Case Report: Successful Outcome for Refractory Diabetic Peripheral Neuropathy in Patients With Ultrasound-Guided Injection Treatment

Diabetic peripheral neuropathy is the most prevalent chronic complication of diabetes and is based on sensory and autonomic nerve symptoms. Generally, intensive glucose control and nerve nourishment are the main treatments. However, it is difficult to improve the symptoms for some patients; such cases are defined as refractory diabetic peripheral neuropathy (RDPN). In this paper, we present five patients treated with saline and mecobalamin by ultrasound-guided injection. The Visual Analog Scale and Toronto Clinical Scoring System were used to evaluate the symptoms, and the neuro-ultrasound scoring system and electrophysiological severity scale were evaluated by ultrasound and electrophysiological examination. In brief, ultrasound-guided hydrodissection may be a safe way to treat RDPN.

PROGNOSTIC ROLE OF NLR AND RBS LEVELS IN DIABETIC PATIENTS WITH SEVERE COVID-19 DISEASE

Objective-This retrospective study was done to assess the role of NLR (Neutrophil to lymphocyte ratio) and RBS (RANDOM BLOOD SUGAR) levels at the time of admission as prognostic markers and correlate them with clinical outcome. Materials and methods:Atotal of 100 diabetic patients with severe COVID-19 Disease, requiring ICU admission were studied at SRN Hospital, Prayagraj. Blood samples were sent for various inammatory markers along with random blood glucose levels. Patients were divided as survivors and non- survivors. Results: The mean NLR was higher in the group of patients who did not survive (11.35±8.09) than in the patients who survived (7.79±5.27). Mean RBS (in mg/dL) in the survivor group and the non-survivor group at the time of admission was 232.19±133.75 and 333.41±130.81 respectively. The NLR, RBS, CRP cutoff were identied as >7.247, >254.6 mg/dL,>12.86 mg/Lrespectively to predict mortality using the ROC curve (p value <0.05). Conclusion:NLR and RBS at the time of admission can be easily used as surrogate markers for predictors of mortality. Screening and intensive glucose control is strictly recommended for all diabetic patients.

Historical HbA1c Values May Explain the Type 2 Diabetes Legacy Effect: UKPDS 88

<p><b>Objective</b> Type 2 diabetes all-cause mortality (ACM) and myocardial infarction (MI) glycaemic legacy effects have not been explained. We examined their relationships with prior individual HbA_1c values and explored the potential impact of instituting earlier, compared with delayed, glucose-lowering therapy. <i></i></p> <p><b>Research design and methods</b> Twenty-year all-cause mortality (ACM) and myocardial infarction (MI) hazard functions were estimated from diagnosis of type 2 diabetes in 3,802 UK Prospective Diabetes Study participants. HbA_1c values impact over time were analysed by weighting them according to their influence on downstream ACM and MI risks. </p> <p><b>Results </b>Hazard ratios for a 1 percentage unit higher HbA_1c for ACM were 1.08 (95% CI 1.07-1.09), 1.18 (1.15–1.21) and 1.36 (1.30–1.42) at 5, 10 and 20 years respectively, and for MI 1.13 (1.11–1.15) at 5 years increasing to 1.31 (1.25–1.36) at 20 years. <br> Imposing a one percentage unit lower HbA_1cfrom diagnosis generated an 18.8% (95% CI 21.1%–16.0%) ACM risk reduction 10-15 years later, whereas delaying this reduction until 10 years after diagnosis showed a 7-fold lower 2.7% (3.1%-2.3%) risk reduction. Corresponding MI risk reductions were 19.7% (22.4%-16.5%) when lowering HbA_1c at diagnosis, and 3-fold lower 6.5% (7.4%-5.3%) when imposed 10 years later.</p> <p><b>Conclusions </b>The glycaemic legacy effects seen in type 2 diabetes are explained largely by historical HbA_1c values having a greater impact than recent values on clinical outcomes. Early detection of diabetes and intensive glucose control from the time of diagnosis is essential to maximise reduction of the long-term risk of glycaemic complications.</p>

The Impact of Frailty on the Effectiveness and Safety of Intensive Glucose Control and Blood Pressure-Lowering Therapy for People With Type 2 Diabetes: Results From the ADVANCE Trial

<b>Objective. </b>To develop a frailty index (FI) and explore the relationship of frailty to subsequent adverse outcomes on the effectiveness and safety of more intensive control of both blood glucose and blood pressure (BP), amongst participants with type-2 diabetes in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. <p><b>Research Design and Methods. </b>Cox proportional-hazard models were used to estimate the effectiveness and safety of intensive glucose control and BP intervention according to frailty (defined as FI>0.21) status. The primary outcomes were macrovascular events and microvascular events. The secondary outcomes were all-cause mortality, cardiovascular mortality, severe hypoglycaemia, and discontinuation of BP treatment due to hypotension/dizziness.</p> <p><b>Results.</b> There were 11140 participants (mean age 65.8, 42.5% female, 25.7% frail). Frailty was an independent predictor of all primary outcomes and secondary outcomes. The effect of intensive glucose treatment on primary outcomes showed some evidence of attenuation in the frail: HRs for combined major macro- and micro-vascular events 1.03, 95%CI 0.90-1.19 in the frail vs 0.84, 95%CI 0.74-0.94 non-frail (p=0.02). A similar trend was observed with BP intervention. <a>Severe hypoglycaemia rates (per 1000 person-years) were higher in the frail: 8.39 (6.15–10.63) vs. 4.80 (3.84–5.76) in non-frail</a> (p<0.001). There was no significant difference in discontinuation of BP treatment between frailty groups.</p> <p><b>Conclusions. </b>It was possible to retrospectively estimate frailty in a trial population, and this FI identified those at higher risk of poor outcomes. Participants with frailty had some attenuation of benefit from intensive glucose lowering and BP lowering treatments. </p>

The Impact of Frailty on the Effectiveness and Safety of Intensive Glucose Control and Blood Pressure-Lowering Therapy for People With Type 2 Diabetes: Results From the ADVANCE Trial

<b>Objective. </b>To develop a frailty index (FI) and explore the relationship of frailty to subsequent adverse outcomes on the effectiveness and safety of more intensive control of both blood glucose and blood pressure (BP), amongst participants with type-2 diabetes in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. <p><b>Research Design and Methods. </b>Cox proportional-hazard models were used to estimate the effectiveness and safety of intensive glucose control and BP intervention according to frailty (defined as FI>0.21) status. The primary outcomes were macrovascular events and microvascular events. The secondary outcomes were all-cause mortality, cardiovascular mortality, severe hypoglycaemia, and discontinuation of BP treatment due to hypotension/dizziness.</p> <p><b>Results.</b> There were 11140 participants (mean age 65.8, 42.5% female, 25.7% frail). Frailty was an independent predictor of all primary outcomes and secondary outcomes. The effect of intensive glucose treatment on primary outcomes showed some evidence of attenuation in the frail: HRs for combined major macro- and micro-vascular events 1.03, 95%CI 0.90-1.19 in the frail vs 0.84, 95%CI 0.74-0.94 non-frail (p=0.02). A similar trend was observed with BP intervention. <a>Severe hypoglycaemia rates (per 1000 person-years) were higher in the frail: 8.39 (6.15–10.63) vs. 4.80 (3.84–5.76) in non-frail</a> (p<0.001). There was no significant difference in discontinuation of BP treatment between frailty groups.</p> <p><b>Conclusions. </b>It was possible to retrospectively estimate frailty in a trial population, and this FI identified those at higher risk of poor outcomes. Participants with frailty had some attenuation of benefit from intensive glucose lowering and BP lowering treatments. </p>

Stress Induced Hyperglycemia in the Context of Acute Coronary Syndrome: Definitions, Interventions, and Underlying Mechanisms

Elevation of glucose level in response to acute coronary syndrome (ACS) has been recognized as stress induced hyperglycemia (SIH). Plenty of clinical studies have documented that SIH occurs very common in patients hospitalized with ACS, even in those without previously known diabetes mellitus. The association between elevated blood glucose levels with adverse outcome in the ACS setting is well-established. Yet, the precise definition of SIH in the context of ACS remains controversial, bringing confusions about clinical management strategy. Several randomized trials aimed to evaluate the effect of insulin-based therapy on outcomes of ACS patients failed to demonstrate a consistent benefit of intensive glucose control. Mechanisms underlying detrimental effects of SIH on patients with ACS are undetermined, oxidative stress might play an important role in the upstream pathways leading to subsequent harmful effects on cardiovascular system. This review aims to discuss various definitions of SIH and their values in predicting adverse outcome in the context of ACS, as well as the effect of intensive glucose control on clinical outcome. Finally, a glimpse of the underlying mechanisms is briefly discussed.

Sugar Is Not Always Sweet: Exploring the Relationship Between Hyperglycemia and COVID-19 in a Predominantly African American Population

Introduction: A relationship between hyperglycemia and outcomes in patients with COVID-19 has been proposed, however there is a paucity of literature on this. In this study, we examined the effect of admission glucose in diabetics and non-diabetics on outcomes in patients hospitalized with COVID-19. Our study uniquely examines this association in a largely African American cohort, a population disproportionately affected by COVID-19. Methods: In this retrospective cohort study, we analyzed all adults admitted with COVID-19 to a designated COVID hospital in Brooklyn, NY from March 1 to May 15, 2020. Diabetics were compared to non-diabetics, and were further stratified based on admission glucoses of 140 and 180 mg/dL. Diagnosis of diabetes was based on history and/or Hba1c &gt; 6.5%. Univariate, multiple and logistic regressions were used for analyses, examining outcomes of mortality, intubation, ICU admission, acute kidney injury (AKI), and length of stay based on admission glucose levels, while controlling for age, gender, lab values (serum creatinine and WBC), and comorbidities including hypertension, cardiovascular disease, and obesity. Outcomes are presented as an adjusted odds ratio (OR) with 95% confidence interval (95% CI). Results: 708 patients were analyzed; 54% diabetics, 83.5% non-Hispanic Blacks, 51% male with a mean age of 68, BMI of 29 kg/m2 and crude mortality rate of 40%. The length of hospital stay was greater in diabetics than non-diabetics, (13±26 days vs 9.5±18.5 days, p&lt;0.05). Diabetics with an admission glucose &gt; 140 mg/dL (vs&lt;140 g/dL) had a 2.4-fold increased odds of both intubation and ICU admission (95% CI: 1.2, 4.5; 1.3, 4.6). Diabetics with admission glucoses &gt; 180 mg/dL (vs &lt;180 g/dL) had a 1.8-fold increased mortality (95% CI: 1.2, 2.9). Non-diabetics with admission glucoses &gt;140 mg/dL (vs&lt;140 g/dL) had a two-fold increased mortality (95% CI: 1.2, 3.5), 3.5-fold increased odds of ICU admission (95% CI: 1.8,6.6) and a 2.3-fold increased odds of both intubation and AKI (95% CI: 1.3, 4.2; 1.3,4.2). Non-diabetics with a glucose &gt;180 mg/dL (vs &lt;180 g/dL) had a four-fold increased mortality (95% CI: 1.8, 8.8), 2.7-fold increased odds of intubation (95% CI: 1.3, 5.6) and 2.9-fold increased odds of ICU admission (95% CI: 1.3, 6.2). Conclusion: Our results show hyperglycemia portends worse outcomes in diabetics and non-diabetics with COVID-19. Elevated admitting glucoses &gt;180 mg/dL increased odds of mortality four-fold in non-diabetics and 1.8- fold in diabetics. In COVID-19, diabetic patients had a 37% greater length of hospital stay than non-diabetics. Whether hyperglycemia is a marker or a cause of more severe COVID-19 is unknown. These findings suggest that patients presenting with hyperglycemia require closer observation and more aggressive therapies. This raises the testable hypothesis that intensive glucose control may improve outcomes in patients with COVID-19.