Infections in patients with diabetes mellitus: A review of pathogenesis

The relation between serum levels of interleukin 10 and interferon-gamma with oral candidiasis in type 2 diabetes mellitus patients

BACKGROUND

Type 2 Diabetes mellitus (T2DM) is one of the most common endocrine diseases that weakens the immune system. Candida albicans, is part of the natural oral flora and increases in cases of compromised immune systems. The exact cause of the increased prevalence of candidiasis in patients with T2DM is still unclear. The study aimed to correlate serum interleukin 10 (IL-10) and interferon-gamma cytokines (IFN-γ) with oral candidiasis in T2DM.

METHODS

In this case-control study, 81 patients with T2DM and 41 non-diabetic individuals aged 30 to 70 years participated. Demographic information, a Blood sample (for blood glucose and cytokine tests), and an oral cotton swab sample from each individual were obtained. The samples were then incubated in a Sabroud dextrose agar medium. Colony growth was calculated and the type of yeast species in individuals with oral candidiasis was identified by culture in CHROMagar Candida medium. IL-10 and IFN-γ were measured by ELISA kit and the data were analyzed using SPSS-18.

RESULTS

An overall of 122 participants comprised 73.77% females and 26.22% males. An increase in interleukin-10 by 40% and a decrease in IFN-γ by 6% can increase oral candidiasis prevalence among diabetic patients. Candida albicans was the most prevalent Candida species (spp.) in the diabetic and non-diabetic groups. The presence of oral candidiasis was not associated with HbA1c or FBS levels in both groups.

CONCLUSION

In the diabetic population, an increase in IL-10 or a decrease in IFN-γ may be associated with an increased risk of oral candidiasis.

Antibiotic use in elderly patients in ambulatory care: A comparison between Hungary and Sweden

Background: The elderly use antibiotics frequently due to their increasing infection susceptibility. Given the high and increasing proportion of elderly in the population, their antibiotic use is substantial. Objective: This study aimed to compare antibiotic use in the elderly in the ambulatory care sector between Hungary and Sweden. Methods: This retrospective, descriptive, cross-national, comparative study included antibacterial use data from the Hungarian National Health Insurance Fund and the Swedish eHealth Agency. Antibiotic use (anatomical therapeutical chemical: J01) was expressed as the number of prescriptions/1000 inhabitants/year or month and was further stratified by age and sex. Results: Antibiotic exposure was higher in the Hungarian elderly population (649.8 prescriptions/1000 inhabitants/year) compared to its Swedish counterparts (545.0 prescriptions/1000 inhabitants/year). Hungary had a similar scale of antibacterial exposure across all elderly age subgroups, with different trends in males and females, while Sweden had a stepwise increase in antibiotic exposure by age in both sexes. The seasonal fluctuation was high in Hungary and reached a peak of 80.7 prescriptions/1000 inhabitants/month in January 2017, while even antibiotic use was detected throughout the year in Sweden. The pattern of antibiotic use in the elderly considerably differed between the two countries. Penicillin and beta-lactamase combinations, such as co-amoxiclav, were more frequently used in Hungary than in Sweden (19.08% vs 1.83% of corresponding total ambulatory antibiotic use). Likewise, quinolones were more commonly used in Hungary than in Sweden (34.53% vs. 9.98). The elderly in Sweden were mostly prescribed narrow spectra penicillins (26.71% vs. 0.29% in Hungary). Conclusion: This cross-national comparison revealed important differences in all aspects of antibiotic use in the elderly between the two countries. The identical scale and pattern of antibiotic use cannot be anticipated due to the poorer health status of the Hungarian elderly population. However, the substantial differences indicate some room for improvement in the antibiotic prescription for the Hungarian elderly.

Oral innate immunity in patients with type 2 diabetes mellitus in a tertiary hospital in Ibadan Nigeria: a cross-sectional study

Introduction

diabetes mellitus is associated with a high prevalence of oral infections. However, it is unclear how diabetes impacts oral innate antimicrobial proteins. This study evaluated salivary lysozyme and histatins, two major innate antimicrobial proteins, in patients with diabetes and non-diabetic controls.

Methods

a cross-sectional study where salivary lysozyme and histatins were measured alongside plasma glucose levels. Values of the salivary proteins were compared between the two groups; their association with glucose levels was also established using correlation and regression analysis.

Results

one hundred and fifty-one participants were recruited for this study, 85 (56.3%) of them had type 2 diabetes mellitus with a median fasting plasma glucose of 108.8 mg/dl (IQR 91.2-134.8) while the remaining 66 (43.7%) healthy non-diabetic controls had a median random plasma glucose of 101 mg/dl (IQR 89-112). The median salivary lysozyme was 32.5 ng/ml (IQR 25.0-39.6) in the group with diabetes and 36.4 ng/ml (IQR 31.4-42.1; p=0.01) in the non-diabetic control group. The median salivary histatins was 9.2 ng/ml (IQR 7.6 -10.2) in the group with diabetes and 14.7 ng/ml (IQR12.8-16.5; p<0.001) in the non-diabetic control group. Salivary lysozyme (r = -0.127; p =0.163) and histatins (r = -0.025; p = 0.424) were both negatively correlated with plasma glucose levels, and logistic regression showed that patients with diabetes are more likely to have lower levels of salivary lysozyme (0.957; p=0.013) and histatins (0.527; p<0.001).

Conclusion

patients with diabetes had reduced levels of salivary lysozyme and histatins, this could provide an insight into the associated high oral infection rates.

Homeostatic microbiome disruption as a cause of insulin secretion disorders. Candida albicans, a new factor in pathogenesis of diabetes: A STROBE compliant cross-sectional study

The study aimed to test the hypothesis that homeostatic microbiome (HM) disorders lead to the increased indirect influence of certain microorganisms (MO) in the gastrointestinal tract, causing a disorder of insulin secretion, insulin resistance, and diabetes. We highlighted Candida and certain types of bacteria since previous in vitro research showed they significantly affect insulin secretion and can cause insulin resistance in obese patients with metabolic syndrome. After determining the type of MO present in the throat swab and the stool, the oral glucose tolerance test (OGTT) test, and analysis of glucose and insulin secretion were performed in patients (n = 38) who were positive for certain types of MO compared to negative patients. Finally, all patients were divided into two groups: overweight patients (body mass index [BMI] < 30) and obese patients (BMI > 30). These two groups were compared for the percentage of certain types of MO to determine which MO can affect an increase in obesity and BMI. The presence of Diphtheroids in the throat (60.5%) reduces insulin secretion in patients compared with the negative group (194.5: 332.4) and the difference was statistically significant (P = .030). The presence of Candida in the throat (10%) increases insulin secretion, but the difference was statistically insignificant. The presence of Candida in the stool (28.9%) also increases insulin secretion and the difference was statistically significant (P = .038). Cumulative results (throat + stool) were similar (180: 332, P = .022). Analysis of BMI showed that the percentage of Diphtheroids in the throat decreases with increased body weight (53.8: 75%) while the percentage of Candida (38.5: 8.3%) and Enterobacter (61.5: 25%) increases, but these differences were statistically insignificant (P > .05). Diphtheroids in the throat can reduce insulin secretion by synthesizing their metabolites. Candida albicans is a conditional pathogen and as a significant indirect factor induces increased insulin secretion and insulin resistance. There are indications that elevated levels of Candida in the intestinal system can cause increased body weight of patients. C albicans should be considered a new factor in the pathogenesis of diabetes.

Molecular and cellular mechanisms involved in tissue-specific metabolic modulation by SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is triggered by the SARS-CoV-2, which is able to infect and cause dysfunction not only in lungs, but also in multiple organs, including central nervous system, skeletal muscle, kidneys, heart, liver, and intestine. Several metabolic disturbances are associated with cell damage or tissue injury, but the mechanisms involved are not yet fully elucidated. Some potential mechanisms involved in the COVID-19-induced tissue dysfunction are proposed, such as: (a) High expression and levels of proinflammatory cytokines, including TNF-α IL-6, IL-1β, INF-α and INF-β, increasing the systemic and tissue inflammatory state; (b) Induction of oxidative stress due to redox imbalance, resulting in cell injury or death induced by elevated production of reactive oxygen species; and (c) Deregulation of the renin-angiotensin-aldosterone system, exacerbating the inflammatory and oxidative stress responses. In this review, we discuss the main metabolic disturbances observed in different target tissues of SARS-CoV-2 and the potential mechanisms involved in these changes associated with the tissue dysfunction.

Implications of Type 2 Diabetes Mellitus in Patients with Acute Cholangitis: A Systematic Review of Current Literature

Introduction: Type 2 diabetes mellitus (T2DM) has been associated with higher rates and poorer prognosis of infections, mainly due to poor glycemic control, reduced response of T-cells and neutrophils, and impaired migration, phagocytosis, and chemotaxis of leukocytes. However, the impact of T2DM on acute cholangitis (AC) has not been assessed so far. Thus, we aimed to explore this association by means of a systematic review of the literature. Methods: This systematic review was carried out based on the recommendations stated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed/MEDLINE, Web of Science and SCOPUS databases to identify relevant publications depicting an association between T2DM and AC from the inception of these search services up to present. Results: We detected a total of 435 eligible records. After we applied the inclusion and exclusion criteria, a total of 14 articles were included in the present systematic review. Included manuscripts focused on the potential role of T2DM as a risk factor for the development of AC and on its contribution to a worse prognosis in AC, e.g., development of sepsis or other complications, the risk of AC recurrence and the impact on mortality. Conclusions: As compared to non-diabetic individuals, patients with T2DM have a higher risk of AC as a complication of choledocholithiasis or gallstone pancreatitis. Several oral hypoglycemic drugs used in the management of T2DM may also be involved in the onset of AC. Diabetic patients who suffer from AC have a higher likelihood of longer hospital stays and sepsis, as well as a higher risk of mortality and more severe forms of AC as compared to non-diabetic individuals.

A comparative review on the anti-nutritional factors of herbal tea concoctions and their reduction strategies

Tea is an important beverage consumed worldwide. Of the different types of tea available, herbal tea is an important beverage consumed owing to its popularity as a drink and stress relieving factors, several different herbal concoctions made from seeds, leaves, or roots are currently consumed and sold as herbal teas. The herbal teas are not the usual tea but "tisanes." They are caffeine free and popular for their medicinal property or immune boosters. Herbal tea formulations are popularly sold and consumed by millions owing to their health benefits as they are rich in antioxidants and minerals. However, plants are also known to contain toxic and anti-nutritional factors. Anti-nutritional factors are known to interfere with the metabolic process and hamper the absorption of important nutrients in the body. These anti-nutritional factors include saponins, tannins, alkaloids, oxalates, lectins, goitrogens, cyanogens, and lethogens. These chemicals are known to have deleterious effects on human health. Therefore, it is important to understand and assess the merits and demerits before consumption. Also, several techniques are currently used to process and reduce the anti-nutrients in foods. This review is focused on comparing the contents of various anti-nutritional factors in some underutilized plants of North-East India used as herbal tea along with processing methods that can be used to reduce the level of these anti-nutrients.

Favorable Aspects of Silymarin in Linezolid Treatment Against Diabetic Methicillin-Resistant Staphylococcus aureus (MRSA) Infected Rats

Background:

Linezolid used for diabetic methicillin-resistant Staphylococcus aureus (MRSA) infections is limited due to hepatotoxicity, lactic acidosis, anemia, and oxidative stress induced by diabetes and linezolid therapy. Silymarin is a hepatoprotective, antioxidant, antibacterial, and antidiabetic.

Objective:

The research investigated the role of silymarin in linezolid treatment against MRSA-infected diabetic rats.

Methods:

Type 2 diabetes mellitus (T2DM) was induced by a high-fat diet (58% calories fat) for 2 weeks, followed by a single intraperitoneal injection of streptozotocin (STZ) 35 mg/kg into Wistar rats. The diabetic rats were rendered neutropenic and subcutaneously injected with 106 CFU/ml of MRSA. Linezolid and silymarin were administered orally at a dose of 50 mg/kg twice daily for 14 days. The bacterial load/abscess, hematological, biochemical, enzymatic parameters, antioxidants, and histopathological studies were performed on the 42nd day.

Results:

The MRSA was confirmed by PCR assay. The minimum inhibitory concentration of linezolid was found to be 0.5-2 μg/ml. The linezolid treated MRSA infected diabetic rats showed 9.69 x 103 CFU / abscess bacterial count, decreased intestinal alkaline phosphatase (IAP), RBC, antioxidants, elevated lactate, and liver markers than diabetic rats. The silymarin treatment showed a decrease in the bacterial count (2.98 x 103 CFU / abscess), serum lactate, liver markers, increased IAP levels, and antioxidants in linezolid treated diabetic infected rats.

Conclusion:

The research concluded that silymarin could be a better herbal therapeutic agent that attenuated diabetic and linezolid induced complications in MRSA-infected diabetic rats.

Household secondary attack rate in SARS-CoV-2 infection during the second wave of the COVID-19 pandemic in South India

Background

Coronavirus disease 2019 (COVID-19) has become a major public health problem since its inception disrupting public life and crippling health systems. The mutated variant of the causative virus, Delta, has been notorious in causing rapid upsurge in cases compared to the Alpha variant. The current study tries to find out the household secondary attack rate (HSAR) of COVID-19 and factors associated with it during the second wave of cases in Kerala.

Methodology

A retrospective cohort study was performed among 313 household contacts of 76 COVID-19 patients who had been admitted in Government Medical College, Thrissur, in the southern state of India, Kerala. Data from the participants were collected via phone using a semi-structured interview schedule, and analysis was performed with SPSS software.

Results

The HSAR among household contacts was 59.1% (53.4-64.6%). The risk of acquiring COVID infection among household contacts was higher among contacts of symptomatic index cases with a P value of 0.001 and an odds ratio of 11 (3.7-32.4). index cases were having a home isolation P value of 0.001 and an odds ratio of 3.2 (2-5.1), with delay in COVID-19 testing for index cases with a P value of 0.006. Regarding characteristics of household contacts, higher age groups (p = 0.048), groups living in the same room with an index case P value of 0.021 and an odds ratio of [1.71 (1-2.8)], groups having physical contact with an index case P value of 0.001 and an odds ratio of [3.7 (2.1-7)], groups with touched or cleaned linen/articles with an index case P value of 0.02 and an odds ratio of [1.8 (1-3.1)], and groups having co-morbidities, especially diabetes mellitus (p = 0.0020), were significantly associated with chances of acquiring infection. However, the history of previous COVID positivity in household contacts was a protective factor against the infection P value of 0.009 with an odds ratio of [0.09 (0.01-0.78)].

Conclusion

The study concludes that the second wave of COVID-19 in Kerala was primarily caused by a high SAR, especially among household contacts, and this could have been the reason for the difficulty in control measures during the wave.

Bacterial Infections among Patients with Chronic Diseases at a Tertiary Care Hospital in Saudi Arabia

Infections caused by multi-drug-resistant bacteria in patients with chronic diseases have been associated with high mortality and morbidity. While few reports have evaluated bacterial infections in multiple chronic disease patients, the focus of the current study was to investigate the prevalence of bacterial infections and the susceptibility profiles of causative strains among various groups of patients suffering from chronic diseases. Microbiological reports of patients suffering from cancer, diabetes mellitus, cardiovascular diseases, kidney diseases, and skin burns were retrospectively collected from a tertiary hospital in Saudi Arabia. Approximately 54.2% of recruited patients were males, and positive urine was the most prevalent specimen associated with kidney disease patients (25%). Escherichia coli isolates were predominant among cardiovascular, kidney, and cancer patients. Staphylococcus aureus was commonly detected in diabetics and those with burns. Although resistance patterns varied based on the type of specimens and underlying diseases, Escherichia coli showed limited resistance to colistin, carbapenems, and tigecycline, while S. aureus demonstrated susceptibility to ciprofloxacin, gentamicin, and rifampin. These observations are crucial for clinicians and policymakers to ensure effective treatment plans and improve outcomes in these patients with comorbidity.

SARS-CoV-2 infection and diabetes: Pathophysiological mechanism of multi-system organ failure

Since the discovery of the coronavirus disease 2019 outbreak, a vast majority of studies have been carried out that confirmed the worst outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in people with preexisting health conditions, including diabetes, obesity, hypertension, cancer, and cardiovascular diseases. Likewise, diabetes itself is one of the leading causes of global public health concerns that impose a heavy global burden on public health as well as socio-economic development. Both diabetes and SARS-CoV-2 infection have their independent ability to induce the pathogenesis and severity of multi-system organ failure, while the co-existence of these two culprits can accelerate the rate of disease progression and magnify the severity of the disease. However, the exact pathophysiology of multi-system organ failure in diabetic patients after SARS-CoV-2 infection is still obscure. This review summarized the organ-specific possible molecular mechanisms of SARS-CoV-2 and diabetes-induced pathophysiology of several diseases of multiple organs, including the lungs, heart, kidneys, brain, eyes, gastrointestinal system, and bones, and sub-sequent manifestation of multi-system organ failure.

Children with type 1 diabetes in COVID-19 pandemic: Difficulties and solutions

Children/adolescents with type 1 diabetes (T1D) require holistic approach and continuous care. However, the coronavirus disease 2019 (COVID-19) pandemic has made challenges for the T1D children and their caregivers, professionals, and the healthcare system. This minireview aims to consolidate and discuss the difficulties and solutions of children with type 1 diabetes in the COVID-19 pandemic. T1D has been the most common type of diabetes in children and adolescents and the last decades has seen a rapid increase in the prevalence of T1D in youths worldwide, which deserves a public concern particularly in the COVID-19 pandemic. As reported in previous studies, T1D is a risk factor related to severe cases, while the virus may induce new-onset diabetes and serious complications. Moreover, restriction strategies influence medical availability and lifestyle, impact glycemic control and compilation management, and thus pose stress on families and health providers of youths with T1D, especially on those with certain fragile conditions. Therefore, special treatment plans are required for children provided by caregivers and the local health system. Latest health tools such as improved medical devices and telemedicine service, as well as a combined support may benefit in this period. This minireview emphasises that continued medical access and support are required to prevent deteriorated condition of children and adolescents with diabetes throughout this pandemic. Therefore, strategies are supposed to be formulated to mitigate the difficulties and stress among this group, particularly in the most at-risk population. Proposed solutions in this minireview may help individuals and the health system to overcome these problems and help youths with T1D in better diabetes management during such emergency situations.

Nitazoxanide, Ivermectin, and Artemether effects against cryptosporidiosis in diabetic mice: parasitological, histopathological, and chemical studies

Human cryptosporidiosis is one of the most significant causes of water borne epidemics of diarrhea worldwide. It is extremely important in immunocompromised hosts and malnourished children as it could cause severe life-threatening diarrhea. Despite the global burden of the disease, there are only few available therapies against cryptosporidiosis. Diabetes mellitus is a common metabolic disorder that impair both the innate and adaptive immune responses of the patient. This study aimed to test the effect of Nitazoxanide, Ivermectin, and Artemether against cryptosporidiosis in diabetic mice. Sixty white albino mice were categorized into 6 groups; 10 mice each: GI: normal non-infected non-treated (healthy- control), GII-GVI (diabetic groups), GII: non-infected non treated (diabetic control), GIII: infected non treated (infected control), GIV: infected and treated with Nitazoxanide (NTZ), GV: infected and treated with Ivermectin (IVC), GVI: infected and treated with Artemether (ART). Parasitological, histopathological, and chemical examinations were done to evaluate the effect of NTZ, IVC, and ART against cryptosporidiosis in diabetic mice. Parasitological examination revealed maximum reduction of oocyst shedding in GVI, while histopathological examination showed the least pathologic changes in GV with mild vascular wall fibrosis and moderate lymphocytic infiltration of islets of Langerhans. Measurement of blood glucose level showed the best results with GIV. Nitazoxanide is effective against cryptosporidiosis in diabetic patients with minimal hyperglycemia, Artemether is especially effective in reducing the oocyst shedding in stool, whereas Ivermectin is associated with the least pathological changes in pancreatic islets of Langerhans.

Bee gomogenat rescues lymphoid organs from degeneration by regulating the crosstalk between apoptosis and autophagy in streptozotocin-induced diabetic mice

Diabetes mellitus (DM) is a metabolic disorder that causes severe complications in several tissues due to redox imbalances, which in turn cause defective angiogenesis in response to ischemia and activate a number of proinflammatory pathways. Our study aimed to investigate the effect of bee gomogenat (BG) dietary supplementation on the architecture of immune organs in a streptozotocin (STZ)-induced type 1 diabetes (T1D) mouse model. Three animal groups were used: the control non-diabetic, diabetic, and BG-treated diabetic groups. STZ-induced diabetes was associated with increased levels of blood glucose, ROS, and IL-6 and decreased levels of IL-2, IL-7, IL-4, and GSH. Moreover, diabetic mice showed alterations in the expression of autophagy markers (LC3, Beclin-1, and P62) and apoptosis markers (Bcl-2 and Bax) in the thymus, spleen, and lymph nodes. Most importantly, the phosphorylation level of AKT (a promoter of cell survival) was significantly decreased, but the expression levels of MCP-1 and HSP-70 (markers of inflammation) were significantly increased in the spleen and lymph nodes in diabetic mice compared to control animals. Interestingly, oral supplementation with BG restored the levels of blood glucose, ROS, IL-6, IL-2, IL-4, IL-7, and GSH in diabetic mice. Treatment with BG significantly abrogated apoptosis and autophagy in lymphoid organs in diabetic mice by restoring the expression levels of LC3, Beclin-1, P62, Bcl-2, and Bax; decreasing inflammatory signals by downregulating the expression of MCP-1 and HSP-70; and promoting cell survival by enhancing the phosphorylation of AKT. Our data were the first to reveal the therapeutic potential of BG on the architecture of lymphoid organs and enhancing the immune system during T1D.

Effectiveness of Copper Nanoparticles in Wound Healing Process Using In Vivo and In Vitro Studies: A Systematic Review

Chronic wounds are defined as wounds that do not heal in an orderly and timely manner through the various stages of the healing process. Copper nanoparticles are essential in dressings for wound healing because they promote angiogenesis and skin regeneration, which hasten the healing process. This systematic investigation sought to explain how copper nanoparticles affect chronic wound healing in vivo and in vitro. We realized a systematic review of original articles studying the effectiveness of copper nanoparticles in the healing process of chronic wounds. The protocol was registered in the PROSPERO database. Several databases were searched between 2012 and January 2022 for English-language papers using MeSH terms and text related to chronic wounds, copper nanoparticles, and wound healing. Quality was evaluated using National Institute for Health and Care Excellence methodology and PRISMA guidelines. We looked at a total of 12 primary studies. Quantitative data were gathered and presented in all studies. Our results suggest that copper nanoparticles could have an excellent healing property, facilitating the liberation of growth factors that help the anti-inflammatory process of the wound and significantly improving antibacterial and antioxidant activities. In addition, copper presents a higher biocompatibility than other metallic ions, promoting regeneration and increasing skin quality.

Type 2 Diabetes Mellitus and COVID-19: A Narrative Review

Type-2 diabetes mellitus (T2DM) is a chronic metabolic disorder. The incidence and prevalence of patients with T2DM are increasing worldwide, even reaching epidemic values in most high- and middle-income countries. T2DM could be a risk factor of developing complications in other diseases. Indeed, some studies suggest a bidirectional interaction between T2DM and COVID-19. A growing body of evidence shows that COVID-19 prognosis in individuals with T2DM is worse compared with those without. Moreover, various studies have reported the emergence of newly diagnosed patients with T2DM after SARS-CoV-2 infection. The most common treatments for T2DM may influence SARS-CoV-2 and their implication in infection is briefly discussed in this review. A better understanding of the link between TD2M and COVID-19 could proactively identify risk factors and, as a result, develop strategies to improve the prognosis for these patients.

Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review

Diabetes mellitus (DM) has been frequently associated with an impaired immune response against infectious agents, making affected patients at risk for more severe disease and sometimes causing worse outcomes. The recent COVID-19 pandemic has seriously affected patients with both diabetes, in particular those carrying comorbidities or with poor glycemic control. As regards pediatric diabetes mellitus, the availability of more accurate and technological tools for glycemic management and the improved markers of metabolic control might mitigate the negative impact of infections. Notably, good metabolic control of diabetes since its diagnosis reduces not only the risk of microangiopathic complications but also of impaired immune response to infectious diseases. Therefore, vaccinations are strongly recommended. Our paper aims to provide the most updated evidence regarding infectious diseases in type 1 pediatric DM.

Systemic inflammation after stroke: implications for post-stroke comorbidities

Immunological mechanisms have come into the focus of current translational stroke research, and the modulation of neuroinflammatory pathways has been identified as a promising therapeutic approach to protect the ischemic brain. However, stroke not only induces a local neuroinflammatory response but also has a profound impact on systemic immunity. In this review, we will summarize the consequences of ischemic stroke on systemic immunity at all stages of the disease, from onset to long‐term outcome, and discuss underlying mechanisms of systemic brain‐immune communication. Furthermore, since stroke commonly occurs in patients with multiple comorbidities, we will also overview the current understanding of the potential role of systemic immunity in common stroke‐related comorbidities, such as cardiac dysfunction, atherosclerosis, diabetes, and infections. Finally, we will highlight how targeting systemic immunity after stroke could improve long‐term outcomes and alleviate comorbidities of stroke patients.

Respiratory Tract Infections in Diabetes - Lessons From Tuberculosis and Influenza to Guide Understanding of COVID-19 Severity

Patients with type-2 diabetes (T2D) are more likely to develop severe respiratory tract infections. Such susceptibility has gained increasing attention since the global spread of Coronavirus Disease 2019 (COVID-19) in early 2020. The earliest reports marked T2D as an important risk-factor for severe forms of disease and mortality across all adult age groups. Several mechanisms have been proposed for this increased susceptibility, including pre-existing immune dysfunction, a lack of metabolic flexibility due to insulin resistance, inadequate dietary quality or adverse interactions with antidiabetic treatments or common comorbidities. Some mechanisms that predispose patients with T2D to severe COVID-19 may indeed be shared with other previously characterized respiratory tract infections. Accordingly, in this review, we give an overview of response to Influenza A virus and to Mycobacterium tuberculosis (Mtb) infections. Similar risk factors and mechanisms are discussed between the two conditions and in the case of COVID-19. Lastly, we address emerging approaches to address research needs in infection and metabolic disease, and perspectives with regards to deployment or repositioning of metabolically active therapeutics.

The challenge of tuberculosis diagnosis and management in the era of the COVID-19 pandemic and diabetes mellitus

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Maxillary Fungal Osteomyelitis Mimicking and Treated as Endodontic Pathosis

Fungal osteomyelitis is a lethal opportunistic infection that affects only a small percentage of patients present to endodontists. It is a highly contagious infection that requires urgent treatment. We discuss three cases in which endodontic pathology was initially recognized but subsequent follow-up revealed severe osteolytic fungal infection of the maxilla manifesting as acute apical abscesses in the maxillary canine region. CBCT demonstrated osteolytic abnormalities, and further histology confirmed the illness was caused by mucormycosis in patients with uncontrolled diabetes mellitus and exposure to COVID-19.

'Perceptions' and 'practices' to antibiotic usage among diabetic patients receiving care from a rural tertiary care center: A mixed-methods study

BACKGROUND

Contribution to antibiotic resistance can happen at two interfaces - doctor prescribing antibiotics inadvertently or patient's usage of antibiotics inadvertently. This study was conducted among diabetic inpatients in a rural tertiary health center in Kolar, South India, to assess the various practices related to antibiotic use and to explore the possible reasons for these practices with regard to antibiotic use.

MATERIALS AND METHODS

An exploratory sequential mixed-methods study was conducted with an initial cross-sectional quantitative study followed by qualitative in-depth interviews during August-September 2019. A pretested semi-structured questionnaire was used to capture the sociodemographic, disease-, and treatment-related characteristics and practices related to antibiotic use. An open-ended interview guide was used to conduct in-depth interviews. The practices to antibiotic use were reported using frequency (percentage). Manual descriptive content analyses were done by two investigators separately to identify codes under the broad topic "reasons for adopted practices with regard to antibiotic use."

RESULTS

Of the 152 diabetic inpatients interviewed, 20 (13.2%) felt that antibiotics are safe drugs and can be used commonly. Among these inpatients, seven (4.6%) knew that antibiotics can kill bacteria and four (2.6%) perceived 'antibiotic resistance' as a big problem in India. The practice of checking the expiry date before using antibiotics was seen in 21 (13.8%) and 44 (29%) of them finished the full course of antibiotics. A total of six codes were identified under the broad theme of "reasons for adopted practices with regard to antibiotic use" among diabetic inpatients.

CONCLUSIONS

Less than one-third of them completed the antibiotic course given by the doctor, and almost everyone was ready for over-the-counter purchase of antibiotics offered by the pharmacist. The reasons for such practices were mostly attributed to the "partial drug purchases" and "incomplete advice by the doctor." There is an urgent need to plan and deliver an interventional package to enhance the knowledge and inculcate good antibiotic usage practices among these high-risk populations.

Practical Applicability of the ISARIC-4C Score on Severity and Mortality due to SARS-CoV-2 Infection in Patients with Type 2 Diabetes

Background and objectives. There is a bidirectional relationship between SARS-CoV-2 infection and diabetes mellitus (DM), as people with DM are more vulnerable, and SARS-CoV-2 infections worsen the prognosis in these patients. The main purpose of the study was to evaluate the application validity of the ISARIC-4C score in patients confirmed with SARS-CoV-2 infection. Materials and Methods. The study included 159 patients previously known to have type 2 DM and confirmed positive for SARS-CoV-2 infection. We analyzed the concordance between the clinical evaluation of the patients and the ISARIC-4C score. Results. The mortality rate in hospitalized patients was 25.15%. The mortality risk was higher for ISARIC-4C values >14 than in the opposite group (63.93% vs. 31.24%; p < 0.001). The area under the curve (AUC) of the mortality score was 0.875 (95% CI: 0.820−0.930; p < 0.001), correctly classifying 77.36% of the cohort. A cut-off value of >14 had a sensitivity of 87.80% (95% CI: 87.66−87.93), specificity 73.72% (95% CI: 73.48−73.96), positive predictive value 53.73% (95% CI: 53.41−54.04), and negative predictive value 94.56% (95% CI: 94.5−94.62). The Cox regression model showed that the length of hospitalization (LH) was significantly influenced by body mass index, lung impairment, and aspartate aminotransferase, increasing the hazards, while lower HbA1c and lower SatO2 significantly decreased the hazards. Conclusions. ISARIC-4C score estimates the likelihood of clinical deterioration and the mortality risk in patients hospitalized with type 2 DM and positive for SARS-CoV-2, being useful in assessing the prognosis from the onset, as well as in developing therapeutic strategies.

L-GSH Supplementation in Conjunction With Rifampicin Augments the Treatment Response to Mycobacterium tuberculosis in a Diabetic Mouse Model

Both active tuberculosis (TB) and asymptomatic latent Mycobacterium tuberculosis (M. tb) infection (LTBI) cause significant health burdens to humans worldwide. Individuals with immunocompromising health conditions, such as Type 2 Diabetes Mellitus (T2DM), have a weakened ability to control M. tb infection and are more susceptible to reactivation of LTBI to active diseases. T2DM cases are known to have glutathione (GSH) deficiency and impaired immune cell function, including the granulomatous response to M. tb infection. We have previously reported that liposomal glutathione (L-GSH) supplementation can restore the immune cell effector responses of T2DM cases. However, the effects of L-GSH supplementation on the bactericidal activities of first-line anti-TB drug rifampicin (RIF) against M. tb infection have yet to be explored. The aim of this study is to elucidate the effects of L-GSH supplementation in conjunction with RIF treatment during an active M. tb infection in a diabetic mouse model. In this study, we evaluated total and reduced levels of GSH, cytokine profiles, malondialdehyde (MDA) levels, M. tb burden, and granulomatous response in the lungs. We show that L-GSH supplementation caused a significant reduction in M. tb burden in the lungs, decreased oxidative stress, and increased the production of IFN-γ, TNF-α, IL-17, IL-10, and TGF-β1compared to the untreated mice. In addition, L-GSH supplementation in conjunction with RIF treatment achieved better control of M. tb infection in the lungs and significantly reduced the levels of oxidative stress compared to treatment with RIF alone. Moreover, L-GSH in conjunction with RIF significantly increased TGF-β1 levels compared to treatment with RIF alone. These findings suggest potential therapeutic benefits of L-GSH supplementation in conjunction with first-line antibiotic therapy against M. tb infection in individuals with T2DM.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Implant Removal Due to Infection After Open Reduction and Internal Fixation: Trends and Predictors

BACKGROUND

Implant removal due to infection is one of the major causes failure following open reduction and internal fixation (ORIF). The aim of this study was to determine trends and predictors of infection-related implant removal following ORIF of extremities using a nationally representative database.

METHODS

Nationwide Inpatient Sample data from 2006 to 2017 was used to identify cases of ORIF following upper and lower extremity fractures, as well as cases that underwent infection-related implant removal following ORIF. Multivariate analysis was performed to identify independent predictors of infection-related implant removal, controlling for patient demographics and comorbidities, hospital characteristics, site of fracture, and year.

RESULTS

For all ORIF procedures, the highest rate of implant removal due to infection was the phalanges/hand (5.61%), phalanges/foot (5.08%), and the radius/ulna (4.85%). Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Tarsal/metatarsal fractures (odds ratio (OR)=1.45, 95% confidence interval (CI): 1.02-2.05), and tibial fractures (OR=1.82, 95% CI: 1.45-2.28) were identified as independent predictors of infection-related implant removal. Male gender (OR=1.67, 95% CI: 1.49-1.87), Obesity (OR=1.85, 95% CI: 1.34-2.54), diabetes mellitus with chronic complications (OR=1.69, 95% CI: 1.13-2.54, P<0.05), deficiency anemia (OR=1.59, 95% CI: 1.14-2.22) were patient factors that were associated with increased infection-related removals. Removal of implant due to infection had a higher total charge associated with the episode of care (mean: $166,041) than non-infection related implant removal (mean: $133,110).

CONCLUSION

Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Diabetes, liver disease, and rheumatoid arthritis were important predictors of infection-related implant removal. The study identified some risk factors for implant related infection following ORIF, such as diabetes, obesity, and anemia, that should be studied further to implement strategies to reduce rate of infection following ORIF.

Influence of Nutritional Status and Physical Exercise on Immune Response in Metabolic Syndrome

Metabolic Syndrome (MetS) is a cluster of metabolic alterations mostly related to visceral adiposity, which in turn promotes glucose intolerance and a chronic systemic inflammatory state, characterized by immune cell infiltration. Such immune system activation increases the risk of severe disease subsequent to viral infections. Strong correlations between elevated body mass index (BMI), type-2-diabetes and increased risk of hospitalization after pandemic influenza H1N1 infection have been described. Similarly, a correlation between elevated blood glucose level and SARS-CoV-2 infection severity and mortality has been described, indicating MetS as an important predictor of clinical outcomes in patients with COVID-19. Adipose secretome, including two of the most abundant and well-studied adipokines, leptin and interleukin-6, is involved in the regulation of energy metabolism and obesity-related low-grade inflammation. Similarly, skeletal muscle hormones—called myokines—released in response to physical exercise affect both metabolic homeostasis and immune system function. Of note, several circulating hormones originate from both adipose tissue and skeletal muscle and display different functions, depending on the metabolic context. This review aims to summarize recent data in the field of exercise immunology, investigating the acute and chronic effects of exercise on myokines release and immune system function.

Diabetes might not be a risk factor for worse prognosis among hospitalized patients due to COVID-19 in a Mediterranean area

AIM

type-2 diabetes (T2DM) seems to worsen the prognosis of patients admitted for COVID-19, although most studies included Asiatic patients. We aimed to assess whether this condition applies for Mediterranean patients.

METHODS

a total of 90 patients admitted for COVID-19 with T2DM were retrospectively compared with 50 patients without T2DM.

RESULTS

subjects with T2DM were older than their counterparts (73.3 ± 12.4 vs 53 ± 15.7 years; p < 0.0001). Either absolute lymphocyte count (1.1 ± 0.6 vs 1.3 ± 0.7 x 109/L; p = 0.005) or hemoglobin (11.9 ± 1.6 vs 13.1 ± 2.1 g/dL; p < 0.0001) were lower among subjects with T2DM. CRP and procalcitonin were higher among subjects with T2DM (91.9 ± 71.2 vs 70.1 ± 63.3 mg/L; p = 0.002 and 0.8 ± 0.3 vs 0.4 ± 0.1 ng/mL; p < 0.0001, respectively). Albumin was lower among patients with T2DM (3.4 ± 0.5 vs 3.8 ± 0.5 g/L: p < 0.001). Length of stay was longer among subjects with T2DM (11.7 ± 7.7 vs 9.7 ± 8.6 days; p = 0.01). However, both groups were comparable regarding both the proportion of subjects who were admitted to the ICU (16.5 % vs 8 %; p = 0.1) and mortality (11 % vs 4 %; p = 0.2).

CONCLUSIONS

in a Mediterranean sample, despite of age, comorbidities, nutritional status, and inflammatory markers, subjects with T2DM with a proper glycemic control admitted for COVID-19 had similar prognostic outcomes than patients without this metabolic condition.

Dendritic Cells and Their Immunotherapeutic Potential for Treating Type 1 Diabetes

Type 1 diabetes (T1D) results from the destruction of pancreatic beta cells through a process that is primarily mediated by T cells. Emerging evidence suggests that dendritic cells (DCs) play a crucial role in initiating and developing this debilitating disease. DCs are professional antigen-presenting cells with the ability to integrate signals arising from tissue infection or injury that present processed antigens from these sites to naïve T cells in secondary lymphoid organs, thereby triggering naïve T cells to differentiate and modulate adaptive immune responses. Recent advancements in our knowledge of the various subsets of DCs and their cellular structures and methods of orchestration over time have resulted in a better understanding of how the T cell response is shaped. DCs employ various arsenal to maintain their tolerance, including the induction of effector T cell deletion or unresponsiveness and the generation and expansion of regulatory T cell populations. Therapies that suppress the immunogenic effects of dendritic cells by blocking T cell costimulatory pathways and proinflammatory cytokine production are currently being sought. Moreover, new strategies are being developed that can regulate DC differentiation and development and harness the tolerogenic capacity of these cells. Here, in this report, we focus on recent advances in the field of DC immunology and evaluate the prospects of DC-based therapeutic strategies to treat T1D.

Combination Antiretroviral Therapy (cART) in Diabetes Exacerbates Diabetogenic Effects on Hippocampal Microstructure, Neurogenesis and Cytokine Perturbation in Male Sprague Dawley Rats

The increasing incidence of diabetes and HIV/AIDS–diabetes comorbidity in society has led to the prevalence of combination antiretroviral therapy (cART) in diabetes, with some reported neural effects. Therefore, the effects of cART and type two diabetes (T2D) on the hippocampal levels of cytokines, lipid peroxidation; histomorphology and neurogenesis were investigated. Adult male Sprague–Dawley rats were divided into four groups: DB (diabetic rats); DAV (diabetic rats treated with cART (efavirenz, emtricitabine and tenofovir); AV (normal rats treated with cART) and the NC group (with no treatment). Following ninety days of treatment, the rats were terminated, and the brains excised. Immunoassay (IL-1α, IL-6, TNFα and MDA); immunohistochemical (Ki67 and DCX) and cresyl violet histomorphology analyses were carried out on brain homogenates and sections, respectively. In comparison to the control, the results showed that cART significantly elevated the IL-6, TNFα and MDA levels, while DB and DAV significantly reduced the body weight, glucose tolerance, IL-1α, IL-6, TNFα and MDA levels. The hippocampal neuronal number was reduced in AV (dentate gyrus; DG region), in the DB group (Cornu Ammonis subregion 1; CA1 and DG regions only) and in DAV (all three hippocampal regions). Additionally, the expression of neurogenic markers Ki67 and doublecortin (DCX) were reduced in the diabetic group, with a greater reduction in the cART+T2D group compared to the control. Furthermore, the neuronal number at all hippocampal regions was negatively corelated with the diabetic parameters (FBG; fasting blood glucose, NFBG; non-fasting blood glucose, AUC; area under the glucose tolerance curve) but positively correlated with body weight. Additionally, the increase in the DG neuronal nuclei area of DB and DAV was significantly positively correlated with FBG, NFBG and AUC and inversely correlated with the estimated number of neurons and neurogenesis. These findings indicate that cART in diabetes (DAV) has similar effects as diabetes relative to the induction of oxidative stress and impairment of the cytokine immune response, but exacerbated neurotoxicity is observed in DAV, as shown by a significantly decreased DCX expression compared to DB and reduction in the number of Cornu Ammonis subregion 3 (CA3) hippocampal neurons, unlike in cART or the diabetes-alone groups.

Systematic on-site testing for SARS-CoV-2 infection among asymptomatic essential workers in Montréal, Canada: a prospective observational and cost-assessment study

BACKGROUND

Essential workers are at increased risk for SARS-CoV-2 infection. We aimed to estimate the yield, acceptability and cost of systematic workplace-based testing of asymptomatic essential workers for SARS-CoV-2 infection.

METHODS

From Jan. 27 to Mar. 12, 2021, we prospectively recruited non-health care essential businesses in Montréal, Canada, through email or telephone contact. Two trained mobile teams, each composed of 2 non-health care professionals, visited businesses. Consenting asymptomatic employees provided saline gargle samples under supervision. Samples were analyzed by means of reverse transcription polymerase chain reaction (RT-PCR). At businesses with outbreaks (≥ 2 participants with a positive result), we retested all participants with a negative result on initial testing. Our primary outcomes were yield (proportion of test results that were positive), acceptability (proportion of participants estimated to be present at the business who agreed to participate) and costs (including training, sample collection and analysis, and communicating results). Our secondary outcome was identification of factors associated with a positive test result on multivariable logistic regression.

RESULTS

Of the 366 businesses contacted, 69 (18.8%) agreed to participate. Nineteen businesses (28%) were manufacturers or suppliers, 12 (17%) were in auto sales or repair, and 11 (16%) were in childcare; the corresponding number of employees was 1225, 242 and 113. The median number of participants per business was 13 (interquartile range [IQR] 8-22). Of an estimated 2348 employees on site, 2128 (90.6%) participated (808 [38.0%] female, median age 48 [IQR 37-57] yr). Of the 2626 tests performed, 53 (2.0%) gave a positive result. Self-reported nonwhite ethnicity (adjusted odds ratio [OR] 3.7, 95% confidence interval [CI] 1.4-9.9) and a negative SARS-CoV-2 test result before the study (adjusted OR 0.4, 95% CI 0.2-0.8) were associated with a positive test result. Five businesses were experiencing an outbreak; at these businesses, 40/917 participants (4.4%) had a positive result on the initial test. We repeated testing for employees with initially negative results at 3 of these businesses over 2-3 weeks: 8/350 participants (2.3%) had a positive result on the second test, and none had a positive result on the third and fourth tests; no employer reported new positive results after our final visit (up to Mar. 26, 2021). At the remaining 64 businesses, 1211 participants were tested once, of whom 5 (0.4%) had a positive result. The per-person RT-PCR cost was $34, and all other costs, $8.67.

INTERPRETATION

On-site saline gargle sampling of essential workers for SARS-CoV-2 testing was acceptable and of modest cost, and appears most useful in the context of outbreaks. This sampling strategy should be evaluated further as a component of efforts to prevent SARS-CoV-2 transmission. PREPRINT: medRxiv - doi:10.1101/2021.05.12.21256956.

The impact of the length of total and intravenous systemic antibiotic therapy for the remission of diabetic foot infections

OBJECTIVE

We investigated the impact of the total length of systemic antibiotic therapy (ABT) and its initial intravenous (IV) part on clinical failure (CF) and microbiological failure (MF) in diabetic foot infections (DFIs).

METHODS

In this single-center, retrospective, unmatched case-control study, we included DFI episodes treated with a combined surgical-antibiotic approach.

RESULTS

We included 721 DFI episodes, 537 with osteomyelitis (DFO). CF occurred in 191 (26.5%) and MF in 42 (5.8%) episodes. Multivariate Cox regression analysis showed that a short ABT of 8-21 days (hazard ratio [HR] 0.4; 95% CI 0.2-0.7) was inversely associated with CF. This was also applicable for IV ABT with relatively short durations of 2-7 days (HR 0.5; 95% CI 0.3-0.8) or 8-14 days (HR 0.6; 95% CI 0.4-0.9). We failed to detect a minimal threshold of total or IV ABT predictive for CF or MF.

CONCLUSIONS

Compared with total ABT of more than 84 days and IV therapy of more than 14 days, shorter total and IV ABT yielded no enhanced risk of CF or MF. Considering the "bias by indication" that is inherent to retrospective DFI studies, the best study design concerning the duration of ABT would be a stratified, prospective randomized trial, which is currently under way in our medical center.

Metabolic Risk Factors Are Associated with the Disease Severity and Prognosis of Hepatitis B Virus-Related Acute on Chronic Liver Failure

Background/Aims

Metabolic risk factors could accelerate hepatitis B virus (HBV)-related mortality; however, their impacts on disease severity in HBV-related acute on chronic liver failure (HBV-ACLF) patients remain unexplored. In this study, we assessed the effects of metabolic risk factors on the outcome of HBV-ACLF patients.

Methods

This study retrospectively enrolled antiviral therapy naïve HBV-ACLF patients from a single center in China. Patients were evaluated according to Child-Turcotte-Pugh score, Model for End-Stage Liver Disease (MELD) score, 30-day, 90-day mortality and survival rate to estimate the prognosis of HBV-ACLF. The impacts of different metabolic risk factors were further analyzed.

Results

A total of 233 patients, including 158 (67.8%) with metabolic risk factors and 75 (32.2%) without metabolic risk factors, were finally analyzed. Patients with metabolic risk factors had significantly higher MELD score (22.6±6.1 vs 19.8±3.8, p<0.001), 90-day mortality rate (56.3% vs 38.7%, p=0.017), and shorter median survival time (58 days vs 75 days hazard ratio, 1.553; 95% confidence interval, 1.061 to 2.274; p=0.036) than patients without them. Moreover, metabolic risk factors were independently associated with patients’ 90-day mortality (hazard ratio, 1.621; 95% confidence interval, 1.016 to 2.585; p=0.043). Prediabetes/diabetes and hypertension were related to higher rates of infection and worse renal function in HBV-ACLF patients.

Conclusions

HBV-ACLF patients with metabolic risk factors, especially prediabetes/diabetes or hypertension, could have more severe disease and lower survival rates. In addition, the existence of metabolic disorder is an independent risk factor for HBV-ACLF patients’ 90-day mortality.

SGLT2 Inhibitors in Type 2 Diabetes Mellitus and Heart Failure-A Concise Review

The incidence of both diabetes mellitus type 2 and heart failure is rapidly growing, and the diseases often coexist. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new antidiabetic drug class that mediates epithelial glucose transport at the renal proximal tubules, inhibiting glucose absorption—resulting in glycosuria—and therefore improving glycemic control. Recent trials have proven that SGLT2i also improve cardiovascular and renal outcomes, including reduced cardiovascular mortality and fewer hospitalizations for heart failure. Reduced preload and afterload, improved vascular function, and changes in tissue sodium and calcium handling may also play a role. The expected paradigm shift in treatment strategies was reflected in the most recent 2021 guidelines published by the European Society of Cardiology, recommending dapagliflozin and empagliflozin as first-line treatment for heart failure patients with reduced ejection fraction. Moreover, the recent results of the EMPEROR-Preserved trial regarding empagliflozin give us hope that there is finally an effective treatment for patients with heart failure with preserved ejection fraction. This review aims to assess the efficacy and safety of these new anti-glycemic oral agents in the management of diabetic and heart failure patients.

Clinical Significance of COVID-19 and Diabetes: In the Pandemic Situation of SARS-CoV-2 Variants including Omicron (B.1.1.529)

Simple Summary

Amidst the dual pandemics of diabetes and coronavirus disease 2019 (COVID-19), with the constant emergence of novel variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a vicious cycle has been created, i.e., a hyperglycemic state contributes to the severe clinical course of COVID-19, which in turn has deleterious effects on glycometabolism and in some cases causes new-onset diabetes. Here, we present a comprehensive review of the current literature on the clinical and experimental findings associated with the interrelationship between diabetes and COVID-19. To control disease outcomes and glucometabolic complications in COVID-19, this issue is still being investigated.

Abstract

The coronavirus disease 2019 (COVID-19) global pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), remains uncontrolled, with the spread of emerging variants. According to accumulating evidence, diabetes is one of the leading risk factors for a severe COVID-19 clinical course, depending on the glycemic state before admission and during COVID-19 hospitalization. Multiple factors are thought to be responsible, including an altered immune response, coexisting comorbidity, and disruption of the renin-angiotensin system through the virus–host interaction. However, the precise underlying mechanisms remain under investigation. Alternatively, the focus is currently on the diabetogenic and ketosis-prone potential of SARS-CoV-2 itself, even for probable triggers of stress and steroid-induced hyperglycemia in COVID-19. In this article, we present a comprehensive review of the recent literature on the clinical and experimental findings associated with diabetes and COVID-19, and we discuss their bidirectional relationship, i.e., the risk for an adverse prognosis and the deleterious effects on glycometabolism. Accurate assessments of the incidence of new-onset diabetes induced by COVID-19 and its pathogenicity are still unknown, especially in the context of the circulation of SARS-CoV-2 variants, such as Omicron (B.1.1.529), which is a major challenge for the future.

Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (T1DM) is an endocrine disorder in which pancreatic β cells stop producing insulin, typically due to autoimmune destruction. This results in hyperglycemia and ketosis; thus, insulin replacement is vital to management. Incidence peaks in puberty and early adulthood, but onset can occur at any age. However, prevalence is highest among adults because persons with T1DM live for many years. Symptoms include polyuria, polydipsia, and weight loss. Acute complications include diabetic ketoacidosis, which requires urgent management. Long-term complications include microvascular and macrovascular disease. Patients with T1DM are at higher risk for other autoimmune diseases and psychosocial issues. Management should focus on optimizing glucose control to reduce acute and long-term complications.

Synthesis and Spectroscopic Characterization of Dapagliflozin/Zn (II), Cr (III) and Se (IV) Novel Complexes That Ameliorate Hepatic Damage, Hyperglycemia and Oxidative Injury Induced by Streptozotocin-Induced Diabetic Male Rats and Their Antibacterial Activity

Diabetes mellitus (DM) causes an imbalance in the oxidative status of the human body. Three novel Dapagliflozin (Dapg) Zn (II), Cr (III) and Se (IV) complexes were prepared and characterized by elemental analysis, IR, electronic spectra, magnetic susceptibility, scanning electron microscopy (SEM) and X-ray diffraction. The molar conductance values confirmed the non-electrolytic nature of the Dapg complexes. According to spectral data, Dapg acts as a bidentate ligand. The thermal analyses of the complexes were studied using the DSC technique. The surface morphology and particle sizes of the Dapg complexes were investigated using SEM and XRD. XRD confirmed the crystalline structure for the complexity. This study investigated the effect of novel metal complexes of Dapg with the metals Zn (II), Cr (III) and Se (IV) on oxidative injury and tissue damage in the hepatic tissue of streptozotocin (STZ)-induced diabetic male rats. DM was experimentally induced in male rats. The diabetic rats received Dapg, Dapg/Zn, Dapg/Cr and Dapg/Se orally for 30 successive days. Male rats exposed to STZ showed multi-histopathological alterations in their hepatic tissue, including inflammatory and structural changes. STZ elevated oxidative stress markers in the hepatic tissue and lowered the antioxidant defense enzymes. Supplementation of Dapg with Zn, Cr or Se novel complexes significantly prevented hepatic injury and suppressed the generation of reactive oxygen species. The Dapg/Zn complex was highly effective against Bacillus subtilis and Streptococcus penumonia, while Dapg/Cr was highly effective against Escherichia coli and Pseudomonas aeruginosa, and Dapg/Se was highly effective against Staphylococcus aureas. In conclusion, Dapg novel metal complexes with Zn, Cr or Se protect against oxidative injury and the pathophysiological and bacterial complications of DM and hepatic tissue injury. The Dapg novel metal complexes improved hepatic functions, reduced blood glucose levels and enhanced the levels of antioxidant defense enzymes in diabetic male rats.

Cutaneous Manifestation of Diabetes Mellitus in an Unsheltered Male Leading to Emergent Hospitalization

Diabetes mellitus (DM) is one of the most common chronic diseases in the United States. It is characterized by increased patient morbidity and mortality due to the many complications that can arise. Certain dermatological findings can be indicative of poorly controlled DM and can be a useful clue to further management. Persons experiencing homelessness (PEH) with DM often have higher rates of diabetic complications than the general diabetic population. Medical providers caring for PEH in the setting of limited resources should carefully evaluate cutaneous disease as a potential indicator of underlying illness. This physical manifestation of illness can serve to guide the next appropriate steps in management. A 41-year-old unsheltered male with an extensive medical history of hypertension, seizures, chronic diarrhea, and cocaine use was seen at a “foot-washing” medical outreach event. He presented with fevers, chills, and multiple painless right lower extremity ulcerated lesions of unspecified origin. A finger-stick glucose measurement was found to be 650 mg/dL. After immediate administration of 10 units of insulin, he was transported immediately to the emergency department and admitted. His month-long hospital course was complicated and involved the amputation of multiple toes. Preemptive outreach and management could have prevented the marked deterioration of his disease and represents the importance of outreach and regular follow-up with the PEH community.

Association of Proteus mirabilis and Providencia stuartii Infections with Diabetes

Background and Objectives: Proteus and Providencia are related genera of opportunistic pathogens belonging to the Morganellaceae family, often a cause of infections in the immunocompromised hosts, such as diabetic patients. Their clinical significance has increased due to their intrinsic resistance to polymyxins, which is often associated with acquired resistance mechanisms. In this study we evaluated the infections caused by Proteus mirabilis and Providencia stuartii in two groups of patients, with diabetes (group 1) and without diabetes (group 2) admitted to the intensive care unit and surgical wards. The infections were investigated in terms of infection type, risk factors, clinical course, predictive factors for unfavourable outcomes and antibiotic resistance profile. Materials and Methods: An observational, retrospective, cross-sectional study was conducted, comprising all patients infected with these pathogens. Bacterial identification and antibiotic sensitivity testing were performed using the Vitek2C automated system. Results: Comparison of the two groups showed that the statistically significant common infectious risk factors were found less frequently among diabetic patients when compared with non-diabetic patients, and that antimicrobial resistance was significantly lower in the diabetic patient group. However, survival rates did not differ between the two groups, drawing attention to the implications of diabetes as comorbidity. Additionally, with regard to the antibiotic resistance profile, 38.89% of P. stuartii strains isolated from diabetic patients belonged to the difficult-to-treat (DTR) phenotype, contributing to the severity of these infections compared with those caused by P. mirabilis, of which 32% were wild type strains and 0% were DTR phenotype. The DTR/extended spectrum beta-lactamase producing P. stuartii isolates more than doubled the risk of mortality, while the presence of nasogastric nutrition tripled the risk. Conclusions: P. stuartii infections that occurred in diabetic patients proved to be more difficult to treat, the majority of them being healthcare-associated bacteremias.

The Role of Mid-Regional Proadrenomedullin in the Differential Diagnosis between Culture-Negative and Culture-Positive Sepsis at Emergency Department Admission

Background: The host response in culture-negative sepsis (CnS) has been marginally explored upon emergency department (ED) admission. It would be of paramount importance to create a clinical prediction rule to support the emergency department physician in identifying septic patients who can be treated with antibiotics immediately without waiting time to draw cultures if they are unlikely to provide useful diagnostic information. Methods: A multivariable logistic regression analysis was applied to identify the independent clinical variables and serum biomarkers of the culture-negative status among 773 undifferentiated septic patients. Those predictors were combined to build a nomogram predictive of CnS. Results: The serum concentrations of six biomarkers, among the eight biomarkers assayed in this study, were significantly lower in the patients with CnS (449) than in those with culture-positive sepsis (324). After correction for co-variates, only mid-regional proadrenomedullin (MR-proADM) was found to be independently correlated with culture-negative status. Absence of diabetes, hemoglobin concentrations, and respiratory source of infection were the other independent clinical variables integrated into the nomogram—its sensitivity and specificity for CnS were 0.80 and 0.79, respectively. Conclusions: Low concentrations of MR-proADM were independently associated with culture-negative sepsis. Our nomogram, based on the MR-proADM levels, did not predict culture-negative status with reasonable certainty in patients with a definitive diagnosis of sepsis at ED admission.

Chronic Running Exercise Regulates Cytotoxic Cell Functions and Zinc Transporter SLC39A10/ZIP10 Levels in Diabetic Rats

The aim of this study is to investigate how chronic running exercise affects ZIP10 levels in thymus and spleen tissue as well as immune parameters in diabetic rats. A total of 40 adult male Wistar rats were divided into 4 equal groups: group 1, control; group 2, exercise control; group 3, diabetes; group 4, diabetes + exercise. Diabetes was induced by injecting intraperitoneal streptozotocin (STZ) at a dose of 40 mg/kg twice with 24-h intervals to the animals in groups 3 and 4. The animals in group 2 and group 4 underwent exercise for 45 min on the rat treadmill for 4 weeks at 20 m/min. Twenty-four hours after the last running exercise, the animals were sacrificed under general anesthesia. Immunological parameters were determined by flow cytometric method; tissue ZIP 10 levels were determined by ELISA method. The diabetic group had the lowest natural killer (NK) and natural killer T (NKT) cells percentages. Chronic exercise partially improved NK and NKT cell percentages in diabetic rats. The diabetic group had the lowest ZIP10 levels in spleen and thymus tissue. ZIP10 values in spleen and thymus tissue of diabetes exercise group were significantly higher than diabetes group. The results of our study show that the impaired cytotoxic cell functions in diabetes are partially corrected with 4 weeks of chronic exercise, and that the suppressed ZIP 10 levels in diabetic rats are reversed by 4 weeks of chronic exercise.

Do patients with diabetic foot ulcer need booster dose of tetanus vaccine?

Purpose

Diabetic foot ulcer is a public health concern around the world. These wounds are prone to a variety of infections including Clostridium Tetani that may lead to tetanus. The aim of this study was to evaluate the immunity status as a result of tetanus vaccination and other preventive measures in these patients.

Methods

We conducted a narrative review of previous studies which were related to the risk of tetanus infection in diabetic foot patients by searching electronic databases.

Results

It was found that usually tetanus antibody titers in diabetic patients are below the protective level and they are not appropriately vaccinated. Therefore, diabetes and lack of immunity, put diabetic foot ulcer patients more at risk of tetanus. But this problem is not given serious attention in diabetes care.

Conclusions

Thus, it is recommended to provide specific guidelines for tetanus vaccination and prophylaxis in diabetic patients. These recommendations can play a vital role in the prevention of diabetic foot ulcers complication.

New Wild-Type Lacticaseibacillus rhamnosus Strains as Candidates to Manage Type 1 Diabetes

The incidence of type 1 diabetes (T1D) has been dramatically increased in developed countries, and beyond the genetic impact, environmental factors, including diet, seem to play an important role in the onset and development of the disease. In this vein, five Lacticaseibacillus rhamnosus, isolated from traditional fermented Greek products, were screened for potential probiotic properties, aiming at maintaining gut homeostasis and antidiabetic capability to alleviate T1D symptoms. L. rhamnosus cell-free supernatants induced strong growth inhibitory activity against common food spoilage and foodborne pathogenic microorganisms, associated with several diseases, including T1D, and were also able to inhibit α-glucosidase activity (up to 44.87%), a promising property for alternatives to the antidiabetic drugs. In addition, survival rates up to 36.76% were recorded during the application of the static in vitro digestion model. The strains had no hemolytic activity and were sensitive to common antibiotics suggested by the European Food and Safety Association, apart from chloramphenicol. However, it is highly unlikely that the resistance has been acquired. In conclusion, our results suggest a great health-promoting potential of the newly isolated wild-type L. rhamnosus strains, but further confirmation of their efficiency in experimental animal models is considered an essential next research step.

Antimicrobial and α-glucosidase inhibitory activities of chemical constituents from Gardenia aqualla (Rubiaceae)

An aliphatic alkene namely pentapentacontene (4) was isolated for the first time from a natural source, Gardenia aqualla, along with fourteen other compounds including nonacosanol (1), tetratriacontanol (2), octatriacontanol (3), β-sitosterol (5) and stigmasterol (6), daucosanol (7), ursolic acid (8), uvaol (9), 3β,19α,23β,24α-tetrahydroxyurs-12-en-28-oic acid (10), lupenone (11), oleanolic acid (12), vanillin (13), vanillic acid (14) and D-mannitol (15). α-glucosidase inhibitory assay revealed that MeOH and EtOAc extracts of leaves had the best activity with IC₅₀ of 9.65 and 20.03 µg/ml respectively. All the tested compounds showed dose dependent inhibition of α-glucosidase and some of them were found to be comparable to acarbose. Compound 10 was the most potent with IC₅₀ = 1.72 μM. It also showed the most interesting antibacterial activity, against the isolate strain of S. typhi and P. aeruginosa and also exhibited the most significant antifungal activities against all the tested yeasts.

Enhanced endocytosis elevated virulence and severity of SARS-CoV-2 due to hyperglycemia in type 2 diabetic patients

Diabetes mellitus is a metabolic disease that causes hyperglycemia. In COVID-19 patients the severity of the disease depends on myriad factors but diabetes mellitus is the most important comorbidity. The current review was conducted to investigate the virulence of SARS-CoV-2 and disease severity of COVID-19 in type 2 diabetes mellitus patients and relevant treatment. The literature published in PubMed, Scopus, Web of Science, and Google Scholar was reviewed up to September 2021. The keywords including SARS-CoV-2, type 2 diabetes mellitus in COVID-19, hyperglycemia in COVID-19, opportunistic infections in type 2 diabetes mellitus and COVID-19 were used in different combinations. Hyperglycemic individuals over-express ACE-2 receptors in the lungs thus increasing the SARS-CoV-2 susceptibility and replication. Although dipeptidyl peptidase-4 plays an important role in glucose homeostasis, additionally it also stimulates the production of proinflammatory cytokines such as IL-6 and TNF-α creating a cytokine storm. Cytokine storm might be responsible for respiratory insufficiency in severe COVID-19 patients. Type 2 diabetes mellitus is associated with immunosuppression and the patients are prone to get many opportunistic infections. Type 2 diabetes mellitus patients with severe COVID-19 have lymphopenia. Moreover, in type 2 diabetes mellitus patients the neutrophils exhibit decreased chemotaxis, hydrogen peroxide production, and phagocytosis. Reduction in lymphocyte count and defective neutrophil capacity renders them with COVID-19 susceptible to opportunistic bacterial and fungal infections increasing the mortality rate. The opportunistic bacterial infections in COVID-19 patients were due to Staphylococcus aureus, Streptococcus pneumonia, and coagulase-negative Staphylococci, E. coli, Pseudomonas aeruginosa, and Klebsiella sp. In COVID-19 patients with type 2 diabetes mellitus, mucormycosis was found to be the most common fungal infection with a higher predilection to males. Hyperglycemia in COVID-19 patients with type 2 diabetes mellitus enhances the SARS-CoV-2 replication with an adverse outcome. A strong correlation exists between the poor prognosis of COVID-19 and type 2 diabetes mellitus. Proper glycemic control in COVID-19 patients with diabetes mellitus might lessen the severity of the disease.

Interleukin-37: A Link Between COVID-19, Diabetes, and the Black Fungus

The COVID-19 pandemic involved millions of people and diabetes was identified as an associated comorbidity. Initiation of systemic corticosteroids in patients suffering from severe COVID-19 was associated with lower mortality. A surge of invasive fungal infections of the maxillofacial region, namely mucormycosis, was linked to a deadly infection known as black fungus. Black fungus, diabetes, corticosteroids, and coronavirus disease 2019 (COVID-19) all have a dysregulated immune response in common, which partly could also be attributed to interleukin 37 (IL-37). IL-37, a new cytokine of the IL-1 family, known for broadly reducing innate inflammation as well as acquired immune responses. The use of corticosteroids in diabetic COVID-19 patients, crowded hospitals, and lack of medical oxygen should be carefully considered to reduce COVID-associated secondary infections.

Influence of Fasting Plasma Glucose Level on Admission of COVID-19 Patients: A Retrospective Study

BACKGROUND

The coronavirus disease 2019 (COVID-19) is a serious global health threat and has spread dramatically worldwide. Prolonged viral shedding is associated with a more severe disease course and inflammatory reaction. Blood glucose levels were significantly associated with an increased hazard ratio (HR) for poor outcomes in COVID-19 patients.

OBJECTIVE

Previous studies focused primarily on the relationship between blood glucose and mortality or severe outcomes, but there were few research studies on the relationship between fasting plasma glucose (FPG) and duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA positive status. To explore the relationship between FPG levels and prolonged duration of SARS-CoV-2 viral positivity, the clinical data of COVID-19 patients were analyzed.

METHOD

In this retrospective study, 99 cases of COVID-19 patients in Beijing Ditan Hospital were recruited, and their clinical and laboratory findings at admission were collected and analyzed. Furthermore, the risk factors for prolonged duration of SARS-CoV-2 RNA shedding were identified, and the relationship between FPG levels and the prolonged presence of SARS-CoV-2 RNA was evaluated.

RESULT

We found that elevated FPG levels were correlated with longer duration of SARS-CoV-2 RNA positivity, classification of COVID-19, imaging changes of chest CT, inflammation-related biomarkers, and CD8+ T cell number in COVID-19 patients. In a logistic regression model, after adjusting for gender and age, COVID-19 patients with elevated FPG were more likely to had longer duration of SARS-CoV-2 RNA positivity than those with normal FPG levels (OR 3.053 [95% CI 1.343, 6.936]).

CONCLUSION

Higher FPG levels (≥6.1 mmol/l) at admission was an independent predictor for prolonged SARS-CoV-2 shedding, regardless of a known history of diabetes. It suggests that intensive monitoring and control of blood glucose are important for all COVID-19 patients.

Immunomodulation of Skin Repair: Cell-Based Therapeutic Strategies for Skin Replacement (A Comprehensive Review)

The immune system has a crucial role in skin wound healing and the application of specific cell-laden immunomodulating biomaterials emerged as a possible treatment option to drive skin tissue regeneration. Cell-laden tissue-engineered skin substitutes have the ability to activate immune pathways, even in the absence of other immune-stimulating signals. In particular, mesenchymal stem cells with their immunomodulatory properties can create a specific immune microenvironment to reduce inflammation, scarring, and support skin regeneration. This review presents an overview of current wound care techniques including skin tissue engineering and biomaterials as a novel and promising approach. We highlight the plasticity and different roles of immune cells, in particular macrophages during various stages of skin wound healing. These aspects are pivotal to promote the regeneration of nonhealing wounds such as ulcers in diabetic patients. We believe that a better understanding of the intrinsic immunomodulatory features of stem cells in implantable skin substitutes will lead to new translational opportunities. This, in turn, will improve skin tissue engineering and regenerative medicine applications.