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.

The role of ultrasound in determining the presence and severity of carpal tunnel syndrome in diabetic patients

Carpal tunnel syndrome (CTS) is seen in 5% of the population and 14%-30% in diabetics. Although electrophysiological tests are used as the gold standard method in the diagnosis, alternative methods are being studying. We aimed to investigate whether the measurement of median nerve cross-sectional area (CSA) by ultrasound is associated with the presence and severity of CTS. This prospective, cross-sectional observational study includes 128 randomly selected T2DM patients. Electrodiagnostic study was performed for all patients to diagnose CTS. Median nerve CSA were measured with ultrasound examination. The severity of the CTS was determined by Padua method. Among 128 diabetes mellitus (DM) patients, 54 (28%) had CTS and 53 (41%) had diabetic peripheral polyneuropathy. The mean duration of DM was 11.55 years. Median nerve CSAs of the patients were significantly higher in patients with CTS (CTS (-): 10.47 ± 2.67 vs CTS: (+) 12.37 ± 3.17; p < 0.001). Median nerve CSA cutoff value of >10 mm2 predicts the diagnosis of CTS. However, minimal, mild, and moderate CTS groups had similar CSA according to Padua classification (p > 0.05 for all). CSA measurement with ultrasonography can be used as an effective method in diagnosing severe CTS disease. However, median nerve CSA values should not be used to reveal the severity of CTS, in order not to miss the demonstration of minimal, mild, and moderate groups, as well as being an indicator of only the severe CTS group.

Normalization of serum TSH doesn’t represent true euthyroidism for patients on levothyroxine treatment

Introduction: To evaluate whether normalisation of serum thyroid-stimulating hormonelevels with levothyroxine is related with metabolic parameters and psychologic wellbeing. Method: The observational, case-control study was conducted from to May to July 2019 in the outpatient thyroid clinics of Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey, and compried hypothyroid patients in the euthyroid state with levothyroxine treatment and euthyroid controls. Psychological wellbeing was assessed using the General Health Questionnaire-12, and metabolic parameters with lipid levels and body composition were analysed for both the groups. Data was analysed using SPSS 25. Results: Of the 159 subjects, 110(69%) were case with a mean age of 50.1±11.7 years, and 49(31%) were controls with a mean age of 47.3±15.2 years. There was no significant difference related to thyroid-stimulating hormonel levels between the groups (p=0.191). Free throxine levels were significantly higher in the cases, while free triiodothyroinine levels were higher in the controls (p<0.001). Total cholesterol and triglycerides levels were significantly higher in the cases than the controls (p<0.05). The cases had lower basal metabolic rate and fat free mass than the controls, but the difference was not significant (p>0.05). The cases scored higher in terms of wellbeing than the controls, but the difference was not significant (p>0.05). Conclusion: Thyroid hormone replacement needs to be adjusted to provide a satisfactory treatment for hypothyroid patients with normal thyroid-stimulating hormone levels who remain clinically and biochemically asymptomatic. In symptomatic patients, peripheral parameters of hypothyroidism, such as lipid levels, ---Continue

Technology-based and supervised exercise interventions for individuals with type 2 diabetes: Randomized controlled trial

AIMS

The purpose of this study was to estimate, for people with type 2 diabetes (T2D), the extent to which glycemic control was affected by a 12-week program using mobile app and wearable smartwatch in comparison to supervised exercise training.

METHODS

This study was a stratified, randomized, assessor-blind, controlled, pragmatic trial with three parallel groups which were supervised, mobile app and wearable smartwatch. Individually tailored exercise regimens delivered through a supervisor, mobile app and wearable smartwatch. Programs consisted of aerobic, resistance exercises, calisthenic, flexibility, balance, and coordination exercises. Primary outcome was change in glycemic control (HbA1c); secondary outcome was Six Minute Walk Test; and explanatory outcomes were exercise behaviour, muscle function, and physical capacity. The groups were contrasted for change in HbA1c and absolute reduction of ≥0.5% (Minimal Important Change). Linear and logistic regressions were used to compare the groups and generalized estimated equations were used to analyze the explanatory outcomes.

RESULTS

In total, 90 people were randomized, 6 were lost over 12 weeks, leaving 84 with outcome data. The difference in HbA1c did not differ between the supervised and the technology groups combined and between the mobile app and smartwatch group. Proportions of people achieving a clinically meaningful difference on HbA1c between the supervised and technology groups were similar (46% vs 43%) and the associated OR was 0.87 (95%CI:0.34-2.28). Within the two technology groups, proportions of people achieving a clinically meaningful difference in HbA1c were 48% in the mobile app and 38% in the smartwatch groups and the associated OR was 0.65 (95%CI:0.21-2.03). The groups did not differ on secondary and explanatory outcomes.

CONCLUSIONS

The results of our trial provide evidence that all outcomes have improved in all groups regardless of the exercise delivery method. Considering the supervised programs are not available for everybody, technological options are crucial to implement to help individuals self-manage most aspects of their diabetes.

The role of mean platelet volume in nonalcoholic fatty liver disease without cardiovascular comorbidities, obesity and diabetes mellitus

BACKGROUND

While the relation of mean platelet volume (MPV) with inflammatory diseases is obvious, its role in nonalcoholic fatty liver disease (NAFLD) without cardiovascular comorbidities, obesity and diabetes mellitus is not clear.

METHODS

A total of 249 patients (nonobese, nondiabetic and not having cardiac diseases) who underwent an abdominal ultrasonography assessment were enrolled. They were divided according to the absence (group 1) or presence (group 2) of hepatic steatosis. The patients with steatosis were further divided according to the severity of steatosis as group 2a (grade 1), 2b (grade 2) and 2c (grade 3). The demographic and laboratory features were compared between groups.

RESULTS

Hepatic steatosis was absent in 120 patients and detected in 129 patients (grade 1, 2, 3 hepatic steatosis in 75, 49 and 5 patients, respectively). BMI, aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio and serum AST, ALT, triglyceride levels were significantly higher in group 2 than in group 1 (P < 0.001, P < 0.001, P < 0.001, P = 0.005, P < 0.001, respectively). BMI, serum AST and triglyceride levels were significant factors for NAFLD (P < 0.001, P = 0.018, P = 0.001). MPV was neither different between groups (P > 0.05) nor a predictor factor for NAFLD (P > 0.05).

CONCLUSION

MPV is a useless parameter to detect NAFLD without cardiovascular comorbidities, obesity and diabetes mellitus.

Does metformin affect mammographic breast density in postmenopausal women with type 2 diabetes

Background: Increased mammographic breast density (MBD) is known to be associated with an increased risk of developing breast cancer.Aims: In this study, we aimed to research the possible relationship between MBD and metformin use in postmenopausal women diagnosed with type 2 diabetes mellitus (T2DM).Method: The patients were divided into two groups: women with T2DM and who were on metformin and women who were newly diagnosed with T2DM and had not yet taken metformin. MBD types are evaluated by a specialist radiologist.Results: Among the 74 women, 32 (43.2%) were in the group that did not use metformin and 42 (56.8%) were in the group of patients using metformin. The duration of breastfeeding (p = .0003), fasting blood glucose (p = .0003) and HbA1c (p = .0006) were statistically significantly higher in the group not using metformin. The quantitative mean ranks of the group members' MBD's were 41.81 in the metformin naïve group and 34.21 in the group using metformin (p = .12).Conclusions: In conclusion, metformin has no statistically significant effect on MBD in postmenopausal female patients with T2DM.

Insulin autoimmune syndrome - time to remember

Not required for Clinical Vignette.

Current situation analysis of diabetic home care patients

OBJECTIVE

Diabetes is one of the primary diagnoses for admission to home health care units. Although there are many studies about elderly diabetic patients, there are not many studies on home care patients with diabetes. The present study aims to analyze the current status of diabetic home care patients with their biochemical data and medications.

METHODS

This was a retrospective study, including 256 diabetic patients who were following up by the Home Health Unit of Istanbul Provincial Health Directorate Public Hospitals Services-2. In this study, we analyzed the current biochemical data of the patients with their medications.

RESULTS

In this study, 185 female (72.3%) and 71 male (27.7%) patients were recruited with the mean HbA1c of 8.25±1.77. Among these patients, 65% of them were using oral antidiabetic (OAD), and 58% were using insulin. There were 21 (8.2%) patients who were not receiving any treatment. While patients who were using only oral antidiabetic have better A1c levels (A1c: 7.73±1.45), patients who were insülin using had HbA1c levels as high as the patients who were not using any medication. This may be due to the progression of diabetes, fear of hypoglycemia or insufficient insülin use. While metformin was the most commonly used OAD, with a 38% usage rate. When compared to HbA1c levels, there was no difference between the types of insulin used (p=0.167).

CONCLUSION

As a result, it is important to plan regular visits and personalized treatment by keeping in mind the benefits to risk ratios in home-care diabetic patients.

Lens autofluorescence ratio as a noninvasive marker of peripheral diabetic neuropathy

INTRODUCTION Diabetes and its complications are the significant cause of morbidity and mortality. Advanced glycation end products play a major role in the pathogenesis of diabetes complications. OBJECTIVES The aim of the study was to investigate the possible use of a biomicroscope (ClearPath DS‑‑120), which shows the age‑‑adjusted lens fluorescence ratio (LFR), for the diagnosis of diabetic peripheral neuropathy (DPN). PATIENTS AND METHODS A total of 160 patients with type 2 diabetes who underwent an LFR measurement were recruited to this study. DPN was defined as the presence of neuropathic pain or feet sensory loss (or both). Neurothesiometer, monofilament test, and DN4 test results were used for the diagnosis of DPN. RESULTS The LFR of 43 patients (27%) was higher than the expected levels. According to the DN4 questionnaire, 35 of 160 patients (21%) had neuropathic pain. Thirty‑‑seven patients (23%) had higher vibration perception thresholds than expected (>25 V). The monofilament test showed that 42 patients (26%) seemed to be affected by DPN. All of the tests, when considered individually, revealed that patients with higher LFR had more problems related to DPN (P <0.05). High LFR had a sensitivity of 50% and a specificity of 81% in the diagnosis of DPN. Although there was no significant difference in fasting blood glucose levels, we observed that HbA1c levels were higher and diabetes duration was longer in patients with higher LFR (P <0.05). CONCLUSIONS The measurement of LFR may have clinical utility for a noninvasive detection of DPN.

Effıcacy and safety of dapagliflozin on diabetic patients receiving high-doses of insulin

OBJECTIVE

In this study we aimed to investigate the efficacy and safety of dapagliflozin addition to diabetic patients using high dose insulin.

METHODS

The current study was carried out in the outpatient diabetic clinics of Fatih Sultan Mehmet Education and Research Hospital. Thirty diabetic patients who were receiving high dose (>0,5U/kg) insulin and oral antidiabetic treatment (other than SGLT 2 inhibitors) were included in this study. Primary end point was the change in HbA1c, insulin doses and serum electrolyte from the addition of dapagliflozin 10 mg to the week 12.

RESULTS

At the end of three month BMI were obviously decreased from 33.31 ±4.51 to 32.14 ±4.66 (p: 0.001). There was also an evident decrease of insulin requirement from 76 ±23.15 U/kg to 57.60 ±17.61 U/day (p<0.001). As well as the decrease in insulin doses, there was also a significant decline in HbA1c (Δ 1.6 %) and fasting blood glucose levels (Δ68.6 mg/dl) (p<0.001). Among serum electrolyte levels slight but meaningful increase of blood urea nitrogen (BUN) and sodium (Na) levels were seen (p: 0.044 and p: 0.026). There were no significant changes in serum cholesterol levels with electrolytes such as potassium, calcium, phosphorus magnesium and vitamin D (p> 0.05).

CONCLUSION

In diabetic patients with inadequately controlled glucose regulation despite high-dose insulin therapy, dapagliflozin may be an alternative combination choice to decrease the need of insulin dose and obtain an optimal HbA1c, fasting plasma glucose levels and weight without major side effects.

Mean platelet volume changes before and after glycated hemoglobin (HbA1c) improvement in a large study population

INTRODUCTION

Diabetes mellitus (DM) is a metabolic disorder associated with both microvascular and macrovascular complications. Mean platelet volume (MPV) is a marker of platelet activity, which plays a major role in the development of vascular complications of DM. The aim of this study is to compare the MPV levels before and after the decrease of glycated hemoglobin (HbA_1c) levels in a large diabetic population.

MATERIAL AND METHODS

This was a retrospective study conducted on type 2 diabetic patients from the outpatient clinic for 1 year between 2014 and 2015 with the participation of 595 diabetic patients.

RESULTS

When we compared the basal and post-treatment values, a significant decrease of MPV and HbA_1c levels was found (HbA_1c: 9.41 ±1.98% vs. 7.43 ±1.29%, p < 0.001; MPV: 9.11 ±1.42 vs. 8.17 ±1.04, p < 0.001). There was also a positive correlation between the mean changes of MPV and HbA_1c levels after the treatment (ΔMPV: 0.93 ±0.96 vs. ΔHbA_1c: 1.96 ±1.43; p = 0.005, r = 0.115). When the participants were divided into two groups according to their basal HbA_1c levels (group A: HbA_1c ≤ 6.5% and group B: HbA_1c > 6.5%), it was clearly seen that improvement of glucose levels led to a significant decrease in MPV levels in both groups.

CONCLUSIONS

The results of this study show that better glycemic control is associated with a significant decrease of MPV levels, regardless of whether the treatment modality is insulin or oral antidiabetic.

The relationship between thyroid antibody titer and levothyroxine dose in patients with overt primary hypothyroidism

BACKGROUND

Both excess and insufficient thyroid hormone replacement may produce adverse effects in various target tissues; therefore, understanding factors that affect achievement of target TSH levels is crucial.

OBJECTIVE

Investigate the relationship between antibody titers and levothyroxine dose.

DESIGN

Retrospective, review of data in medical records.

SETTING

Thyroid center of Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey.

PATIENTS AND METHODS

The study population consisted of patients that had been diagnosed as having overt primary hypothyroidism and were taking levothyroxine for at least one year. The serum TSH level for an euthyroid state was between 0.5-4 mIU/L. The levels of anti-thyroid peroxidase (TPOAb) considered positive for antibodies were < 5.6 IU/mL and for anti-thyroglobulin (TgAb) autoantibodies < 4.10 IU/ mL.

MAIN OUTCOME MEASURE

Daily levothyroxine doses of antibody-positive and negative patients and association of daily drug requirement with antibody titers.

RESULTS

The study population consisted of the 303 patients (273 females and 30 males with the mean [SD] age of 46.6 [13.2] years). In the antibody-positive group (n=210) average daily levothyroxine dose was statistically significantly higher than in the antibody-negative group (n=93) (mean of 78.8 [36.7] vs 64.2 [27.1] mg/day, P=.001, respectively). There was a low but statistically significant positive relationship between the TPOAb (r=0.217, P < .01) and TgAb levels (r=0.158, P < .05) and levothyroxine doses in the antibody-positive group.

CONCLUSION

Antibody titers are positively associated with larger levothyroxine (LT-4) replacement dosing in patients with autoimmune thyroiditis.

LIMITATION

Unknown antibody titers before starting levothyroxine use.

The Effect of Glucose Variability on QTc Duration and Dispersion in Patients with Type 2 Diabetes Mellitus

Objective:

Glycemic variability (GV) is a new term with the episodes of hyper and hypoglycemia in diabetic patients. Both prolonged QT interval and QTd are potential risk factors for malignant ventricular arrhythmias affecting the mortality of different groups of patients including diabetes mellitus. In this study, we aimed to evaluate if the glucose variability increasing the QTc interval and QTc dispersion in type 2 diabetes mellitus.

Methods:

We included 275 consecutive patients with type 2 diabetes. We quantified the GV with standard deviation (SD) and coefficient of variation (CV) from 7 point glucose measures. We investigated the relationship of GV parameters with QT parameters.

Results:

The prevalence of prolonged QTc duration was 21%, no patients have prolonged QTc dispersion (> 80 ms). SD of the patients with prolonged QTc duration was significantly higher than the others (45.14 ±24.45 vs. 37.78 ±9.03 p<0.05). There was also a significant relationship between SD and QTc dispersion (r: 0.164; p: 0.007). There were no relationship between the QT parameters and microvascular diabetic complications. SD and HbA1c levels were significantly higher on the patients having peripheral neuropathy (p<0.005).

Conclusion:

The result of this study demonstratess that increased glycemic variability is associated with prolonged QTc duration and QTc dispersion. It is important to focus on targeting optimal glycemic control with GV as an additional goal point along with the traditional following parameters such as fasting-postprandial blood glucose and HbA1c.

The effect of ezetimibe monotheraphy on mean platelet volume in patients with hyperlipidaemia: a retrospective study of 45 patients

OBJECTIVE

To investigate the effect of ezetimibe on platelet functions as a drug which increases mevalonate levels.

METHODS

This retrospective study was conducted in Istanbul, Turkey, and comprised record of normolipidaemic and hyperlipidaemic patients taken from the outpatient clinic from October 2004 to February 2015,. The results were taken from the baseline and third-month data of ezetimibe treatment. SPSS 22 was used for statistical analysis.

RESULTS

Of the total, there were 50(53%) normolipidaemic patients and 45(47%) hyperlipidaemic ones. Pre- and post-treatment values of mean platelet volume were significantly higher in the hyperlipidaemic group than controls (p<0.001). In the hyperlipidaemic group there was no significant difference between pre- and post-treatment values of mean platelet volume (8.96±0.93 vs. 8.92±0.84; p>0.05).

CONCLUSIONS

The use of ezetimibe alone should not be the first choice in hyperlipidaemia treatment.

Myocardial injury and acute renal failure associated with lactic acidosis due to suicide attempt with metformin

Metformin-associated lactic acidosis (MALA) is one of the most important drug toxicities with a high morbidity and mortality rate. We report herein a case of suicide attempt with metformin presenting as MALA and acute renal failure on admission to emergency department and acute myocardial injury later on hospitalisation. An obvious improvement of metabolic parameters was seen in our patient provided by anti-ischaemic treatment together with bicarbonate infusion and haemodialysis. Although myocardial injury due to MALA is not a common disorder, we must be aware that metformin overdose with lack of tissue oxygenation, hypoperfusion, and arrhythmias may cause myocardial ischaemia.

Assesment of psychiatric symptoms and co-morbidities in patients with irritable bowel syndrome

AIM

To determine the psychiatric symptom assessment of patients seeking treatment for irritable bowel syndrome (IBS) and to demonstrate the presence of more complicated psychiatric disorders.

SUBJECTS AND METHOD

The participants were recruited from patients who were attending internal medicine and gastroenterology clinics and who fullfilled the Rome III criteria for IBS. Fifty patients with IBS (IBS group) and 50 patients with complaints other than gastrointestinal symptoms (control group) were randomly selected. All participants were screened by the Structured Clinical Interview for DSM-IV (SCID-I), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Check list - 90 (Revised) [SCL-90-R].

RESULTS

Seventeen patients (34%) and three control subjects (6%) had at least one psychiatric diagnosis (p = 0.001). Global severity index (GSI) total scores and SCL-90-R items were significantly higher in the IBS group than the control group (0.92 +/- 0.46 vs 0.358 +/- 0.19, p < 0.001). Beck anxiety inventory and BDI scores were higher in the IBS group than the control group (p < 0.001). Axis-I psychiatric disorders diagnosed with SCID-I were significantly higher in the IBS group (34% vs 6%) [p = 0.001]. Among the Axis-I disorders, somatoform and anxiety disorders were higher in the patient group than in the control subjects (p = 0.002 and p = 0.0057) whereas there was no difference for mood disorders (p = 0.204). Seven (14%) of the patients and two (4%) of the control subjects had at least one Axis-II psychiatric disorder diagnosed with SCID-II without any significance (p = 0.159).

CONCLUSION

These findings suggest that except for mood and personality disorders, almost all psychiatric symptoms and disease co-morbities with IBS are higher than in the sample without IBS. We can easily use SCL-90-R, BAI and BDI in internal medicine and gastroenterology clinics to detect psychiatric symptom levels and then to refer patients to a psychiatrist for further evaluation and treatment.

Effects of thyroxin therapy on cardiac function in patients with subclinical hypothyroidism: index of myocardial performance in the evaluation of left ventricular function

OBJECTIVE

We investigated the effects of thyroxine (T4) therapy on the cardiac function in subclinical hypothyroidism (SHT) by using the index of myocardial performance (IMP) and the conventional echocardiographic parameters.

METHODS

Forty-five SHT patients (F/M:38/7, age 39.9+/-7.9) and 29 healthy subjects (F/M:25/4, age 38.3+/-8.6) were studied. Patients were randomly assigned, in a double-blind manner to receive T4 therapy (group I) or a placebo (group II) and for a period of up to 12 months, were followed up using thyroid function tests and both conventional and Doppler echocardiographic measurements.

RESULTS

At the baseline, the SHT patients has a significantly higher isovolumic relaxation time (IRT) (98.3+/-23.7 vs. 81.7+/-14.7<0.01), IMP (0.52+/-0.06 vs. 0.42+/-0.05; P<0.001), A max (late mitral peak velocity) (83.4+/-12.6 vs. 74.3+/-13.5; P<0.01) and significantly lower (early mitral peak velocity) Emax/Amax ratio (1.19+/-0.18 vs. 1.34+/-0.17; P<0.01) than the individuals in the control group. In group I, the thyroid hormone profile became normalized after 1 year of L-T4 therapy, but there was no significant change in the left ventricular (LV) morphology or systolic function. After 1 year of follow-up, group I showed a significant reduction of MPI (0.53+/-0.05 vs. 0.42+/-0.07; P<0.001), Amax (84.2+/-13.7 vs. 74.5+/-11; P<0.001) and IRT (98.6+/-23.7 vs. 82.9+/- 23.3; P<0.001) along with a normalization of the E/A ratio (1.17+/-0.16 vs. 1.33+/-0.19; P<0.001). Conversely, no change was observed in group II.

CONCLUSIONS

An impairment of left ventricular diastolic function, which may be reversible with T4 therapy, was observed in the SHT patients, and IMP may be useful in the evaluation of LV myocardial dysfunction in these patients.