonstrated reduced variability compared with serum osmolality (0.72% vs. 1.16%, respectively, 37.5% reduction; p < 0.001). The standard serum osmolality cut-off value of ≥ 300 mOsm/kg in diagnosing AVP-D, AVP-R, and primary polydipsia (PP) achieved a sensitivity of 76.19% and specificity of 76.92%. A serum sodium cut-off value of ≥ 148 mmol/L demonstrated 100% specificity in excluding PP. This cut-off was used alongside urine osmolality cut-off values of > 630 mOsm/kg (for PP) and < 383 mOsm/kg (for AVP-D/AVP-R). Review of post-desmopressin urine osmolality and clinical monitoring was performed in equivocal diagnostic cases (n = 6), achieving 100% sensitivity and 100% specificity within the study sample.

CONCLUSIONS

This study demonstrates that a serum sodium cut-off of ≥ 148 mmol/L in tandem with urine osmolality yields the best diagnostic accuracy to differentiate between AVP-D, AVP-R, and PP. Serum sodium may be more reliable than serum osmolality in the investigation of patients with PPS, demonstrating lower biological and analytical variability.

COVID-19-associated rhino-orbito-cerebral mucormycosis: a single center prospective study of 264 patients

PURPOSE

Outbreaks of mucormycosis were reported worldwide throughout the COVID-19 pandemic. We report clinical outcomes of a treatment protocol for COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

Patients with biopsy-proven mucormycosis and COVID-19 were included. All received intravenous amphotericin B deoxycholate 1 mg/kg and surgical endoscopic sinus debridement (FESS). Those with rhino-orbital or cerebral disease limited to the cavernous sinus were eligible for transcutaneous retrobulbar amphotericin B (TRAMB). Patients were followed with weekly imaging, endoscopic examinations, and serial debridement as necessary. Patients were discharged on oral posaconazole for 6 months.

RESULTS

In total, 264 patients were followed for a mean of 2.5 months. On presentation, 163 patients (174 eyes) had eye involvement. Of these, 141 eyes (81.0%) had light perception or worse vision. By the last follow-up, 163 patients (176 eyes) were affected, and of these, 96 eyes (54.5%) had no light perception. Twenty-one patients (8%) died and 3 orbits (0.5%) were exenterated. There was no change in mortality (p = 0.38) or exenteration (p = 0.38) in the 55 patients who received TRAMB compared to patients with rhino-orbital or cerebral disease limited to the cavernous sinus who did not. Asymptomatic COVID-19 was associated with higher mortality than symptomatic COVID-19 (p = 0.025). Uncontrolled diabetes was a risk factor for death (p = 0.022). New diabetes was associated with increased mortality versus pre-existing diabetes (p = 0.005).

CONCLUSION

A multidisciplinary approach is crucial to manage COVID-19-ROCM. In our cohort, TRAMB therapy did not increase mortality or exenteration rates. While poor vision on presentation was profound, some vision recovery was noted with treatment. COVID-19 immune dysregulation may predispose patients to ROCM, particularly those with asymptomatic disease.

Increased serum ferritin is associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis: A quantitative analysis

CONTEXT

Effect of serum ferritin on severity of coronavirus disease 2019 (COVID-19)-associated rhino-orbito-cerebral mucormycosis.

PURPOSE

To study the association between increased serum ferritin and severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

SETTINGS AND DESIGN

A cross-sectional study.

METHODS

Hundred ( n ) out of 155 treatment-naive patients of COVID-19 infection presenting with the signs and symptoms of rhino-orbito-cerebral mucormycosis were enrolled in study. Based on the classification proposed by Honavar, the study patients were classified into four stages: Stage 1: involvement of the nasal mucosa ( n = 11), Stage 2: involvement of paranasal sinuses ( n = 14), Stage 3: involvement of the orbit ( n = 37), Stage 4: involvement of the central nervous system ( n = 38). Stage 3 was further divided into four substages: 3a: nasolacrimal duct, medial orbit, vision unaffected ( n = 4); 3b: diffuse orbital involvement (>1 quadrant or >2 structures), vision unaffected ( n = 15); 3c: central retinal artery occlusion or ophthalmic artery occlusion, superior ophthalmic vein thrombosis, involvement of superior orbital fissure, inferior orbital fissure, orbital apex, diminution or loss of vision ( n = 13); 3d: bilateral orbital involvement ( n = 5). Fasting blood sugar (FBS), postprandial blood sugar (PPBS), and inflammatory markers (serum ferritin, interleukin-6, C-reactive protein, and D-dimer) were assessed. Serum level of ferritin was analyzed by using chemiluminescence immunoassay method.

RESULTS

Mean FBS (mg/dl) was 165.03 ± 70.43 for stage 1, 185.67 ± 64.82 for stage 2, 159.05 ± 68.60 for stage 3, and 158.20 ± 62.05 for stage 4. Mean PPBS (mg/dl) was 238.70 ± 141.29 for stage 1, 252 ± 103.69 for stage 2, 257.09 ± 103.48 for stage 3, and 229.53 ± 76.81 for stage 4. Mean serum ferritin (μg/l) was 302.67 ± 266.95 in stage 1, 444.19 ± 116.36 in stage 2, 504.85 ± 205.99 in stage 3, and 825.95 ± 777.30 in stage 4. A statistically significant increase in serum ferritin levels with severity of disease ( P = 0.005) was noted. Similar trend was observed in substages of stage 3. Pearson correlation analysis showed a positive correlation between serum ferritin and severity of disease ( P = 0.0007).

CONCLUSION

Increased serum ferritin was significantly independently associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

Predicting COVID-19 Patient Disposition Using the National Early Warning Score 2: A Retrospective Cohort Study

Objectives To evaluate the effectiveness of the National Early Warning Score 2 (NEWS2) in predicting the need for hospital admission and close monitoring of suspected patients with COVID-19 presenting to the Emergency Department (ED). This study aims to determine whether NEWS2 can aid in identifying high-risk patients with COVID-19 requiring urgent care and admission. Methodology Retrospective data from electronic health records of 300 patients with COVID-19 who presented to Mediclinic Parkview Hospital ED between January 1, 2021, and June 30, 2021, were analyzed. Collected variables included age, gender, body mass index (BMI), vital signs, and patient disposition. Statistical analysis was conducted to assess the ability of NEWS2 to predict COVID-19 patient disposition. Results A total of 300 patients were included, and their NEWS2 scores were analyzed to predict clinical deterioration. NEWS2, with a cutoff value of 2, predicted hospital admission with 86% sensitivity and 75% specificity. It achieved an average area under the curve (AUC) of 0.86 for predicting outcomes at 24 to 72 hours from the time of initial presentation to the ED. Conclusions NEWS2 demonstrates high sensitivity in predicting the disposition of patients with COVID-19. Our findings support the use of NEWS2 as a useful tool for the initial assessment of patients with COVID-19 presenting to the ED, assisting in identifying patients at risk of deterioration.

Predictors of severity of SARS-CoV-2 infections in Brazil: Post hoc analyses of a randomised controlled trial

OBJECTIVES

To identify demographic, clinical and immunological factors associated with adverse COVID-19 outcomes.

METHODS

A large randomised controlled trial of ChAdOx1 nCoV-19 was undertaken in Brazil. Participants were randomised 1:1 either to receive ChAdOx1 nCov-19 or to a control group. COVID-19 infections were confirmed by nucleic acid amplification test (NAAT) and classified using the WHO clinical progression scale. Anti-spike antibody responses and serum neutralising activity were measured 28 days after second vaccination in some participants. Exploratory analyses were conducted into factors associated with COVID-19 infection severity and hospitalisation, using logistic regression models adjusted for demographic and clinical factors.

RESULTS

10,416 participants were enrolled; 1790 had NAAT-positive COVID-19 infection; 63 cases required hospitalisation. More severe infection was associated with greater body-mass index (BMI) (odds ratio [OR] = 1.06 [95 %CI: 1.01-1.10], p = 0.01) and diabetes (OR = 3.67 [1.59-8.07], p = 0.003). Hospitalisation risk increased with greater age (OR = 1.06 [1.03-1.08], p < 0.001) and BMI (OR = 1.10 [1.05-1.16], p < 0.001). More severe infection and hospitalisation risks increased >180 days after last vaccination. In the fully vaccinated subgroup (n = 841), only greater age predicted hospitalisation (OR = 1.07 [1.03-1.12], p < 0.001). Serological responses to two vaccine doses diminished with age.

CONCLUSIONS

Unvaccinated individuals with high BMI and diabetes risked more severe COVID-19 outcomes. Vaccination mitigated this risk.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04536051.

Unveiling the Broad-Spectrum Efficacy of Volatile Terpenes to Fight Against SARS-COV-2-Associated Mucormycosis

Mucormycosis, a life-threatening fungal infection caused by Mucorales, affects immunocompromised patients, especially SARS-CoV-2 ones. Existing antifungal therapies, like amphotericin B, have serious health risks. The current study reviews the literature regarding an overview of SARS-CoV-2-associated mucormycosis, along with different terpenes from diverse edible sources, such as basil, ginger, and clove, which are detected till June 2024. The antifungal potential of collected terpenes, their classifications, mechanisms of action, minimum inhibitory concentration (MIC) values, and future perspectives are discussed here. The search identified 89 fungicidal volatile terpenes, belonging to about 26 families, from which 45 were selected for further in silico analysis. The results highlighted oryzalexin B (60), oryzalexin D (62), carvacrol (4), mansorin B (66), muzigadial (86), and lubimin (80) as potential antifungal agents against lanosterol 14α-demethylase, CotH3, and mucoricin as potential targets in Mucorales. CotH3 is crucial for activating GRP-78, a host co-receptor for ACE2, which is essential for SARS-CoV-2 pathogenesis. Additionally, carvacrol was in vitro investigated against Mucor racemosus via the agar diffusion method, giving an MIC value of 1 mg/mL, compared to 0.1 mg/mL of ketoconazole. This study suggests promising potential for volatile terpenes in combating SARS-CoV-2-associated mucormycosis, with the need for further refined in vitro and in vivo studies to establish clinical efficacy.

Self-Reported Post-COVID Symptoms at 18 Months After Infection Among Adults in Southern Brazil: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

Currently, there is a limited understanding of the long-term consequences following acute COVID-19, referred to as long COVID. This cross-sectional study aims to analyze the prevalence of persistent signs and symptoms of long COVID, 18 months after primary SARS-CoV-2 infection in adults in southern Brazil.

METHODS

Using two national databases (the digital registry of SARS-CoV-2 positive cases), 370 individuals living in the state of Paraná (Brazil) were recruited. Data were collected through telephone interviews conducted in 2021 and 2022.

RESULTS

The overall prevalence of long COVID was 66.2% among study participants. During the acute phase of infection, the most common symptom clusters included neurological symptoms (87.0%; n = 318), followed by respiratory (82.0%; n = 301), musculoskeletal (66.0%; n = 241), digestive (50.0%; n = 184), psychological (38.0%; n = 138), and endocrine symptoms (28.0%; n = 104). In the 18 month follow-up, the main persistent symptoms were memory loss (42.7%), fatigue (32.2%), anxiety (23.5%), dyspnea (19.7%), and hair loss (19.7%). The proportion of participants with long COVID was statistically higher in females (73.9%), those with a family income below two minimum wages (94.7%), those who do not practice physical activity (83.3%), those who report poor sleep quality (93.3%), those who use long-term medication (85.9%), those who needed health care in the previous six months (87.3%), those who required professional and/or family care (79.3%), those who were in the ICU (79.0%), and those who used ventilatory support (77.5%).

CONCLUSIONS

Long COVID is a complex condition that requires long-term monitoring and investment in health services due to its high prevalence and the health consequences in the population.

Use of Machine Learning to Predict Individual Postprandial Glycemic Responses to Food Among Individuals With Type 2 Diabetes in India: Protocol for a Prospective Cohort Study

BACKGROUND

Type 2 diabetes (T2D) is a leading cause of premature morbidity and mortality globally and affects more than 100 million people in the world's most populous country, India. Nutrition is a critical and evidence-based component of effective blood glucose control and most dietary advice emphasizes carbohydrate and calorie reduction. Emerging global evidence demonstrates marked interindividual differences in postprandial glucose response (PPGR) although no such data exists in India and previous studies have primarily evaluated PPGR variation in individuals without diabetes.

OBJECTIVE

This prospective cohort study seeks to characterize the PPGR variability among individuals with diabetes living in India and to identify factors associated with these differences.

METHODS

Adults with T2D and a hemoglobin A1c of ≥7 are being enrolled from 14 sites around India. Participants wear a continuous glucose monitor, eat a series of standardized meals, and record all free-living foods, activities, and medication use for a 14-day period. The study's primary outcome is PPGR, calculated as the incremental area under the curve 2 hours after each logged meal.

RESULTS

Data collection commenced in May 2022, and the results will be ready for publication by September 2025. Results from our study will generate data to facilitate the creation of machine learning models to predict individual PPGR responses and to facilitate the prescription of personalized diets for individuals with T2D.

CONCLUSIONS

This study will provide the first large scale examination variability in blood glucose responses to food in India and will be among the first to estimate PPGR variability for individuals with T2D in any jurisdiction.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2022/02/040619; https://tinyurl.com/mrywf6bf.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59308.

Mathematical model for understanding the relationship between diabetes and novel coronavirus

A new model is proposed to explore interactions between diabetes and novel coronavirus. The model accounted for both the omicron variant and variants varying from omicron. The model investigated compartments such as hospitalization, diabetes, co-infection, omicron variant, and quarantine. Additionally, the impact of different vaccination doses is assessed. Sensitivity analysis is carried out to determine disease prevalence and control options, emphasizing the significance of knowing epidemics and their characteristics. The model is validated using actual data from Japan. The parameters are fitted with the help of "Least Square Curve Fitting" method to describe the dynamic behavior of the proposed model. Simulation results and theoretical findings demonstrate the dynamic behavior of novel coronavirus and diabetes mellitus (DM). Biological illustrations that illustrate impact of model parameters are evaluated. Furthermore, effect of vaccine efficacy and vaccination rates for the vaccine's first, second, and booster doses is conducted. The impact of various preventive measures, such as hospitalization rate, quarantine or self-isolation rate, vaccine dose-1, dose-2, and booster dose, is considered for diabetic individuals in contact with symptomatic or asymptomatic COVID-19 infectious people in the proposed model. The findings demonstrate the significance of vaccine doses on people with diabetes and individuals infectious with omicron variant. The proposed work helps with subsequent prevention efforts and the design of a vaccination policy to mitigate the effect of the novel coronavirus.

Risk factors for the mortality of hemodialysis patients with COVID-19 in northern Hunan province, China

PURPOSE

Exploring the risk factors for mortality of hemodialysis patients undergoing COVID-19 and the changes in mortality before and after the opening of the epidemic in northern Hunan province, China.

METHODS

We analyzed 230 hemodialysis patients with COVID-19 in the Yiyang Central Hospital from November 01, 2022 to February 28, 2023. Demographic data, laboratory data and public diseases were collected. Cox regression analysis was used to identify risk factors and independent predictors of mortality. The receiver operating characteristic (ROC) curve was used to determine the diagnostic value of risk factors in hemodialysis COVID-19 patients.

RESULTS

The average duration of the disease was 12.53 days. The mortality rate in our cohort was 28.70%. Independent predictors of mortality in our cohort were: age (hazard ratio [HR] 1.09; 95% confidence interval [CI], 1.05-1.14; P < 0.001), elevated procalcitonin (PCT) levels (HR 1.02; 95%CI, 1.01-1.03; P < 0.001), and higher white blood cell-neutrophil ratio (NWR) (HR 1.04; 95%CI, 1.04-1.07; P = 0.004). Areas under the ROC curve (AUC) for age, NWR, PCT, age*NWR were 0.70 (95%CI: 0.62-0.77), 0.82 (95%CI: 0.75-0.90), 0.64 (95%CI: 0.55-0.73), and 0.89 (0.85,0.94).

CONCLUSION

We discovered that old age, high levels of NWR and PCT might be predictors of mortality, reported the causes and prognostic predictors of mortality in hemodialysis populations with COVID-19 from northern Hunan, China.

Clinical Profile and Outcomes of COVID-19 Positive Patients with Chronic Obstructive Pulmonary Disease (COPD) in a Tertiary Government COVID-19 Referral Center

Introduction

It is anticipated that Chronic Obstructive Pulmonary Disease (COPD) has greater risk in acquiring COVID-19 infection and poorer outcome. However, current worldwide data are conflicting.

Objectives

This study primarily aims to compare the outcomes of COVID-19 patients with COPD and those without COPD in terms of length of hospital stay (LOS), recovery or mortality, treatment received, and predictors of mortality.

Methods

This is a retrospective cohort chart review of 1,017 admitted adult COVID-19 patients from July to December 2020. Age, gender, smoking status, current control and medications for COPD, COVID-19 severity, symptoms, treatment, and outcomes of the two study groups were compared.

Results

Prevalence rate of COPD was 3.8%. COVID-19 patients with COPD were older (median age of 69 vs 54, p<0.001), male (87% vs 50%, p<0.001), hypertensive (72% vs 48%, p=0.004), and with tuberculosis (31% vs 11%, p=0.002). COVID-19 patients with COPD more commonly needed oxygen therapy, High Flow Nasal Cannula, Mechanical Ventilation, Tocilizumab, Convalescent Plasma Therapy and Dexamethasone, and had longer LOS. Significant risk factors for mortality are malignancy, investigational therapies, smoking, and older age. There was no difference in survival rates between the two groups.

Conclusion

COPD increases the risk for severe COVID-19 and lengthens LOS.

Cardiometabolic Health Intervention Using Music and Exercise (CHIME) Delivered via Telehealth to Wheelchair Users: Protocol for a Randomized Controlled Trial

BACKGROUND

Wheelchair users live predominantly sedentary lifestyles and have a substantially higher risk for cardiometabolic disease and mortality compared to people without disabilities. Exercise training has been found to be effective in improving cardiometabolic health (CMH) outcomes among people without disabilities, but research on wheelchair users is limited and of poor quality.

OBJECTIVE

The primary aim of this study is to examine the immediate and sustained effects of a 24-week, telehealth, movement-to-music cardiovascular (M2M-C) exercise program on core indicators of CMH among adult wheelchair users compared to an active control group. The secondary aim is to explore the beneficial effects of M2M-C exercises on cardiovascular capacity, physical activity, and quality of life. Intervention components include tailored exercises and remote performance monitoring, delivered via live videoconference training by a telecoach and asynchronous videos.

METHODS

This study's design is a parallel-arm randomized controlled trial enrolling 132 physically inactive adult wheelchair users with poor cardiometabolic profiles. The M2M-C intervention group involves 24 weeks of virtual live and monitored home exercise training (3×/wk, 15-40 min/session), followed by a 12-week maintenance period where participants have access to an online media library of exercise videos. The control group involves 36 weeks of self-guided exercise through access to a media library of exercise videos, including videos for range of motion, muscle strength, and balance. The primary outcomes are cardiometabolic indicators of health, and assessors are blinded.

RESULTS

Recruitment procedures started in January 2024 with the first participant enrolled on March 18, 2024. All data are anticipated to be collected by November 2027, and the main results of the trial are anticipated to be published by February 2028. Secondary analyses of data will be subsequently published. A total of 16 participants have been recruited as of paper submission.

CONCLUSIONS

The knowledge obtained from this trial will provide evidence to inform exercise prescriptions aimed at improving CMH among adult wheelchair users.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05606432; https://clinicaltrials.gov/study/NCT05606432.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57423.

Association between nursing workload and staff size with the occurrence of adverse events and deaths of patients with COVID-19: A retrospective cohort study

BACKGROUND

The safety of patients in the intensive care unit (ICU) is significantly impacted by inadequate staffing of nursing professionals to meet the demand for care of critically ill patients. COVID-19 patients increased nurses' workload, particularly in high-intensity care settings like the ICU.

AIM

To evaluate the association of workload and number of patients per nursing professional with the occurrence of adverse events and death in critically ill patients with COVID-19 in the ICU.

STUDY DESIGN

This is a retrospective cohort study. This study analysed patients with COVID-19, aged 12 years or older, admitted between 1 April 2020 and 31 May 2021 in the ICU of a hospital in Brazil. Nursing workload was measured by the Nursing Activities Score (NAS). The independent variables were the ratio of the NAS score per nursing professional (NNR) and the ratio of the number of patients per nursing professional (PNR). Dependent variables included adverse events (pressure injuries and health care-associated infections-HAIs) and death in the ICU.

RESULTS

Of the 386 included patients, 59.59% were male and the median age was 60.5 years. The median NAS, NNR and PNR values were 72.81%, 128% and 1.64, respectively. The frequency of pressure injuries (31.09%) exceeded that of HAIs (16.06%), and 218 patients (56.48%) died. The NNR was associated with HAIs (OR 1.006; CI95% 1.001-1.012; p = .012), pressure injury (OR 1.005; CI95% 1.000-1.010; p = .033) and death (OR 1.010; CI95% 1.005-1.015; p < .001) in the ICU. There was no association between PNR values and the study's dependent variables.

CONCLUSION

A high workload per nursing professional was associated with the occurrence of adverse events and deaths of patients with COVID-19 in the ICU, while the nursing staff sizing was not.

RELEVANCE TO CLINICAL PRACTICE

The results reinforce the importance of evaluating the workload of nursing professionals to establish safety measures for the care of patients with infectious diseases.

Comparative efficacy and safety of sitagliptin or gliclazide combined with metformin in treatment-naive patients with type 2 diabetes: A single-center, prospective, randomized, controlled, noninferiority study with genetic polymorphism analysis

BACKGROUND

This study evaluates the efficacy and safety of sitagliptin versus gliclazide, combined with metformin, in treatment-naive patients with type 2 diabetes mellitus (T2DM) and glucotoxicity.

METHODS

In this single-center, randomized, controlled noninferiority trial, 129 treatment-naive patients with T2DM with glucotoxicity (fasting plasma glucose [FPG] ≥ 200 mg/dL and glycated hemoglobin ≥ 9.0%) were randomized to receive sitagliptin plus metformin (n = 66) or gliclazide plus metformin (n = 63) for 12 weeks. Sitagliptin and gliclazide were given for the first 4 weeks, followed by metformin monotherapy for 8 weeks. Efficacy end points included changes in glycemic control, body weight, and β-cell function at baseline, 4 weeks, and 12 weeks.

RESULTS

After 12 weeks, mean glycated hemoglobin reductions were 4.03% in the sitagliptin group and 4.13% in the gliclazide group, with a mean difference of -0.097 (95% confidence interval, -0.648 to 0.453), confirming noninferiority. Both groups showed significant FPG reductions at 4 weeks (P < .05). The sitagliptin group achieved faster glycemic targets, greater FPG and body weight reductions, and higher rates of FPG < 6.1 mmol/L (26.2% vs 5.7%; P = .012). No significant differences were observed in β-cell function or hypoglycemia incidence (P > .05). Genetic analysis showed specific single-nucleotide polymorphisms affected drug efficacy: dipeptidyl peptidase-4 rs2909451 TT and rs4664443 GG genotypes showed lower efficacy with sitagliptin, while GLP1R rs3765467 AG and KCNJ11 rs2285676 CC genotypes responded better to sitagliptin.

CONCLUSION

Sitagliptin combined with metformin is noninferior to gliclazide combined with metformin in treatment-naive patients with T2DM with glucotoxicity. Genetic polymorphisms significantly affect drug efficacy, highlighting the importance of personalized medicine. The sitagliptin group achieved glycemic targets more quickly and had greater weight reductions without increased adverse effects.

Knowledge, Awareness, and Influence of the COVID-19 Pandemic on Students of Biomedical Faculties: A Cross-Sectional Study

Background/Objectives: The COVID-19 pandemic has had a profound impact on physical, mental, and social aspects of life worldwide. This study aimed to explore and compare differences in knowledge, awareness, behavior, and the psychological impact of the pandemic among students of biomedical faculties at the University of Zagreb. Methods: A cross-sectional study was conducted between 27 November 2020 and 19 January 2021 involving 518 students from the School of Dental Medicine, School of Medicine, Faculty of Pharmacy and Biochemistry, and Faculty of Veterinary Medicine. An anonymous online questionnaire was distributed, assessing participants' knowledge about SARS-CoV-2, information sources, attitudes, and psychological responses. Data were analyzed using descriptive statistics and appropriate statistical tests. Results: The median knowledge score was 61.54%, with senior and female students demonstrating significantly more knowledge (p < 0.001 and p = 0.044, respectively). Students who consulted the scientific literature and official websites had higher knowledge levels (p < 0.001). Most participants used media and social networks for pandemic information, while scientific sources were underutilized. Psychological impacts were evident, with 46.3% expressing fear about the future and 25% reporting anxiety if they were to be infected. Additionally, those who engaged with the scientific literature were more likely to accept vaccination and showed lower levels of COVID-19 stigma. A majority (64.5%) believed that the media exaggerated the pandemic's risks. Conclusions: Biomedical students demonstrated moderate knowledge about COVID-19, with a clear link between scientific literacy and more informed, less stigmatizing attitudes. This study underscores the importance of reliable information sources in shaping public health awareness and highlights the need for further education on COVID-19 symptoms and preventive measures.

Antidiabetic agent use and clinical outcomes in patients with diabetes hospitalized for COVID-19: a systematic review and meta-analysis

Background

The effect of antidiabetic agents on mortality outcomes is unclear for individuals with diabetes mellitus (DM) who are hospitalized for COVID-19.

Purpose

To examine the relationship between antidiabetic agent use and clinical outcomes in individuals with DM hospitalized for COVID-19.

Methods

A systematic review of the literature (2020-2024) was performed across five databases. Included articles reported primary research (English) reporting clinical outcomes of adult patients (≥18 yrs.) with DM receiving antidiabetic agents who were hospitalized for COVID-19. Following PRISMA guidelines articles underwent independent dual review. Quality appraisal was completed for included studies. Independent reviewers used a structured data extraction form to retrieve relevant data. Aggregated data were synthesized by treatment regimen and reported descriptively. Random effects meta-analyses were performed to assess relative risk and prevalence of mortality.

Results

After removing duplicates, title and abstract screening of 4,898 articles identified 118 articles for full-text review and 35 articles were retained for analysis. Included articles were primarily from China (15/35, 43%) and retrospective in nature (31/35, 89%). Fourteen studies (40%) assessed multiple antidiabetic agents, fifteen studies (42%) focused on metformin, three studies (9%) assessed the use of DPP-4 inhibitors, and three single studies (9%) investigated the use of insulin, TZD, and SGLT2 inhibitors. Despite differences among studies, the overall relative risk of mortality among metformin and DPP-4 inhibitor users was 0.432 (95% CI = 0.268-0.695, z = 3.45, p < 0.001) and the overall prevalence of mortality among all antidiabetic users was 16% (95% CI = 13%-19%, z = 10.70, p < 0.001).

Conclusions and implications

Synthesis of findings suggest that patients who remained on oral agents (with/without supplemental insulin therapy) exhibited decreased mortality and lower inflammatory markers. Results indicate that individuals with DM should continue oral antidiabetic agents with additional basal insulin as needed to improve glycemic control and reduce mortality. Further work is needed to uncover mechanism(s) and clarify medical management approaches.

Τhiazolidine-4-One Derivatives with Variable Modes of Inhibitory Action Against DPP4, a Drug Target with Multiple Activities and Established Role in Diabetes Mellitus Type II

Background/Objectives: DPP4 is an enzyme with multiple natural substrates and probable involvement in various mechanisms. It constitutes a drug target for the treatment of diabetes II, although, also related to other disorders. While a number of drugs with competitive inhibitory action and covalent binding capacity are available, undesired side effects exist partly attributed to drug kinetics, and research for finding novel, potent, and safer compounds continues. Despite the research, a low number of uncompetitive and non-competitive inhibitors, which could be of worth for pharmaceutical and mechanism studies, was mentioned. Methods: In the present study sixteen 3-(benzo[d]thiazol-2-yl)-2-aryl thiazolidin-4-ones were selected for evaluation, based on structural characteristics and docking analysis and were tested in vitro for DPP4 inhibitory action using H-Gly-Pro-amidomethyl coumarin substrate. Their mode of inhibition was also in vitro explored. Results: Twelve compounds exhibited IC50 values at the nM range with the best showing IC50 = 12 ± 0.5 nM, better than sitagliptin. Most compounds exhibited a competitive mode of inhibition. Inhibition modes of uncompetitive, non-competitive, and mixed type were also identified. Docking analysis was in accordance with the in vitro results, with a linear correlation of logIC50 with a Probability of Binding Factor(PF) derived using docking analysis to a specific target box and to the whole enzyme. According to the docking results, two probable sites of binding for uncompetitive inhibitors were highlighted in the wider area of the active site and in the propeller loop. Conclusions: Potent inhibitors with IC50 at the nM range and competitive, non-competitive, uncompetitive, and mixed modes of action, one better than sitagliptin, were found. Docking analysis was used to estimate probable sites and ways of binding. However, crystallographic or NMR studies are needed to elucidate the exact way of binding especially for uncompetitive and non-competitive inhibitors.

A Vaccine Against Fibroblast Activation Protein Improves Murine Cardiac Fibrosis by Preventing the Accumulation of Myofibroblasts

BACKGROUND

Myofibroblasts are primary cells involved in chronic response-induced cardiac fibrosis. Fibroblast activation protein (FAP) is a relatively specific marker of activated myofibroblasts and a potential target molecule. This study aimed to clarify whether a vaccine targeting FAP could eliminate myofibroblasts in chronic cardiac stress model mice and reduce cardiac fibrosis.

METHODS

We coadministered a FAP peptide vaccine with a cytosine-phosphate-guanine (CpG) K3 oligonucleotide adjuvant to male C57/BL6J mice and confirmed an elevation in the anti-FAP antibody titer. After continuous angiotensin II and phenylephrine administration for 28 days, we evaluated the degree of cardiac fibrosis and the number of myofibroblasts in cardiac tissues.

RESULTS

We found that cardiac fibrosis was significantly decreased in the FAP-vaccinated mice compared with the angiotensin II and phenylephrine control mice (3.45±1.11% versus 8.62±4.79%; P=4.59×10-3) and that the accumulation of FAP-positive cells was also significantly decreased, as indicated by FAP immunohistochemical staining (4077±1746 versus 7327±1741 cells/mm2; FAP vaccine versus angiotensin II and phenylephrine control; P=6.67×10-3). No systemic or organ-specific inflammation due to antibody-dependent cell cytotoxicity induced by the FAP vaccine was observed. Although the transient activation of myofibroblasts has an important role in maintaining the structural robustness in the process of tissue repair, the FAP vaccine showed no adverse effects in myocardial infarction and skin injury models.

CONCLUSIONS

Our study demonstrates the FAP vaccine can be a therapeutic tool for cardiac fibrosis.

Polypharmacy or potentially inappropriate medications among older adults with COVID-19 in a secondary hospital in China and their association with mortality

Elderly patients with multiple concomitant chronic diseases are the particularly vulnerable during the Coronavirus disease 2019 (COVID-19) epidemic, which accounts for a large number of COVID-19-related deaths. The purpose of the study was to investigate the impact of polypharmacy and potentially inappropriate medications (PIMs) on in-hospital mortality in a secondary hospital in China. A cross-sectional, retrospective study was conducted using electronic medical data collected from Shanghai Gonghui Hospital from April 2022 to June 2022. Two types of PIMs were adopted, involving the evaluation of the PIM status of older patients with COVID-19 (age ≥ 60 years) identified by AGS/Beers Criteria (PIM-Beers) and the PIM related to Covid-19 antiviral NMV/r (Nirmatrelvir/ritonavir) (PIM-NMV/r). Multivariate logistic regression was used to identify the risk factors associated with PIM use and in-hospital mortality. A total of 617 older COVID-19 inpatients were included in the study. The prevalence of polypharmacy and excessive polypharmacy were 24.6% and 19.1%, respectively. The prevalence of PIMs, PIM-Beers, and PIM-NMV/r were 25.8%, 22.5%, and 60.8%, respectively. Multivariate regression demonstrated that male (OR: 0.57 [95% CI: 0.33-0.98], p = 0.044), diabetes (OR: 2.05 [95% CI: 1.11-3.80], p = 0.023), the more number of medications (OR: 1.44 [95% CI: 1.20-1.72], p < 0.001) and given NMV/r (OR: 3.67 [95% CI: 1.48-9.10], p = 0.005) were influencing factors associated with PIM use. A multivariate logistic regression demonstrated that severe COVID-19 (OR: 6.56 [95% CI: 1.13-38.03], p = 0.036), polypharmacy (OR: 15.43 [95% CI: 3.20-74.29], p = 0.001), excessive polypharmacy (OR: 51.09 [95% CI: 5.23-499.52], p = 0.001), and long-term hospitalization (OR: 0.08 [95% CI: 0.02-0.32], p < 0.001) were influencing factors associated with in-hospital mortality in older COVID-19 inpatients. The polypharmacy and drug-drug interactions of NMV/r were observed in many older COVID-19 inpatients. Older patients with severe COVID-19, a higher number of medications and long-term hospitalization had a higher in-hospital mortality. This result highlights the importance of conducting clinical pharmacists-led medication reviews to identify PIMs of NMV/r and collaboratively working with the physicians to ensure medication appropriateness.