Severe COVID-19 illness in an Indian adolescent with autoimmune polyendocrinopathy syndrome-1

Autoimmune polyglandular syndrome-1 (APS-1)also known as autoimmune polyendocrinopathy candidiasis ectodermal dystrophy is a rare autosomal recessive disorder caused by mutation of AIRE gene on chromosome 21q22.3 with an overall prevalence of <1:100,000. Here, we present a 16-year-old male having clinical history of evolution of symptoms for oral candidiasis, hypoparathyroidism, and adrenal insufficiency (AI). He developed rare endocrine and non-endocrine manifestations such as type-1 diabetes (T1D) and autoimmune hepatitis, respectively. The patient while on hormone replacement therapy along with immunosuppressants developed liver cirrhosis and portal hypertension with esophageal varices and candidiasis. Subsequently, he was admitted for complaints of cough, cold and fever and was confirmed to be affected by SARS-CoV-2 by reverse transcription-polymerase chain reaction method. In his prolonged ICU stay of 26 days, he required oxygen therapy, intravenous glucocorticoids, remdesivir, low molecular weight heparin, and hemodynamic support with inotropes. His medical management with subcutaneous insulin therapy and azathioprine was continued. He was discharged after complete resolution of symptoms and negative tests for SARS-CoV-2 and was advised radiological and clinical follow-up. Reports suggest that risk of severe COVID does not increase in patients with AI or autoimmunity. However, our patient possibly developed severe COVID not only due to AI and autoimmunity but also associated rare manifestations like hyperglycemia due to T1D and cirrhosis. Thus, good glycemic control and well-tolerated modern immunosuppressant therapy may be useful in improving prognosis of severe COVID-19 illness in patients with APS-1.

A Comparison between Type-2 Diabetics and Non-Diabetics in Terms of Papillary Bleeding Index (PBI)

OBJECTIVES: The purpose of this study was to compare the Type 2 diabetes mellitus patients and non-diabetics in terms of Papillary bleeding index (PBI) of periodontal disease. METHODOLOGY: This comparative cross-sectional study was conducted during the period of November 2020 to February 2021 in three (3) tertiary care hospitals of Peshawar. The sampling technique was purposive sampling. The sample comprised 105 individuals, 56 participants in Type–2 diabetes group and 49 in non-diabetes group. Male and females, having age between 40-65 years were recruited. Each diabetic and non-diabetic were clinically examined for periodontitis. Age and sex-matched participants suffering from periodontitis without a history of diabetes as well as with good glycemic control (HbA1c) were considered as controls subjects. Glycated hemoglobulin (HbA1c) was carried out for all the participants free of cost by using Human Gmbh-Max-Planck-Ring 21-65205 Wiesbaden-Germany kit. The study was approved by the ethical committee of the Peshawar Medical College. Data was analyzed using software package SPSS version 20. RESULTS: Out of 56 diabetics, 24 subjects brushed once daily, 15 brushed twice daily, 11 brushed occasionally and 6 didn’t brush whereas in 49 non diabetics, 20 subjects brushed once daily, 13 brushed twice daily, 11 brushed occasionally and 5 didn’t brush. The clinical parameter mean (PBI) was recorded in our study. Score was 2.09 (±0.82) in diabetics and 1.02 (±0.47) in non-diabetics. P-value measured by the chi square test was significant. Spearman correlation test was performed to explore the association between the type 2 diabetes and Papillary bleeding index (PBI). CONCLUSION: We concluded that a significant difference exists between the mean PBI scores of Type 2 diabetics and non-diabetics.

Relationship between Atherogenic Index of Plasma with HbA1c Levels in Type 2 Diabetes Mellitus Patients

Type 2 Diabetes Mellitus (T2DM) is a global health problem due to an increasing prevalence and incidence. HbA1c as aparameter for glycemic control is still above the desired target of 7%. Atherogenic Index of Plasma (AIP) is predicted to be anindicator of cardiovascular disease risk in T2DM. Dyslipidemia in T2DM patients showed a result of increased triglycerideand decreased HDL cholesterol levels. This study aimed to determine the relationship between HbA1c and AIP, triglycerides,and HDL cholesterol in T2DM patients. An analytical observational study using a cross-sectional method on 74 DMT2patients who underwent HbA1c and lipid profile examinations in January-March 2020. Atherogenic index of plasma wascalculated by the logarithmic equation (triglycerides/HDL cholesterol). Data were analyzed by SPSS 25.0. The relationshipbetween HbA1c with AIP, triglycerides, and HDL cholesterol using the Pearson correlation test. Atherogenic index of plasma(0.25±0.25) and triglycerides (211.92±146.09 mg/dL) were found to be higher in the poor glycemic control group (HbA1c> 7%) than AIP (-0.04±0.20) and triglycerides (108.96±38.96 mg/dL) in the good glycemic control group (p < 0.05). HDLcholesterol (40.08±12.64 mg/dL) was found to be higher in the poor glycemic control group than HDL cholesterol(52.28±18.12 mg/dL) in the good glycemic control group (p < 0.05). There was a significant positive correlation betweenHbA1c and AIP (r=0.411, p=0.000), HbA1c with triglycerides (r=0.418, p=0.000), and a significant negative correlationbetween HbA1c and HDL cholesterol (r=-0.233, p=0.046). Insulin resistance can cause lipid metabolism disorders,inflammation, oxidative stress, and coagulation disorders. Maintaining glycemic control and lipid control plays an importantrole in preventing diabetes complications. There is a significant positive correlation between HbA1c and AIP, HbA1c andtriglycerides, and a significant negative correlation between HbA1c and total cholesterol in T2DM patients.

Role of motivational interviewing in type 1 diabetes mellitus with sub optimal glycemic control.

Objective: To determine the role of motivational interviewing in better management of diabetes mellitus in children. Study Design: Observational Cross Sectional Study. Setting: Children Hospital & Institute of Child Health Multan. Period: November 2019 to May 2020. Material & Methods: Fifty-six poorly controlled follow up diabetic children of 8 to 15 years of both sexes, with HBA1c more than 10 %were included. Their social status, educational status whether studying or not was noted. All patients were advised subcutaneous Insulin according to weight. All children were counselled and motivated for self-care, problem identification and solution, and proper diabetic management by a team consisting of an endocrinologist, a dietitian, a psychologist and a nurse. Glycemic control was assessed using HbA1c, at 1st visit, 3rd and 6th month. A decline in HbA1c by ≥1% was considered for good control of DM, while ≤1% decrease was taken as poor control of DM. Data was analyzed by using SPSS version 20. Result: Out of 56 patients. 50%(n=28) were females and ,50%(n=28) were males.42.9 % (n=24) patients were age ranges between 8 to 11.5 years while 57.1%(n=32) more than 11.5 to 15 years, with mean age of 11.8±1.97 years 28.6% diabetic children belonged to lower, 57.1% middle while 14.3% upper socioeconomic status. 69.4%children were going to school while 27.6% were not studying. Good glycemic control was observed in 85.7% diabetic children which is statistically significant (p-value <0.001). Conclusion: Motivational interview proved to be a good tool for the better outcome of diabetic children, who need both knowledge and practical communication for their management regarding behavioral changes, lifestyle issues and self-management. It must be a part of diabetic management programs.

Characterizing Autonomy Supportiveness in Diabetes Peer Health Coaches

BackgroundPrior studies have shown that peer health coaching improves outcomes among adults with chronic conditions such as diabetes. These studies have also suggested that higher ratings of their peer coach’s autonomy supportiveness, i.e., the degree to which a coach supports participant choice, is associated with improved outcomes. The types of actual behaviors and interactions that participants in these coaching relationships perceive as being more or less autonomy supportive are important to define. This investigation aims to more concretely characterize the ways in which participants perceive autonomy support and how important these perceptions are to their satisfaction with their peer coaches.MethodsThis article is a qualitative investigation of the US Department of Veterans Affairs–Technology Enhanced Coaching (VA-TEC) study, a parallel randomized controlled trial with diabetes patients with poor glycemic control at the Detroit VA Medical Center. Intervention arm participants work for 6 months with peer coaches who are also VA patients who now have good glycemic control. Researchers conducted semi-structured interviews with veterans who had recently completed their 6 months of coaching. Responses to Health Care Climate Questionnaire (HCCQ) items in the trial’s 6-month survey were used to identify veterans for interviews who rated their coaches either especially high or low in terms of autonomy supportiveness. Interview responses were then analyzed in order to elucidate veterans’ perceptions of autonomy support in their coaching relationships.ResultsSemi-structured interviews were conducted with 17 of the veterans who completed the VA-TEC program. Veterans who rated their coaches higher on HCCQ items tended to emphasize the positivity and non-judgmental nature of their coaches. They also described coaches who offered them choices and non-directive suggestions in identifying health behavior goals. Veterans who gave their coaches lower HCCQ ratings described coaches who tended to be less personally engaged and less focused on addressing veterans’ specific concerns about diabetes. Some veterans who rated their coaches lower on autonomy-supportiveness felt their coaches underestimated their existing knowledge of diabetes and were overly directive in providing advice. Overall, participants’ HCCQ ratings correlated well with expressed satisfaction with their coach in interviews.&nbsp;ConclusionsVA-TEC participant feedback outlines meaningful ways in which coaches can support autonomy. These include, among others, eliciting participants’ personal goals, remaining positive and non-judgmental, providing suggestions for behavior changes without being overly directive, and maintaining a balance between discussing diabetes and the types of personal conversations that are crucial to building trust. The effective behaviors described in this investigation can be used to train future coaches and other lay health workers.

Effects of SGLT2 Inhibitors on the Risks of Hypertension and Heart Failure in Diabetic Patients: A Systematic Review

Diabetes mellitus (DM) with uncontrolled blood sugar causes a variety of problems, including coronary artery disease, stroke, heart failure, hypertension, nephropathy, neuropathy, and retinopathy. These consequences harm the diabetic patients' lives. Many studies have shown that diabetic patients have a higher rate of heart failure and a worse prognosis than non-diabetic people. Sodium and glucose co-transporter receptor-2 (SGLT2) inhibitors are a relatively new class of anti-diabetic drugs. They not only regulate blood sugar but also have positive cardiovascular effects via a variety of mechanisms. This review intends to show that SGLT2 inhibitors, in addition to good glycemic control, possess a cardioprotective role. We conducted a literature review and identified 20 adequately powered clinical trials and animal studies in type 2 DM that investigated the cardiovascular (CV) effects of SGLT2 inhibitors (particularly heart failure and hypertension). These studies looked at the cardiovascular effects of three SGLT2 inhibitors: Empagliflozin, Canagliflozin, and Dapagliflozin. In diabetic patients, these three inhibitors of SGLT2 significantly lowered the risk of heart failure and hypertension, making them valuable therapy for lowering CV risks in high cardiovascular-risk individuals with T2DM. Finally, the use of SGLT2 inhibitors in patients without diabetes mellitus showed positive metabolic outcomes in weight and blood pressure control.

Progression of knowledge in diabetes mellitus and covid-19

The Coronavirus Disease 19 (COVID-19) is a pandemic infectious disease caused by the novel corona virus Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). Diabetes mellitus (DM) and hyperglycemia are among the major comorbidities in patients with COVID-19 which might modulate immune and inflammatory responses leading to poor outcomes. Several reports show that patients with DM and COVID-19 are at an increased risk for developing severe complications including acute respiratory distress syndrome, multi-organ failure, and death. Furthermore, compromised innate immunity, pro-inflammatory cytokine milieu, reduced expression of ACE-2 and use of renin-angiotensin-aldosterone system antagonists in diabetic patients may also contribute to poor prognosis in COVID-19. However, the mechanisms underlying the relationship between COVID-19 and DM remain to be elucidated. The severity and mortality was significantly higher in diabetic patients which may predispose patients with COVID-19 to poor outcomes. Most of these conclusions are preliminary, and further investigation of the optimal management in diabetic patients is necessary. Thus, it is imperative that diabetic patients should take all necessary precautions and ensure good glycemic control amid with COVID-19 pandemic.

The Role of the Inflammatory and the Vascular Pathogenesis in a Model of Streptozotocin Induced Diabetic Neuropathy in Rats

Background Peripheral diabetic neuropathy (DN) is one of the major health problems facing the whole world. There is no treatment that could completely reverse or prevent progression of DN except for good glycemic control. The inflammatory and vascular pathways are two main domains that are incorporated in the pathogenesis of diabetic neuropathic pain (DNP) and DN. Thus, targeting both of them could be an appropriate way to delay progression of DN. Aim To investigate the role of the inflammatory and the vascular pathogenesis in diabetic mechanical allodynia. Method Twenty male Wistar rats were divided randomly into naïve and diabetic groups (n = 10). Diabetes was induced through i.p injection of single dose of streptozotocin (STZ) (50mg/kg), then 8 weeks after induction of diabetes, the sciatic content of tumor necrosis factor alpha (TNFα) and vascular endothelial growth factor (VEGF) was assessed using ELISA technique. Additionally, the number of intercellular adhesion molecule-1 (ICAM-1) as well as CD31, the most specific vascular marker, positively stained vessels was counted manually in sciatic nerves cross sections. Whereas, DNP was assessed weekly throughout the experiment using 60%mechanical threshold of paw withdrawal test. Results There was a significant increase in the sciatic content of TNFα, VEGF and ICAM-1 positively stained vessels and a significant decrease in CD31 positively stained vessels in the diabetic group as compared to the naïve group. There was a correlation between TNFα, VEGF, ICAM-1, CD31 positively stained vessels in one side and the 60% mechanical threshold on the other side (r=-0.8, -0.9, -0.8 and 0.7 respectively). Conclusion The diabetic mechanical allodynia is negatively correlated to the sciatic nerve content TNFα, VEGF, ICAM-1 and positively correlated to the CD31.

New Fast Acting Glucagon for Recovery from Hypoglycemia, a Life-Threatening Situation: Nasal Powder and Injected Stable Solutions

The goal of diabetes care is to achieve and maintain good glycemic control over time, so as to prevent or delay the development of micro- and macrovascular complications in type 1 (T1D) and type 2 diabetes (T2D). However, numerous barriers hinder the achievement of this goal, first of all the frequent episodes of hypoglycemia typical in patients treated with insulin as T1D patients, or sulphonylureas as T2D patients. The prevention strategy and treatment of hypoglycemia are important for the well-being of patients with diabetes. Hypoglycemia is strongly associated with an increased risk of cardiovascular disease in diabetic patients, due probably to the release of inflammatory markers and prothrombotic effects triggered by hypoglycemia. Treatment of hypoglycemia is traditionally based on administration of carbohydrates or of glucagon via intramuscular (IM) or subcutaneous injection (SC). The injection of traditional glucagon is cumbersome, such that glucagon is an under-utilized drug. In 1983, it was shown for the first time that intranasal (IN) glucagon increases blood glucose levels in healthy volunteers, and in 1989–1992 that IN glucagon is similar to IM glucagon in resolving hypoglycemia in normal volunteers and in patients with diabetes, both adults and children. IN glucagon was developed in 2010 and continued in 2015; in 2019 IN glucagon obtained approval in the US, Canada, and Europe for severe hypoglycemia in children and adults. In the 2010s, two ready-to-use injectable formulations, a stable non-aqueous glucagon solution and the glucagon analog dasiglucagon, were developed, showing an efficacy similar to traditional glucagon, and approved in the US in 2020 and in 2021, respectively, for severe hypoglycemia in adults and in children. Fast-acting glucagon (nasal administration and injected solutions) appears to represent a major breakthrough in the treatment of severe hypoglycemia in insulin-treated patients with diabetes, both adults and children. It is anticipated that the availability of fast-acting glucagon will expand the use of glucagon, improve overall metabolic control, and prevent hypoglycemia-related complications, in particular cardiovascular complications and cognitive impairment.