bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-Tropical Diabetic Hand Syndrome in Peru: A Case Report
Authors: Miranda Gonzalo Francisco , Rafael Luciana del Pilar
Published: May 2021

Background: The diabetic foot is the most studied spectrum in relation to musculoskeletal complications in diabetic patients but upper extremities may be affected, producing from superficial hand injuries to multiorganic failure due to sepsis. Tropical diabetic hand syndrome has been used to describe a potentially dangerous infection in the hand, generally diagnosed in areas of the tropics. Nevertheless, cases have been seen in non-tropical areas in marginal urban areas which are part of the spectrum of Non tropical diabetic hand syndrome.

Clinical Case: A 52-year-old woman, from marginal urban area of Lima- Peru with type 2 diabetes mellitus (T2DM) of 6 years in poor metabolic control. She was admitted to the emergency room with two weeks of volume increase, erythema, purulent secretion, flogosis in the fifth finger of the left hand and fever. Initial tests confirmed mild diabetic ketoacidosis and sepsis (pH: 7.29; Glucose: 320 mg / dl, Bicarbonate: 15 mEq/L, Ketone bodies - urine (+), leukocytes 14360 cells/mm3, CRP: 180). Intravenous antibiotic was started. A surgical debridement and amputation of the fifth finger of the left hand was decided. Patient with unfavorable evolution, on the eight day, was admitted to new surgical debridement without clinical improvement. Arterial Doppler Ultrasound and CT angiography confirmed distal arterial insufficiency due to monophasic flow in the left ulnar artery with the presence of collateral circulattion. A third surgical debridement and amputation of the fourth finger of the left hand was done with favorable postoperative clinical evolution.

Non tropical diabetic hand syndrome affects predominantly women, between 50 to 60 years, with low socio-cultural level and deficient glycemic control, as in case presented. Other factors include body mass index < 20kg/m2, DM 1 and diabetic neuropathy. Diabetic neuropathy is the most common risk factor in Non tropical diabetic hand syndrome cases, with a prevalence of 88%, while peripheral arterial disease was present in 11% of cases. In this report, neuropathy and peripheral arterial disease were present.

Conclusion: Non tropical diabetic hand syndrome is uncommon and underdiagnosed complication of Diabetes Mellitus that has an important clinical repercussion as an important cause of disability. Detailed physical examination of the hands in a patient with diabetes for detection of these cases is highlighted because an early diagnosis and treatment improves prognosis.
Smartphone Camera to Image the Retina for Primary Care MDs and Diabetologists
Authors: Lau Chap-Kay Kendra , Wu Gloria
Published: May 2021

Background: Imaging is an important tool for diagnosis of hypertension and diabetes for all physicians. In the US, 300 million smartphones were purchased in 2019. Purpose: A smartphone-based ophthalmoscope for fundus imaging was compared to an office based retina camera to evaluate the average time spent on each device. Methods: Inclusion criteria: Patients with 20/20-20/50 vision, informed consent was obtained. D-Eye/iphone digital direct ophthalmoscope (Padova, Italy) was used on the dilated and undilated eyes of patients, video recorded to attain an image of the optic nerve and internally timed in the iPhone. Optos (Marlborough, MA) was then used to take retinal images of both dilated and undilated eyes of patients for comparison. The start time and end time was recorded from the timestamp of the 1st and last image taken on Optos, then the difference between both timestamps was calculated to obtain time spent on Optos. Results: For dilated patients (n=12, 24 eyes), the average time taken to obtain a clear video of both eyes using D-Eye was 28.08 seconds. The average time to take images of both eyes using Optos was 1.83 minutes. For undilated patients (n=10, 20 eyes), the average time of a clear video of both eyes using D-Eye was 29.8 seconds. The average time to take clear images of both eyes using Optos was 1.2 minutes.

Conclusion: The portable D-Eye attachment may be useful at primary care settings, eye MD offices, bedside, ER, and wheelchair patients for evaluation and diagnosis. The D-Eye attachment for the smartphone is useful for imaging both dilated and undilated eyes. We look forward to future studies of the D-Eye for more complex retinal images.
The Peruvian Experience: New-Onset Diabetes Presenting With Diabetic Ketoacidosis in Patients With COVID19 Infections
Authors: Ramos-Yataco Anthony , Capcha Kelly Jasmin Meza , Harbuz-Miller Inga
Published: May 2021

Introduction: Data has emerged about patients with T2DM may experience DKA and HHS if infected with SARS-CoV-2. There is limited data about new-onset diabetes in patients with COVID-19. We describe a case series of three Peruvian patients with new onset diabetes presenting with DKA who remained insulin dependent several months after infection resolution. Case 1: A 59-year-old man with no significant past medical history and normal glucose presented with fever and dyspnea for five days. He was hospitalized with hypoxemic respiratory failure and tested positive forCOVID19. Hypoxemia improved with supportive care, but on day three, he became lethargic, tachycardic, and tachypneic with 95% oxygen saturation on room air. Biochemistry revealed an anion gap metabolic acidosis with pH 7.3, bicarbonate 10 mmol/L (22–28), β-hydroxybutyrate 5.4 mmol/L (<0.5), and glucose 679 mg/dL. He was treated with continuous insulin infusion. After DKA resolved, he was transitioned to basal-bolus insulin and remained insulin-dependent during outpatient follow-up. Case 2: A 49-year-old man in good health prior to admission, was transferred to our hospital for acute respiratory failure and positive testing for SARS-CoV-2. Two days later he became confused, tachycardic, and tachypneic with 90% oxygen saturation. DKA was diagnosed based on a pH 7.1, bicarbonate 8 mmol/L, β-hydroxybutyrate 5 mmol/L and glucose 625 mg/dL. He was transferred to the ICU for continuous insulin infusion. After resolution of his DKA, subcutaneous insulin was started. Preadmission hemoglobin A1c was 4.5%. He remained on insulin post hospital discharge. Case 3: A 33-year-old man with normal glucose prior to admission was transferred to our hospital from an outpatient office with a two-day history of dyspnea and altered sensorium. He was tachycardic and tachypneic with 96% oxygen saturation on 3L nasal cannula. He tested positive for SARS-CoV-2. DKA was diagnosed with glucose 690 mg/dL, bicarbonate 4 mmol/L, serum β-hydroxybutyrate 5.8 mmol/L and pH 6.6. He was resuscitated with intravenous fluids and an insulin infusion was started. DKA resolved after 5 days and he was discharged home on subcutaneous insulin. He remained insulin-dependent on follow-up. Conclusion: New-onset diabetes with DKA due to SARS-CoV-2 is increasingly recognized, and beta-cell dysfunction can be permanent, resulting in insulin-dependent diabetes. Accordingly, our patients remained insulin-dependent several months post discharge.
Using Technology to Treat a Diabetic Emergency at Home in the Time of COVID19 Pandemic
Authors: Mundada Rachana , Marco Cheryl , Miller Jeffrey L
Published: May 2021

Introduction: Severe out-break of the novel coronavirus has majorly impacted the health care facilities across all settings. Hospital facilities especially the ambulatory clinics began to adjust the ways to triage, assess and treat patients by using methods that do not rely on traditional face-face encounter. Here, we present one such scenario from the initial phase of pandemic in which team effort was involved in a diabetic emergency to overcome the barriers of emergent ambulatory care. Case Description: We present a 78-year-old female with past medical history of Type 2 diabetes mellitus, hyperthyroidism, multi-nodular goiter, hypertension, mild coronary artery disease, diastolic heart failure and dyslipidemia who called the clinic with an elevated point of care glucose of 436mg/dl. Other symptoms included high fever, polyuria and polydipsia having just been discharged from hospital with a diagnosis of COVID-19 infection. She was on metformin 500 mg twice a day, glimepiride 2 mg daily, methimazole 5 mg daily, carvedilol 12.5 mg twice a day, losartan 100 mg daily, pravastatin 20 mg daily and furosemide 40 mg daily. Her most recent blood work showed an A1C of 8% (7.4 and 7.1 last year), TSH - 0.29 (0.4 -4.5 mIU/ml), FT4 - 1.1 (0.8–1.8 ng/ml), metabolic panel showed plasma glucose of 283 mg/dl along with normal electrolytes and kidney function. The patient was admitted to hospital about a week ago with flu like illness and high fever and was found to be COVID positive and was discharged home with instructions on isolation and follow up. However, while at home she noticed hyperglycemia 400–500 mg/dl despite oral agents, associated with polyuria and polydipsia but no nausea or vomiting. Given the significant symptomatic hyperglycemia along with symptomatic COVID infection it was clear that she acutely needed insulin therapy. As the patient was insulin naïve and COVID positive, there were several barriers in initiating insulin without hospitalization: we could not get her into the Endocrine office and she was declined ED evaluation because of her COVID positivity. She and the family were relatively computer novice so could not access our electronic health record video system. After discussion over the phone, our certified diabetes educator walked them through the process of downloading an app for video communication. Utilizing remote video communication, the patient’s 20-year-old grandson was educated on all the steps of Insulin use for the patient as she was still delirious. Gratifyingly, she responded well to initiation of insulin and subsequent glucoses were in the 100’s along with improvement in her symptoms. Conclusion: This case emphasizes how team effort and the zeal of health care community to serve patients can overcome shortcomings.
Diabetes Prevalence and Risk Factors in Patients With Chronic Mental Illness on Second-Generation Antipsychotics
Authors: Sahay Priya , Shikh Simran , Akinbowale Carol , Azim Salman Meher , Lamberti J Steven , Olivares Telva E , Brazill Kevin P , Miedlich Susanne U
Published: May 2021

The rates of obesity and type 2 diabetes (T2D) are much higher in patients with chronic mental illness compared to the general population1. Second-generation antipsychotic medications (SGA) are clearly contributory to these adverse metabolic phenotypes2. Thus, annual monitoring of fasting plasma glucose (FPG) levels is recommended to screen for T2D in patients on SGA3. Of note, FPG, and also HbA1c, have poor sensitivities in detecting T2D early, with nearly 50% of cases being missed using either of the above tests when compared to oral Glucose Tolerance Testing (oGTT,4). We thus screened patients with schizophrenia, schizoaffective or bipolar disorder on SGA per oGTT. We hypothesized that we would identify more patients with T2D per oGTT compared to FPG or HbA1c testing alone. To identify risk factors for T2D, we also assessed BMI, waist/hip ratio, blood pressure, dietary habits (UKDDQ = UK Diabetes and Diet Questionnaire), physical activity records (3d pedometer records), measures of psychopathology, cognition (PHQ-9 = Patient Health Questionnaire, SLUMS = Saint Louis University Mental Status exam) as well as HOMA IR (Homeostatic Model Assessment of Insulin Resistance), Matsuda index and lipid profile. Data were analyzed using SPSS, comparing normal and prediabetic patients to patients with T2D (per oGTT criteria). Thus far, we screened 22 patients per oGTT and newly identified 5 patients with T2D (23%), only one patient had T2D per HbA1c criterion, 4 were identified per elevated FPG, 3 patients had elevated 2h plasma glucose levels. Patients with T2D had significantly lower Matsuda indices (p<0.0001); trends towards higher HOMA IR and waist/hip ratios were observed in diabetic compared to non-diabetic patients (p=0.08). Patients with T2D tended to be heavier, had worse dietary habits (higher UKDDQ scores), and surprisingly were less depressed (lower PHQ-9 scores) than non-diabetic patients (p<0.25). In conclusion, oGTT is more sensitive in identifying patients with T2D early compared to FPG or HbA1c alone. Matsuda indices, HOMA IR and waist/hip ratios may serve as additional markers to distinguish non-diabetic from diabetic patients. Since metabolic syndrome and diabetes are all risk factors for an increased cardiovascular mortality in patients with chronic mental illness, identifying and treating T2D early and aggressively should be primary goals of care in this high-risk patient population. References:1 Lean ME, Pajonk FG. Diabetes Care. 2003 May;26(5):1597–605.2 Allison DB, Mentore JL, Heo M, et al. Am J Psychiatry 1999 Nov;156(11):1686–1696.3 American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Diabetes Care. 2004 Feb;27(2):596–601.4 Cowie CC, Rust KF, Byrd-Holt DD, et al. Diabetes Care 2010 Mar;33(3):562–568.
Initial Combination Empagliflozin and Linagliptin Improves Kidney Fibrotic Marker in Patients With Type 2 Diabetes: A Randomized Controlled Trial
Authors: Sathavarodom Nattapol , Putthanuparp Thanaporn , Pinphanichakarn Verapon
Published: May 2021

Background: Transforming growth factor-beta 1 (TGF- ß1) is a novel cytokine marker and also one of the therapeutic targets in the treatment of diabetic kidney disease. Both sodium glucose co-transporter 2 inhibitor and dipeptidyl-peptides 4 inhibitor reduce TGF- ß 1 level in animal studies, but whether it is effective in human is unknown. Objective: To evaluate the effects of combinations of empagliflozin/linagliptin, comparing with empagliflozin alone, in patients with type 2 diabetes. Material and Methods: Subjects are randomized to a combination of empagliflozin 10 mg and linagliptin 5 mg (n = 23), or empagliflozin 10 mg (n = 22) as add-on to standard treatment for 12 weeks. The primary end point is changed from baseline in serum TGF- ß1 at 12 weeks. Results: Among the 45 subjects who completed the study, mean change in TGF-ß1 was -928.2 + 1,204.2 pg/mL, and +206.6 + 592.5 pg/mL in the empagliflozin/linagliptin group and empagliflozin group, respectively (p <0.001). Mean change in estimated glomerular filtration rate (eGFR) increased in the empagliflozin /linagliptin group 4.4 + 7.59 mL/min/1.73m2, whereas mean eGFR decreased in empagliflozin group -0.06 + 11.16 mL/min/1.73m2 (p =0.133). Mean change in HbA1c was -1.3 + 0.6% and -0.4 + 0.6% in empagliflozin/linagliptin and empagliflozin group, respectively (p<0.001). Baseline level of eGFR significantly correlated with baseline TGF- ß1 but did not predict response to therapy. Conclusion: Initial combination empagliflozin and linagliptin may delay progression of kidney fibrosis as early as 12 weeks of treatment. Our study supports that this combination had synergistic action not only glycemic control but also beneficial in kidney protection. Keyword: transforming growth factor - ß1, diabetic kidney disease, combination empagliflozin and linagliptin
Treatment of Diabetic Wounds With Photodynamic Therapy - Preliminary Results
Authors: Berbert Mariana , Arruda Sicilia , Bichuetti Camila , Campos Alice , Ceron Patricia , Magalhães Fernanda , Moraes Fernanda , Pelegrinelli Ana Claudia , Silva Pamella , Simone Vitoria , Thedei Jr. Geraldo
Published: May 2021

Diabetic patients have greater susceptibility to developing diabetic foot ulcers (DFU), which associated with peripheral arterial disease and/or infection, causes greater difficulty in the healing process. Photodynamic therapy (PDT) presents itself as a promising alternative for ulcer healing. This study aims to analyze the effectiveness and benefits of PDT in the treatment of diabetic wounds, associating the presence of arteriopathy, the size of the lesion, the presence and type of infection and the need for amputation. After the approval of the ethics committee in research and signing of the TCLE, six patients with eight diabetic wounds were evaluated. The study was carried out in an outpatient clinic of a medium complexity hospital in the interior of Minas Gerais, Brazil, with frequency of two weekly meetings, for a period of 5 months. Cultures were collected at the beginning and end of treatment, arterial doppler of the affected lower limb was performed. The photosensitizer used was methylene blue, with subsequent emission of LED light at a power of 100 mW/cm2, for 10 minutes. The data were analyzed by the Qui2 test, using the Software SPSS 25.0, with a significance level of 5% and are described with mean ± EPM. Age was 65.50 ± 7.58 years, 50% male. All had type 2 diabetes mellitus and the disease time was 9.50 ± 8.22 years. Five reported the presence of comorbidities such as SAH and dyslipidemia, and two presented concomitantly nephropathy and retinopathy. One patient was a smoker and two reported previous smoking. All lesions presented grade I classification by Texas classification (superficial cleft not involving tendon, capsule or bone). Five stage B ulcers (infection only), two stage C ulcers (ischemia only) and A stage D ulcer (infection and ischemia). At US arterial doppler, three patients had total viability of the affected limb and three presented arteriopathy, but only two with collateral. There was no association between arteriopathy and injury reduction (p=0.109). The mean area of injury was 11.15 ± 14.93 cm2. There was a reduction of 46.51 ± 31.10%. There was no association between injury area and percentage of reduction (p = 0.213), but there is a tendency for greater reductions in smaller lesions. Infection was present in 75% of the lesions. There was no association between the presence of infection and reduction of lesions (p=0.446). So far, we can conclude that the presence of arteriopathy without collateral, makes the procedure impossible. There was no association with the presence of infection and reduction of the lesion, and can also be used as a stimulator of the healing process. There was no association with wound size and percentage of reduction. It’s a promising therapy that should be better analyzed.
Trends in Diabetes Subgroups and Their Risk for All-Cause, Cardiovascular Disease and Diabetes-Specific Mortality in the US: A Data-Driven Reproducible Machine Learning Approach
Authors: Antonio-Villa Neftali Eduardo , Fernández-Chirino Luisa , Vargas-Vazquez Arsenio , Bahena-López Jessica Paola , Bello-Chavolla Omar Yaxmehen
Published: May 2021

Background: Diabetes has been described as a heterogeneous entity which can be studied through data-driven subgroups (obesity related [MOD], severe-insulin deficient [SIID], severe-insulin resistant [SIRD] and age-related diabetes [MARD]). However, trends in prevalence and mortality risk are still unclear. Aims: To analyze diabetes subgroup trends and to evaluate mortality risk in the US. Methods: Data and follow-up causes of mortality (all-cause, cardiovascular disease, and diabetes specific) was collected from NHANES cycles 1999–2018. Subgroup diabetes classification was performed using the self-normalizing neural networks algorithm using clinical parameters (HbA1c, time since diabetes diagnosis, HOMA2-IR, HOMA2-B, and BMI) proposed by Bello-Chavolla et al (https://bit.ly/3jSm1xv). Prevalence was estimated using sample weights. 2-year cycles were used as a continuous variable to evaluate the biannual change (BC) of the overall prevalence of diabetes and subgroups. Trends were stratified according to race. Cox-proportional and Fine-Gray semiparametric hazard regression models were used to evaluate mortality risk. Results: Data from 59,204 adult subjects was extracted for trend analysis. Follow-up information was obtained for 3,980 subjects. Diabetes prevalence in the US increased from 8.2% (95%CI 7.8–8.6) in 1999–2000 to 13.9% (95% CI 13.4–14.4) in 2017–2018 (BC 1.38%, 95% CI 1.20–1.56, p<0.001). Non-Hispanic Blacks had the largest increase in diabetes prevalence (BC: 1.40%, 95%CI 0.71–2.08, p=0.027), followed by Non-Hispanic Whites (BC: 1.36%, 95%CI 1.13–1.58, p<0.001), and Mexican Americans (BC: 1.33%, 95%CI 1.20–1.54, p<0.001). Regarding diabetes subgroups, MARD had the highest prevalence, with a moderate increase over time; however, MOD had the greatest increase over time (1.5%, [95%CI 1.2–1.8] to 4.5% [95%CI 4.0–5.0]; BC: 0.73% [95%CI 0.60–0.86], p<0.01). Both SIRD and SIID had non-significant increases in prevalence during the studied period. Non-Hispanic Blacks had an increase in the prevalence in MOD and SIID, Mexican Americans in MOD and SIRD, and non-Hispanic Whites in MOD and MARD. Compared with MOD, the risk for all-cause mortality was higher for MARD (HR 2.9 95% CI: 2.1–3.9), SIRD (HR 2.0 95% CI: 1.5–2.8), and SIID (HR 1.6 95% CI: 1.1–2.3). For CVD mortality, only MARD (HR 2.8 95% CI: 1.4–5.7) and SIRD (HR 2.5 95% CI: 1.2–5.3) displayed higher risk. For diabetes-specific mortality, only MARD (HR 2.2 95% CI: 1.3–3.7) was associated. Conclusion: There is an overall increase in diabetes prevalence and its subgroups from 1999 to 2018; MORD had the highest increase. The risk for all-cause, CVD and diabetes-specific mortality was different among subgroups. Our results supports the use of diabetes subgroups for a better understanding of diabetes and its complications.
Outcomes in Hospitalizations for Patients Admitted With Hyperosmolar Hyperglycemic State and Obesity: Analysis of National Inpatient Sample
Authors: Shaka Hafeez , Velazquez Genaro , Marcos-Abdala Hernan Gerardo , Edigin Ehizogie , Asemota Iriagbonse , Akuna Emmanuel , Murthi Mukunthan , Velagapudi Sujitha
Published: May 2021

Introduction: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS) is a highly lethal disease with an estimated mortality rate of up to 20%. Although mortality has decreased in recent years, its incidence has increased in the setting of a higher prevalence of underlying conditions that have been previously well described, such as uncontrolled diabetes, Obesity, and a high-carbohydrate diet. All these comorbidities usually overlap with acute complications such as infections or dehydration, which incite the onset of HHS. Currently, limited literature exists for the role of obesity in mortality, hospital stay, and other adverse outcomes in patients with HHS. It is important to know which underlying conditions truly affect outcomes for patients being treated for this condition so further studies can be done, and treatment optimized.

Objective: We aim to prove if obesity plays a role in increasing mortality and secondary adverse outcomes in patients with HHS compared to non-obese patients.

Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. 42,740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of Obesity as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders.

Results: Out of the 42 740 hospitalizations with HHS, 9,630 had Obesity. The in-hospital mortality for patients with HHS was 45 overall, out of which 45 patients had Obesity as a secondary diagnosis. Compared with patients without Obesity, non-obese patients had similar in-hospital mortality (OR 0.77, 95% CI 0.39–1.52, p=0.45) when adjusted for patient and hospital characteristics. Patients with HHS and Obesity had similar lengths of hospital stay, total hospital charges, rate of Sepsis, Septic Shock, and ARF in comparison to patients without Obesity; however, non-obese patients had higher odds of developing AKI throughout hospitalization.

Conclusion: Although it is known and described that being obese plays a significant role in the onset of diabetes, and consequently HHS, there is no statistically significant difference in mortality or most other adverse outcomes compared to patients that are not obese and develop HHS. Although being obese plays a major role in inciting HHS in the general population, there is no need for a different approach to treatment, and outcomes are similar to non-obese patients with HHS.
Breastfeeding Is Associated With Lower Prevalence of Metabolic Syndrome in Women With Recent Gestational Diabetes in the Early Postpartum Period
Authors: Neves João Sergio , Blair Rachel , Nicklas Jacinda M , Horn Christine , Skurnik Geraldine , Seely Ellen W
Published: May 2021

Introduction: Women with gestational diabetes (GD) are at increased risk of future cardiovascular disease. The identification of factors that reduce metabolic syndrome (MetS) is important to improve cardiovascular outcomes. MetS has been shown to be associated with breastfeeding in women remote from pregnancy. We examined the association of breastfeeding with MetS in women with recent GD in the very early postpartum (pp) period. Methods: We performed a secondary analysis of the Balance After Baby (BAB) program which enrolled women with recent GD. GD was defined by Carpenter-Coustan criteria, a 50 gram glucose load test >200 mg/dL or by clinician diagnosis. Data collected during an early (~6 weeks) pp visit was used in this analysis. At this visit, weight, height, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG) and lipid panel were obtained. MetS was classified per NCEP III. We defined breastfeeding as currently breastfeeding or not currently breastfeeding. We performed Student’s t-tests and Wilcoxon rank-sum tests as appropriate, and fit logistic and linear regression models. Models were adjusted for age, race/ethnicity, low household income, pre-pregnancy BMI, and weeks since delivery. An exploratory model further adjusted for postpartum weight retention. Results: Of 181 women enrolled in BAB, 178 were included in this analysis (3 excluded for missing lipid panels). The mean (± SD) age of participants was 33 ± 5 years and were 8.0 ± 1.8 weeks since delivery. Thirty-four % were Hispanic. Of non-Hispanics, 31.5% were White, 18.5% Asian and 12.9% Black/African American. The prevalence of MetS was 42.9% in women not breastfeeding versus 17.1% in women breastfeeding (P < 0.001; adjusted odds ratio [aOR] 0.16 [95% CI 0.06–0.41]). Breastfeeding women had significantly lower odds of FPG ≥100 mg/dL (aOR 0.36 [95% CI 0.14–0.95], p=0.039), HDL <50 mg/dL (aOR 0.19 [95% CI 0.08–0.46], p<0.001), and triglycerides (TG) ≥150 mg/dL (aOR 0.26 [95% CI 0.10–0.66], p=0.005). There was no significant difference in WC or BP between groups. All ORs remained significant after adjusting for weight retention. When evaluated as continuous variables, WC, FPG, and TG were significantly lower and HDL significantly higher in women breastfeeding in the early pp period (vs not breastfeeding). Conclusion: In a diverse population of women with recent GD, there was a lower prevalence of MetS in women breastfeeding compared to those not breastfeeding in the early postpartum period. This study extends the findings of an association of breastfeeding with MetS previously reported at times remote from pregnancy. Further studies are needed to determine if there is a protective role of breastfeeding on the risk of MetS.
Cardiometabolic Outcomes of Women Exposed to Hyperglycaemia First Detected in Pregnancy at 3–6 Years Post-Partum in an Urban South African Setting
Authors: Nicolaou Veronique , Soepnel Larske , Levitt Naomi Sharlene , Huddle Kenneth , Klipstein-Grobusch Kirsten , Shane Norris
Published: May 2021

Objective: Comparison of cardiometabolic outcomes in women exposed to hyperglycaemia first detected in pregnancy (HFDP) and a control group 3–6 years post-partum in urban South Africa. Design and Methods: A comparative study was performed of 103 women exposed to HFDP and 101 not exposed to HFDP 3–6 years post-partum at Chris Hani Baragwanath Academic Hospital, Soweto. Index pregnancy data were obtained from medical records. Post-partum, participants were re-evaluated for biochemical analysis (two-hour 75gm OGTT, fasting insulin, lipids creatinine and glucose levels). Cardiovascular risk was assessed by estimation of the Framingham risk score (FRS). Carotid intima media thickness (CIMT) was used as a surrogate marker for subclinical atherosclerosis. Factors associated with progression to these cardiometabolic outcomes were assessed using multivariable logistic and linear regression models. Results: 46 (45.1%) HFDP-exposed women progressed to diabetes compared to 5 (5.0%) women in the control group (p<0.001); only 20 (43.4%) of the HFDP group were aware of their diabetic status. Adjusted odds ratio (aOR, 95% confidence interval (CI)) of progressing to type 2 diabetes was 11.0 (3.3–36.2). Both 10-year estimated cardiovascular risk (FRS) and mean CIMT were statistically higher in the HFDP-exposed group (8.46 IQR 4.9–14.4; 0.48 mm IQR 0.44-0,53, respectively) compared to the control group (3.48 IQR 2.1–5.7; 0.46mm IQR 0.42–0.50 respectively) though mostly driven by age, systolic blood pressure and diabetes. Conclusion: African women with a history of HFDP have an increased risk of cardiometabolic conditions within 6 years post-partum in an urban sub-Saharan African setting.
Co-Morbidity of Type 1 Diabetes Promotes Endometriosis Status-A Pilot Study
Authors: Alhallak Iad , Graham Garrett L , Quick Charles M , Simmen Rosalia C M
Published: May 2021

Diabetes (DM) is a disease with significant morbidity and mortality and is a major public health problem worldwide. Endometriosis (ENDO) is a chronic estrogen-dependent gynecological condition that affects ~10% of reproductive-age women, causes debilitating pain and infertility, and carries an increased risk for ovarian cancer. Little is known about the co-morbidity of endometriosis and diabetes (Type 1, T1DM; Type 2, T2DM), despite both conditions sharing similar pathophysiology including chronic inflammation triggered by overactivation of the immune response. To evaluate if ENDO is promoted in women diagnosed with DM, we analyzed the expression of key molecular ENDO markers in endometriosis with no associated ovarian lesions collected from non-diabetic and diabetic patients at ENDO surgery. Formalin-fixed, paraffin-embedded sections, identified from analyses of TRINETX data set and retrieved from the Pathology Department, represented women with ENDO alone (n=10; mean age of 42 yo), ENDO/T1DM (n=6; mean age of 28 yo), and ENDO/T2DM (n=7, mean age of 42 yo). Body mass indices (kg/m2) were comparable for women with T1DM (mean of 44.8) and T2DM (mean of 42.5) and higher than for ENDO alone women (mean of 30.8). Endometriotic lesions were analyzed by immunohistochemistry for markers of cellular proliferation (Ki67, PTEN, NICD1) and steroid hormone receptor expression (ESR1, ESR2, PGR-Total, PGR-B) in the epithelial and stromal compartments. We found that immunoreactive ESR1 in lesion epithelial glands (cytoplasm and nuclei) were higher in ENDO/T1DM and ENDO/T2DM than in ENDO alone (P<0.05). ENDO/T1DM lesions also showed higher immunoreactivity for ESR2 (epithelial cytoplasm and nuclei; P<0.05) and Ki67 (epithelial and stromal nuclei; P<0.05) than for ENDO alone and ENDO/T2DM. The nuclear levels of immunoreactive NICD1, the intracellular signaling component of NOTCH1, and of tumor suppressor PTEN tended to be higher and were lower (P<0.05), respectively in lesion stroma of ENDO/T1DM than of the other groups. The nuclear levels of immunoreactive PGR-T in lesion stroma were highly attenuated in ENDO/T1DM compared to ENDO alone and ENDO/T2DM (P<0.05). There were no differences noted in nuclear PGR-B levels among the groups. Limitations to the current study include the small size of patient cohorts, and the diagnosis of DM at, or close to, the time of ENDO surgery. Given the significant changes in key ENDO markers (lower PGR-T and PTEN; higher ESR1, ESR2, Ki67 and NICD1) associated with co-morbid T1DM in ectopic lesions, our findings suggest that women with T1DM show more significant ENDO progression than women without DM and with T2DM. Our results support synergistic co-morbidity of ENDO and T1DM, which while currently underdiagnosed, may have significant implications in ENDO disease management.
The Influence of Sleep on Glycated Hemoglobin in Pregnancy With Gestational Diabetes
Authors: Facanha Cristina Sampaio , De Bruin Veralice S , Lopes Fernando Henrique A , Faria Magno M P , Machado Paula S , Pinheiro Mariana V , Facanha Arthur S , Magalhaes Maria Leticia C , Macedo Rejane B , De Bruin Pedro F
Published: May 2021

Background: Sleep disturbances have been associated with poor glycemic control in differential clinical settings. Both short and long sleep duration, influence insulin resistance and blood glucose in diabetic patients. Pregnancy is an additional risk for reduced sleep quality and quantity, and the presence of hyperglycemia, as a complicating factor, has being increasingly frequent. Different measures of sleep evaluation, both objectively and subjectively, can provide additional information about the influence of sleep in metabolic control in Gestational Diabetes Mellitus (GDM). Objective: To investigate the influence of sleep quality and objective sleep measures on glycated hemoglobin (HBA1C) in patients with GDM. Methodology: This is a cross-sectional study examining patients with GDM from 2nd to 3rd trimester of pregnancy. Clinical data and behavior questionnaires were collected by a face-to-face interview. Self-Rated Sleep Quality was evaluated by Pittsburgh Sleep Quality Index- (PSQI). In order to improve the accuracy of the information, a 14-day sleep log was obtained, and objective sleep measurements were registered by actigraphic record (5 to 7 days). Results: Overall, GDM patients (N=311), aged from 20 to 46 y (33.1±5.6) were evaluated. Sleep duration ≤6 hours/night was found in 43.4%, and 63.9% reported poor sleep quality (PSQI>5). Sleep duration measured by actigraphy was correlated with sleep duration registered by sleep log (r=.45, p=.04), and with PSQI (r=-.33, p=.002). Sleep quality and sleep duration registered by either actigraphy or sleep log were not correlated with Hba1c. Amongst all, Hba1c varied from 4.3 to 7.0 mg/dL (5.9 ±.53). Sleep fragmentation, measured by the length of time patient spends awake after sleep onset (WASO) was correlated withHba1c level in patients with GDM (r=.41, p=0.04). Conclusion: Sleep duration obtained from the sleep log was a reliable measure correlating with objective sleep parameters registered by actigraphy and with sleep quality. In GDM patients, increased wake time after sleep onset was correlated with higher Hba1c.
Characterization of Viral Insulin-Like Peptides Reveals Unique White Adipose Tissue Specific Characteristics
Authors: Chrudinova Martina , Francois Moreau , Noh Hye Lim , Panikova Terezie , Zakova Lenka , Friedline Randall H , Alsina-Fernandez Jorge , Kim Jason K , Jiracek Jiri , Kahn Ronald C , Altindis Emrah
Published: May 2021

The members of the insulin superfamily are well conserved across the evolution tree. We recently showed that four viruses in the Iridoviridae family possess genes that share high similarity with human insulin and IGF-1. By chemically synthesizing single chain (sc, IGF-1 like) forms of these viral insulin/IGF-1 like peptides (VILPs), we previously showed that sc VILPs have insulin/IGF properties in vitro and in vivo. However, characteristics of double chain (dc, insulin-like) VILPs remain unknown. In this study, we characterized dc forms of VILPs for Grouper iridovirus (GIV), Singapore grouper iridovirus (SGIV) and Lymphocystis disease virus-1 (LCDV-1). We showed that GIV and SGIV dcVILPs bind to both isoforms of human insulin receptor (IR-A, IR-B) and they bind to IGF-1R with a higher affinity than human insulin. These dcVILPs stimulate receptor phosphorylation and post-receptor signaling in vitro and in vivo. LCDV-1 dcVILP stimulated a weak response in in vitro signaling experiments, although we could not determine binding competition. Both GIV and SGIV dcVILPs stimulated glucose uptake in mice. In vivo infusion experiments in awake mice revealed that while insulin (2.5 mU/kg/min) and GIV dcVILP (125 mU/kg/min) stimulate a comparable glucose uptake in heart, skeletal muscle and brown adipose tissue, GIV dcVILP stimulates ~2 fold higher glucose uptake in white adipose tissue (WAT) compared to insulin. This is due to increased Akt phosphorylation and glucose transporter type 4 (GLUT4) expression compared to insulin specifically in WAT. Taken together, these results show that dc GIV and SGIV dcVILPs are active members of the insulin superfamily with unique characteristics. This observation evokes questions about their potential roles in human disease including diabetes and cancer. Elucidating the mechanism of tissue specificity for GIV dcVILP will help us to better understand insulin action and design new analogues that specifically target the tissues.
Employing User-Centered Design and Learning Science Theory to Enhance Remote Delivery of Diabetes Education and Survival Skills at Hospital Discharge
Authors: Prince Grace , Lewis Daniel Rees , Pollack Teresa , Karam Susan , Touma Emilie , Khorzad Rebeca , Bailey Stacy , Gatchell David , Ankenman Bruce , Holl Jane , Wallia Amisha
Published: May 2021

Learning diabetes mellitus (DM) survival skills is critically important, especially for those newly diagnosed upon discharge. COVID-19 has created new educational challenges, as DM self-management education and support is difficult to deliver remotely and can be time intensive. Content and format have not been re-designed for remote delivery; however, learning sciences research can help us create effective remote education strategies. We conducted interviews with users to identify critical needs in assuming immediate DM self-care at discharge from the hospital. We then mapped these user needs to relevant learning science theories to inform potential re-designs for remote delivery of DM education and survival skills at discharge.

We conducted 12 semi-structured interviews with “users,” which included 18 participants (8 minority; 6>65 years): patients newly diagnosed with DM at discharge (N=6 [33%]), their caregivers (N=4 [22%]), and laypersons new to DM (N=8 [45%]). Users were asked about their discharge needs, laypersons about perceived needs. Three investigators performed iterative rounds of inductive coding of the transcripts (using MAXQDA software), utilizing a constant comparative method to identify codes describing dominant user needs. Learning science theory was applied to identify potential re-designs for remote delivery.

Dominant user needs during hospitalization included being overwhelmed with DM self-care information (6/12 sessions) and difficulty organizing self-care equipment (5/12 sessions). Dominant user needs at home included remembering DM self-care steps (6/12 sessions), understanding correct insulin dosing (9/12 sessions), feeling fearful injecting insulin (9/12 sessions), with some noting difficulty in tracking glucose (4/12 sessions) and confusing insulin types (4/12 sessions). When learning science theory was applied, analysis mapped to three discrete educational strategies, most dominant of which is the spiral design approach—cycles of teaching the same topic but with increasing complexity. This design follows the pre-teaching principle—curriculum-based conceptual overview of self-care. Self-care at home mapped to the need for segmented learning and goal directed practice and feedback, with the potential need for behavioral therapies to reduce fear.

Learning sciences has demonstrated that learning complex procedures and concepts, such as DM self-care, requires time, repetition, and continued support. With short hospital stays and the complexity of learning DM self-care, patients cannot gain needed knowledge structures to organize the information received during hospitalization. This study suggests specific learning science strategies for the design of an effective remote delivery of DM education and skills.
Hypothalamic Gliosis in Adolescents With Type 1 Diabetes and Disordered Eating Behaviors
Authors: Ying Nip Angel Siu , Pihoker Catherine , Schur Ellen A , Melhorn Susan , Roth Christian L
Published: May 2021

Background: The hypothalamus and brainstem are thought to be the principal homeostatic brain areas responsible for regulating appetite and weight. Research suggests that inflammation plays a role in the onset and maintenance of eating-related maladaptive behaviors. Hypothalamic inflammation and reactive gliosis mediate disruptions in energy homeostasis, especially with obesity. Data from SEARCH in Youth for Diabetes has demonstrated high prevalence of disordered eating behaviors (DEB) including insulin omission and binge eating, in individuals with type 1 diabetes (T1D). Limited studies have used neuroimaging techniques for investigation of hypothalamic gliosis in individuals with T1D and DEB.

Objectives: To determine the feasibility of assessing hypothalamic gliosis with structural MRI in adolescents with T1D with and without DEB.

Research Design and Methods: Adolescents with T1D with and without DEB, aged 13–19, were invited to participate. Participants with current use of medications known to alter appetite were excluded. They completed the Diabetes Eating Problem Survey - Revised (DEPS-R). A score ≥ 20 was indicative of DEB. Height, weight and waist circumference were obtained, and BMI was calculated. HbA1c was obtained from their prior clinic visit, within 2 months of the study visit. Basal insulin (glargine) was administered the night before, and participants on insulin pump continued with their basal insulin infusion. Participants received rapid-acting insulin prior to the MRI study, and blood glucoses were measured before and after the MRI. Mediobasal hypothalamic (MBH) gliosis was measured by T2 relaxation time.

Results: Eight subjects (50% female, mean age 17.8±2.3 years) have completed the study without adverse outcomes. Mean HbA1c was 8.5% (range 7.3–10%). Five subjects screened positive for DEB. There was no significant difference in BMI between DEB and non-DEB groups. In this cohort, females had longer T2 relaxation times in left MBH than males (p=0.035). Compared to non-DEB group, participants with DEB had longer T2 relaxation time in left MBH, adjusted for sex and age (p=0.001). In this initial sample, relationships between MBH T2 relaxation times and glycemic control, BMI or waist circumference did not emerge.

Conclusion: The study protocol with insulin injection and MRI to study the hypothalamic gliosis in individuals with T1D is feasible. Structural MRI indicates increased T2 relaxation times as a marker of hypothalamic gliosis in participants with DEB. Further studies with larger sample size are crucial to validate these findings and to study specific eating behaviors and their associations with MBH gliosis in individuals with T1D.
The CGM Experience of Minority Adults With Type 1 Diabetes in the South Bronx
Authors: Lozada Orquera Faustina Alejandra , Leung Vivien , Ortega Susel Rodriguez
Published: May 2021

Objective: To describe the state of type 1 diabetes (T1D) in minority adults in the South Bronx, and their experience with continuous glucose monitoring (CGM). Introduction: In a recent analysis of data from the Type 1 Diabetes Exchange Registry, one notable finding was the difference in metabolic control and use of diabetes technology in patients of different socioeconomic status and racial/ethnic backgrounds. With limited data available on Hispanic and Black patients, we sought to examine the use of and experience with continuous glucose monitoring (CGM) in our hospital system, which primarily serves a low-income, minority population in the South Bronx. Methods: 68 adults with T1D who attended the Endocrinology clinic at our hospital from 2017 to 2019 were identified. Patients were contacted by telephone to complete a questionnaire regarding CGM use and satisfaction. A retrospective chart review was conducted to obtain additional demographic and clinical information. Results: Out of 68 patients with T1D in the hospital database who were contacted, 47 patients completed the questionnaire. The age range was 23 to 63 years. 42.6% were male. 59.6% were Hispanic, 19.1% Black/African American (AA), 4.3% Caucasian, and 17% not specified. 87.2% had public insurance. Overall, 48.9% of patients were actively using CGM, 19.1% had discontinued use of CGM, and 31.9% had never used CGM. In Hispanic patients using CGM, mean HbA1C was 8.2% compared to 10.1% in Hispanic non-users. In Black/AA patients using CGM, mean HbA1C was 9.2% compared to 9.9% in Black/AA non-users. Hospitalizations for acute diabetes complications were lower in CGM users (4.3%) compared to non-CGM users (16.7%). Among active CGM users, 74% rated their satisfaction as “extremely satisfied” or “very satisfied.” Perceived benefits included the prevention of hypoglycemia and awareness of inappropriate food intake. Discussion: Our study population, mainly comprised of Hispanic and Black T1D adults, showed a higher CGM utilization rate than previously reported. After stratification by socioeconomic status, CGM utilization was reported to be as low as 16% in Hispanic and 10% in Black patients with household income <$50,000/year in the T1D Exchange Registry. By comparison, 49% of our studied population possessing similar demographics was actively using CGM. This study demonstrated that CGM acceptance was high in this largely minority, low-income population in the South Bronx, and was associated with lower A1C levels, high degree of patient satisfaction and reduction in diabetes-related hospitalizations. However, glycemic control remained suboptimal overall despite CGM access. Additional strategies to optimize the utility of CGM are needed to improve clinical outcomes such as HbA1C levels in minority T1D patients.