COVID-19 and diabetes mellitus: implications for prognosis and clinical management

GDF-15 (a biomarker for metformin) and the risk of COVID-19: A two-sample Mendelian randomization study

BACKGROUND

Regarding the impact of metformin on COVID-19, there are currently varying opinions from multiple studies. Growth differentiation factor 15 (GDF-15) is a biomarker of metformin use and dosage, and we used two-sample Mendelian randomization (MR) to assess the causal effect of GDF-15 (metformin) on COVID-19 susceptibility, hospitalization, and severe COVID-19, thereby guiding the selection of glucose-lowering agents for diabetic patients during the COVID-19 pandemic.

METHODS

Two sets of genetic tools were utilized for MR analysis, derived from publicly available genetic data. The first set was GDF-15 genome-wide association study (GWAS) data from a study with 5440 participants, while the second set was COVID-19 GWAS data from the Host Genetics Initiative (HGI) GWAS meta-analysis. The primary method used to assess causal effects was random effects inverse variance weighted estimation. Complementary methods included weighted median and MR-Egger analyses. Sensitivity analysis was performed using Cochran Q tests, MR-Egger intercept tests, MR-PRESSO, leave-one-out analyses, and funnel plots.

RESULTS

GDF-15 increased the risk of severe COVID-19 in patients (OR = 1.10, 95% CI 1.03-1.19; P = .006); there was no causal effect of GDF-15 on hospitalization for COVID-19 (OR = 1.02, 95% CI 0.96-1.07; P = .47) or susceptibility to COVID-19 in the general population (OR = 1.010, 95% CI 0.988-1.034; P = .354).

CONCLUSIONS

Our study supports the notion that GDF-15 increases the risk of severe COVID-19 in patients. However, there is no causal relationship between GDF-15 and hospitalization or susceptibility to COVID-19.

Healthy diets, lifestyle changes and well-being during and after lockdown: longitudinal evidence from the West Midlands

Background

'Lockdowns' to control the spread of COVID-19 in the UK affected many aspects of life and may have adversely affected diets. We aimed to examine (1) the effect of lockdowns on fruit and vegetable consumption, as a proxy for healthy diets more generally, and on weight and well-being, (2) whether any subgroup was particularly affected and (3) the barriers and facilitators to a healthy diet in lockdown.

Methods

We conducted a mixed-method longitudinal study, involving an online survey of 1003 adults in the West Midlands, UK, 494 of whom were surveyed at two different points in time. Our first time point was during stringent COVID-19 lockdown and the second during a period of more relaxed restrictions. We asked quantitative questions about fruit and vegetable consumption; physical activity, sociodemographic characteristics, body mass index and well-being and qualitative questions about the reasons behind reported changes.

Results

We find no evidence for decreased fruit and vegetable consumption during lockdown compared with afterwards. If anything, consumption increased by half a portion daily among women, particularly among those who normally have a long commute. This finding, combined with a significant increase in physical activity, suggests that behaviours were healthier during lockdown, consistent with higher self-reported health. However, well-being deteriorated markedly, and participants reported being heavier during the lockdown as well. Our qualitative data suggest that an abundance of resources (more time) supported higher fruit and vegetable consumption during lockdown, despite increased access issues.

Conclusions

Our results may assuage concerns that lockdowns adversely affected diets. They may point to the impact of commuting on diet, particularly for women. We add longitudinal evidence to a growing body of literature on the adverse effect of lockdown on mental health.

Comorbidities, Associated Diseases, and Risk Assessment in COVID-19-A Systematic Review

It is considered that COVID-19's pandemic expansion is responsible for the particular increase in deaths, especially among the population with comorbidities. The health system is often overwhelmed by the large number of cases of patients addressing it, by the regional limitation of funds, and by the gravity of cases at subjects suffering from this pathology. Several associated conditions including diabetes, cardiovascular illnesses, obesity, persistent lung condition, neurodegenerative diseases, etc., increase the mortality risk and hospitalization of subjects suffering from COVID-19. The rapid identification of patients with increased risk of death from the SARS-CoV-2 virus, the stratification in accordance with the risk and the allocation of human, financial, and logistical resources in proportion must be a priority for health systems worldwide.

COVID-19 and diabetes: What do we know so far?

Coronavirus disease 2019 (COVID-19) management has been challenging for patients with comorbidities. Patients with diabetes and COVID-19, in particular, have shown severe symptoms and rapid progression of the disease. They also have a high mortality rate compared to the non-diabetic population. The high mortality rate is caused in people with diabetes who are in a pro-inflammatory condition; this could worsen COVID-19. In addition, people with diabetes have circulatory issues and COVID-19 infection can lead to further clotting problems. It is critical to understand the mechanisms underlying the adverse clinical outcomes in patients with diabetes and COVID-19. This review discusses various disease conditions contributing to poor prognosis in diabetic COVID-19 patients such as hyperglycemia, insulin resistance, impaired pancreatic function, and production of advanced glycation end products.

Elevated plasma level of the glycolysis byproduct methylglyoxal on admission is an independent biomarker of mortality in ICU COVID-19 patients

Biomarkers to identify ICU COVID-19 patients at high risk for mortality are urgently needed for therapeutic care and management. Here we found plasma levels of the glycolysis byproduct methylglyoxal (MG) were 4.4-fold higher in ICU patients upon admission that later died (n = 33), and 1.7-fold higher in ICU patients that survived (n = 32),compared to uninfected controls (n = 30). The increased MG in patients that died correlated inversely with the levels of the MG-degrading enzyme glyoxalase-1 (r² = - 0.50), and its co-factor glutathione (r² = - 0.63), and positively with monocytes (r² = 0.29). The inflammation markers, SSAO (r² = 0.52), TNF-α (r² = 0.41), IL-1β (r² = 0.25), CRP (r² = 0.26) also correlated positively with MG. Logistic regression analysis provides evidence of a significant relationship between the elevated MG upon admission into ICU and death (P < 0.0001), with 42% of the death variability explained. From these data we conclude that elevated plasma MG on admission is a novel independent biomarker that predicts mortality in ICU COVID-19 patients.

Prevalence and impact of diabetes in hospitalized COVID-19 patients: A systematic review and meta-analysis

BACKGROUND

Diabetes is a cardiometabolic comorbidity that may predispose COVID-19 patients to worse clinical outcomes. This study sought to determine the prevalence of diabetes in hospitalized COVID-19 patients and investigate the association of diabetes severe COVID-19, rate of acute respiratory distress syndrome (ARDS), mortality, and need for mechanical ventilation by performing a systematic review and meta-analysis.

METHODS

Individual studies were selected using a defined search strategy, including results up until July 2021 from PubMed, Embase, and Cochrane Central Register of Controlled Trials. A random-effects meta-analysis was performed to estimate the proportions and level of association of diabetes with clinical outcomes in hospitalized COVID-19 patients. Forest plots were generated to retrieve the odds ratios (OR), and the quality and risk assessment was performed for all studies included in the meta-analysis.

RESULTS

The total number of patients included in this study was 10 648, of whom 3112 had diabetes (29.23%). The overall pooled estimate of prevalence of diabetes in the meta-analysis cohort was 31% (95% CI, 0.25-0.38; z = 16.09, P < .0001). Diabetes significantly increased the odds of severe COVID-19 (OR 3.39; 95% CI, 2.14-5.37; P < .0001), ARDS (OR 2.55; 95% CI, 1.74-3.75; P = <.0001), in-hospital mortality (OR 2.44; 95% CI, 1.93-3.09; P < .0001), and mechanical ventilation (OR 3.03; 95% CI, 2.17-4.22; P < .0001).

CONCLUSIONS

Our meta-analysis demonstrates that diabetes is significantly associated with increased odds of severe COVID-19, increased ARDS rate, mortality, and need for mechanical ventilation in hospitalized patients. We also estimated an overall pooled prevalence of diabetes of 31% in hospitalized COVID-19 patients.

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review

BACKGROUND

Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

OBJECTIVE

The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

METHODS

We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

RESULTS

Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

CONCLUSIONS

Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

Development and Validation of CoV19-OM Intensive Care Unit Score: An Early ICU Identification for Laboratory-Confirmed SARS-CoV-2 Patients from a Retrospective Cohort Study in Oman

Objective

To develop and validate a clinical score that will identify potential admittance to an intensive care unit (ICU) for a coronavirus disease 2019 (COVID-19) case.

Materials and methods

The clinical scoring system was developed using a least absolute shrinkage and selection operator logistic regression. The prediction algorithm was constructed and cross-validated using a development cohort of 313 COVID-19 patients, and was validated using an independent retrospective set of 64 COVID-19 patients.

Results

The majority of patients were Omani in nationality (n = 181, 58%). Multivariate logistic regression identified eight independent predictors of ICU admission that were included in the clinical score: hospitalization (OR, 1.079; 95% CI, 1.058–1.100), absolute lymphocyte count (OR, 0.526; 95% CI, 0.379–0.729), C-reactive protein (OR, 1.009; 95% CI, 1.006–1.011), lactate dehydrogenase (OR, 1.0008; 95% CI, 1.0004–1.0012), CURB-65 score (OR, 2.666; 95% CI, 2.212–3.213), chronic kidney disease with an estimated glomerular filtration rate of less than 70 (OR, 0.249; 95% CI, 0.155–0.402), shortness of breath (OR, 3.494; 95% CI, 2.528–6.168), and bilateral infiltrates in chest radiography (OR, 6.335; 95% CI, 3.427–11.713). The mean area under a curve (AUC) for the development cohort was 0.86 (95% CI, 0.85–0.87), and for the validation cohort, 0.85 (95% CI, 0.82–0.88).

Conclusion

This study presents a web application for identifying potential admittance to an ICU for a COVID-19 case, according to a clinical risk score based on eight significant characteristics of the patient (http://3.14.27.202/cov19-icu-score/).

Mechanisms of Insulin Resistance at the Crossroad of Obesity with Associated Metabolic Abnormalities and Cognitive Dysfunction

Obesity mediates most of its direct medical sequelae through the development of insulin resistance (IR). The cellular effects of insulin occur through two main postreceptor pathways that are the phosphatidylinositol 3-kinase (PI3-K) and the mitogen-activated protein kinase (MAP-K) pathways. Obesity-related IR implicates the PI3-K pathway that confers the metabolic effects of insulin. Numerous and complex pathogenic pathways link obesity with the development of IR, including chronic inflammation, mitochondrial dysfunction (with the associated production of reactive oxygen species and endoplasmic reticulum stress), gut microbiota dysbiosis and adipose extracellular matrix remodelling. IR itself plays a key role in the development of metabolic dysfunction, including hypertension, dyslipidaemia and dysglycaemia. Furthermore, IR promotes weight gain related to secondary hyperinsulinaemia, with a resulting vicious cycle of worsening IR and its metabolic sequelae. Ultimately, IR underlies obesity-related conditions such as type 2 diabetes mellitus (T2D) and polycystic ovary syndrome (PCOS). IR also underlies many obesity-related malignancies, through the effects of compensatory hyperinsulinaemia on the relatively intact MAP-K insulin pathway, which controls cellular growth processes and mitoses. Furthermore, the emergent data over recent decades support an important role of obesity- and T2D-related central IR in the development of cognitive dysfunction, including effects on hippocampal synaptic plasticity. Importantly, IR is largely reversible through the optimisation of lifestyle factors that include regular engagement in physical activity with the avoidance of sedentariness, improved diet including increased fibre intake and sleep sufficiency. IR lies at the key crossroad between obesity and both metabolic and cognitive dysfunction. Given the importance of IR in the pathogenesis of many 21st century chronic diseases and its eminent reversibility, it is important that we all embrace and facilitate optimised lifestyles to improve the future health and wellbeing of the populace.

Impact of the COVID-19 pandemic on neuroendocrine tumour services in England

PURPOSE

During the COVID-19 pandemic, there have been particular concerns regarding the related impact on specialist tumour services. Neuroendocrine tumour (NET) services are delivered in a highly specialised setting, typically delivered in a small number of centres that fulfil specific criteria as defined by the European Neuroendocrine Tumour Society (ENETS). We aimed to address the COVID-19-related impact on specialist NET tumour services in England and other countries.

METHODS

Electronic survey addressing patient access and delivery of care distributed to all ENETS Centres of Excellence (CoE) in England and matching number of ENETS CoE elsewhere. Semi-quantitative and qualitative analyses of survey responses were performed.

RESULTS

Survey response of ENETS CoE in England was 55% (6/11). Responses from six non-UK ENETS CoE elsewhere were received and analysed in a similar manner. Relevant disruption of various NET services was noted across all responding Centres, which included delayed patient appointments and investigations, reduced availability of treatment modalities including delayed surgical treatment and a major negative impact on research activities. The comparison between English and non-UK ENETS CoE suggested that the former had significantly greater concerns related to future research funding (p = 0.014), whilst having less disruption to multidisciplinary meetings (p = 0.01). A trend was also noted towards virtual patient appointments in ENETS CoE in England vs. elsewhere (p = 0.092).

CONCLUSIONS

Restoration of highly specialised NET services following COVID-19 and planning for future service delivery and research funding must take account of the severe challenges encountered during the pandemic.

Analysis of Anxiety and Depression Status in Patients Undergoing Radiotherapy During the COVID-19 Epidemic

Background: The 2019 coronavirus (COVID-19) had caused a global pandemic and disrupted millions of lives. Cancer patients are a special group at greater risk of contracting viruses. This study aimed to evaluate the anxiety and depression status of cancer patients undergoing radiotherapy during the COVID-19 epidemic. Methods: 396 cancer patients who underwent radiotherapy were enrolled in this study. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate patient anxiety and depression, respectively. 373 cancer patients completed the questionnaires. Results: During the COVID-19 outbreak, the incidence of anxiety and depression in cancer patients were 34.9 and 33.8%, respectively. Approximately 31.4% of tumor radiotherapy patients had anxiety and depression. Based on univariate analysis, age, work status, education level, and clinical stage were related to anxiety and depression in cancer patients. Based on multiple regression analysis, age and clinical stage were related to anxiety, but only age was related to depression. Conclusions: Due to the COVID-19 pandemic, cancer patients experienced increased psychological problems. Our results have contributed to a better understanding of these psychological problems in cancer patients and provide a basis for psychological counseling and intervention.