Diabetes prevalence and mortality in COVID-19 patients: a systematic review, meta-analysis, and meta-regression

Real-world effectiveness of azvudine versus nirmatrelvir-ritonavir in hospitalized patients with COVID-19 and pre-existing diabetes

Azvudine and nirmatrelvir-ritonavir are prioritized treatments for SARS-CoV-2 infection in China, but their effectiveness and safety in hospitalized patients with COVID-19 and pre-existing diabetes remains unknown. In this retrospective cohort study, we collected 32,864 hospitalized COVID-19 patients from nine hospitals, among which 636 azvudine recipients and 318 nirmatrelvir-ritonavir recipients were enrolled for final analysis after exclusion and propensity score matching. Kaplan-Meier and multivariate Cox regression analysis results showed that azvudine had a lower risk of all-cause death compared with nirmatrelvir-ritonavir for the treatment of patients with COVID-19 and pre-existing diabetes (log rank: p = 0.044; HR: 0.63; 95% CI: 0.431-0.934). No significant difference was found in composite disease progression between the two groups. Five sensitivity analyses verified the robustness of the results. Overall, azvudine may be comparable to nirmatrelvir-ritonavir in terms of both all-cause death and composite disease progression among hospitalized patients with COVID-19 and pre-existing diabetes, with acceptable adverse events.

Mitochondrial oxidative stress, mitochondrial ROS storms in long COVID pathogenesis

Significance

This review discusses the coronavirus disease 2019 (COVID-19) pathophysiology in the context of diabetes and intracellular reactions by COVID-19, including mitochondrial oxidative stress storms, mitochondrial ROS storms, and long COVID.

Recent advances

The long COVID is suffered in ~10% of the COVID-19 patients. Even the virus does not exist, the patients suffer the long COVID for even over a year, This disease could be a mitochondria dysregulation disease.

Critical issues

Patients who recover from COVID-19 can develop new or persistent symptoms of multi-organ complications lasting weeks or months, called long COVID. The underlying mechanisms involved in the long COVID is still unclear. Once the symptoms of long COVID persist, they cause significant damage, leading to numerous, persistent symptoms.

Future directions

A comprehensive map of the stages and pathogenetic mechanisms related to long COVID and effective drugs to treat and prevent it are required, which will aid the development of future long COVID treatments and symptom relief.

Long-term effects of coronavirus disease 2019 on diabetes complications and mortality in people with diabetes: Two cohorts in the UK and Hong Kong

AIM

To evaluate the long-term associations between coronavirus disease 2019 (COVID-19) and diabetes complications and mortality, in patients with diabetes.

MATERIALS AND METHODS

People with diabetes diagnosed with COVID-19 infection (exposed group), from 16 March 2020 to 31 May 2021 from the UK Biobank (UKB cohort; n = 2456), and from 1 April 2020 to 31 May 2022 from the electronic health records in Hong Kong (HK cohort; n = 80 546), were recruited. Each patient was randomly matched with participants with diabetes but without COVID-19 (unexposed group), based on age and sex (UKB, n = 41 801; HK, n = 391 849). Patients were followed for up to 18 months until 31 August 2021 for UKB, and up to 28 months until 15 August 2022 for HK. Characteristics between cohorts were further adjusted with Inverse Probability Treatment Weighting. Long-term association of COVID-19 with multi-organ disease complications and all-cause mortality after 21 days of diagnosis was evaluated by Cox regression.

RESULTS

Compared with uninfected participants, patients with COVID-19 infection with diabetes were consistently associated with higher risks of cardiovascular diseases (coronary heart disease [CHD]: hazard ratio [HR] [UKB]: 1.6 [95% confidence interval {CI}: 1.0, 2.4], HR [HK]: 1.2 [95% CI: 1.0, 1.5]; and stroke: HR [UKB]: 2.0 [95% CI: 1.1, 3.6], HR [HK]: 1.5 [95% CI: 1.3, 1.8]), microvascular disease (end stage renal disease: HR [UKB]: 2.1 [95% CI: 1.1, 4.0], HR [HK]: 1.2 [95% CI: 1.1, 1.4]) and all-cause mortality (HR [UKB]: 4.6 [95% CI: 3.8, 5.5], HR [HK]: 2.6 [95% CI: 2.5, 2.8]), in both cohorts.

CONCLUSIONS

COVID-19 infection is associated with long-term increased risks of diabetes complications (especially cardiovascular complications, and mortality) in people with diabetes. Monitoring for signs/symptoms of developing these long-term complications post-COVID-19 infection in the infected patient population of people with diabetes may be beneficial in minimizing their morbidity and mortality.

Mechanically ventilated COVID-19 patients admitted to the intensive care unit in the United States with or without respiratory failure secondary to COVID-19 pneumonia: a retrospective comparison of characteristics and outcomes

BACKGROUND

There is increasing heterogeneity in the clinical phenotype of patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19,) and reasons for mechanical ventilation are not limited to COVID pneumonia. We aimed to compare the characteristics and outcomes of intubated patients admitted to the ICU with the primary diagnosis of acute hypoxemic respiratory failure (AHRF) from COVID-19 pneumonia to those patients admitted for an alternative diagnosis.

METHODS

Retrospective cohort study of adults with confirmed SARS-CoV-2 infection admitted to nine ICUs between March 18, 2020, and April 30, 2021, at an urban university institution. We compared characteristics between the two groups using appropriate statistics. We performed logistic regression to identify risk factors for death in the mechanically ventilated COVID-19 population.

RESULTS

After exclusions, the final sample consisted of 319 patients with respiratory failure secondary to COVID pneumonia and 150 patients intubated for alternative diagnoses. The former group had higher ICU and hospital mortality rates (57.7% vs. 36.7%, P<0.001 and 58.9% vs. 39.3%, P<0.001, respectively). Patients with AHRF secondary to COVID-19 pneumonia also had longer ICU and hospital lengths-of-stay (12 vs. 6 days, P<0.001 and 20 vs. 13.5 days, P=0.001). After risk-adjustment, these patients had 2.25 times higher odds of death (95% confidence interval, 1.42-3.56; P=0.001).

CONCLUSIONS

Mechanically ventilated COVID-19 patients admitted to the ICU with COVID-19-associated respiratory failure are at higher risk of hospital death and have worse ICU utilization outcomes than those whose reason for admission is unrelated to COVID pneumonia.

Circulating ACE2 level and zinc/albumin ratio as potential biomarkers for a precision medicine approach to COVID-19

Highly mutable influenza is successfully countered based on individual susceptibility and similar precision-like medicine approach should be effective against SARS-COV-2. Among predictive markers to bring precision medicine to COVID-19, circulating ACE2 has potential features being upregulated in both severe COVID-19 and predisposing comorbidities. Spike SARS-CoVs were shown to induce ADAM17-mediated shedding of enzymatic active ACE2, thus accounting for its increased activity that has also been suggested to induce positive feedback loops leading to COVID-19-like manifestations. For this reason, pre-existing ACE2 activity and inhibition of ACE2/ADAM17 zinc-metalloproteases through zinc chelating agents have been proposed to predict COVID-19 outcome before infection and to protect from COVID-19, respectively. Since most diagnostic laboratories are not equipped for enzymatic activity determination, other potential predictive markers of disease progression exploitable by diagnostic laboratories were explored. Concentrations of circulating albumin, zinc, ACE2 protein and its activity were investigated in healthy, diabetic (COVID-19-susceptible) and SARS-CoV-2-negative COVID-19 individuals. ACE2 both protein levels and activity significantly increased in COVID-19 and diabetic patients. Abnormal high levels of ACE2 characterised a subgroup (16-19%) of diabetics, while COVID-19 patients were characterised by significantly higher zinc/albumin ratios, pointing to a relative increase of albumin-unbound zinc species, such as free zinc ones. Data on circulating ACE2 levels are in line with the hypothesis that they can drive susceptibility to COVID-19 and elevated zinc/albumin ratios support the therapeutic use of zinc chelating inhibitors of ACE2/ADAM17 zinc-metalloproteases in a targeted therapy for COVID-19.

Impact of diabetes on COVID-19 patient health outcomes in a vulnerable racial minority community

BACKGROUND

Diabetes is a growing health concern in the United States and especially New York City. New York City subsequently became an epicenter for the coronavirus pandemic in the Spring of 2020. Previous studies suggest that diabetes is a risk factor for adverse outcomes in COVID-19.

OBJECTIVE

To investigate the association between diabetes and COVID-19 outcomes as well as assess other covariates that may impact health outcomes.

DESIGN

Retrospective cohort study of COVID-19 hospitalized patients from March to May, 2020.

PARTICIPANTS

In total, 1805 patients were tested for COVID-19 and 778 tested positive for COVID-19. Patients were categorized into 2 groups: diabetes (measured by an Hba1c >6.5 or had a history of diabetes) and those without diabetes.

RESULTS

After controlling for other comorbidities, diabetes was associated with increased risk of mortality (aRR = 1.28, 95% CI 1.03-1.57, p = 0.0231) and discharge to tertiary care centers (aRR = 1.69, 95% CI 1.04-2.77, p = 0.036). compared to non-diabetes. Age and coronary artery disease (CAD) increased the risk of mortality among diabetic patients compared to patients with diabetes alone without CAD or advanced age. The diabetes cohort had more patients with resolving acute respiratory failure (62.2%), acute kidney injury secondary to COVID-19 (49.0%) and sepsis secondary to COVID-19 (30.1%).

CONCLUSION

This investigation found that COVID-19 patients with diabetes had increased mortality, multiple complications at discharge, and increased rates of admission to a tertiary care center than those without diabetes suggesting a more severe and complicated disease course that required additional services at time of discharge.

Disease Duration and Chronic Complications Associate With Immune Activation in Individuals With Longstanding Type 1 Diabetes

CONTEXT

Type 1 diabetes (T1D) is associated with alterations of the immune response which persist even after the autoimmunity aspect is resolved. Clinical factors that cause dysregulation, however, are not fully understood.

OBJECTIVE

To identify clinical factors that affect immune dysregulation in people with longstanding T1D.

DESIGN

In this cross-sectional study, 243 participants with longstanding T1D were recruited between February 2016 and June 2017 at the Radboudumc, the Netherlands. Blood was drawn to determine immune cell phenotype and functionality, as well as circulating inflammatory proteome. Multivariate linear regression was used to determine the association between glycated hemoglobin (HbA1c) levels, duration of diabetes, insulin need, and diabetes complications with inflammation.

RESULTS

HbA1c level is positively associated with circulating inflammatory markers (P < .05), but not with immune cell number and phenotype. Diabetes duration is associated with increased number of circulating immune cells (P < .05), inflammatory proteome (P < .05), and negatively associated with adaptive immune response against Mycobacterium tuberculosis and Rhizopus oryzae (P < .05). Diabetes nephropathy is associated with increased circulating immune cells (P < .05) and inflammatory markers (P < .05).

CONCLUSION

Disease duration and chronic complications associate with persistent alterations in the immune response of individuals with long standing T1D.

Improved LSTM-based deep learning model for COVID-19 prediction using optimized approach

Individuals in any country are badly impacted both economically and physically whenever an epidemic of infectious illnesses breaks out. A novel coronavirus strain was responsible for the outbreak of the coronavirus sickness in 2019. Corona Virus Disease 2019 (COVID-19) is the name that the World Health Organization (WHO) officially gave to the pneumonia that was caused by the novel coronavirus on February 11, 2020. The use of models that are informed by machine learning is currently a major focus of study in the field of improved forecasting. By displaying annual trends, forecasting models can be of use in performing impact assessments of potential outcomes. In this paper, proposed forecast models consisting of time series models such as long short-term memory (LSTM), bidirectional long short-term memory (Bi-LSTM), generalized regression unit (GRU), and dense-LSTM have been evaluated for time series prediction of confirmed cases, deaths, and recoveries in 12 major countries that have been affected by COVID-19. Tensorflow1.0 was used for programming. Indices known as mean absolute error (MAE), root means square error (RMSE), Median Absolute Error (MEDAE) and r2 score are utilized in the process of evaluating the performance of models. We presented various ways to time-series forecasting by making use of LSTM models (LSTM, BiLSTM), and we compared these proposed methods to other machine learning models to evaluate the performance of the models. Our study suggests that LSTM based models are among the most advanced models to forecast time series data.

Causal relationship between type 1 diabetes mellitus and six high-frequency infectious diseases: A two-sample mendelian randomization study

Purpose

Type 1 diabetes mellitus (T1DM) is associated with different types of infections; however, studies on the causal relationship between T1DM and infectious diseases are lacking. Therefore, our study aimed to explore the causalities between T1DM and six high-frequency infections using a Mendelian randomization (MR) approach.

Methods

Two-sample MR studies were conducted to explore the causalities between T1DM and six high-frequency infections: sepsis, acute lower respiratory infections (ALRIs), intestinal infections (IIs), infections of the genitourinary tract (GUTIs) in pregnancy, infections of the skin and subcutaneous tissues (SSTIs), and urinary tract infections (UTIs). Data on summary statistics for T1DM and infections were obtained from the European Bioinformatics Institute database, the United Kingdom Biobank, FinnGen biobank, and Medical Research Council Integrative Epidemiology Unit. All data obtained for summary statistics were from European countries. The inverse-variance weighted (IVW) method was employed as the main analysis. Considering the multiple comparisons, statistical significance was set at p< 0.008. If univariate MR analyses found a significant causal association, multivariable MR (MVMR) analyses were performed to adjust body mass index (BMI) and glycated hemoglobin (HbA1c). MVMR-IVW was performed as the primary analysis, and the least absolute shrinkage and selection operator (LASSO) regression and MVMR-Robust were performed as complementary analyses.

Results

MR analysis showed that susceptibility to IIs increased in patients with T1DM by 6.09% using the IVW-fixed method [odds ratio (OR)=1.0609; 95% confidence interval (CI): 1.0281-1.0947, p=0.0002]. Results were still significant after multiple testing. Sensitivity analyses did not show any significant horizontal pleiotropy or heterogeneity. After adjusting for BMI and HbA1c, MVMR-IVW (OR=1.0942; 95% CI: 1.0666-1.1224, p<0.0001) showed significant outcomes that were consistent with those of LASSO regression and MVMR-Robust. However, no significant causal relationship was found between T1DM and sepsis susceptibility, ALRI susceptibility, GUTI susceptibility in pregnancy, SSTI susceptibility, and UTI susceptibility.

Conclusions

Our MR analysis genetically predicted increased susceptibility to IIs in T1DM. However, no causality between T1DM and sepsis, ALRIs, GUTIs in pregnancy, SSTIs, or UTIs was found. Larger epidemiological and metagenomic studies are required to further investigate the observed associations between the susceptibility of certain infectious diseases with T1DM.

Improving outcomes in co-morbid diabetes and COVID-19: A quasi-experimental study

BACKGROUND

High-risk people living with diabetes (PLWD) have increased risk for morbidity and mortality. During the first coronavirus disease 2019 (COVID-19) wave in 2020 in Cape Town, South Africa, high-risk PLWD with COVID-19 were fast-tracked into a field hospital and managed aggressively. This study evaluated the effects of this intervention by assessing the impact of this intervention on clinical outcomes in this cohort.

METHODS

A retrospective quasi-experimental study design compared patients admitted pre- and post-intervention.

RESULTS

A total of 183 participants were enrolled, with the two groups having similar demographic and clinical pre-Covid-19 baselines. Glucose control on admission was better in the experimental group (8.1% vs 9.3% [p = 0.013]). The experimental group needed less oxygen (p  0.001), fewer antibiotics (p  0.001) and fewer steroids (p = 0.003), while the control group had a higher incidence of acute kidney injury during admission (p = 0.046). The median glucose control was better in the experimental group (8.3 vs 10.0; p = 0.006). The two groups had similar clinical outcomes for discharge home (94% vs 89%), escalation in care (2% vs 3%) and inpatient death (4% vs 8%).

CONCLUSION

This study demonstrated that a risk-based approach to high-risk PLWD with COVID-19 may yield good clinical outcomes while making financial savings and preventing emotional distress.Contribution: We propose a risk-based approach to guide clinical management of high risk patients, which departs significantly from the current disease-based model. More research using randomised control trial methodology should explore this hypothesis.

Risks of Severe COVID-19 Outcomes Among Patients With Diabetic Polyneuropathy in the United States

CONTEXT

Diabetic neuropathy (DN) affects more than 50% of diabetic patients who are also likely to have compromised immune system and respiratory function, both of which can make them susceptible to the SARS-CoV-2 virus.

OBJECTIVE

To assess the risk of severe COVID-19 illness among adults with DN, compared with those with no DN and those with no diabetes.

SETTING

The analysis utilized electronic health records from 55 US health care organizations in the TriNetX research database.

DESIGN

A retrospective cohort study.

PARTICIPANTS

The analysis included 882 650 adults diagnosed with COVID-19 in January 2020 to June 2021, including 16 641 with DN, 81 329 with diabetes with no neuropathy, and 784 680 with no diabetes.

OUTCOME MEASURES

The presence of health care utilization (admissions to emergency department, hospital, intensive care unit), 30-day mortality, clinical presentation (cough, fever, hypoxemia, dyspnea, or acute respiratory distress syndrome), and diagnostic test results after being infected affected by COVID-19.

RESULTS

The DN cohort was 1.19 to 2.47 times more likely than the non-DN cohorts to utilize care resources, receive critical care, and have higher 30-day mortality rates. Patients with DN also showed increased risk (1.13-2.18 times) of severe symptoms, such as hypoxemia, dyspnea, and acute respiratory distress syndrome.

CONCLUSIONS

Patients with DN had a significantly greater risk of developing severe COVID-19-related complications than those with no DN. It is critical for the public health community to continue preventive measures, such as social distancing, wearing masks, and vaccination, to reduce infection rates, particularly in higher risk groups, such as those with DN.

Quality of systematic reviews of COVID-19 in people with diabetes: A systematic review

OBJECTIVE

To investigate the methodological quality of published systematic reviews of factors associated with COVID-19 in people with diabetes.

METHOD

Systematic review with registration protocol in PROSPERO, under the number CRD42020222418. Searches were carried out from October to November 2020 in the databases of the MedLine, Web of Science, Scopus, Lilacs, Embase and Cochrane libraries, in addition to searching the reference list of the selected studies. Systematic review studies with or without meta-analysis and without date and language restrictions were included. Data were extracted in a standardized way and the quality of the studies was assessed using the Assessment of Multiple Systematic Reviews scale.

RESULTS

Twelve reviews, published between 2020 and 2021, with a predominance of the English language, systematic reviews of observational studies with meta-analysis with a sample ranging from six to 83 studies, were included. Regarding financing, most of the study reported did not receive this type of support. Regarding to the assessment of the methodological quality of the studies, three were of moderate quality, five were classified as low quality and three with critically low quality.

CONCLUSIONS

The analyzed articles presented a bias in the preparation of reports on their studies, suggesting the need to use mechanisms to improve adherence to the established reporting guidelines and methodological evaluation tools.

[Quality of systematic reviews of COVID-19 in people with diabetes: A systematic review]

Objective

To investigate the methodological quality of published systematic reviews of factors associated with COVID-19 in people with diabetes.

Method

Systematic review with registration protocol in PROSPERO, under the number CRD42020222418. Searches were carried out from October to November 2020 in the databases of the Medline, Web of Science, Scopus, LILACS, Embase and Cochrane Library, in addition to searching the reference list of the selected studies. Systematic review studies with or without meta-analysis and without date and language restrictions were included. Data were extracted in a standardized way and the quality of the studies was assessed using the Assessment of Multiple Systematic Reviews scale.

Results

Twelve reviews, published between 2020 and 2021, with a predominance of the English language, systematic reviews of observational studies with meta-analysis with a sample ranging from 6 to 83 studies, were included. Regarding financing, most of the study reported did not receive this type of support. Regarding to the assessment of the methodological quality of the studies, 3 were of moderate quality, 5 were classified as low quality and 3 with critically low quality.

Conclusions

The analyzed articles presented a bias in the preparation of reports on their studies, suggesting the need to use mechanisms to improve adherence to the established reporting guidelines and methodological evaluation tools.

Joint Effect of Diabetes Mellitus and Hypertension on COVID-19 in-Hospital Mortality Stratified by Age Group and Other Comorbidities: A Cohort Retrospective Study Using Hospital-Based Data in Sleman, Yogyakarta

The joint effect of diabetes mellitus and hypertension on COVID-19 has rarely been evaluated but had potential as a major risk factor. This study aims to investigate the joint effect between diabetes mellitus and hypertension on in-hospital mortality among COVID-19 patients in Yogyakarta stratified by age groups and other comorbidities status. Methods: This cohort retrospective study collected data from two major hospitals in the Sleman district and a total of 2779 hospitalized COVID-19 patients were included in this study. The study outcome was COVID-19 in-hospital mortality (deceased or discharged alive) and the main risk factors were diabetes mellitus (DM) and hypertension (HT). The multiple logistic regression model was utilized to estimate adjusted odds ratio (AOR) and calculate the joint effect. Results: COVID-19 patients who have both DM and hypertension were three times (AOR: 3.21; 95% CI: 2.45-4.19) more likely to have in-hospital mortality than those without both comorbidities. The highest risk of in-hospital mortality was found in COVID-19 patients without other comorbidities (other than DM and HT) and younger age (age 0-40 years), with AOR equal to 22.40 (95% CI: 6.61-75.99). Conclusions: This study identified a joint effect between diabetes mellitus and hypertension which increases the risk of in-hospital mortality among COVID-19 patients. Targeted public health, clinical, and health education intervention should be carried out on individuals with diabetes mellitus and/or hypertension.

Insulin use in type II diabetic patients: a predictive of mortality in covid-19 infection

INTRODUCTION

Starting December 2019, the world has been devastated by the rapid spread of coronavirus disease 2019 (Covid-19). Many risk factors have been associated with worse outcomes and death from Covid-19 pneumonia including having diabetes mellitus. To date, it is not clear if all group of diabetics share the same risk of complications with COVID-19 infection. This study aims to compare disease severity and mortality rate in insulin users versus non-insulin users.

METHODS

In this retrospective case-control study conducted at the largest health care network in New York state, we included adult, diabetic patients admitted from March 2020 to October 2020 with Covid-19 pneumonia. We compared the baseline characteristics in addition to outcomes of diabetic patients on home insulin (cases) and non-insulin user diabetics (controls). In addition, to determine if home insulin use is associated with an increased mortality, we conducted a cox regression analysis.

RESULTS

We included 696 patients in the study period with a median age of 57 years, interquartile range [IQR] 51-62, and median body mass index 29.9 (IQR: 26-34.7). The majority (476 [68%]) were males. We identified 227 cases (33%) and 469 controls (67%). More cases than controls were hypertensive (74% vs 67%, p = 0.03), on ACE/ARB (50% vs 42%, p = 0.05), and had a hemoglobin A1c > 8.1 (71% vs 44%, p < 0.001). More cases had AKI (52% vs 38%, p < 0.001), however no significant differences were found in intubation rates (26% vs 24%, p = 0.54), detection of pulmonary embolism (4% vs 6%, p = 0.19) or death rate (15% vs 11%, p = 0.22) comparing cases and controls. In a multivariate analysis, we found that home insulin use was independently associated with increased risk of death: Hazard ratio: 1.92, 95% confidence interval (1.13-3.23).

CONCLUSION

We showed herein that diabetic patients on home insulin with COVID-19 pneumonia, have worse outcomes and increased mortality compared to diabetics on oral antihyperglycemic agents. Close monitoring of insulin-dependent type II diabetic patients is needed in the current pandemic.

Death and invasive mechanical ventilation risk in hospitalized COVID-19 patients treated with anti-SARS-CoV-2 monoclonal antibodies and/or antiviral agents: A systematic review and network meta-analysis protocol

BACKGROUND

The ongoing COVID-19 pandemic has claimed >4 million lives globally, and these deaths often occurred in hospitalized patients with comorbidities. Therefore, the proposed review aims to distinguish the inpatient mortality and invasive mechanical ventilation risk in COVID-19 patients treated with the anti-SARS-CoV-2 monoclonal antibodies and/or the antiviral agents.

METHODS

A search in PubMed, Embase, and Scopus will ensue for the publications on randomized controlled trials testing the above, irrespective of the publication date or geographic boundary. Risk of bias assessment of the studies included in the review will occur using the Cochrane risk of bias tool for randomized trials (RoB 2). Frequentist method network meta-analyses (NMA) will compare each outcome's risk across both types of anti-SARS-CoV-2 agents in one model and each in separate models. Additional NMA models will compare these in COVID-19 patients who were severely or critically ill, immunocompromised, admitted to the intensive care unit, diagnosed by nucleic acid amplification test, not treated with steroids, <18 years old, and at risk of infection due to variants of concern. The plan of excluding non-hospitalized patients from the proposed review is to minimize intransitivity risk. The acceptance of the network consistency assumption will transpire if the local and overall inconsistency assessment indicates no inconsistency. For each NMA model, the effect sizes (risk ratio) and their 95% confidence intervals will get reported in league tables. The best intervention prediction and quality of evidence grading will happen using the surface under the cumulative ranking curve values and the Grading of Recommendations Assessment, Development and Evaluation-based Confidence in Network Meta-Analysis approach, respectively. Sensitivity analysis will repeat the preliminary NMA while excluding the trials at high risk of bias. The Stata statistical software (v16) will be used for analysis. The statistical significance will get determined at p<0.05 and 95% confidence interval.

TRIAL REGISTRATION

PROSPERO Registration No: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021277663.

Mortality related to COVID-19 in patients with rheumatic and musculoskeletal diseases, first wave of the outbreak: a single-center study

Objectives

The aim of this study was to assess the cause-specific mortality rate related to COVID-19 (CMR) in patients with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 and to analyze the role of the different RMDs in their mortality risk.

Methods

An observational longitudinal study was conducted during the first pandemic wave in our center. Patients with the diagnosis of RMDs and COVID-19 were included. Main outcome is the death related to COVID-19. Independent variable - type of RMDs: autoimmune rheumatic diseases (ARD), such as chronic inflammatory arthritis (CIA) and connective tissue diseases (CTD) and non-autoimmune Rheumatic Diseases (non-ARD). Survival techniques were used to estimate the CMR per 1000 patients-month with a 95% confidence interval (CI), and Cox multivariate regression analysis was run to examine the effect of ARD compared to non-ARD on mortality risk adjusted by confounders. Results were expressed by Hazard Ratio (HR) and CI.

Results

Overall, 405 patients were included (642.5 patients-month). During the study period, 44 (10.86%) deaths were recorded. CMR was 68.48 (50.96-92.01). After adjusting for confounders, HR of mortality in ARD compared to non-ARD did not achieve statistical significance [HR: 1.15 (0.64-2.07)], neither CTD versus CIA nor CTD versus non-ARD. Age and certain comorbidities which are being diagnosed in March compared to April or May [HR: 2.43 (1.1-5.55)] increased the mortality risk. Glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) dropped from the final model.

Conclusion

In patients with RMDs and COVID-19, CMR was 6.8% patients-month. This study shows that mortality risk is higher in males, older patients, and similar between CTD, CIA, and non-ARD. COVID-19 management improved after the first month of pandemic.

Plain Language Summaries

Mortality related to the outbreak of COVID-19 in patients with rheumatic and musculoskeletal diseases Why was this study done? - To report the COVID-19-specific mortality rate in patients with a variety of RMDs during the first pandemic peak in a tertiary hospital in Madrid and to analyze the role of specific types of ARD and other possible factors in the risk of death related to COVID-19. What did the researchers do? - We performed a retrospective observational study during the first wave of the COVID-19 pandemic in Madrid, Spain. What did the researchers find? - In this study, neither the different diagnoses of RMDs, including CIA, CTD, or non-ARD disease or its treatment were not implicated as a potential risk of death related to COVID-19- In consonance with other studies, RMDs patients and COVID-19, older age, male sex, and certain comorbidities implied more mortality risk- Our data reflect COVID-19 severity in a particular context, time, and population. In times of the absence of COVID-19 vaccine, healthcare, social, and political measures taken to contain the coronavirus outbreak have worked properly. What do the findings mean? - The presence of comorbidities in RMDs patients represents a greater risk than the different types of RMDs themselves, in the development of COVID-19 fatal outcome. It is important to integrate the control of comorbidities in the daily management.

Clinical and Laboratory Features in the Israeli Population with COVID-19 Infection after Pfizer-BioNTech mRNA Booster Vaccination

Background: Immune protection following either vaccination or infection with SARS-CoV-2 decreases over time. Objective: We aim to describe clinical and sociodemographic characteristics associated with COVID-19 infection at least 14 days after booster vaccination in the Israeli population. Methods: We conducted a population-based study among adult members of Leumit Health Services (LHS) in Israel. Nasopharyngeal swabs were examined for SARS-CoV-2 by real-time RT-PCR. The hematological and biochemical parameters in the peripheral blood before booster vaccination were evaluated. Results: Between 1 February 2021 and 30 November 2021, 136,683 individuals in LHS were vaccinated with a booster (third dose) of the BNT162b2 vaccine. Of these, 1171 (0.9%) were diagnosed with COVID-19 by testing positive for SARS-CoV-2 RT-PCR at least >14 days after the booster vaccination. The COVID-19-positive group was characterized by higher rates of chronic kidney disease than the matched COVID-19-negative group (43 (3.7%) vs. 3646 (2.7%); p = 0.039). Anemia, lower peripheral blood lymphocytes, monocytes, basophils, C3 Complement, cholesterol, and prothrombin time were also associated with COVID-19 after booster vaccination. Conclusion: People with chronic kidney disease and anemia should be included in possible future annual SARS-CoV-2 vaccination recommendations.

The Concern of COVID-19 Vaccine Safety Is behind Its Low Uptake among Patients with Diabetes Mellitus in Sudan

Diabetic patients are vulnerable to developing severe complications and have a higher risk of death due to COVID-19 infection. Vaccination remains the mainstay during the current situation to mitigate the risks related to COVID-19 infection. Therefore, the aim of the current study was to assess the vaccination status and the factors associated with COVID-19 vaccine uptake among patients with diabetes mellitus (DM) in Sudan. A hospital-based cross-sectional study was conducted from January to February 2022 at Gadarif Hospital in eastern Sudan. Information on sociodemographics, the contracting of COVID-19 during the pandemic, beliefs toward COVID-19 vaccinations, and barriers related to COVID-19 vaccinations was obtained through an interview questionnaire among adult (≥18 years) patients with DM. Bivariate and multinomial logistic regression analyses performed. A total of 568 diabetic patients were enrolled, with a mean (SD) age of 53.07 (12.69) years. The majority of the participants were female (67.6%), urban residents (63.4%), uneducated (60.6%) and employed (73.2%). There was a history of COVID-19 in 97.4% of participants, and 29.2% of them had hypertension along with DM. About 31% received the vaccine, out of which 17.9% received the first dose, 13.2% received the second dose, and 0.2% received the third dose. Multinomial logistic regression analysis showed a significant association between belief in the safety of the COVID-19 vaccine and having had two doses of it (adjusted Odds ratio = 20.42, p < 0.001). The prevalence of COVID-19 infection was high, while the rate of COVID-19 vaccination uptake was low and inadequate among the participants. Appropriate health education and targeted interventions toward awareness of safety concerns are highly recommended.

Epidemiological features and dynamic changes in blood biochemical indices for COVID-19 patients in Hebi

BACKGROUND

Millions of people have died of coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and retrospective studies of the disease in local regions are necessary.

AIM

To characterize the epidemiological features and dynamic changes in blood biochemical indices for SARS-CoV-2-infected patients in Hebi, a representative city with a large floating population in North China.

METHODS

From January 25 to February 10, 2020, the clinical data of patients who tested positive for SARS-CoV-2 by quantitative real-time polymerase chain reaction in Hebi city (China) were evaluated at admission, and laboratory data for hematologic parameters, inflammatory indices, coagulation function indices, liver function indices, blood lipid indices, renal function indices, myocardial enzyme activities and five blood biochemical markers of immunity were evaluated at admission, upon hospitalization and before discharge.

RESULTS

Sixteen confirmed COVID-19 patients developed pneumonia but were cured after adequate treatment. Fever and fatigue were the common symptoms. The most common laboratory abnormalities of patients at admission were leukopenia, eosinopenia, decreased percentage of eosinophils, elevated high sensitivity C-reactive protein and fibrinogen levels, hypoalbuminemia, mildly increased aspartate transferase activity and levels of bilirubin, and increased levels of β2-microglobulin. Importantly, aggravated liver dysfunction was detected in most patients, which may be partially attributed to virus infection as well as medicinal treatment.

CONCLUSION

This study provides several potential diagnostic markers and dynamic biochemical indices of disease progression to better prevent, diagnose and treat COVID-19 infection.

Diabetes, Metformin and the Clinical Course of Covid-19: Outcomes, Mechanisms and Suggestions on the Therapeutic Use of Metformin

Objectives: Pre-existing or new diabetes confers an adverse prognosis in people with Covid-19. We reviewed the clinical literature on clinical outcomes in metformin-treated subjects presenting with Covid-19. Methods: Structured PubMed search: metformin AND [covid (ti) OR covid-19 (ti) OR covid19 (ti) OR coronavirus (ti) OR SARS-Cov2 (ti)], supplemented with another PubMed search: "diabetes AND [covid OR covid-19 OR covid19 OR coronavirus (i) OR SARS-Cov2 (ti)]" (limited to "Clinical Study", "Clinical Trial", "Controlled Clinical Trial", "Meta-Analysis", "Observational Study", "Randomized Controlled Trial", "Systematic Review"). Results: The effects of metformin on the clinical course of Covid-19 were evaluated in retrospective analyses: most noted improved clinical outcomes amongst type 2 diabetes patients treated with metformin at the time of hospitalisation with Covid-19 infection. These outcomes include reduced admission into intensive care and reduced mortality in subgroups with versus without metformin treatment. Conclusion: The pleiotropic actions of metformin associated with lower background cardiovascular risk may mediate some of these effects, for example reductions of insulin resistance, systemic inflammation and hypercoagulability. Modulation by metformin of the cell-surface ACE2 protein (a key binding target for SARS-CoV 2 spike protein) via the AMP kinase pathway may be involved. While pre-existing metformin treatment offers potentially beneficial effects and can be continued when Covid-19 infection is not severe, reports of increased acidosis and lactic acidosis in patients with more severe Covid-19 disease remind that metformin should be withdrawn in patients with hypoxaemia or acute renal disease. Prospective study of the clinical and metabolic effects of metformin in Covid-19 is warranted.

Metformin use in patients hospitalized with COVID-19: lower inflammation, oxidative stress, and thrombotic risk markers and better clinical outcomes

Diabetes mellitus (DM) is associated with a greater risk of COVID-19 and an increased mortality when the disease is contracted. Metformin use in patients with DM is associated with less COVID-19-related mortality, but the underlying mechanism behind this association remains unclear. Our aim was to explore the effects of metformin on markers of inflammation, oxidative stress, and hypercoagulability, and on clinical outcomes. Patients with DM on metformin (n = 34) and metformin naïve (n = 41), and patients without DM (n = 73) were enrolled within 48 h of hospital admission for COVID-19. Patients on metformin compared to naïve patients had a lower white blood cell count (p = 0.02), d-dimer (p = 0.04), urinary 11-dehydro thromboxane B₂ (p = 0.01) and urinary liver-type fatty acid binding protein (p = 0.03) levels and had lower sequential organ failure assessment score (p = 0.002), and intubation rate (p = 0.03), fewer hospitalized days (p = 0.13), lower in-hospital mortality (p = 0.12) and lower mortality plus nonfatal thrombotic event occurrences (p = 0.10). Patients on metformin had similar clinical outcomes compared to patients without DM. In a multiple regression analysis, metformin use was associated with less days in hospital and lower intubation rate. In conclusion, metformin treatment in COVID-19 patients with DM was associated with lower markers of inflammation, renal ischemia, and thrombosis, and fewer hospitalized days and intubation requirement. Further focused studies are required to support these findings.

Association of serum C-reactive protein (CRP) and D-dimer concentration on the severity of COVID-19 cases with or without diabetes: a systematic review and meta-analysis

INTRODUCTION

Coronavirus disease (COVID-19) is a highly contagious disease that poses major public health risks. Fewer studies link high CRP and D-dimer levels to severe COVID-19 infection. Therefore, this study investigates the association of serum CRP and D-dimer concentration with COVID-19 severity in diabetic and non-diabetic patients.

AREAS COVERED

Relevant published articles were identified using electronic search engines, such as Google Scholar, PubMed, Springer, Science Direct, and Researchgate. A total of 29 articles reporting on 15,282 patients (4,733 diabetes and 10,549 non-diabetes) were included in this systematic review and meta-analysis. RevMan V5.4, STATA V14 software, and SPSS V25 were used for the meta-analysis. Egger's regression and Begg-Mazumdar's test were used for assessing publication bias. The pooled result of all studies revealed that serum CRP (Standard mean difference (SMD) 0.41 mg/L; P < 0.0001; I2 93%) and D-dimer (SMD 0.32 mg/L; P < 0.0001; I2 83%) concentration was significantly higher in COVID-19 diabetic patients. The prevalence of COVID-19 infection was comparatively higher in male diabetic patients (OR 2.41; P < 0.00001; I2 88%). There was no publication bias. CRP and D-dimer rose with age in COVID-19 diabetic and non-diabetic patients.

EXPERT OPINION

Overall, the serum CRP and D-dimer concentration in COVID-19 diabetic patients was significantly higher than non-diabetic patients indicating severe illness.

Preliminary study regarding the predicted body weight-based dexamethasone therapy in patients with COVID-19 pneumonia

BACKGROUND

The RECOVERY clinical trial reported that 6 mg of dexamethasone once daily for up to 10 days reduces the 28-day mortality in patients with coronavirus disease 2019 (COVID-19) receiving respiratory support. In our clinical setting, a fixed dose of dexamethasone has prompted the question of whether inflammatory modulation effects sufficiently reduce lung injury. Therefore, preliminary verification on the possibility of predicted body weight (PBW)-based dexamethasone therapy was conducted in patients with COVID-19 pneumonia.

METHODS

This single-center retrospective study was conducted in a Japanese University Hospital to compare the treatment strategies/management in different periods. Consecutive patients (n = 90) with COVID-19 pneumonia requiring oxygen therapy and were treated with dexamethasone between June 2020 and May 2021 were analyzed. Initially, 60 patients administered a fixed dexamethasone dose of 6.6 mg/day were defined as the conventional group, and then, 30 patients were changed to PBW-based therapy. The 30-day discharged alive rate and duration of oxygen therapy were analyzed using the Kaplan-Meier method and compared using the log-rank test. The multivariable Cox regression was used to evaluate the effects of PBW-based dexamethasone therapy on high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or mechanical ventilation (MV).

RESULTS

In the PBW-based group, 9, 13, and 8 patients were administered 6.6, 9.9, and 13.2 mg/day of dexamethasone, respectively. Additional respiratory support including HFNC, NIV, or MV was significantly less frequently used in the PBW-based group (P = 0.0046), with significantly greater cumulative incidence of being discharged alive and shorter oxygen demand within 30 days (92 vs. 89%, log-rank P = 0.0094, 90 vs. 92%, log-rank P = 0.0002, respectively). Patients treated with PBW-based therapy significantly decreased the use of additional respiratory support after adjusting for baseline imbalances (adjusted odds ratio, 0.224; 95% confidence interval, 0.062-0.813, P = 0.023). Infection occurred in 13 (21%) and 2 (7%) patients in the conventional and PBW-based groups, respectively (P = 0.082).

CONCLUSIONS

In patients with COVID-19 pneumonia requiring oxygen therapy, PBW-based dexamethasone therapy may potentially shorten the length of hospital stay and duration of oxygen therapy and risk of using HFNC, NPPV, or MV without increasing serious adverse events or 30-day mortality.

Association of clinical characteristics, antidiabetic and cardiovascular agents with diabetes mellitus and COVID-19: a 7-month follow-up cohort study

BACKGROUND

The prognostic factors of long-term outcomes in hospitalized patients with diabetes mellitus and COVID-19 are lacking.

METHODS

In this retrospective cohort study, we evaluated patients aged ≥ 18-years-old with the COVID-19 diagnosis who were hospitalized between Feb 20 and Oct 29, 2020, in the Sina Hospital, Tehran, Iran. 1323 patients with COVID-19 entered in the final analysis, of whom 393 (29.7%) patients had diabetes. We followed up patients for incurring in-hospital death, severe COVID-19, in-hospital complications, and 7-month all-cause mortality. By doing univariate analysis, variables with unadjusted P-value < 0.1 in univariate analyses were regarded as the confounders to include in the logistic regression models. We made adjustments for possible clinical (model 1) and both clinical and laboratory (model 2) confounders.

RESULTS

After multivariable regression, it was revealed that preadmission use of sulfonylureas was associated with a borderline increased risk of severity in both models [model 1, OR (95% CI):1.83 (0.91-3.71), P-value: 0.092; model 2, 2.05 (0.87-4.79), P-value: 0.099] and major adverse events (MAE: each of the severe COVID-19, multi-organ damage, or in-hospital mortality) in model 1 [OR (95% CI): 1.86 (0.90-3.87), P-value: 0.094]. Preadmission use of ACEIs/ARBs was associated with borderline increased risk of MAE in the only model 1 [OR (95% CI):1.83 (0.96-3.48), P-value: 0.066].

CONCLUSIONS

Preadmission use of sulfonylureas and ACEIs/ARBs were associated with borderline increased risk of in-hospital adverse outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-021-00901-4.

Mental health burden of patients with diabetes before and after the initial outbreak of COVID-19: predictors of mental health impairment

Background

The COVID-19 pandemic is affecting people’s mental health worldwide. Patients with diabetes are at risk for a severe course of illness when infected with SARS-CoV-2. The present study aims to retrospectively examine mental health changes in patients with diabetes in Germany before and after the initial COVID-19 outbreak, and to furthermore explore potential predictors of such changes.

Methods

Over the course of eight weeks from April to June 2020, 253 individuals diagnosed with diabetes participated in an online cross-sectional study. Participants completed an anonymous survey including demographics, depression (PHQ-2) and generalized anxiety symptoms (GAD-2), distress (DT), and health status (EQ-5D-3L). In addition, all instruments used were modified to retrospectively ask participants to recall their mental health and health status before the outbreak had started. Additionally examined factors were COVID-19-related fear, trust in governmental actions to face the pandemic, and the subjective level of information about COVID-19.

Results

This study shows a significant increase in prevalence of depression symptoms, generalized anxiety symptoms and distress, as well as significantly decreased health statuses in diabetes patients after the initial COVID-19 outbreak. Increased depression symptoms, generalized anxiety symptoms and distress were predicted by COVID-19-related fear, whereas trust in governmental actions to face COVID-19 predicted higher depression symptoms.

Conclusions

The results indicate a negative impact of the initial COVID-19 outbreak on mental health and health status in patients with diabetes. In order to improve the efficacy of psychological support strategies for diabetes patients during the pandemic, possible predictors of mental health impairment such as the aforementioned should be examined more thoroughly and addressed more openly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12101-z.

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

BACKGROUND

One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA).

OBJECTIVES

To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA.

DESIGN

A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.

METHODS

Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient's final treatment outcome (survival or death).

RESULTS

Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399-638 mg/dl], 11.4% [IQR 9.9-13.5%], 7.16 [IQR 7.00-7.22], 10 mmol/l [IQR 6.9-13 mmol/l], and 24.5 mEq/l [18-29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07-15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38-7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37-5.17; p = 0.004] compared to those who survived.

CONCLUSION

DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

Rate and Predictors of Hesitancy toward SARS-CoV-2 Vaccine among Type 2 Diabetic Patients: Results from an Italian Survey

Vaccine hesitancy (VH) has been identified as one of the major health concerns of our time by the World Health Organization. It may prove especially detrimental in the light of the ongoing SARS-CoV-2 pandemic, as vaccination campaigns still represent the primary strategy against the detrimental consequences of the pandemic. Among patients suffering from type 2 diabetes mellitus (DB), who are particularly vulnerable to COVID-19, VH might represent an even more serious threat. Therefore, our study focuses on identifying potential determinants of VH among patients with type 2 diabetes. Study participants (n = 1176) filled in a two-section online self-administered questionnaire, answering questions regarding demographic and anamnestic data, as well as their intention to accept any vaccination against COVID-19. Some possible reasons underlying VH were investigated as well. An overall hesitancy rate of 14.2% was registered. Data showed how older age, male gender, higher education level, and having been vaccinated for seasonal influenza in 2020-2021 were associated with a significantly higher propensity to receive the COVID-19 vaccine. On the contrary, having experienced adverse effects following past vaccinations was a negative predictor. In addition to confirming an array of predictors of VH, we found a worryingly high prevalence of VH among diabetics, who have been shown to be particularly exposed to severe COVID-19 and death. These findings may be useful in planning targeted action toward acceptance improvement and enhancing the efficacy of vaccination campaigns.

Diagnosis and Management Considerations in Steroid-Related Hyperglycemia in COVID-19: A Position Statement from the Endocrine Society of India

The current coronavirus disease (COVID-19) pandemic is showing no signs of abatement and result in significant morbidity and mortality in the infected patients. Many therapeutic agents ranging widely between antivirals and anti-inflammatory drugs have been used to mitigate the disease burden. In the deluge of the drugs being used for COVID-19 infection, glucocorticoids (GCs) stand out by reducing mortality amongst in-hospital severe-to-critically ill patients. Health-care practitioners have seen this as a glimmer of hope and started using these drugs more frequently than ever in clinical practice. The fear of mortality in the short term has overridden the concern of adverse long-term consequences with steroid use. The ease of availability, low cost, and apparent clinical improvement in the short term have led to the unscrupulous use of the steroids even in mild COVID-19 patients including self-medication with steroids. The use of GCs has led to the increasing incidence of hyperglycemia and consequent acute complications of diabetic ketoacidosis and mucormycosis in COVID-19 patients. There is an urgent need to dissipate information about optimum management of hyperglycemia during steroid use. In view of this, the Endocrine Society of India has formulated this position statement about the diagnosis and management of hyperglycemia due to the use of GCs in patients with COVID-19 infection.