coronavirus

Posted on Diabetes

COVID-19 may trigger new diabetes, experts warn

Emerging evidence suggests that COVID-19 may actually trigger the onset of diabetes in healthy people and also cause severe complications of pre-existing diabetes.

A letter published today in the New England Journal of Medicine and signed by an international group of 17 leading diabetes experts involved in the CoviDiab Registry project, a collaborative international research initiative, announces the establishment of a Global Registry of new cases of diabetes in patients with COVID-19.

The Registry aims to understand the extent and the characteristics of the manifestations of diabetes in patients with COVID-19, and the best strategies for the treatment and monitoring of affected patients, during and after the pandemic.

Clinical observations so far show a bi-directional relationship between COVID-19 and diabetes. On the one hand, diabetes is associated with increased risk of COVID-19 severity and mortality. Between 20 and 30% of patients who died with COVID-19 have been reported to have diabetes. On the other hand, new-onset diabetes and atypical metabolic complications of pre-existing diabetes, including life-threatening ones, have been observed in people with COVID-19.

It is still unclear how SARS-Cov-2, the virus that causes COVID-19, impacts diabetes. Previous research has shown that ACE-2, the protein that binds to SARS-Cov-2 allowing the virus to enter human cells, is not only located in the lungs but also in organs and tissues involved in glucose metabolism such as the pancreas, the small intestine, the fat tissue, the liver and the kidney. Researchers hypothesise that by entering these tissues, the virus may cause multiple and complex dysfunctions of glucose metabolism. It has also been known for many years that virus infections can precipitate type 1 diabetes.

Francesco Rubino, Professor of Metabolic Surgery at King’s College London and co-lead investigator of the CoviDiab Registry project, said: “Diabetes is one of the most prevalent chronic diseases and we are now realizing the consequences of the inevitable clash between two pandemics. Given the short period of human contact with this new coronavirus, the exact mechanism by which the virus influences glucose metabolism is still unclear and we don’t know whether the acute manifestation of diabetes in these patients represent classic type 1, type 2 or possibly a new form of diabetes”.

Paul Zimmet, Professor of Diabetes at Monash University in Melbourne, Honorary President of the International Diabetes Federation and co-lead investigator in the CoviDiab Registry project said: “We don’t yet know the magnitude of the new onset diabetes in COVID-19 and if it will persist or resolve after the infection; and if so, whether or not or COVID-19 increases risk of future diabetes. By establishing this Global Registry, we are calling on the international medical community to rapidly share relevant clinical observations that can help answer these questions”.

Stephanie Amiel, Professor of Diabetes Research at King’s College London and a co-investigator of the CoviDiab Registry project said: “The registry focuses on routinely collected clinical data that will help us examine insulin secretory capacity, insulin resistance and autoimmune antibody status to understand how COVID-19 related diabetes develops, its natural history and best management. Studying COVID-19-related diabetes may uncover novel mechanisms of disease.”

Posted on Diet

HOW CAN GOOD NUTRITION OPTIMISE OUR IMMUNE FUNCTION?

The global pandemic has shone a light – as never before – on how each of us manages our health and immunity. While we don’t yet know enough about the Covid-19 virus and how it operates, there is growing evidence from researchers and medics that our own health and lifestyles create a particular risk profile, with type 2 diabetes, inflammation, obesity and poor immune function all putting us at greater risk of worse health outcomes if exposed to the virus.

Professor Tim Spector, of King’s College London, said recently: “Obesity and poor diet is emerging as one of the biggest risks factors for a severe response to Covid-19 infection that can no longer be ignored.[1]” And Professor Philip Calder and colleagues writing in the journal, Nutrients, commented: “There is a need for additional strategies to support the immune system, in order to reduce the impact of respiratory and other infections.”

Kale in shape of a human heart

This e-news from the Health and Food Supplements Information Service (www.hsis.org) shines a spotlight on the latest news around immunity and asks: How can good nutrition optimise our immune health?

What is immunity?

Our immunity is unique to each person and involves both innate and adaptive immune systems that combine to fight off infections and foreign bodies. It isn’t like a simple dial that can be turned up or down but is a highly complex system involving the gut, skin, bone marrow, tonsils, spleen and mucous membranes.[2] 

Innate immunity is the ‘quick response’ baseline protection we have from birth that includes our skin, gut environment, and types of immune cells including phagocytes and natural killer cells. Adaptive immunity is slowly learnt in response to new bacteria or viruses and relies on the actions of T lymphocytes and B lymphocytes which target and destroy bacteria or virus-infected cells in our bodies. It is the adaptive system that generates an immune memory to enable our bodies to recognise specific viruses and bacteria the next time they attack.

Dr Carrie Ruxton, a dietitian at the Health and Food Supplements Information Service, says: “One issue with the popular concept of ‘boosting’ immunity is that we actually don’t want this to happen. Like many other body systems, such as blood glucose levels or brain oxygen levels, our immune response works across a tight optimal range. Too low and our sluggish system will not successfully attack and contain pathogens, but too high and we are at risk of developing so-called autoimmune conditions where the body’s overreactive immune response starts to attack normal healthy tissue. Examples of these conditions include type 1 diabetes, multiple sclerosis, rheumatoid arthritis and psoriasis.”

Frontline nutrients

While we cannot ‘boost’ immunity, we can ensure that our own personal immunity is functioning optimally. Nutrition is a big part of this, with a healthy balanced diet working hand in hand with appropriate supplementation.

The Global Centre for Nutrition and Health highlights the role that micronutrients have in supporting aspects of immune function, saying: “Poor nutrition, due to either insufficient dietary intake of key nutrients or a poor overall diet quality, can compromise immune function and increase overall infection risk. Micronutrients, commonly known as vitamins and minerals, are required in small quantities but are critical for health and pivotal in strengthening the immune system.[3]”

The key nutrients are:

Vitamin A – plays a role in the regulation of the innate immune response through natural killer cells, macrophages and neutrophils, as well as cell-mediated immunity through the growth and differentiation of B cells. Cell-mediated simply means an immune response that doesn’t involve an antigen. Food sources include dairy foods, broccoli, kale and eggs.

Raw vegetables balancing

Vitamin C – influences the production of interferon, a protein made by immune cells which can inhibit virus replication, including the influenza A virus. Vitamin C also has anti-inflammatory and anti-oxidant effects which are important in limiting damage by free radicals released during rapid immune response.[4] Studies show that vitamin C represses the viral lytic cycle (the stage at which a virus bursts out of the host cell to infect other cells)[5].  Food sources include citrus fruits and juices, peppers, berries and spinach.

Vitamin D – one of the most important nutrients for the immune system. Many immune cells have vitamin D receptors and vitamin D has been shown to increase the killing capacity of immune cells (e.g. macrophages), control the production of inflammatory cytokines, and help immune cells lock onto antigens (proteins on the surface of bacteria and viruses)[6]. Studies have reported associations between poor vitamin D status (blood levels) and susceptibility to acute respiratory tract infections. Meta-analyses (super studies) have reported that vitamin D supplementation prevents acute respiratory infections.[7],[8] Dietary sources are limited – mainly oily fish and eggs – so UK health experts recommend that everyone consider a daily supplement of 10 micrograms[9].

Vitamin E – working with vitamin C, vitamin E acts as a powerful anti-oxidant that helps protect body cells by strengthening their cell walls. Vitamin E also supports T cell function by improving the cells’ membrane defenses and reducing inflammation. Studies show that vitamin E has clinical relevance as it affects host susceptibility to infectious diseases, such as respiratory infections, and allergic diseases, such as asthma.[10] Food sources include vegetable oils, nuts and seeds.

Zinc – plays a role in innate immunity, adaptive immunity and the production of cytokines – proteins that are produced across the immune system to attack invading microorganisms.[11] In the initial immune response, zinc supplies in the blood are drained to supplement immune cells.[12] When people are low in zinc, the immune response is the first to suffer and there is a greater risk of oxidative stress (free radical attack) and inflammation.[13] Food sources include seafood, pork and beans.

Omega-3 fatty acids – the most important are DHA and EPA, found in oily fish and fish oil supplements. These support immune function by acting directly to resolve inflammation and promote healing once bacteria and viruses have been neutralised. Commenting in the journal, Nutrients, Professor Calder and colleagues explained: “Nutritional deficiencies in these essential fatty acids can result in delayed or suboptimal resolution of inflammation. This could be very important in the context of severe COVID-19 which manifests as uncontrolled inflammation, the so-called cytokine storm linked with acute respiratory distress syndrome (ARDS).” Natural dietary sources are limited to oily fish and seafood, so supplements made from fish oil or algae (vegan) are important alternatives if you don’t eat fish regularly.

Personal protection

The new review paper, published in Nutrients,[14] strongly recommends nutrition strategies to help support immune function, concluding that: “Optimal nutrient intake, including supplementing above the [recommended daily amount, RDA] for certain immune-supporting vitamins, promotes optimal immune function, helps to control the impact of infections, and could help limit the emergence of novel, more virulent strains of pathogenic viruses.”

In summary, Dr Carrie Ruxton comments: “Ensuring that we have the right balance of vitamins, minerals and essential fatty acids in our diets, is an important step in providing personal protection to our immune systems. We can’t control our environment – including the bacteria, viruses and yeast that could potentially cause infection – but we can do everything possible to get our immune systems ready to respond. As the evidence shows, certain nutrients can help, and a daily multivitamin and multimineral supplement, plus a fish oil supplement if you don’t regularly eat oily fish, is worth considering and is good, common sense.”

Posted on Diabetes

First study of COVID-19 patients with diabetes shows that 10% die within seven days of hospital admission

New Alder Hey Hospital Liverpool. Images by Gareth Jones


The first study of COVID-19 to specifically analyse the effect of the disease in hospitalised patients with diabetes has found that one in ten patients dies within 7 days of hospital admission, and one in five is intubated and mechanically ventilated by this point. The research is published in Diabetologia (the journal of the European Association for the Study of Diabetes [EASD]), by Professor Bertrand Cariou and Professor Samy Hadjadj, diabetologists at l’institut du thorax, University Hospital Nantes, INSERM, CNRS, and University of Nantes, France, and colleagues.

The study shows that two thirds (65%) of COVID-19 patients with diabetes admitted to hospital are men, and the average age of all patients is 70 years. Worse blood sugar control did not seem to impact a patient’s outcome, however the presence of diabetic complications and increasing age increase the risk of death, and increased BMI is associated with both increased risk of needing mechanical ventilation and with increased risk of death.

The CORONADO study analysed 1,317 patients admitted to 53 French hospitals (public and private) between 10 and 31 March 2020. The majority of hospitalised subjects had type 2 diabetes (89%) while only 3% had type 1 diabetes, with other types of diabetes in the remaining cases. In 3% of cases, diabetes was actually diagnosed during hospitalisation for COVID-19.

Microvascular complications (eye, kidney and nerves) were found in 47% of the subjects in the study, while macrovascular complications (arteries of the heart, brain, legs) were present in 41% of the patients analysed. Across all patients in this study, by day 7 one in five (20.3%) had been intubated and placed on a ventilator in intensive care, and one in 10 (10.3%) had died. A further 18% had been discharged home at this point.

The presence of microvascular or macrovascular complications each more than doubled the risk of death at day 7. Advanced age also substantially increased the risk of death, with the group of patients aged 75 years and more than 14 times more likely to die than younger patients aged under 55 years, while patients 65-74 years old were three times more likely to die than those under 55 years. The presence of the respiratory condition obstructive sleep apnoea almost tripled the risk of death at 7 days, as did the presence of dyspnoea symptoms (shortness of breath).

The study also confirmed that insulin, and indeed all treatments for modifying blood sugar, are not a risk factor for severe forms of COVID-19 and should be continued in patients with diabetes. Encouragingly, there were no deaths in patients under 65 years old with type 1 diabetes, but the authors highlight there were only 39 patients with type 1 diabetes in this study and other work is ongoing to establish the effect of COVID-19 in this specific population.

Increasing BMI raised the risk of reaching the combined primary outcome of the study (intubation/ventilation or death at day 7). Women were 25% less likely to reach the combined primary endpoint than men (a result that had borderline statistical significance). However, when looking at death only, men were not statistically more likely to die at day 7 than women.

The authors say: “The risk factors for severe form of COVID-19 are identical to those found in the general population: age and BMI.”

They add: “Elderly populations with long-term diabetes with advanced diabetic complications and/or treated obstructive sleep apnoea were particularly at risk of early death, and might require specific management to avoid infection with the novel coronavirus. BMI also appears as an independent prognostic factor for COVID-19 severity in the population living with diabetes requiring hospital admission. The link between obesity and COVID-19 requires further study.”

The authors plan to publish further work in the summer detailing outcomes of some 3000 patients with diabetes hospitalised with COVID-19, looking at their status 28 days after admission to hospital. The next study will also make more detailed comparisons of COVID-19 outcomes in patients with and without diabetes.

Posted on Autism

Overcoming challenges of autistic individuals during the COVID-19 pandemic

The COVID-19 pandemic is stressful enough, but for children and adults with autism spectrum disorder (ASD) and their families, the crisis can be especially difficult.

Adrien A. Eshraghi, M.D., M.Sc., professor of Otolaryngology, Neurological Surgery and Biomedical Engineering, has dedicated much of his career to caring for individuals with various disabilities including individuals with autism, who are very dear to him.

Dr. Eshraghi and Miller School coauthors published a new correspondence titled COVID-19: overcoming the challenges faced by individuals with autism and their families in The Lancet Psychiatry*. In this commentary, the authors address specific challenges patients with autism and their families might encounter during the pandemic, as well as what healthcare providers should know and do to ensure optimal and safe care.

Chances are good that providers caring for COVID-19 patients in all settings, including the emergency room (ER) and inpatient settings, will encounter adults and children with autism.

“Autism spectrum disorder prevalence has increased significantly in the last 20 years. In 2004, the prevalence of autism was 1 in 166. Today the Centers for Disease Control (CDC) estimates that 1 in 54 children are on the autism spectrum”, according to Dr. Eshraghi, who also is the director of the University of Miami Hearing Research and Communication Disorders Laboratory and co-director of the University of Miami Ear Institute.

The goal of this paper is to define the challenges these patients face in a pandemic like this, so physicians, caregivers, and the overall health system can better anticipate and meet the needs of these particular patients. At a time when everyone is stressed about contracting COVID-19, becoming better educated about how to manage patients with autism will increase patient and provider safely, while appropriately helping these patients and their families.”

People with autism are at higher risk for COVID-19 complications, according to the CDC. This is because they tend to have immune disorders and other comorbidities.

The process of isolating can be especially hard on children with autism and their families. The pandemic disrupts routine, which is problematic for these patients and caregivers. Patients might have difficulty comprehending the situation and expressing themselves.

Depending on where they are on the spectrum–from extremely high to low functioning –patients might have challenges with communicating, hyperactivity, and behavioral issues. Some individuals on the spectrum are extremely sensitive to sound or bright light.

Because of all these multiple challenges which may be experienced at the same time in some instances, people with autism and their caregivers are likely experiencing heightened stress during this time.

If patients need medical care during the pandemic, the situation for patients and their families often becomes even more overwhelming, according to Dr. Eshraghi.

“The healthcare environment, especially in the emergency room, can be difficult and overstimulating for people with autism spectrum disorder possibly due of the crowd, sounds and lights,” Dr. Eshraghi said. “It’s important to reduce that stress. For example, caregivers are not allowed into many ER exam and hospital rooms during the pandemic. But in the case of autism, patients need their caregivers to help keep them be calm and facilitate communication with providers.”

Dr. Eshraghi recommends that ERs train staff to recognize the signs of autism and understand how to best manage these patients. Often, that means thinking out of the box.

If the patient is running around the ER waiting room, for example, it is not because the parents don’t know how to discipline the child, but rather the child is overwhelmed because of the environment.

“Another issue with people on the spectrum is that some don’t have a concept of having to wait for their turn, so they’re impatient when they have to wait,” Dr. Eshraghi said.

At a time when it is important to wear masks, children with autism might refuse or take off their masks because of sensory issues.

Potential solutions include bringing the child and caregiver to wait in an exam room, rather than keeping them in the waiting room. If the patient keeps taking off his or her mask, provide parents with additional masks to keep the child, parents, and providers safe.

Telehealth can also be a viable and promising solution, but research is needed to develop telehealth services geared specifically toward people with autism, he said. It might actually be even an opportunity for many kids on the spectrum to use these online services, even post COVID-19.

“It’s important that providers and hospital staffs not judge those parents and avoid unintentional discrimination, simply because they don’t understand the behaviors of a person on the autism spectrum,” Dr. Eshraghi said.

A pandemic presents a perfect storm of challenges for patients with autism and their family.

“We need policies to help those people who are more vulnerable during a pandemic,” Dr. Eshraghi said. “Hopefully, this paper will bring these patients’ needs and potential solutions to light.”

“Those with autism spectrum disorder are not just another vulnerable population in the context of COVID-19. While they may share similar needs with other vulnerable groups, some are in fact quite unique. We hope our commentary begins to provide a framework for strategic enhancement and investment in healthcare, therapy, education, and family support during future crises” said co-author Michael Alessandri, Ph.D., executive director of the University of Miami-Nova Southeastern University Center for Autism and Related Disabilities (CARD).

“The care required by individuals with ASD and their families during this pandemic is the care we all desire for ourselves and our families” said co-author Daniel S. Messinger, Ph.D., professor and coordinator of the Developmental Psychology Program.

“It is imperative to understand the challenges encountered by individuals with ASD and their families in this era of COVID-19 to develop solutions for ameliorating or mitigating these challenges” said co-author Rahul Mittal, Ph.D., researcher in Dr. Eshraghi’s Hearing Research and Communication Disorders Laboratory at the University of Miami Miller School of Medicine.

Posted on Infectious Diseases

Evidence suggests a small but important number of people will develop coronavirus-related psychosis


Researchers at Orygen and La Trobe University in Melbourne, Australia have completed a rapid review of contemporary epidemic and pandemic research to assess the potential impact of COVID-19 on people with psychosis.

The review, published online ahead of print in Schizophrenia Research, found an increase in the prevalence of psychosis as a result of COVID-19 would likely be associated with viral exposure, pre-existing vulnerability and psychosocial stress. The review also suggested that people with psychosis may present a major challenge and potential infection control risk to clinical teams working with them.

Orygen research fellow and co-lead author on the study, Dr Ellie Brown looked at published research on viruses such as MERS, SARS, swine influenza and other influenzas that have occurred in the past 20 years, to examine if there was any connection to how these viruses might impact people with psychosis.

“COVID-19 is a very stressful experience for everyone, particularly those with complex mental health needs,” Dr Brown said. “We know that psychosis, and first episodes of psychosis, are commonly triggered by substantial psychosocial stresses. In the context of COVID-19, this could include stress relating to isolation and having to potentially remain within challenging family situations.

“People with psychosis are a population that are particularly vulnerable in the current COVID-19 pandemic and their needs are often overlooked.

“This research shows that their thoughts around contamination, and their understanding around concepts such as physical distancing may be different from the wider population.”

Co-lead author of the research, Professor Richard Gray of La Trobe University said another important finding from the research was that psychotic symptoms, such as hearing voices, may occur in a small number of people with COVID-19.

“Maintaining infection control procedures when people are psychotic is challenging,” Professor Gray said. “In order for them not to become potential transmitters of the virus, clinicians and service providers may benefit from specific infection control advice to mitigate any transmission risk.”

Dr Brown said that although mental health disorders such as depression and anxiety were important to focus on during the COVID-19 pandemic, the community needed to be aware that the smaller but more severe spectrum of mental health conditions could be impacted as well.

Professor Gray agreed. “This is a group that’s probably going to need more support, with isolation, physical distancing, hand washing etc, and clinicians may be the ones who need to be thinking and working on this to assist this vulnerable population,” he said.