Impact of diabetes mellitus on in-hospital mortality in adult patients with COVID-19: a systematic review and meta-analysis

Burden and risk profile of acute kidney injury in severe COVID-19 pneumonia admissions: a Finding from Jimma University medical center, Ethiopia

BACKGROUND

Acute kidney injury (AKI) is a serious complication of the Corona Virus Disease of 2019 (COVID-19). However, data on its magnitude and risk factors among hospitalized patients in Ethiopia is limited. This study aimed to determine the magnitude of AKI and associated factors among patients admitted for severe COVID-19 pneumonia.

METHODS

An institution-based retrospective cross-sectional study was conducted among 224 patients admitted to Jimma University Medical Center in Ethiopia for severe COVID-19 pneumonia from May 2020 to December 2021. Systematic random sampling was used to select study participants. Medical records were reviewed to extract sociodemographic, clinical, laboratory, therapeutic, and comorbidity data. Bivariable and multivariable logistic regressions were performed to examine factors associated with AKI. The magnitude of the association between the explanatory variables and AKI was estimated using an adjusted odds ratio (AOR) with a 95% confidence interval (CI), and significance was declared at a p-value of 0.05.

RESULTS

The magnitude of AKI was 42% (95% CI: 35.3-48.2%) in the study area. Mechanical ventilation, vasopressors, and antibiotics were required in 32.6, 3.7, and 97.7% of the patients, respectively. After adjusting for possible confounders, male sex (AOR 2.79, 95% CI: 1.3-6.5), fever (AOR 6.5, 95% CI: 2.7-15.6), hypoxemia (AOR 5.1, 95% CI: 1.4-18.9), comorbidities (AOR 2.8, 95% CI: 1.1-7.0), and severe anemia (AOR 10, 95% CI: 1.7-65.7) remained significantly associated with higher odds of AKI.

CONCLUSION

The burden of AKI among patients with severe COVID-19 pneumonia is high in our setting. Male sex, abnormal vital signs, chronic conditions, and anemia can identify individuals at increased risk and require close monitoring and prevention efforts.

Mortality-related risk factors of inpatients with diabetes and COVID-19: A multicenter retrospective study in Belgium

BACKGROUND AND AIMS

We describe mortality-related risk factors of inpatients with diabetes and coronavirus disease 2019 (COVID-19) in Belgium.

METHODS

We conducted a multicenter retrospective study from March to May, 2020, in 8 Belgian centers. Data on admission of patients with diabetes and COVID-19 were collected. Survivors were compared to non-survivors to identify prognostic risk factors for in-hospital death using multivariate analysis in both the total population and in the subgroup of patients admitted in the intensive care unit (ICU).

RESULTS

The study included 375 patients. The mortality rate was 26.4% (99/375) in the total population and 40% (27/67) in the ICU. Multivariate analysis identified older age (HR 1.05 [CI 1.03-1.07], P<0.0001) and male gender (HR 2.01 [1.31-3.07], P=0.0013) as main independent risk factors for in-hospital death in the total population. Metformin (HR 0.51 [0.34-0.78], P=0.0018) and renin-angiotensin-aldosterone system blockers (HR 0.56 [0.36-0.86], P=0.0088) use before admission were independent protective factors. In the ICU, chronic kidney disease (CKD) was identified as an independent risk factor for death (HR 4.96 [2.14-11.5], P<0.001).

CONCLUSION

In-hospital mortality due to the first wave of COVID-19 pandemic in Belgium was high in patients with diabetes. We found that advanced age and male gender were independent risk factors for in-hospital death. We also showed that metformin use before admission was associated with a significant reduction of COVID-19-related in-hospital mortality. Finally, we showed that CKD is a COVID-19-related mortality risk factor in patients with diabetes admitted in the ICU.

Risk factors for SARS-CoV-2 infection: a test-negative case-control study with additional population controls in Norway

OBJECTIVES

This study aims to assess risk factors for SARS-CoV-2 infection by combined design; first comparing positive cases to negative controls as determined by PCR testing and then comparing these two groups to an additional prepandemic population control group.

DESIGN AND SETTING

Test-negative design (TND), multicentre case-control study with additional population controls in South-Eastern Norway.

PARTICIPANTS

Adults who underwent SARS-CoV-2 PCR testing between February and December 2020. PCR-positive cases, PCR-negative controls and additional age-matched population controls.

PRIMARY OUTCOME MEASURES

The associations between various risk factors based on self- reported questionnaire and SARS-CoV-2 infection comparing PCR-positive cases and PCR-negative controls. Using subgroup analysis, the risk factors for both PCR-positive and PCR-negative participants were compared with a population control group.

RESULTS

In total, 400 PCR-positive cases, 719 PCR-negative controls and 14 509 population controls were included. Male sex was associated with the risk of SARS-CoV-2 infection only in the TND study (OR 1.9, 95% CI 1.4 to 2.6), but not when PCR-positive cases were compared with population controls (OR 1.2, 95% CI 0.9. to 1.5). Some factors were positively (asthma, wood heating) or negatively (hypertension) associated with SARS-CoV-2 infection when PCR-positive cases were compared with population controls, but lacked convincing association in the TND study. Smoking was negatively associated with the risk of SARS-CoV-2 infection in both analyses (OR 0.5, 95% CI 0.3 to 0.8 and OR 0.6, 95% CI 0.4 to 0.8).

CONCLUSIONS

Male sex was a possible risk factor for SARS-CoV-2 infection only in the TND study, whereas smoking was negatively associated with SARS-CoV-2 infection in both the TND study and when using population controls. Several factors were associated with SARS-CoV-2 infection when PCR-positive cases were compared with population controls, but not in the TND study, highlighting the strength of combining case-control study designs during the pandemic.

Increased risk of poor clinical outcome in COVID-19 patients with diabetes mellitus and in-hospital mortality predictors: A retrospective cohort from a tertiary hospital in Indonesia

AIM

To determine association between diabetes in confirmed cases of COVID-19 and intensive care admission and in-hospital mortality, evaluate several laboratory parameters as mortality predictor and develop predictors of in-hospital mortality among diabetics with COVID-19.

METHODS

This retrospective cohort recruited all cases of COVID-19 hospitalized in Fatmawati General Hospital from March to October 2020. Inclusion criterion was RT-PCR confirmed cases of COVID-19 who aged 18 years and older while exclusion criteria were incomplete medical record or cannot be found and pregnant women.

RESULTS

We enrolled 506 participants to this study with median age of 51 years (IQR:22), female (56.32%), and diabetes (28.46%). Diabetes increased intensive care admission (adjusted OR: 2.57; 95% CI: 3.52-10.43) and in-hospital mortality (adjusted OR: 2.50; 95% CI: 1.61-3.89). In predicting in-hospital mortality, ferritin and lactate dehydrogenase offered an acceptable discrimination, AUC: 0.71 (95% CI: 0.62-0.79) and AUC: 0.70 (95% CI: 0.61-0.78), respectively. The optimal cut-off of predicting mortality for ferritin was 786 g/mL and for LDH was 514.94 u/L. Factors include age above 70 years old, RBGs level on admission above 250 mg/dL or below 140 mg/dL, ferritin level above 786 ng/mL and presence of ARDS increased the odds of mortality among individuals with diabetes.

CONCLUSIONS

Diabetes increases risk intensive care admission and in hospital mortality in COVID-19. Multivariate analysis showed that older age, RBG on admission, high ferritin level, presence of ARDS increased the odds of mortality among individuals with diabetes.

Clinical outcomes of COVID-19 in patients with chronic diseases

OBJECTIVE

This study was carried out to evaluate the clinical outcomes of patients having chronic diseases (CD) and COVID-19 infection.

METHODS

The study was carried out retrospectively by including 1.516 patients with CDs who applied to two education and research hospitals between June 01, 2021, and August 01, 2021, and were diagnosed with COVID-19. As CDs; cardiovascular diseases, diabetes mellitus (DM), hyperlipidemia, asthma, chronic obstructive pulmonary diseases, rheumatological diseases, malignancy, cerebrovascular disease, and chronic kidney diseases (CKD) were screened and evaluated statistically.

RESULTS

A total of 1.516 patients with a mean age of 58.05±18.51 years were included in the study. It has been observed that 68.9% of COVID-19 patients have at least one CD. Women were more tend to have CDs than men (73.8% vs. 64.8%). Patients with a history of CD were significantly older and had a longer hospital stay than those without. Patients with CDs were 5.49 times more likely to be hospitalized in the intensive care unit (ICU) and their death rate was 2.52 times higher than the other patients. After the regression analysis, while hypertension (HT) (Odds Ratio [OR]: 2.39), DM (OR: 3.64), and any type of cancer (OR: 2.75) were seen as independent risk factors in hospitalizations in the ICU, cardiovascular diseases (OR: 2.27), CKD (OR: 3.69) and psychiatric disorders (OR: 2.18) were seen as independent risk factors associated with mortality.

CONCLUSION

The follow-up of COVID-19 patients with CDs should be done more cautiously than others. It should be kept in mind that patients with HT, DM, and cancer may need intensive care at any time of hospitalization, while those with cerebrovascular disease, CKD, and psychiatric problems may have a higher mortality rate than other patients.

Antidiabetic Treatment before Hospitalization and Admission Parameters in Patients with Type 2 Diabetes, Obesity, and SARS-CoV-2 Viral Infection

BACKGROUND

SARS-CoV-2 viral infection is a current and important topic for patients with comorbidities of type 2 diabetes and obesity, associated with increased risk of mortality and morbidity. This study aims to analyze, compare and describe admission parameters in patients with type 2 diabetes, obesity, and SARS-CoV-2 infection based on whether they received insulin therapy before hospital admission.

METHODS

Our study enrolled patients diagnosed with type 2 diabetes, obesity, and SARS-CoV-2 viral infection, 81 patients without insulin treatment before hospital admission, and 81 patients with insulin at "Gavril Curteanu" Municipal Clinical Hospital of Oradea, Romania, between August 2020 and March 2022. RT-PCR/rapid antigen tests were used for detecting SARS-CoV-2 viral infection.

RESULTS

The severe form of COVID-19 was found in 66% of all patients (65% in the group without insulin and 67% in the group with insulin). Oxygen saturation at the time of hospital admission was greater or equal to 90% in 62% of all patients. The most associated comorbidities we founded in this study were: hypertension in 75% of all patients (grade two hypertension 63% in the group without insulin and 64% in the group with insulin), ischemic heart disease in 35% of patients (25% in the group without insulin and 44% in the group with insulin, n = 0.008), heart failure in 9.3% of all patients (8.6% in the group without insulin and 10% in the group with insulin). CRP and procalcitonin are increased in both groups at hospital admission, with a slightly higher trend in the group with insulin therapy before hospital admission. We found that 56% of patients in the group with insulin treatment were with uncontrolled diabetes on admission. Only 10% of patients required a change in antidiabetic treatment with insulin therapy at discharge. In our study, 89% of all patients did not require short-term home oxygen therapy at discharge.

CONCLUSIONS

Antidiabetic therapy taken before hospital admission did not protect patients against cytokine storm in COVID-19, but is very important in the pathophysiological stage of comorbidities. Paraclinical parameters at hospitalization showed differences in correlation with oral antidiabetic treatment like metformin or insulin therapy. Changing the antidiabetic treatment for a small percentage of patients in the group who had not been receiving insulin therapy before discharge was necessary. It is necessary for future studies to see all changes involved in antidiabetic treatment in patients with diabetes type 2 and obesity after SARS-CoV2 viral infection and its long-term evolution.

COVID-19 and Diabetes Mellitus: From Pathophysiology to Clinical Management

An increase in the severity of the coronavirus disease 2019 (COVID-19) was observed in patients infected with the acute severe metabolism syndrome coronavirus type 2 (SARS-CoV-2). Patients who have COVID-19 infection may also be more susceptible to hyperglycemia. When paired with other risk factors, hyperglycemia might alter immune and inflammatory responses, predisposing people to significant COVID-19 and perhaps deadly outcomes. Angiotensin-converting accelerator 2 (ACE2), a component of the renin-angiotensin-aldosterone system (RAAS), is the principal entry receptor for SARS-CoV-2; nevertheless, dipeptidyl enzyme 4 (DPP4) may potentially serve as a binding target. However, preliminary data did not indicate a substantial effect on the susceptibility to SARS-CoV-2 using glucose-lowering DPP4 inhibitors. Because of their pharmacologic characteristics, salt-glucose cotransporter 2 (SGLT2) inhibitors should not be advised for COVID-19 patients because they may have adverse effects. Currently, taking a hypoglycemic drug should be the most efficient way to manage acute glycemia. The majority of market proof is said to categorize two diabetes mellitus (DM) and fails to distinguish between the two primary categories of DM due to its widespread use. For grouping one DM and COVID-19, there is now some constrained proof available. Most of those findings are just preliminary, so further research will undoubtedly be required to determine the best course of action for DM patients.

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.

COVID-19, Endothelium and the Cardiometabolic Patient: A Possible Role for Capillary Leak Syndrome

Capillary leak syndrome is an under-diagnosed condition leading to serious hypoalbuminemia with diffuse edema, pulmonary edema, severe hypotension, and possibly death. Sepsis leading to hemophagocytic lymphohistiocytosis (HLH) is a major risk factor; however, capillary hyper-permeability is the core underlying pathophysiological mechanism. Endothelial dysfunction plays a major role in cardiometabolic disease through insulin resistance, lipotoxicity, and, eventually, oxidative stress and chronic inflammation. We review the literature concerning the aforementioned mechanisms as well-established risk factors for adverse COVID-19 outcomes. We especially focus on data regarding the underlying endothelial effects of SARS-CoV-2 infection, including direct damage and increased vascular leakage through a hyper-inflammatory cascade and diminished nitric oxide bioavailability. Interestingly, an increased incidence of hypoalbuminemia has been observed in patients with severe COVID-19, especially those with underlying cardiometabolic disease. Importantly, low albumin levels present a strong, positive association with poor disease outcomes. Therefore, in this review article, we highlight the important role of cardiovascular risk factors on endothelium integrity and the possible link of endothelial damage in the hypoalbuminemia-associated adverse prognosis of COVID-19 patients.

The Role of Diabetes and Hyperglycemia on COVID-19 Infection Course-A Narrative Review

It was previously reported that subjects with diabetes mellitus (DM) are more vulnerable to several bacterial or viral infections. In the era of coronavirus disease 2019 (COVID-19) pandemic, it is reasonable to wonder whether DM is a risk factor for COVID-19 infection, too. It is not yet clear whether DM increases the risk for contracting COVID-19 infection or not. However, patients with DM when infected are more likely to develop severe or even fatal COVID-19 disease course than patients without DM. Certain characteristics of DM patients may also deteriorate prognosis. On the other hand, hyperglycemia per se is related to unfavorable outcomes, and the risk may be higher for COVID-19 subjects without pre-existing DM. In addition, individuals with DM may experience prolonged symptoms, need readmission, or develop complications such as mucormycosis long after recovery from COVID-19; close follow-up is hence necessary in some selected cases. We here present a narrative review of the literature in order to set light into the relationship between COVID-19 infection and DM/hyperglycemia.

The Value of Clinical Frailty Scale (CFS) as a Prognostic Tool in Predicting Mortality in COVID-19—A Retrospective Cohort Study

Background: Due to the unpredictable nature of COVID-19, there is a need to identify patients at high risk of severe course of the disease and a higher mortality rate. Objective: This study aims to find the correlation between frailty and mortality in adult, hospitalized patients with COVID-19. Methods: Clinical records of 201 patients who suffered from COVID-19 and were hospitalized between October 2020 and February 2021 were retrospectively analyzed. Demographic, clinical, and biochemical data were collected. Patients were assessed using Clinical Frailty Scale (CFS) and were divided into three groups: CFS 1–3 fit; CFS 4–6 vulnerable and with mild to moderate frailty; CSF 7–9, severe frailty. The association between frailty and in-hospital mortality was the primary outcome. Results: Severe frailty or terminal illness was observed in 26 patients (12.94%) from a cohort of 201 patients. Those patients were older (median age 80.73, p < 0.001) and had more comorbidities. Frailty was also associated with higher requirement for oxygen supplementation, greater risk of in-hospital complications and worse biochemical laboratory results. An increase in CFS score also correlated with higher mortality (OR = 1.89, p < 0.001). The Conclusions: Clinical Frailty Scale (CFS) can be used as a potentially useful tool in predicting mortality in patients with COVID-19.

The Effects of COVID-19 Lockdown on Glycaemic Control and Lipid Profile in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis

The impact of the COVID-19 lockdown on glycaemic control and other metabolic parameters in patients with type 2 diabetes is still evolving. Aim: This systematic review and meta-analysis aims to examine the effects of COVID-19 lockdown on glycaemic control and lipid profile in patients with type 2 diabetes. Methods: The PRISMA framework was the method used to conduct the systematic review and meta-analysis, and the search strategy was based on the population, intervention, control and outcome (PICO) model. The Health Sciences Research databases was accessed via EBSCO-host, and EMBASE were searched for relevant articles. Searches were conducted from inception of the databases until 17 September 2021. Results: The results identified three distinct areas: glycaemic control, lipid parameters and body mass index. It was found that COVID-19 lockdown led to a significant (p < 0.01) increase in the levels of glycated haemoglobin (%) compared with pre-COVID group (gp) with a mean difference of 0.34 (95% CI: 0.30, 0.38). Eleven studies contributed to the data for glycated haemoglobin analysis with a total of 16,895 participants (post-COVID-19 lockdown gp, n = 8417; pre-COVID gp, n = 8478). The meta-analysis of fasting plasma glucose (mg/dL) also showed a significant (p < 0.05) increase in levels of post-COVID-19 lockdown gp compared with pre-COVID gp, with a mean difference of 7.19 (95% CI: 5.28, 9.10). Six studies contributed to fasting plasma glucose analysis involving a total of 2327 participants (post-COVID-19 lockdown, n = 1159; pre-COVID gp, n = 1168). The body mass index (BMI) (kg/m²) analysis also demonstrated that post-COVID-19 lockdown gp had a significantly (p < 0.05) higher BMI than the pre-COVID gp with a mean difference of 1.13 (95% CI: 0.99; 1.28), involving six studies and a total of 2363 participants (post-COVID-19 lockdown gp, n = 1186; pre-COVID gp, n = 1177). There were significantly (p < 0.05) lower levels of total cholesterol (mmol/L), triglyceride (mmol/L) and LDL cholesterol (mmol/L), and higher levels of HDL cholesterol (mg/dL) in the post-COVID-19 lockdown gp compared with pre-COVID gp, although these results were not consistent following sensitivity analysis. Conclusion: The findings of the systematic review and meta-analysis have demonstrated that COVID-19 lockdown resulted in a significant increase (p < 0.05) in the levels of glycated haemoglobin, fasting glucose and body mass index in patients with type 2 diabetes. In contrast, the effect of the lockdown on lipid parameters, including total cholesterol, triglycerides, LDL and HDL cholesterol was not consistent.

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.

Mortality and Clinical Outcomes among Patients with COVID-19 and Diabetes

Background Diabetes mellitus (DM) is a decisive risk factor for severe illness in coronavirus disease 2019 (COVID-19). India is home to a large number of people with DM, and many of them were infected with COVID-19. It is critical to understand the impact of DM on mortality and other clinical outcomes of COVID-19 infection from this region. Aims The primary objective of our study was to analyze the mortality rate in people with DM infected with COVID-19. The secondary objectives were to assess the effect of various comorbidities on mortality and study the impact of DM on other clinical outcomes. Methods This is a retrospective study of COVID-19 infected patients admitted to a tertiary care hospital in north India in the early phase of the pandemic. Results Of the 1211 cases admitted, 19 were excluded because of incomplete data, and 1192 cases were finally considered for analysis. DM constituted 26.8% of total patients. The overall mortality rate was 6.1%, and the rate was 10.7% in the presence of diabetes (p < 0.01, OR 2.55). In univariate analysis, increased age, chronic kidney disease (CKD), coronary artery disease (CAD), stroke, and cancer were associated with mortality. On multiple logistic regression, the independent predictors of mortality were CAD, CKD, and cancer. Breathlessness and low SpO₂ at presentation, extensive involvement in CXR, and elevated ANC/ALC ratio were also significantly associated with mortality. Conclusions The presence of comorbidities such as DM, hypertension, CAD, CKD, and cancer strongly predict the risk of mortality in COVID-19 infection. Early triaging and aggressive therapy of patients with these comorbidities can optimize clinical outcomes.

Diabetes and COVID-19: Population Impact 18 Months Into the Pandemic

Eighteen months into the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) pandemic, epidemiologic studies indicate that diabetes is a central contributor to severe COVID-19 morbidity, and, conversely, COVID-19 has had a devastating effect on the population with diabetes. In this literature synthesis, we summarize the relationship of diabetes to COVID-19-related morbidity and mortality, discuss the predictors of severe adverse outcomes and implications of the overall pandemic, and critique the current status of and identify needs for epidemiologic studies for the next phase of the pandemic. Case series show that ∼30-40% of people with COVID-19-related hospitalization, severe morbidity requiring intensive care, and/or death have type 2 or type 1 diabetes. Among hospitalized individuals with diabetes, ∼21-43% required intensive care and case fatality is ∼25%. Risk of severe morbidity and mortality is 100-250% higher among people with diabetes than those without, even after adjustment for sociodemographic factors and comorbid conditions. Impact on the general population with diabetes has been similarly dire, as overall mortality rates were 50% higher than historical trends, a net increase more than twice that of the general population. Of the excess deaths, ∼75-80% are not officially attributed to COVID-19, which raises unanswered questions about missed attribution or collateral impact. Many predictors of poor outcomes have been identified, particularly comorbid conditions (chronic kidney disease, coronary heart disease, and heart failure), concurrent obesity, and acute and chronic poor HbA1c control, that point to the potential to reduce severe morbidity and mortality in its next stages. However, response to the continuing pandemic will benefit from population-wide studies with broader examination of the risks of exposure, infection, and hospitalization, for which few data currently exist. The indirect impact of the pandemic's effects on health services, health behaviors, disease management, care, control, and complications has not been well quantified; determining this impact will be essential to lessen the future impact. Expanding epidemiologic studies of the relationship of diabetes to COVID-19 beyond few high-income countries will also be essential to limit the burden in low- and middle-income countries where 80% of individuals with diabetes reside and where the COVID-19 pandemic has been so damaging.

Management of Patients With Glucocorticoid-Related Diseases and COVID-19

The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a global health crisis affecting millions of people worldwide. SARS-CoV-2 enters the host cells by binding to angiotensin-converting enzyme 2 (ACE2) after being cleaved by the transmembrane protease serine 2 (TMPRSS2). In addition to the lung, gastrointestinal tract and kidney, ACE2 is also extensively expressed in endocrine tissues, including the pituitary and adrenal glands. Although glucocorticoids could play a central role as immunosuppressants during the cytokine storm, they can have both stimulating and inhibitory effects on immune response, depending on the timing of their administration and their circulating levels. Patients with adrenal insufficiency (AI) or Cushing's syndrome (CS) are therefore vulnerable groups in relation to COVID-19. Additionally, patients with adrenocortical carcinoma (ACC) could also be more vulnerable to COVID-19 due to the immunosuppressive state caused by the cancer itself, by secreted glucocorticoids, and by anticancer treatments. This review comprehensively summarizes the current literature on susceptibility to and outcome of COVID-19 in AI, CS and ACC patients and emphasizes potential pathophysiological mechanisms of susceptibility to COVID-19 as well as the management of these patients in case of SARS-CoV-2. Finally, by performing an in silico analysis, we describe the mRNA expression of ACE2, TMPRSS2 and the genes encoding their co-receptors CTSB, CTSL and FURIN in normal adrenal and adrenocortical tumors (both adenomas and carcinomas).