The Rapid Transition to Telemedicine and Its Effect on Access to Care for Patients With Type 1 Diabetes During the COVID-19 Pandemic

OBJECTIVEWe compared the uptake of telemedicine for diabetes care across multiple demographic groups during the coronavirus disease 2019 pandemic to understand the impact of telemedicine adoption on access to care.RESEARCH DESIGN AND METHODSThe study analyzed demographic information of patients with type 1 diabetes seen between 1 January 2018 and 30 June 2020 at a single center. We compared the odds of completing a visit via telemedicine across multiple demographic characteristics.RESULTSAmong 28,977 patient visits, the odds of completing a visit via telemedicine were lower among non-English-speaking (1.7% vs. 2.7%; adjusted odds ratio [aOR] 0.45, 95% CI 0.26–0.79) and Medicaid-insured (32.0% vs. 35.9%; aOR 0.83, 95% CI 0.72–0.95) pediatric patients. No clinically significant differences were observed for other demographic factors.CONCLUSIONSRapid transition to telemedicine did not significantly impact access to diabetes care for most demographic groups. However, disparities in access to care for historically marginalized groups merit close attention to ensure that use of telemedicine does not exacerbate these inequities.     

Self-Rated Health and Health Care Use Among Women With Histories of Gestational Diabetes Mellitus

OBJECTIVE

To examine self-rated health and health care utilization among women with a history of gestational diabetes mellitus (hGDM).

RESEARCH DESIGN AND METHODS

This study was a cross-sectional analysis of the 2006 National Health Interview Survey of parous women with (n = 370) and without (n = 6,695) hGDM.

RESULTS

Women with hGDM reported fair or poor health status and ≥10 office visits in the past year more frequently than women without hGDM. The higher prevalence of obesity in hGDM women accounted for their poorer self-rated health after adjustment for other demographic factors. Whereas the association between hGDM and more frequent office visits was reduced after adjustment for demographic factors including health insurance, hGDM was still associated with a lower odds of contact with a mental health professional.

CONCLUSIONS

Because of obesity, women with hGDM have poorer self-rated health than women without hGDM. Contact with mental health providers was reduced compared with women without hGDM.Self-rated health can act as a global summary measure of health and has been found to correlate with mortality (1) and health care use (2) independent of chronic disease. Studies that examine self-rated health among women with a history of gestational diabetes mellitus (hGDM) conflict (3–6), and health care use among hGDM women has not been reported. Women with hGDM may have poorer self-rated health than women without hGDM because of their poorer socioeconomic status (7), greater prevalence of obesity (7), and/or greater prevalence of postpartum depression (5). Therefore, we sought to determine whether women with hGDM had poorer self-rated health than parous women without hGDM, whether any differences persisted after adjustment for demographic factors and consideration of BMI and mental health distress, and whether hGDM women had different patterns of health care use than women without hGDM.     

Diabetes Risk Perception and Intention to Adopt Healthy Lifest yles Among Primary Care Patients

OBJECTIVE

To examine perceived risk of developing diabetes in primary care patients.

RESEARCH DESIGN AND METHODS

We recruited 150 nondiabetic primary care patients. We made standard clinical measurements, collected fasting blood samples, and used the validated Risk Perception Survey for Developing Diabetes questionnaire.

RESULTS

Patients with high perceived risk were more likely than those with low perceived risk to have a family history of diabetes (68 vs. 18%; P < 0.0001) and to have metabolic syndrome (53 vs. 35%; P = 0.04). However, patients with high perceived risk were not more likely to have intentions to adopt healthier lifestyle in the coming year (high 26.0% vs. low 29.2%; P = 0.69).

CONCLUSIONS

Primary care patients with higher perceived risk of diabetes were at higher actual risk but did not express greater intention to adopt healthier lifestyles. Aspects of health behavior theory other than perceived risk need to be explored to help target efforts in the primary prevention of diabetes.Many clinical trials have shown that healthier lifestyles leading to modest weight loss can prevent diabetes in populations at risk (1,2), but changing behavior in real-life patients remains a challenge. Risk perception is a major component of most health behavior theories (3). Perceived risk to develop diabetes can be measured using a validated questionnaire such as the Risk Perception Survey for Developing Diabetes (RPS-DD) (4). There are no reports of diabetes risk perception estimated by the RPS-DD in primary care settings. We tested the hypotheses that primary care patients who perceive themselves at higher risk are 1) actually at higher risk for future diabetes and 2) more likely to intend to adopt healthier lifestyle behaviors.     

HDL Cholesterol and Cancer Risk Among Patients With Type 2 Diabetes

OBJECTIVETo investigate the relationship between HDL cholesterol (HDL-C) and cancer risk among type 2 diabetic patients.RESULTSDuring a mean follow-up period of 6.4 years, 3,711 type 2 diabetic patients had a cancer diagnosis. A significant inverse association between HDL-C and the risk of cancer was found among men and women. The multivariable-adjusted hazard ratios (HRs) of cancer at various levels of HDL-C at baseline (<30, 30–39.9, 40–49.9, 50–59.9, 60–69.9, 70–79.9, and ≥80 mg/dL) were 1.00, 0.87, 0.95, 1.01, 0.61, 0.45, and 0.37, respectively, in men (P_trend = 0.027) and 1.00, 0.98, 0.88, 0.85, 0.84, 0.86, and 0.84, respectively, in women (P_trend = 0.025). When stratified by race, BMI, smoking status, or medication use, the inverse association was still present. With an updated mean of HDL-C used in the analysis, the inverse association of HDL-C with cancer risk did not change. The inverse association substantially attenuated after excluding patients who died of or were diagnosed with cancer during the first 2 years of follow-up.CONCLUSIONSThe study suggests an inverse association of HDL-C with cancer risk among men and women with type 2 diabetes, whereas the effect of HDL-C was partially mediated by reverse causation.     

Risk of Blindness Among Patients With Diabetes and Newly Diagnosed Diabetic Retinopathy

OBJECTIVETo evaluate the association between initial diabetic retinopathy (DR) severity/risk of blindness in patients with newly diagnosed DR/good vision in the U.S.RESEARCH DESIGN AND METHODSThis retrospective cohort study evaluated adult patients with good vision (20/40 or better) and newly diagnosed DR between 1 January 2013 and 31 December 2017 (index date) in the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) Registry. The primary exposure of interest was DR severity at index: mild nonproliferative DR (NPDR), moderate NPDR, severe NPDR, and proliferative DR (PDR). The main outcome measure was development of sustained blindness (SB), defined as study eyes with Snellen visual acuity readings of 20/200 or worse at two separate visits ≥3 months apart that did not improve beyond 20/100.RESULTSAmong 53,535 eligible eyes (mean follow-up 662.5 days), 678 (1.3%) eyes developed SB. Eyes with PDR at index represented 10.5% (5,629 of 53,535) of the analysis population but made up 26.5% (180 of 678) of eyes that developed SB. Kaplan-Meier analysis revealed that eyes with moderate NPDR, severe NPDR, and PDR at index were 2.6, 3.6, and 4.0 times more likely, respectively, to develop SB after 2 years of DR diagnosis versus eyes with mild DR at index. In a Cox proportional hazards model adjusted for index characteristics/development of ocular conditions during follow-up, eyes with PDR had an increased risk of developing SB versus eyes with mild NPDR at index (hazard ratio 2.26 [95% CI 2.09−2.45]).CONCLUSIONSIn this longitudinal ophthalmologic registry population involving eyes with good vision, more advanced DR at first diagnosis was a significant risk factor for developing SB.     

Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations

OBJECTIVEClinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the U.S.RESEARCH DESIGN AND METHODSElectronic health record data were analyzed from 513,165 adults with type 2 diabetes receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both one or more eGFRs and one or more uACRs and each test individually in the 1, 2, and 3 years ending September 2019 by health care organization and clinical practice site. Elevated albuminuria was defined as uACR ≥30 mg/g.RESULTSThe 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th–90th percentile) from 44.7 to 63.3% across organizations and from 13.3 to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30% at uACR testing rates of 20%, 50%, and 100%, respectively.CONCLUSIONSWhile eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.     

Prior Glucose-Lowering Medication Use and 30-Day Outcomes Among 64,892 Veterans With Diabetes and COVID-19

OBJECTIVETo identify preinfection risk factors for adverse outcomes among veterans with diabetes and coronavirus disease 2019 (COVID-19) infection.RESEARCH DESIGN AND METHODSWe identified all Veterans Health Administration patients with diabetes and one or more positive nasal swab(s) for severe acute respiratory syndrome coronavirus 2 (1 March 2020–10 March 2021) (n = 64,892). We examined associations of HbA_1c and glucose-lowering medication use with hospitalization, intensive care unit (ICU) admission, and mortality at 30 days using logistic regression models and during 4.4 months of follow-up (range <1–13.1) using proportional hazards models.RESULTSCompared with HbA_1c <7.0%, HbA_1c ≥9.0% was associated with higher odds of hospitalization, ICU admission, and death at 30 days (odds ratio [OR] 1.27 [95% CI 1.19–1.35], 1.28 [95% CI 1.15–1.42], 1.30 [95% CI 1.17–1.44], respectively) as well as higher risk of death over 4.4 months (hazard ratio [HR] 1.22 [95% CI 1.12–1.32]). Insulin use was associated with higher odds of hospitalization, ICU admission, and death (OR 1.12 [95% CI 1.07–1.18], 1.12 [95% CI 1.04–1.22], and 1.18 [95% CI 1.09–1.27], respectively) and higher risk of death (HR 1.12 [95% CI 1.07–1.18]). Sodium–glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP1-RA), or angiotensin receptor blocker use were associated with lower odds of hospitalization (OR 0.92 [95% CI 0.85–0.99], 0.88 [95% CI 0.81–0.96], and 0.94 [95% CI 0.89–0.99], respectively). Metformin and SGLT2i use were associated with lower odds (OR 0.84 [95% CI 0.78–0.91], 0.82 [95% CI 0.72–0.94], respectively) and risk of death (HR 0.84 [95% CI 0.79–0.89], 0.82 [95% CI 0.74–0.92], respectively).CONCLUSIONSAmong veterans with diabetes and COVID-19, higher HbA_1c and insulin use were directly associated with adverse outcomes, while use of a GLP1-RA, metformin, and SGLT2i was inversely associated.     

The Health Care Resource Utilization and Costs Among Patients With Type 2 Diabetes and Either Cardiovascular Disease or Cardiovascular Risk Factors An Analysis of a US Health Insurance Database

PurposeHealth care costs and cardiovascular (CV) outcomes were evaluated among US patients with type 2 diabetes (T2D) and cardiovascular disease (CVD) or CV risk factors.MethodsPatients with ≥24 months of continuous enrollment were selected from the MarketScan Commercial and Medicare databases from January 1, 2014, to September 30, 2018. For the first qualifying 24-month period, months 1 to 12 defined the baseline period and months 13 to 24 defined the follow-up period. All patients had ≥2 T2D diagnoses during baseline. Two cohorts were created: (1) patients with ≥1 CVD diagnosis during baseline (“CVD cohort”); and (2) patients with ≥1 CV risk factor (“CV risk cohort”) and no diagnosed CVD during baseline. The percentage of patients with subsequent CVD diagnoses and annual all-cause, T2D-related, and CV-related costs in baseline and follow-up periods were reported.FindingsIn total, 1,106,716 patients met inclusion criteria: CVD cohort, 224,018 patients; CV risk cohort, 812,144 patients; and no diagnosed CVD or CV risk factors, 70,554. During baseline, 40.2% of the CVD cohort had 2 or more CVD diagnoses. During follow-up, 10.5% of the CV risk cohort had evidence of CVD (ie, emergent CVD). During baseline, the CVD cohort had mean (SD) all-cause costs of $38,985 ($69,936); T2D-related costs, $16,208 ($34,104); and CV-related annual costs, $18,842 ($44,457). The CV risk cohort had mean all-cause costs of $13,207 ($27,057); T2D-related costs, $5226 ($12,268); and CV-related costs, $2754 ($10,586). During follow-up, the CV risk cohort with emergent CVD had higher mean all-cause, T2D-related, and CV-related annual costs than costs among patients without CVD (all-cause, $39,365 [$67,731] vs $13,401 [$27,530]; T2D related, $18,520 [$37,256] vs $5732 [$12,540]; and CV related, $18,893 [$43,584] vs $2650 [$10,501], respectively).ImplicationsCosts for patients with T2D and either CVD or CV risk are substantial. In this analysis, ∼10% of patients with CV risk were diagnosed with emergent CVD. All-cause costs among patients with emergent CVD were nearly 3 times higher than those among patients with CV risk only. Because costs associated with CVD in the T2D population are high, preventing CVD events in patients with T2D has the potential to decrease overall health care costs and avoid additional disease burden for these patients.     

Early Use of Remdesivir and Risk of Disease Progression in Hospitalized Patients With Mild to Moderate COVID-19

PurposePreliminary data suggest that remdesivir may influence the course of COVID-19 according to the duration of pre-admission symptoms. We aim to evaluate whether early use of remdesivir is associated with a reduced COVID-19 progression in a homogeneous cohort of patients with mild to moderate COVID-19.MethodsThis prospective, observational study included patients with COVID-19 pneumonia treated with remdesivir at the University Hospital of Pisa (Italy) from September 2020 to January 2021. According to national recommendations, remdesivir was prescribed in patients with pneumonia who required oxygen supplementation by nasal cannula or mask but without the need for high-flow nasal cannula, non-invasive or invasive mechanical ventilation and had symptoms from no more than 10 days. Patients who received early (≤5 days from onset of symptoms) versus late (>5 days from onset of symptoms) remdesivir were compared. The primary outcome was a composite of high-flow nasal cannula, non-invasive or invasive mechanical ventilation, or death. A multivariate logistic regression analysis was performed to identify factors independently associated with the composite endpoint.FindingsAmong 312 consecutive patients with COVID-19 pneumonia who received remdesivir, 90 (28.8%) received early remdesivir, whereas 222 (71.2%) received late remdesivir. Twenty-nine patients (32.2%) in the early-remdesivir group versus 104 patients (46.8%) in the late-remdesivir group met the primary end point (P = 0.018). On multivariate analysis, a history of dyspnea at home (odds ratio = 2.53; 95% CI, 1.55–4.12; P < 0.001) was the strongest factor independently associated with the progression to severe COVID-19, whereas early-remdesivir use was a protective factor (odds ratio = 0.49; 95% CI, 0.27–0.87; P = 0.015). The delayed admission to the hospital was associated with a delayed administration of remdesivir.ImplicationsThe early use of remdesivir (<5 days from symptoms onset) may reduce COVID-19 progression. The identification of patients who need early hospitalization and early remdesivir may provide clinical benefit in patients with COVID-19.     

Severe Hypoglycemia,Cardiac Structure and Function,and Risk of Cardiovascular Events Among Older Adults With Diabetes

OBJECTIVETo assess the association of severe hypoglycemia measured at baseline with cardiovascular disease (CVD) among community-dwelling older individuals with diabetes, a group particularly susceptible to hypoglycemia.RESEARCH DESIGN AND METHODSWe included older adults with diabetes from the Atherosclerosis Risk in Communities (ARIC) study who attended visit 5 (2011–2013, baseline). Severe hypoglycemia at baseline was defined with use of first position ICD-9 codes from hospitalizations, emergency department visits, and ambulance calls. We examined cross-sectional associations of severe hypoglycemia with echocardiographic indices of cardiac structure-function. We prospectively evaluated the risks of incident or recurrent CVD (coronary heart disease, stroke, or heart failure) and all-cause mortality, from baseline to 31 December 2018, using negative binomial and Cox regression models.RESULTSAmong 2,193 participants (mean [SD] age 76 [5] years, 57% female, 32% Blacks), 79 had a history of severe hypoglycemia at baseline. Severe hypoglycemia was associated with a lower left ventricular (LV) ejection fraction (adjusted β-coefficient −3.66% [95% CI −5.54, −1.78]), higher LV end diastolic volume (14.80 mL [95% CI 8.77, 20.84]), higher E-to-A ratio (0.11 [95% CI 0.03, 0.18]), and higher septal E/e′ (2.48 [95% CI 1.13, 3.82]). In adjusted models, severe hypoglycemia was associated with incident or recurrent CVD (incidence rate ratio 2.19 (95% CI 1.24, 3.88]) and all-cause mortality (hazard ratio 1.71 [95% CI 1.10, 2.67]) among those without prevalent CVD.CONCLUSIONSOur findings suggest that a history of severe hypoglycemia is associated with alterations in cardiac function and is an important marker of future cardiovascular risk in older adults.     

重型颅脑损伤后呼吸机相关性肺炎的危险因素及护理

[目的 ]探讨重型颅脑损伤后呼吸机相关性肺炎 (VAP)的危险因素及护理对策。 [方法 ]对 98例行机械通气治疗的重型颅脑损伤病人进行回顾性分析。 [结果 ] 98例中发生VAP 67例 ,发生率为 68.4% ;年龄 >60岁、深静脉留置导管、每 2 4h更换呼吸机管道、机械通气时间≥ 2 0d、GCS评分 3分～ 5分、气管切开是造成VAP的重要原因 (P <0 .0 5或P <0 .0 1) ;VAP的主要病原菌为肠杆菌科细菌 ( 4 3 .5 % )和铜绿假单孢菌 ( 4 0 .6% ) ,对多数抗生素有较高耐药率。 [结论 ]预防VAP首先应针对发生VAP的危险因素采取相应的护理     

重型颅脑损伤病人的观察及其护理

重型颅脑损伤是脑外科常见急症 ,在临床上有突变、多变的特点 ,死亡率高达 5 0 % [1] 。因此 ,密切观察重型颅脑损伤病人伤后或术后变化 ,采取积极正确的护理措施 ,对改善重型颅脑损伤病人的预后甚为重要。作者对 1998年 1月— 2 0 0 2年 12月我院收治的 92例重型颅脑损伤病人的护理进行了总结 ,旨在提高病人的生存率。1　临床资料　　本组 92例 ,男 78例 ,女 14例 ,年龄 10岁～ 78岁。入院时均经CT检查。开放性颅脑损伤 6例 ,闭合性损伤 86例。其中颅内血肿 61例 ,脑挫裂伤 2 9例 ,脑干损伤 2例。入院时昏迷程度按格拉斯哥昏迷评分标准GC…     

Lung Ultrasound in Patients with Acute Respiratory Failure Reduces Conventional Imaging and Health Care Provider Exposure to COVID-19

Lung ultrasound gained a leading position in the last year as an imaging technique for the assessment and management of patients with acute respiratory failure. In coronavirus disease 2019 (COVID-19), its role may be of further importance because it is performed bedside and may limit chest X-ray and the need for transport to radiology for computed tomography (CT) scan. Since February 21, we progressively turned into a coronavirus-dedicated intensive care unit and applied an ultrasound-based approach to avoid traditional imaging and limit contamination as much as possible. We performed a complete daily examination with lung ultrasound score computation and systematic search of complications (pneumothorax, ventilator-associated pneumonia); on-duty physicians were free to perform CT or chest X-ray when deemed indicated. We compared conventional imaging exams performed in the first 4 wk of the COVID-19 epidemic with those in the same time frame in 2019: there were 84 patients in 2020 and 112 in 2019; 64 and 22 (76.2% vs. 19.6%, p < 0.001) had acute respiratory failure, respectively, of which 55 (85.9%) were COVID-19 in 2020. When COVID-19 patients in 2020 were compared with acute respiratory failure patients in 2019, the median number of chest X-rays was 1.0 (1.0–2.0) versus 3.0 (1.0–4.0) (p = 0.0098); 2 patients 2 (3.6%) versus 7 patients (31.8%) had undergone at least one thoracic CT scan (p = 0.001). A self-imposed ultrasound-based approach reduces the number of chest X-rays and thoracic CT scans in COVID-19 patients compared with patients with standard acute respiratory failure, thus reducing the number of health care providers exposed to possible contamination and sparing personal protective equipment.     

Developing an mHealth Intervention to Reduce COVID-19–Associated Psychological Distress Among Health Care Workers in Nigeria: Protocol for a Design and Feasibility Study

BackgroundGlobally, COVID-19–related psychological distress is seriously eroding health care workers’ mental health and well-being, especially in low-income countries like Nigeria. The use of mobile health (mHealth) interventions is now increasingly recognized as an innovative approach that may improve mental health and well-being. This project aims to develop an mHealth psychological intervention (mPsyI) to reduce COVID-19–related psychological distress among health care workers in Nigeria.ObjectiveOur objective is to present a study protocol to determine the level of COVID-19–related psychological distress among health care workers in Nigeria; explore health care workers’ experience of COVID-19–related psychological distress; develop and pilot test mPsyI to reduce this distress; and assess the feasibility of this intervention (such as usability, engagement, and satisfaction).MethodsA mixed (quantitative and qualitative) methods approach is used in which health care workers will be recruited from 2 tertiary health care facilities in southwest Nigeria. The study is divided into 4 phases based on the study objectives. Phase 1 involves a quantitative survey to assess the type and levels of psychosocial distress. Phase 2 collects qualitative data on psychosocial distress among health care workers. Phase 3 involves development of the mHealth-based psychological intervention, and phase 4 is a mixed methods study to assess the feasibility and acceptability of the intervention.ResultsThis study was funded in November 2020 by the Global Effort on COVID-19 Health Research, and collection of preliminary baseline data started in July 2021.ConclusionsThis is the first study to report the development of an mHealth-based intervention to reduce COVID-19–related psychological distress among health care workers in Nigeria. Using a mixed methods design in this study can potentially facilitate the adaptation of an evidence-based treatment method that is culturally sensitive and cost-effective for the management of COVID-19–related psychological distress among health care workers in Nigeria.International Registered Report Identifier (IRRID)DERR1-10.2196/36174