Infections in Diabetes Mellitus and Hyperglycemia

Microbiological profiles in periprosthetic joint infections after total knee arthroplasty: a comparative analysis of diabetic and non-diabetic patients

AIM OF THE STUDY

The purpose of this study is to conduct a comparative analysis of the microbiological profiles in periprosthetic joint infections (PJIs) after total knee arthroplasty (TKA) between diabetic and non-diabetic patients. The study aims to address what are the variations in microbial colonization and infection patterns between diabetic and non-diabetic patients undergoing total knee arthroplasty.

METHODS

A retrospective analysis of 2,569 culture-positive cases of PJIs post-TKA was conducted, comparing outcomes between diabetic (n = 321) and non-diabetic (n = 2,248) patients. Demographic, clinical, and microbiological data were collected and analyzed using descriptive statistics, chi-squared tests, logistic regression, and other statistical tests.

RESULTS

Diabetic patients exhibited distinct microbial colonization patterns, with a higher prevalence of pathogens such as Staphylococcus aureus (p = 0.033), Pseudomonas aeruginosa (p < 0.001), Streptococcus spp. (Streptococcus agalactiae and Streptococcus dysgalactiae; p = 0.010, 0.016 respectively), Candida spp. (p = 0.010), and Corynebacterium spp. (p = 0.024). Additionally, diabetic patients were at increased risk of polymicrobial infections. Comorbidities associated with diabetes, including chronic pulmonary disease, renal insufficiency, and peripheral artery disease, were significantly more prevalent in diabetic patients and further complicated PJI outcomes.

CONCLUSION

This study underscores the importance of tailored perioperative antimicrobial strategies and vigilant infection control measures in diabetic patients undergoing TKA. Understanding the differential microbial profiles and associated comorbidities can inform targeted interventions to mitigate the risk of PJIs and improve outcomes in this high-risk population. Further research is warranted to elucidate the underlying mechanisms and optimize management strategies for diabetic patients undergoing TKA.

Prediction model of pressure injury occurrence in diabetic patients during ICU hospitalization--XGBoost machine learning model can be interpreted based on SHAP

BACKGROUND

The occurrence of pressure injury in patients with diabetes during ICU hospitalization can result in severe complications, including infections and non-healing wounds.

AIMS

The aim of this study was to predict the occurrence of pressure injury in ICU patients with diabetes using machine learning models.

STUDY DESIGN

In this study, LASSO regression was used for feature screening, XGBoost was employed for machine learning model construction, ROC curve analysis, calibration curve analysis, clinical decision curve analysis, sensitivity, specificity, accuracy, and F1 score were used for evaluating the model's performance.

RESULTS

Out of the 503 ICU patients with diabetes included in the study, pressure injury developed in 170 cases, resulting in an incidence rate of 33.8 %. The XGBoost model had a higher AUC for predicting pressure injury in patients with diabetes during ICU hospitalization (train: 0.896, 95 %CI: 0.863 to 0.929; test: 0.835, 95 % CI: 0.761-0.908). The importance of SHAP variables in the model from high to low was: 'Days in ICU', 'Mechanical Ventilation', 'Neutrophil Count', 'Consciousness', 'Glucose', and 'Warming Blanket'.

CONCLUSION

The XGBoost machine learning model we constructed has shown high performance in predicting the occurrence of pressure injury in ICU patients with diabetes. Additionally, the SHAP method enables the interpretation of the results provided by the machine learning model.

RELEVANCE TO CLINICAL PRACTICE

Improve the ability to predict the early occurrence of pressure injury in diabetic patients in the ICU. This will enable clinicians to intervene early and reduce the occurrence of complications.

High sugar diets can increase susceptibility to bacterial infection in Drosophila melanogaster

Overnutrition with dietary sugar can worsen infection outcomes in diverse organisms including insects and humans, through generally unknown mechanisms. In the present study, we show that adult Drosophila melanogaster fed high-sugar diets became more susceptible to infection by the Gram-negative bacteria Providencia rettgeri and Serratia marcescens. We found that P. rettgeri and S. marcescens proliferate more rapidly in D. melanogaster fed a high-sugar diet, resulting in increased probability of host death. D. melanogaster become hyperglycemic on the high-sugar diet, and we find evidence that the extra carbon availability may promote S. marcescens growth within the host. However, we found no evidence that increased carbon availability directly supports greater P. rettgeri growth. D. melanogaster on both diets fully induce transcription of antimicrobial peptide (AMP) genes in response to infection, but D. melanogaster provided with high-sugar diets show reduced production of AMP protein. Thus, overnutrition with dietary sugar may impair host immunity at the level of AMP translation. Our results demonstrate that dietary sugar can shape infection dynamics by impacting both host and pathogen, depending on the nutritional requirements of the pathogen and by altering the physiological capacity of the host to sustain an immune response.

Dynamic Adhesive Behavior and Biofilm Formation of Staphylococcus aureus on Polylactic Acid Surfaces in Diabetic Environments

Interest in biodegradable implants has focused attention on the resorbable polymer polylactic acid. However, the risk of these materials promoting infection, especially in patients with existing pathologies, needs to be monitored. The enrichment of a bacterial adhesion medium with compounds that are associated with human pathologies can help in understanding how these components affect the development of infectious processes. Specifically, this work evaluates the influence of glucose and ketone bodies (in a diabetic context) on the adhesion dynamics of S. aureus to the biomaterial polylactic acid, employing different approaches and discussing the results based on the physical properties of the bacterial surface and its metabolic activity. The combination of ketoacidosis and hyperglycemia (GK2) appears to be the worst scenario: this system promotes a state of continuous bacterial colonization over time, suppressing the stationary phase of adhesion and strengthening the attachment of bacteria to the surface. In addition, these supplements cause a significant increase in the metabolic activity of the bacteria. Compared to non-enriched media, biofilm formation doubles under ketoacidosis conditions, while in the planktonic state, it is glucose that triggers metabolic activity, which is practically suppressed when only ketone components are present. Both information must be complementary to understand what can happen in a real system, where planktonic bacteria are the ones that initially colonize a surface, and, subsequently, these attached bacteria end up forming a biofilm. This information highlights the need for good monitoring of diabetic patients, especially if they use an implanted device made of PLA.

Analysis of risk factors related to chronic non-healing wound infection and the construction of a clinical prediction model

This study is aimed to analyse the risk factors associated with chronic non-healing wound infections, establish a clinical prediction model, and validate its performance. Clinical data were retrospectively collected from 260 patients with chronic non-healing wounds treated in the plastic surgery ward of Shanxi Provincial People's Hospital between January 2022 and December 2023 who met the inclusion criteria. Risk factors were analysed, and a clinical prediction model was constructed using both single and multifactor logistic regression analyses to determine the factors associated with chronic non-healing wound infections. The model's discrimination and calibration were assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve and calibration curve. Multivariate logistic regression analysis identified several independent risk factors for chronic non-healing wound infection: long-term smoking (odds ratio [OR]: 4.122, 95% CI: 3.412-5.312, p < 0.05), history of diabetes (OR: 3.213, 95% CI: 2.867-4.521, p < 0.05), elevated C-reactive protein (OR: 2.981, 95% CI: 2.312-3.579, p < 0.05), elevated procalcitonin (OR: 2.253, 95% CI: 1.893-3.412, p < 0.05) and reduced albumin (OR: 1.892, 95% CI: 1.322-3.112, p < 0.05). The clinical prediction model's C-index was 0.762, with the corrected C-index from internal validation using the bootstrap method being 0.747. The ROC curve indicated an area under the curve (AUC) of 0.762 (95% CI: 0.702-0.822). Both the AUC and C-indexes ranged between 0.7 and 0.9, suggesting moderate-to-good predictive accuracy. The calibration chart demonstrated a good fit between the model's calibration curve and the ideal curve. Long-term smoking, diabetes, elevated C-reactive protein, elevated procalcitonin and reduced albumin are confirmed as independent risk factors for bacterial infection in patients with chronic non-healing wounds. The clinical prediction model based on these factors shows robust performance and substantial predictive value.

Vasculitis and infectious risk in a patient with type 2 diabetes mellitus: A case report

The connection between vasculitis and infection is complex. The present study described a typical situation for a patient with unbalanced type 2 diabetes and chronic complications, in which a lack of adherence to the protection and care measures ultimately led to the appearance of some of the worst consequences of the condition, namely, ulceration, gangrene and amputation. In the context of an unstable condition with significant metabolic imbalance there was an impaired response to infections in the present patient, and the amputation resulted in wound persistence and ulcer development, followed by superinfection with methicillin-resistant Staphylococcus aureus according to the antibiogram performed. In this case, an episode of vasculitis was triggered without evidence of bacteraemia. The present case report highlighted the importance of proper hygiene and good metabolic control in patients with diabetes that suffer from amputations and conditions that expose them to certain complications, including vasculitis.

A multimodal therapy for infected diabetic wounds based on glucose-responsive nanocomposite-integrated microneedles

Diabetic wounds in a state of high glucose are refractory to treatment and healing, especially if they are infected with bacteria. Herein, a novel nanocomposite (CIP/GOx@ZIF-8) was synthesized by loading ciprofloxacin hydrochloride (CIP) and glucose oxidase (GOx) into zeolitic imidazole framework-8 (ZIF-8) that exhibited good glucose sensitivity and catalytic activity. The high glucose in diabetic wounds could be decomposed into hydrogen peroxide (H2O2) and gluconic acid via the catalysis of GOx, which further destroyed CIP/GOx@ZIF-8 to release Zn2+ and cargos. The combination of glucose starvation, Zn2+, H2O2 and CIP could elevate the antibacterial effect and reduce bacterial resistance. Subsequently, the nanocomposite was fabricated into dissolving microneedles (CIP/GOx@ZIF-8 MNs) using polyvinylpyrrolidone (PVP). The microneedles exhibited good mechanical strength, puncture performance, dissolving performance, glucose responsiveness, antibacterial performance and biocompatibility. For in vivo wound healing, CIP/GOx@ZIF-8 MNs with good biosafety facilitated neovascularization and collagen deposition as well as reduced inflammation, and the wounds were almost healed after treatment. This multimodal therapeutic strategy is created to provide a unique treatment for infected diabetic wounds.

Endometritis risk factors after arterial embolisation for postpartum haemorrhage

Various complications of arterial embolisation (AE) for postpartum haemorrhage (PPH) are reported. Endometritis (EM) frequently causes abscesses, increasing hysterectomy risk. However, risk factors for EM after AE for PPH are unclear. We explored these risk factors. We included patients who underwent AE for PPH in our hospital from 2005 to 2020 and compared those who did (EM group) and did not develop EM after AE (non-EM group) in a case-control study. Twenty patients met the study criteria; eight patients (40%) had EM. There were no differences in risk factors between groups involved in infection, such as premature rupture of membranes. However, the contrast medium extravasation rate on computed tomography scans before the AE procedure was significantly higher in the EM group (p=.019) compared to the non-EM group. The greatest EM risk factor was contrast medium extravasation before AE for PPH, determined by classification and regression tree modelling (relative risk: 4.5).Impact StatementWhat is already known on this subject? Reportedly, the clinical success rate of arterial embolisation (AE) for critical haemorrhage in obstetrics is high, around 90%. However, information regarding AE complications is limited. Endometritis is one of these complications, which not only causes prolonged hospitalisation but may also require further treatment, such as hysterectomy. However, the incidence rate and risk factors for EM remain unknown.What do the results of this study add? In this study, 40.0% of patients developed EM after AE for PPH. Extravasation of contrast medium was the top risk factor (relative risk: 4.5 compared to those without EM, p=.019). The second-leading risk factor was a bleeding volume greater than 2500 mL (relative risk: 4.5 compared to those without EM, p=.019).What are the implications of these findings for future clinical practice and/or future research? We created an EM prediction model using extravasation and a bleeding volume greater than 2500 mL. The model was 87.5% sensitive and 66.7% specific. This prediction model allows for the early detection and treatment of EM by recognising high-risk patients and providing intensive postpartum management.

Concurrent bacterial liver abscess and mild encephalitis/encephalopathy with reversible splenial lesion in a patient with poorly controlled type 2 diabetes

A 34-year-old man with poorly controlled type 2 diabetes was admitted to our hospital because of fever, headache, vomiting, and impaired consciousness. His hemoglobin A1c level was as high as 11.0%. Abdominal computed tomography revealed a bacterial liver abscess, while head magnetic resonance imaging simultaneously showed a high-signal lesion on diffusion-weighted imaging and a low-signal lesion on the apparent diffusion coefficient map of the splenium of the corpus callosum. No significant findings were detected in the cerebrospinal fluid. The latter findings led to a diagnosis of mild encephalitis/encephalopathy with reversible splenial lesions. His impaired consciousness resolved on Day 5 after treatment with ceftriaxone and metronidazole infusion and intensive insulin therapy; magnetic resonance imaging on Day 20 showed that the lesion in the splenium of the corpus callosum had disappeared. We propose that when a person with poorly controlled diabetes develops a bacterial infection and presents with impaired consciousness and headache, clinicians should consider the complications of mild encephalitis/encephalopathy with reversible splenial lesion.

Effects of Gut Microbiome Modulation on Reducing Adverse Health Outcomes among Elderly and Diabetes Patients during the COVID-19 Pandemic: A Randomised, Double-Blind, Placebo-Controlled Trial (IMPACT Study)

Gut microbiota is believed to be a major determinant of health outcomes. We hypothesised that a novel oral microbiome formula (SIM01) can reduce the risk of adverse health outcomes in at-risk subjects during the coronavirus disease 2019 (COVID-19) pandemic. In this single-centre, double-blind, randomised, placebo-controlled trial, we recruited subjects aged ≥65 years or with type two diabetes mellitus. Eligible subjects were randomised in a 1:1 ratio to receive three months of SIM01 or placebo (vitamin C) within one week of the first COVID-19 vaccine dose. Both the researchers and participants were blinded to the groups allocated. The rate of adverse health outcomes was significantly lower in the SIM01 group than the placebo at one month (6 [2.9%] vs. 25 [12.6], p < 0.001) and three months (0 vs. 5 [3.1%], p = 0.025). At three months, more subjects who received SIM01 than the placebo reported better sleep quality (53 [41.4%] vs. 22 [19.3%], p < 0.001), improved skin condition (18 [14.1%] vs. 8 [7.0%], p = 0.043), and better mood (27 [21.2%] vs. 13 [11.4%], p = 0.043). Subjects who received SIM01 showed a significant increase in beneficial Bifidobacteria and butyrate-producing bacteria in faecal samples and strengthened the microbial ecology network. SIM01 reduced adverse health outcomes and restored gut dysbiosis in elderly and diabetes patients during the COVID-19 pandemic.

Assessment of Oral Hygiene, Gingival, and Periodontal Health, and Teeth Eruption among Type 1 Diabetic Saudi Children

Aims and objectives

To determine the differences between type 1 diabetic children and healthy children regarding oral hygiene, gingival and periodontal health, and permanent teeth eruption.Materials and methods: A case-control study was conducted on 80 children (40 type 1 diabetic children and 40 healthy children) aged 6-12-year-old. The groups were further divided into subgroups (early and late mixed dentition). All study aspects were examined clinically using the simplified oral hygiene index, Löe and Silness gingival index, clinical attachment loss (CAL), and Logan and Kronfeld stages for tooth eruption. The data were analyzed using Fisher's exact test, chi-squared test, and logistic regression models. A p-value of ≤0.05 was the threshold for statistical significance.

Results

No significant difference was found between diabetic and healthy children regarding oral hygiene and gingival health. Most children had poor oral hygiene (52.5% in the case group and 60% in the control group), with fair gingival health (70% in the case group and 55% in the control group). Diabetic children had significantly (p = 0.05) more periodontitis than healthy children. Teeth in the advanced stage of the eruption were significantly higher in diabetic than control subjects (p = 0.048 in stage V and p = 0.003 in stage VI). Older diabetic children in late mixed dentition exhibited accelerated eruption.

Conclusion

Periodontitis was significantly more common in diabetic than in healthy children. The advanced stage of the eruption was significantly higher in diabetic than in control subjects.

Clinical significance

Type 1 diabetic children had more periodontal disease and advanced stage of permanent teeth eruption compared to healthy children. Therefore, periodic dental evaluation and a strong preventive plan for diabetic children is crucial.

How to cite this article

Mandura RA, El Meligy OA, Attar MH, et al. Assessment of Oral Hygiene, Gingival, and Periodontal Health, and Teeth Eruption among Type 1 Diabetic Saudi Children. Int J Clin Pediatr Dent 2022;15(6):711-716.

Tree-based, two-stage risk factor analysis for postoperative sepsis based on Sepsis-3 criteria in elderly patients: A retrospective cohort study

Background

Sepsis remains the leading cause of postoperative death in elderly patients and is defined as organ dysfunction with proven or suspected infection according to Sepsis-3 criteria. To better avoid potential non-linear associations between the risk factors, we firstly used a tree-based analytic methods to explore the putative risk factors of geriatric sepsis based on the criteria in the study.

Methods

Data of 7,302 surgical patients aged ≥ 65 years at the Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were collected. An analytic method that combined tree-based analysis with the method of Mantel-Haenszel and logistic regression was adopted to assess the association between 17 putative risk factors and postoperative sepsis defined by the Sepsis-3 guideline by controlling 16 potential confounding factors.

Results

Among the 16 potential covariates, six major confounders were statistically identified by the tree-based model, including cerebrovascular diseases, preoperative infusion of red blood cells, pneumonia, age ≥ 75, malignant tumor and diabetes. Our analysis indicated that emergency surgery increases the risk of postoperative sepsis in elderly patients by more than six times. The type of surgery is also a crucial risk factor for sepsis, particularly transplantation and neurosurgery. Other risk factors were duration of surgery > 120 min, administration of steroids, hypoalbuminemia, elevated creatinine, blood urea nitrogen, hematocrit, platelets, glucose, white blood cell count, abnormal neutrophil-to-lymphocyte ratio and elevated hsCRP-to-albumin ratio.

Conclusions

Our study uses an effective method to explore some risk factors for postoperative sepsis in elderly by adjusting many potential confounders and it can provide information for intervention design.

Effect of Citrullus colocynthis on glycemic factors and lipid profile in type II diabetic patients: a systematic review and meta-analysis

Purpose

In this systematic review and meta-analysis, we investigated the effect and side effects of Citrullus colocynthis on glycemic factors and lipid profile in diabetic patients.

Methods

We systematically searched English and Persian databases from inception till August 2021 using Medical Subject Headings (MeSH). Two authors independently extracted data and assessed the quality of studies. The standardized mean differences were pooled using fixed-effect models, and statistical heterogeneity was assessed using the I squared (I²) index.

Results

Of the 321 articles searched in the databases, 136 related articles were screened, 14 relevant full-text articles were assessed for eligibility; finally, four articles were included in the study, three articles were entered into the meta-analysis. The results of the meta-analysis indicated that Citrullus colocynthis does not have a significant effect on fasting blood sugar (FBS), hemoglobin A1c (HBA1c), low-density lipoprotein (LDL), total cholesterol, and triglyceride indices but increases high-density lipoprotein (HDL) (Mean Difference: 5.76; 95% CI: 1.69 to 9.84; P = 0.006; I2 = 0%).

Conclusions

The meta-analysis results showed that Citrullus colocynthis has no significant effect on glycemic and metabolic indices of diabetes - except HDL. Due to the relatively low quality and the small number of included trials, conducting further large scale well-designed randomized clinical trials to determine the effect of Citrullus colocynthis on glycemic and metabolic indices seems essential.

Supplementary information

The online version contains supplementary material available at 10.1007/s40200-022-01045-9.

Surgical treatment on infective endocarditis: impact of diabetes on mortality

BACKGROUND

Type 2 diabetes mellitus (DM) is a frequent co-morbidity among patients suffering from infective endocarditis (IE). The aim of the study was to evaluate the impact of type 2 DM on the early-, intermediate- and long-term mortality of patients who underwent surgical treatment of endocarditis.

METHODS

We performed an observational cohort study in the large tertiary center in Israel during 14 years. All data of patients who underwent surgical treatment of endocarditis, performed between 2006 and 2020 were extracted from the departmental database. Patients were divided into two groups: Group I (non-diabetic patients), and Group II (diabetic patients).

RESULTS

The study population includes 420 patients. Group I (non-diabetic patients), comprise 326 patients, and Group II (diabetic patients), comprise 94 patients. Mean follow-up duration was 39.3 ± 28.1 months. Short-term, 30-day and in-hospital mortality, also intermediate-term mortality (1- and 3-year) was higher in the DM group compared with the non-DM group, but did not reach statistical significance: 11.7% vs. 7.7%. (p = 0.215); 12.8% vs. 8.3% (p = 0.285); 20.2% vs. 13.2% (p = 0.1) and 23.4% vs. 15.6% (p = 0.09) respectively. Long-term, 5-year mortality was significantly higher in the DM group, compared to the non-DM group: 30.9% vs. 16.6% (p = 0.003). Furthermore, predictors for long-term mortality included diabetes (CI 1.056-2.785, p = 0.029), as demonstrated by regression analysis.

CONCLUSIONS

Diabetic patients have trend to increasing mortality at the short- and intermediate period post-surgery for IE, but this is not statistically significant. Survival of diabetic patients deteriorates after more than three years follow surgery. Diabetes is an independent predictor for long-term, 5-year mortality after surgical treatment of endocarditis, regardless of the patients age and comorbidities. Trial registration Ethical Committee of Sheba Medical Centre, Israel on 02.12. 2014, Protocol 4257.

Donor Heterogeneity in the Human Macrophage Response to a Biomaterial under Hyperglycemia in vitro

Macrophages have a commanding role in scaffold-driven in situ tissue regeneration. Depending on their polarization state, macrophages mediate the formation and remodeling of new tissue by secreting growth factors and cytokines. Therefore, successful outcomes of material-driven in situ tissue vascular tissue engineering depends largely on the immuno-regenerative potential of the recipient. A large cohort of patients requiring vascular replacements suffers from systemic multifactorial diseases, like diabetes, which gives rise to a hyperglycemic and aggressive oxidative inflammatory environment that is hypothesized to hamper a well-balanced regenerative process. Here, we aimed to fundamentally explore the effects of hyperglycemia, as one of the hallmarks of diabetes, on the macrophage response to 3D electrospun synthetic biomaterials for in situ tissue engineering, in terms of inflammatory profile and tissue regenerative capacity. To simulate the early phases of the in situ regenerative cascade, we used a bottom-up in vitro approach. Primary human macrophages (n=8 donors) and (myo)fibroblasts in mono- or co-culture were seeded in 2D, as well as in a 3D electrospun resorbable polycaprolactone bisurea (PCL-BU) scaffold and exposed to normoglycemic (5.5 mM glucose), hyperglycemic (25 mM glucose) and osmotic control conditions (5.5 mM glucose, 19.5 mM mannitol). The results showed that macrophage polarization by biochemical stimuli was effective under all glycemic conditions and that the polarization states dictated expression of the receptors SCL2A1 (glucose transporter 1) and CD36 (fatty acid transporter). In 3D, the macrophage response to hyperglycemic conditions was strongly donor-dependent in terms of phenotype, cytokine secretion profile, and metabolic receptor expression. When co-cultured with (myo)fibroblasts, hyperglycemic conditions led to an increased expression of fibrogenic markers (ACTA2, COL1, COL3, IL-1β). Together, these findings show that the hyperglycemic and hyperosmotic conditions may indeed influence the process of macrophage-driven in situ tissue engineering, and that the extent of this is likely to be patient-specific.

Isolation and identification of Aspergillus fumigatus from Immunocompromised patients in AL- Najaf Province

The present study was conducted to isolation and identification of Aspergillus fumigatus. Isolated from immunocompromised patients with (Diabetes, Cancer) by different identification methods including direct examination, laboratory culture and electron microscopy. During the period from (July to September 2016), a total of 50 swab were collected from immunocompromised patients with attending to the in AL- Sadder Medical City (the Center for Diabetes and Endocrinology) and (Euphrates middle Center for cancer diseases). In AL-Najaf Governorate, the samples were collected as following: 30 swab from the eyes of cancer patients who were suffering from prostate, leukemia, stomach and intestines cancer, also 20 swabs from the ears of diabetic patients. The percentage of female to male was as following, 29 females (58%) males and 21 (42%). In this study, the results show that the incidence of aspergillosis in women was higher than the male. The results of the present study reveal that the prevalence of aspergillosis from patient with cancer was more than diabetes patients which was 18 (66.66%) and 9 (33.33%), respectively.

Effect of Comorbid Diabetes on Clinical Characteristics of COVID-19 Patients Infected by the Wild-Type or Delta Variant of SARS-CoV-2

BACKGROUND

Diabetes is one of the most common comorbidities in COVID-19 patients that pertains to disease severity, but the causal mechanism regarding its negative impact on COVID-19 outcome has yet been uncovered.

METHODS

We retrospectively analyzed 459 COVID-19 patients admitted in early 2020 and 336 COVID-19 patients admitted in August 2021, with their demographic information, medical history, vaccination status (if applied), and laboratory data reported.

RESULTS

Among COVID-19 patients, compared to the non-diabetic group, the diabetic group exhibited elder age, higher proportion of patients with other major comorbidities, more severe dysfunction of innate immune cells, more refractory blood coagulopathy and more detrimental organ damage. For the wild-type SARS-CoV-2 infection, diabetic comorbidity was associated with COVID-19 severity but not mortality, and the glycemic levels in the non-diabetic group upon infection experienced high and analogous to those in the diabetic group. Besides, infected by the delta variant of SARS-CoV-2, the non-diabetic patients did not demonstrate hyperglycemia, and despite different vaccination statuses, the diabetic patients exhibited comparable antibody responses to non-diabetic, showing the robustness of acquired immunity.

CONCLUSIONS

SARS-CoV-2 infection may superimpose the deterioration of innate immune systems in diabetic patients, which contributes to their worsened disease outcome, but timely COVID-19 immunization could provide adequate protection in diabetic population that leads to favored prognosis.

Glucocorticoid excess and COVID-19 disease

The pandemic of coronavirus disease (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing high and rapid morbidity and mortality. Immune system response plays a crucial role in controlling and resolving the viral infection. Exogenous or endogenous glucocorticoid excess is characterized by increased susceptibility to infections, due to impairment of the innate and adaptive immune system. In addition, diabetes, hypertension, obesity and thromboembolism are conditions overrepresented in patients with hypercortisolism. Thus patients with chronic glucocorticoid (GC) excess may be at high risk of developing COVID-19 infection with a severe clinical course. Care and control of all comorbidities should be one of the primary goals in patients with hypercortisolism requiring immediate and aggressive treatment. The European Society of Endocrinology (ESE), has recently commissioned an urgent clinical guidance document on management of Cushing's syndrome in a COVID-19 period. In this review, we aim to discuss and expand some clinical points related to GC excess that may have an impact on COVID-19 infection, in terms of both contagion risk and clinical outcome. This document is addressed to all specialists who approach patients with endogenous or exogenous GC excess and COVID-19 infection.

The impact of diabetes mellitus on treatment and outcomes of rheumatoid arthritis at 5-year follow-up: results from a multi-ethnic Asian cohort

Objectives

We evaluated the impact of type 2 diabetes mellitus (T2DM) on RA treatment and outcomes in a longitudinal RA cohort.

Methods

We analysed data collected in the period 2001-2013 involving 583 RA patients, including demographics, diabetes diagnosis, clinical features, treatment, ACR functional class, HAQ, and quality-of-life measurement using the Short-Form 36.

Results

Seventy-seven (13.2%) of the RA patients had T2DM. DAS28 was not different in patients with T2DM at 5 years post-RA diagnosis. Fewer T2DM patients received MTX than those without T2DM (51% vs 80%, P < 0.001). Using univariate analysis, T2DM patients were more likely to experience poorer outcomes in terms of ACR functional status (P = 0.009), joint surgery (P = 0.007), knee arthroplasty (P < 0.001) and hospital admissions (P = 0.006). Multivariate regression analyses showed more knee arthroplasty (P = 0.047) in patients with T2DM.

Conclusion

Fewer patients with T2DM received MTX compared with those without T2DM. Patients with RA and T2DM were at higher risk of knee arthroplasty than RA patients without T2DM.

Immunological Mechanisms of Sickness Behavior in Viral Infection

Sickness behavior is the common denominator for a plethora of changes in normal behavioral routines and systemic metabolism during an infection. Typical symptoms include temperature, muscle weakness, and loss of appetite. Whereas we experience these changes as a pathology, in fact they are a carefully orchestrated response mediated by the immune system. Its purpose is to optimize immune cell functionality against pathogens whilst minimizing viral replication in infected cells. Sickness behavior is controlled at several levels, most notably by the central nervous system, but also by other organs that mediate systemic homeostasis, such as the liver and adipose tissue. Nevertheless, the changes mediated by these organs are ultimately initiated by immune cells, usually through local or systemic secretion of cytokines. The nature of infection determines which cytokine profile is induced by immune cells and therefore which sickness behavior ensues. In context of infection, sickness behavior is typically beneficial. However, inappropriate activation of the immune system may induce adverse aspects of sickness behavior. For example, tissue stress caused by obesity may result in chronic activation of the immune system, leading to lasting changes in systemic metabolism. Concurrently, metabolic disease prevents induction of appropriate sickness behavior following viral infection, thus impairing the normal immune response. In this article, we will revisit recent literature that elucidates both the benefits and the negative aspects of sickness behavior in context of viral infection.

Immuno-regenerative biomaterials for in situ cardiovascular tissue engineering - Do patient characteristics warrant precision engineering?

In situ tissue engineering using bioresorbable material implants - or scaffolds - that harness the patient's immune response while guiding neotissue formation at the site of implantation is emerging as a novel therapy to regenerate human tissues. For the cardiovascular system, the use of such implants, like blood vessels and heart valves, is gradually entering the stage of clinical translation. This opens up the question if and to what extent patient characteristics influence tissue outcomes, necessitating the precision engineering of scaffolds to guide patient-specific neo-tissue formation. Because of the current scarcity of human in vivo data, herein we review and evaluate in vitro and preclinical investigations to predict the potential role of patient-specific parameters like sex, age, ethnicity, hemodynamics, and a multifactorial disease profile, with special emphasis on their contribution to the inflammation-driven processes of in situ tissue engineering. We conclude that patient-specific conditions have a strong impact on key aspects of in situ cardiovascular tissue engineering, including inflammation, hemodynamic conditions, scaffold resorption, and tissue remodeling capacity, suggesting that a tailored approach may be required to engineer immuno-regenerative biomaterials for safe and predictive clinical applicability.

Blood glucose regulation in context of infection

The immune and endocrine systems collectively control homeostasis in the body. The endocrine system ensures that values of essential factors and nutrients such as glucose, electrolytes and vitamins are maintained within threshold values. The immune system resolves local disruptions in tissue homeostasis, caused by pathogens or malfunctioning cells. The immediate goals of these two systems do not always align. The immune system benefits from optimal access to nutrients for itself and restriction of nutrient availability to all other organs to limit pathogen replication. The endocrine system aims to ensure optimal nutrient access for all organs, limited only by the nutrients stores that the body has available. The actual state of homeostatic parameters such as blood glucose levels represents a careful balance based on regulatory signals from the immune and endocrine systems. This state is not static but continuously adjusted in response to changes in the current metabolic needs of the body, the amount of resources it has available and the level of threats it encounters. This balance is maintained by the ability of the immune and endocrine systems to interact and co-regulate systemic metabolism. In context of metabolic disease, this system is disrupted, which impairs functionality of both systems. The failure of the endocrine system to retain levels of nutrients such as glucose within threshold values impairs functionality of the immune system. In addition, metabolic stress of organs in context of obesity is perceived by the immune system as a disruption in local homeostasis, which it tries to resolve by the excretion of factors which further disrupt normal metabolic control. In this chapter, we will discuss how the immune and endocrine systems interact under homeostatic conditions and during infection with a focus on blood glucose regulation. In addition, we will discuss how this system fails in the context of metabolic disease.

Advances in pharmacotherapy for diabetic foot osteomyelitis

Introduction: The diagnosis of diabetic foot osteomyelitis (DFO) is usually clinical. Its severity is related to the location and depth of the lesion, and the presence of necrosis or gangrene. The aetiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial, and DFO is often associated with chronic or recurring ulceration.Areas covered: We built on the  International Working Group on the Diabetic Foot (IWGDF) guidelines on the management of diabetic foot infection, providing an outline of the current and new concepts in pharmacotherapy in DFO. We assess future strategies in both medical, surgical and combination management of DFO.Expert opinion: Surgical removal of infected bone is considered as the standard treatment, but a medical approach of certain selected situations has now proven efficacy in selected patients. The combination of new modalities in local antibiotic delivery may provide better long-term solutions and more lasting remission and avoid the disadvantages of prolonged systemic antibiotics.

Management of diabetes in elderly patients during the COVID-19 pandemic: current and future perspectives

Introduction: The COVID-19 pandemic has affected the entire population with the most deleterious effects in elders. Elders, especially those with diabetes, are at the highest risk of COVID-19 related adverse outcomes and mortality. This is usually linked to the comorbidities that accumulate with age, diabetes-related chronic inflammation, and the pandemic's psychosocial effects.Areas covered: We present some approaches to manage these complicated elderly patients with diabetes during the COVID-19 pandemic. In the inpatient setting, we suggest similar (pre-pandemic) glycemic targets and emphasize the importance of using IV insulin and possible use of continuous glucose monitoring to reduce exposure and PPE utilization. Outside the hospital, we recommend optimal glycemic control within the limits imposed by considerations of safety. We also describe the advantages and challenges of using various technological platforms in clinical care.Expert opinion: The COVID-19 pandemic has lifted the veil off serious deficiencies in the infrastructures for care at both the individual level and the population level and also highlighted some of the strengths, all of which affect individuals with diabetes and COVID-19. We anticipate that things will not return to 'normal' after the COVID-19 pandemic has run its course, but rather they will be superseded by 'New Normal.'

Eumycetoma of the Foot due to Fusarium solani in a Person with Diabetes Mellitus: Report of a Case and Review of Literature

Eumycetomas are chronic suppurative granulomas caused by fungi characterised by invasive tumefactive lesions, sinuses and discharging grains. Herein, we describe a case of pedal eumycetoma due to Fusarium solani sensu stricto in a person with diabetes mellitus. A 45-year-old gentleman presented with an insidious onset swelling over his right foot with nodules and discharging grains. He had received itraconazole and anti-tuberculous therapy elsewhere, without response. Re-evaluation included a biopsy which confirmed eumycetoma and newly diagnosed diabetes. Surgical excision followed by histopathological, microbiological and multigene sequencing analyses [translation elongation factor, calmodulin and internal transcribed spacer region of rDNA] of the mould on culture were performed. Histopathology revealed septate fungal hyphae amidst a dense inflammatory infiltrate (Splendore-Hoeppli) reaction. Oral voriconazole was started and good glycemic control attained. Tissue growth sequences showed > 99% similarity with Fusarium solani sensu stricto. Antifungal susceptibility testing showed lowest MIC to voriconazole (0.5 mg/L). The patient showed excellent response to combined therapeutic modality with a near-complete resolution in size of lesion and obliteration of sinuses following 4 months of therapy and is planned for prolonged voriconazole therapy till complete radiological resolution. Diabetes predisposes to fungal infections of foot but eumycetomas are uncommon. Combined surgery and antifungals can improve morbidity and avoid amputations.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

COVID-19: Are Non-Communicable Diseases Risk Factors for Its Severity?

OBJECTIVE

To identify and describe the mechanisms of lifestyle characteristics-obesity, DM, hypertension and physical inactivity-that may lead to the severity of illness among individuals with COVID-19.

DATA SOURCE

A scoping review was conducted by searching electronic databases of PubMed and Scopus from December 2019 to August 2020.

INCLUSION/EXCLUSION CRITERIA

inclusion criteria were studies that explicitly describe the mechanism of COVID-19 in relationship with either hypertension, type 2 diabetes mellitus type 2 (DM), obesity and/or physical inactivity. Studies of epidemiological background, descriptive surveys and interventional studies were excluded.

DATA EXTRACTION

study characteristics were tabulated according to purpose, type of non-communicable diseases (NCDs), the hypothesis on the mechanism of infestation (MOI) and conclusion.

DATA SYNTHESIS

NCDs were categorized according to type and hypothesis on mechanisms of infestation. The interplay between COVID-19, type of NCDs and MOI leading to the severity of the disease was appraised.

RESULTS

Twenty-four (24) studies were identified from 357 unique records. Eight studies postulated the mechanism of infestation and interaction between COVID 19 illness severity and Obesity, while 7 studies described COVID-19 and DM. Five studies highlighted the interaction between COVID-19 and hypertension with 4 studies showing how physical activity restriction suppresses immunity.

CONCLUSION

The current review, identified and explicitly described the mechanisms of the lifestyle characteristics that may increase the severity of illness among people with COVID-19.

Type 2 diabetes and viral infection; cause and effect of disease

The recent pandemic of COVID-19 has made abundantly clear that Type 2 diabetes (T2D) increases the risk of more frequent and more severe viral infections. At the same time, pro-inflammatory cytokines of an anti-viral Type-I profile promote insulin resistance and form a risk factor for development of T2D. What this illustrates is that there is a reciprocal, detrimental interaction between the immune and endocrine system in the context of T2D. Why these two systems would interact at all long remained unclear. Recent findings indicate that transient changes in systemic metabolism are induced by the immune system as a strategy against viral infection. In people with T2D, this system fails, thereby negatively impacting the antiviral immune response. In addition, immune-mediated changes in systemic metabolism upon infection may aggravate glycemic control in T2D. In this review, we will discuss recent literature that sheds more light on how T2D impairs immune responses to viral infection and how virus-induced activation of the immune system increases risk of development of T2D.

Association between Liver Cirrhosis and Diabetes Mellitus: A Review on Hepatic Outcomes

BACKGROUND

Liver cirrhosis (LC) is largely associated with diabetes mellitus (DM). More than 80% of patients with LC manifest glucose intolerance and about 30% have type 2 DM. A particular and yet unrecognized entity is hepatogenous diabetes (HD), defined as impaired glucose regulation caused by altered liver function following LC. Numerous studies have shown that DM could negatively influence liver-related outcomes.

AIM

We aimed to investigate whether patients with LC and DM are at higher risk for hepatic encephalopathy (HE), variceal hemorrhage (VH), infections and hepatocellular carcinoma (HCC). The impact of DM on liver transplant (LT) outcomes was also addressed.

METHODS

Literature search was performed in PubMed, Ovid, and Elsevier databases. Population-based observational studies reporting liver outcomes in patients with LC were included.

RESULTS

Diabetics are at higher risk for HE, including post-transjugular intrahepatic portosystemic shunt HE. DM also increases the risk of VH and contributes to elevated portal pressure and variceal re-bleeding, while uncontrolled DM is associated with increased risk of bacterial infections. DM also increases the risk of HCC and contributes to adverse LT outcomes.

CONCLUSIONS

Patients with DM and LC may benefit from close follow-up in order to reduce readmissions and mortality. Due to the heterogeneity of available research, prospective multicenter clinical trials are needed to further validate these findings.

Type 2 diabetes mellitus and risk of community-acquired pneumonia: a systematic review and meta-analysis of observational studies

BACKGROUND

People with type 2 diabetes are at greater risk for infections than those without type 2 diabetes. Our objective was to examine the association between type 2 diabetes and the risk of community-acquired pneumonia (CAP).

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, ProQuest theses and dissertations, Global Health, the Global Index Medicus of the World Health Organization, and Google Scholar. We included observational studies published in English or French between Jan. 1, 1946 (start of MEDLINE) and July 18, 2020. Two independent reviewers extracted data and assessed quality using the ROBINS-I tool. DerSimonian-Laird random-effects models were used to pool estimates of the association between type 2 diabetes and CAP.

RESULTS

Our systematic review included 15 articles, reporting on 13 cohort studies and 4 case-control studies (14 538 968 patients). All studies reported an increased risk of pneumonia among patients with type 2 diabetes, and all were at serious risk of bias. When estimates were pooled across studies, the pooled relative risk was 1.64 (95% confidence interval [CI] 1.55-1.73); although there was a substantial amount of relative heterogeneity (I 2 94.2), the amount of absolute heterogeneity was more modest (T2 0.008). The relative risk was 1.70 (95% CI 1.63-1.77, I 2 85.2%, T2 0.002) among cohort studies (n = 13), and the odds ratio was 1.54 (95% CI 1.14-2.09, I 2 92.7%, T2 0.07) among case-control studies (n = 4).

INTERPRETATION

Type 2 diabetes may be associated with an increased risk of CAP; however, the available evidence is from studies at serious risk of bias, and additional, high-quality studies are needed to confirm these findings.

PROSPERO REGISTRATION

CRD42018116409.

Sedentary behavior, exercise and COVID-19: immune and metabolic implications in obesity and its comorbidities

Many reports showed a dramatic decrease in the levels of physical activity during the current pandemic of SARS-CoV-2. This has substantial immune and metabolic implications, especially in those at risk or with metabolic diseases including individuals with obesity and Type 2 diabetes. In this study we discussed the route from physical inactivity to immune and metabolic aberrancies; focusing on how insulin resistance could represent an adaptive mechanism to the low physical activity levels and on how such an adaptive mechanism could shift to a pathognomonic feature of metabolic diseases, creating a vicious circle of immune and metabolic aberrancies. We provide a theoretical framework to the severe immunopathology of COVID-19 in patients with metabolic diseases. We finally discuss the idea of exercise as a potential adjuvant against COVID-19 and emphasize how even interrupting prolonged periods of sitting with short time breaks of very light activity could be a feasible strategy to limit the deleterious effects of the outbreak.

Factors leading to high morbidity and mortality of COVID-19 in patients with type 2 diabetes

Coronavirus disease 2019 (COVID-19) is a recent pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus. Diabetes (mostly type 2 diabetes mellitus, T2DM) and hyperglycemia are among the major comorbidities in patients with COVID-19 leading to poor outcomes. Reports show that patients with diabetes and COVID-19 are at an increased risk for developing severe complications including acute respiratory distress syndrome, multi-organ failure, and death. Here we explore potential mechanistic links that could explain the observed higher morbidity and mortality in this patient population. Patients with T2DM have an underlying increased level of inflammation associated with obesity and insulin resistance in addition to other comorbidities including hypertension, obesity, cardiovascular disease, dyslipidemia, and being older. We review evidence that T2DM with hyperglycemia are among factors that lead to elevated expression of angiotensin-converting enzyme 2 (ACE2) in lungs and other tissues; ACE2 is the cellular "receptor" and port of viral entry. The preexisting chronic inflammation with augmented inflammatory response to the infection and the increasing viral load leads to extreme systemic immune response ("cytokine storm") that is strongly associated with increased severity of COVID-19. Based on the available evidence, it is recommended by a panel of experts that safe but stringent control of blood glucose, blood pressure, and lipids be carried out in patients with T2DM, measures that could potentially serve to decrease the severity of COVID-19 should these patients contract the viral infection. Once the infection occurs, then attention should be directed to proper glycemic control with use of insulin and frequent monitoring of blood glucose levels.

Molecular mechanisms involved in the positive effects of physical activity on coping with COVID-19

PURPOSE

Physical activity (PA) represents the first line of defence against diseases characterised by increased inflammation status, such as metabolic and infectious diseases. Conversely, a sedentary lifestyle-associated with obesity, type 2 diabetes and cardiovascular disorders-negatively impacts on general health status, including susceptibility to infections. At a time of a pandemic SARS-CoV2 infection, and in the context of the multiorgan crosstalk (widely accepted as a mechanism participating in the pathophysiology of all organs and systems), we examine the complex interplay mediated by skeletal muscle contraction involving the immune system and how this contributes to control health status and to counteract viral infections. In so doing, we review the molecular mechanisms and expression of molecules modulated by PA, able to provide the proper molecular equipment against viral infections such as the current SARS-CoV2.

METHODS

A critical review of the literature was performed to elucidate the molecular mechanisms and mediators induced by PA that potentially impact on viral infections such as SARS-CoV2.

RESULTS

We showed the effects mediated by regular moderate PA on viral adverse effects through the regulation of biological processes involving the crosstalk between skeletal muscle, the immune system and adipose tissue. Evidence was provided of the effects mediated by modulation of the expression of inflammation markers.

CONCLUSION

A tigth association between PA and reduction in inflammation status allows effective counteracting of SARS-CoV2 infection. It is therefore essential to persuade people to keep active.

Molecular mechanisms involved in the positive effects of physical activity on coping with COVID-19

PURPOSE

Physical activity (PA) represents the first line of defence against diseases characterised by increased inflammation status, such as metabolic and infectious diseases. Conversely, a sedentary lifestyle-associated with obesity, type 2 diabetes and cardiovascular disorders-negatively impacts on general health status, including susceptibility to infections. At a time of a pandemic SARS-CoV2 infection, and in the context of the multiorgan crosstalk (widely accepted as a mechanism participating in the pathophysiology of all organs and systems), we examine the complex interplay mediated by skeletal muscle contraction involving the immune system and how this contributes to control health status and to counteract viral infections. In so doing, we review the molecular mechanisms and expression of molecules modulated by PA, able to provide the proper molecular equipment against viral infections such as the current SARS-CoV2.

METHODS

A critical review of the literature was performed to elucidate the molecular mechanisms and mediators induced by PA that potentially impact on viral infections such as SARS-CoV2.

RESULTS

We showed the effects mediated by regular moderate PA on viral adverse effects through the regulation of biological processes involving the crosstalk between skeletal muscle, the immune system and adipose tissue. Evidence was provided of the effects mediated by modulation of the expression of inflammation markers.

CONCLUSION

A tigth association between PA and reduction in inflammation status allows effective counteracting of SARS-CoV2 infection. It is therefore essential to persuade people to keep active.

Clinical spectrum, etiology and outcome of infectious disease emergencies in adult diabetic patients in northern India

BACKGROUND AND AIMS

The patients with diabetes mellitus (DM) have an increased incidence of both common and unusual infections. Despite an increasing prevalence of DM in India, local data on the epidemiology and clinical spectrum of associated infections are lacking. We aimed to investigate the spectrum, etiology, and outcome of infectious disorders in adult patients with DM admitted in a medical emergency.

METHODS

A single-center retrospective observational study conducted between January 2018 to June 2019 in a tertiary care hospital in north India. Based on clinical presentation, radiological features, and microbiological or pathological evidence, 152 diabetic patients aged 12 years and above were diagnosed with the infectious syndrome.

RESULTS

Urinary tract infection was the most prevalent infectious syndrome (32.2%), followed by pneumonia and empyema (26.3%), skin and soft tissue infections (6.6%), sepsis of unknown primary source (6.6%), pulmonary tuberculosis (4.6%), rhinocerebral infections (4.6%), infectious diarrhea (3.9%), and viral encephalitis (2.6%). The majority of the infections were community-acquired (94.7%). 80.3% of study cases had type 2 DM. The common presenting symptoms were fever (46.1%), dyspnea (27.6%), and altered sensorium (25.7%). Shock and diabetic ketoacidosis were frequent, and each was seen in 27.6% of cases. The mortality rate was 27.6% and was higher with sepsis of unrecognized source (50.0%) and lung infections (30.0%). The presence of shock was the independent predictor of mortality on a multivariant analysis (p-value 0.000).

CONCLUSIONS

Urinary tract and lung infections remain common in DM. Establishing a microbiological etiology and identification of the source are necessary steps to reduce mortality.

Cellulitis: Home or Inpatient Intravenous Therapy in a Veteran Population

There are few studies describing outpatient parenteral antimicrobial therapy (OPAT) for cellulitis treatment. The Hospital in Home (HIH) program is a multidisciplinary team at the Cincinnati VA Medical Center (CVAMC) that provides acute care in patients’ homes similar to inpatient hospital care for a variety of indications, including cellulitis. Efficacy of OPAT for cellulitis treatment in the HIH program has not been directly compared with inpatient treatment. The primary objective of this retrospective review is to compare the rates of efficacy of intravenous (IV) antibiotics for cellulitis treatment for patients followed by HIH and inpatient settings. Treatment failure was defined as a change in IV antibiotic medications prescribed. A retrospective chart review was completed at CVAMC for patients enrolled in HIH ( n = 111) and patients who received inpatient treatment at CVAMC ( n = 111) with IV antibiotics for a primary diagnosis of cellulitis from January 1, 2014, through June 30, 2018. Six patients in the HIH group experienced IV antibiotic treatment failure compared with 11 in the inpatient group. The HIH group showed non-inferiority in rates of treatment failure compared with the inpatient group ( p = .21). OPAT with the HIH program appears to be non-inferior to inpatient IV antibiotic treatment for cellulitis infections. Tolerance issues and rates of adverse events do not appear to be worse in patients treated with OPAT in the Veteran population.

Aggressive Quarantine Measures Reduce the High Morbidity of COVID-19 in Patients on Maintenance Hemodialysis and Medical Staff of Hemodialysis Facilities in Wuhan, China

INTRODUCTION

Maintenance hemodialysis (MHD) patients are highly vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Medical staff of dialysis facilities without sufficient biosecurity protection are susceptible once exposed to asymptomatic coronavirus disease 2019 (COVID-19) patients. This study evaluated the epidemiological characteristics of COVID-19 in all MHD patients and medical staff of dialysis facilities in Wuhan, China.

METHODS

We collected COVID-19 morbidity and mortality data from MHD patients and medical staff from 52 hemodialysis centers in Wuhan. Then, we analyzed the symptoms and signs of patients and staff in our hospital (Tongji Hospital in Wuhan), and chest CT, SARS-CoV-2 nucleic acid detection and laboratory tests were performed. After aggressive quarantine of the COVID-19 patients, we followed up on the prognosis of them.

RESULTS

We analyzed the hemodialysis data from Wuhan and found that 10% of MHD patients and 6.0% of medical staff were suspected of COVID-19. Further detection of SARS-CoV-2 nucleic acid showed that 1.7% of MHD patients and 2.9% of medical staff were confirmed as having COVID-19. In our facility, 18.9% (46/244) of patients and 9.5% (6/63) of medical staff were suspected of COVID-19. Among them, 2.9% (7/244) of MHD patients and 4.8% (3/63) of medical staff tested positive for SARS-CoV-2 were confirmed as having COVID-19. Interestingly, 87.0% of MHD patients suspected of COVID-19 did not have obvious symptoms, but the CT screening showed features of viral pneumonia. There were no significant differences in symptoms, CT findings, comorbidity and laboratory findings of SARS-CoV-2 nucleic-acid-positive and -negative patients. We followed up these patients and found that 57 patients with COVID-19 died (COVID-19 mortality 8.9%). Two patients from our dialysis center with COVID-19 (mortality 4.3%) died. No new infections occurred in our dialysis center after aggressive quarantine was initiated.

CONCLUSIONS

The SARS-CoV-2 infection rates in MHD patients and medical staff in dialysis facilities were both high in Wuhan. Frequent chest CT and SARS-CoV-2 nucleic acid detection were needed to screen COVID-19 patients in dialysis facilities. Through the lessons of this experience on the aggressive diagnosis and quarantine measures of COVID-19 patients, we hope medical staff avoid more infections in serious epidemic areas.

Higher frequency of hospitalization but lower relative mortality for pandemic influenza in people with type 2 diabetes

BACKGROUND

There is limited evidence linking type 2 diabetes (T2D) to influenza-related complications.

OBJECTIVES

To test a set of research questions relating to pandemic influenza vaccination, hospitalization and mortality in people with and without T2D.

METHODS

In this population-based cohort study, we linked individual-level data from several national registers for all Norwegian residents aged 30 years or more as of January 2009. People with or without T2D at baseline (n = 2 992 228) were followed until December 2013. We used Cox regression to estimate adjusted hazard ratios (aHRs).

RESULTS

Pandemic influenza hospitalization was more common in individuals with T2D (aHR = 2.46, 95% CI 2.04-2.98). The mortality hazard ratio associated with hospitalization for pandemic influenza was lower in people with T2D (aHR = 1.82, 95% CI 1.21-2.74) than in those without T2D (aHR = 3.89, 95% CI 3.27-4.62). The same pattern was observed when restricting to 90-day mortality (aHR = 3.89, 95% CI 1.25-12.06 amongst those with T2D and aHR = 10.79, 95% CI 7.23-16.10 amongst those without T2D). The rate of hospitalization for pandemic influenza was 78% lower in those vaccinated compared to nonvaccinated amongst people with T2D (aHR = 0.22, 95% CI 0.11-0.39), whilst the corresponding estimate for those without T2D was 59% lower (aHR = 0.41, 95% CI 0.33-0.52). Mortality was 25% lower in those vaccinated compared to nonvaccinated amongst people with T2D (aHR = 0.75, 95% CI 0.73-0.77), whilst the corresponding estimate for those without T2D was 9% (aHR = 0.91, 95% CI 0.90-0.92).

CONCLUSIONS

There may have been a lower threshold for pandemic influenza hospitalization for people with T2D, rather than more severe influenza infection. Our combined results support the importance of influenza vaccination amongst people with T2D, especially during pandemics.

High Glucose Environments Interfere with Bone Marrow-Derived Macrophage Inflammatory Mediator Release, the TLR4 Pathway and Glucose Metabolism

Macrophages may be a crucial aspect of diabetic complications associated with the inflammatory response. In this study, we examined how hyperglycaemia, a common aspect of diabetes, modulates bone marrow-derived macrophages (BMDMs) under an inflammatory stimulus. To perform this study, BMDMs from non-diabetic and diabetic (60 mg/kg alloxan, i.v.) male C57BL/6 mice (CEUA/FCF/USP-488) were cultured under normal (5.5 mM) and high glucose (HG, 25 or 40 mM) conditions and stimulated or not stimulated with lipopolysaccharide (LPS, 100 ng/mL). Compared to the BMDMs from the normoglycaemic mice, the LPS-stimulated BMDMs from the diabetic mice presented reduced TLR4 expression on the cell surface, lower phagocytic capacity, and reduced secretion of NO and lactate but greater oxygen consumption and greater phosphorylation of p46 SAPK/JNK, p42 ERK MAPK, pAKT and pPKC-δ. When the BMDMs from the non-diabetic mice were cultured under high-glucose conditions and stimulated with LPS, TLR4 expression was reduced on the cell surface and NO and H2O2 levels were reduced. In contrast, the diabetic BMDMs cultured under high glucose conditions presented increased levels of lactate and reduced phosphorylation of AKT, PKC-δ and p46 SAPK/JNK but enhanced phosphorylation of the p46 subunit of SAPK/JNK after LPS stimulation. High glucose levels appear to modify macrophage behaviour, affecting different aspects of diabetic and healthy BMDMs under the same LPS stimulus. Thus, hyperglycaemia leaves a glucose legacy, altering the basal steady state of macrophages.

High blood glucose variability is associated with bacteremia and mortality in patients hospitalized with acute infection

BACKGROUND

Limited data are available regarding the association between glucose levels variability (GV) and outcomes of patients hospitalized with acute infectious diseases.

AIM

To determine the association between GV and bacteremia, length of stay (LOS) and mortality.

METHODS

A retrospective study of patients hospitalized in departments of medicine with respiratory tract, urinary tract and skin and soft tissue infections during 2011-17. GV was assessed by the coefficient of variation (CV) of glucose levels during hospitalization and was divided into tertiles (CV ≤ 16%, 17-29%, >29%). LOS, bacteremia rates and all-cause mortality (30 days, 90 days and after 5 years) were evaluated for the patients with and without DM according the three GV categories.

RESULTS

The study consisted of 1485 patients, 838 (56%) were diabetic. There was no significant association between GV and LOS. Bacteremia rates were higher in the upper GV tertile compared with the lower one (6% vs. 2%, P = 0.007). Mid and upper tertiles compared with the lower one were significantly associated with increased 30-day mortality (13% vs. 5%, P = 0.005; and 40% vs. 5%, P = 0.002, respectively). A decreased 5 years survival was observed for both diabetic and non-diabetic patients in the mid and upper GV tertiles [adjusted HRs 0.8 (95% CI, 0.6-1.04) and 0.6 (95% CI, 0.5-0.9) in diabetic patients and 0.7 (95% CI, 0.5-0.9) and 0.5 (95% CI, 0.3-0.7) in the non-diabetic ones].

CONCLUSION

In diabetic and non-diabetic patients, hospitalized in non-ICU setting with acute infectious diseases, increased GV is associated with increased risk of bacteremia, short and long-term mortality.

Control Strategies for Infection Prevention in Total Joint Arthroplasty

Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.

[Prevention and treatment of infectious diseases in diabetic patients]

The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.

Association between the Vicious Cycle of Diabetes-Associated Complications and Glycemic Control among the Elderly: A Systematic Review

Background and objectives: Improved quality of life (QoL) and life expectancy of elderly diabetic patients revolves around optimal glycemic control. Inadequate glycemic control may lead to the development of diabetes-associated complications (DAC), which not only complicate the disease, but also affect morbidity and mortality. Based on the available literature, the aim was to elucidate the vicious cycle underpinning the relationship between diabetes complications and glycemic control. Materials and Methods: A comprehensive literature search was performed to find eligible studies published between 1 January 2000 and 22 September 2018 pertaining to diabetes complications and glycemic control. Results: Initially, 261 studies were retrieved. Out of these, 67 were duplicates and therefore were excluded. From the 194 remaining articles, 85 were removed based on irrelevant titles and/or abstracts. Subsequently, the texts of 109 articles were read in full and 71 studies were removed at this stage for failing to provide relevant information. Finally, 38 articles were selected for this review. Depression, impaired cognition, poor physical functioning, frailty, malnutrition, chronic pain, and poor self-care behavior were identified as the major diabetes-associated complications that were associated with poor glycemic control in elderly diabetic patients. Conclusions: This paper proposes that diabetes-associated complications are interrelated, and that impaired glycemic control aggravates diabetes complications; as a result, patient’s self-care abilities are compromised. A schema is generated to reflect a synthesis of the literature found through the systematic review process. This not only affects patients’ therapeutic goals, but may also hamper their health-related quality of life (HRQoL) and financial status.

Low prevalence of rheumatoid arthritis among patients with pre-existing type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM) is a non-autoimmune disease characterized by chronic hyperglycemia and increased non-enzymatic glycation of amino groups. Glycation occurs through a series of events eventually leading to the formation of irreversible "advanced glycation end-products" (AGEs). AGEs may affect the function of long-lived proteins, including cytokines, immunoglobulins and their receptors, resulting in a "less active" immune system. We aimed to test the hypothesis that a common inflammatory chronic disease, such as rheumatoid arthritis (RA), in which the earliest event is an inflammatory response to unknown stimulus, has a lower prevalence in these patients than in normoglycemic, non-diabetic subjects.

Methods

In this study, we compared the prevalence of RA in a prospectively followed outpatient cohort of patients with T2DM patients (n=1,630) with a control, matched, non-diabetic population (n=1,630).

Results

Among non-diabetic controls, 13 patients (prevalence 0.80%) with RA were identified. An almost 3-fold lower prevalence of RA (0.25%) was found in consecutive patients with T2DM (P=0.029). Most of the RA cases among participants with T2DM were diagnosed early after diabetes onset. The onset of RA in patients with T2DM occurred at significantly older age (64±15 years) as compared to the non-diabetes group (48±18 years; P=0.004).

Conclusions

The prevalence of RA is lower and occurs in an older age in patients with pre-existing T2DM in comparison with people without T2DM.

Beneficial Effect of Intestinal Fermentation of Natural Polysaccharides

With the rapid development of modern society, many chronic diseases are increasing including diabetes, obesity, cardiovascular diseases, etc., which further cause an increased death rate worldwide. A high caloric diet with reduced natural polysaccharides, typically indigestible polysaccharides, is considered a health risk factor. With solid evidence accumulating that indigestible polysaccharides can effectively prevent and/or ameliorate symptoms of many chronic diseases, we give a narrative review of many natural polysaccharides extracted from various food resources which mainly contribute their health beneficial functions via intestinal fermentation.