Glycemic outcomes and patient satisfaction and self-management improves in transition from standard to virtual multidisciplinary care.

AIMS: With advances in cloud-based technologies, there has been a rise in remote T1D care. We hypothesized that transitioning T1DM care to a virtual, multidisciplinary clinic could improve measures beyond HbA1c. METHODS: To assess the impact of transitioning from standard to virtual T1DM care, we evaluated glycemic measures and patient reported outcomes. RESULTS: Sixty-one adults with T1DM were included, with mean age 40.2 ± 13.5 years and diabetes duration 16.9 ± 9.0 years. Most patients were treated with insulin pumps and CGM. The number of annual diabetes care encounters rose from 2.1 ± 4.2 to 12.8 ± 5.5. Baseline HbA1c was 7.9 ± 1.6 %(63 ± 16.9 mmol/mol), declining to 7.3 ± 1.1 %(56 ± 8.5 mmol/mol) and 7.1 ± 1.0 %(54 ± 7.7 mmol/mol) at 6 and 12 months respectively (p < 0.001 for both). In parallel, TIR improved from 63.1 ± 19.3 % to 69.2 ± 13.8 % (p < 0.001) and 67.5 ± 19.4 % (p = 0.03) at 6 and 12 months respectively, while TBR declined. Scores from validated diabetes treatment and self-management questionnaires rose significantly and these rises were associated with a reduction in HbA1c, the latter score was also associated with increased TIR. There was a trend toward a correlation between encounter frequency and improvement in HbA1c and TIR. CONCLUSIONS: Transitioning from standard to virtual, coordinated, multidisciplinary T1DM care is associated with increased visit frequency, improving glycemic control, treatment satisfaction and self-care behaviors.

[EXCESS WEIGHT AND SOCIODEMOGRAPHIC RISK FACTORS FOR SARS-COV-2 INFECTION IN ISRAEL].

BACKGROUND: Studies to date have demonstrated an increased prevalence of obesity and low socioeconomic status (SES( among people with confirmed cases of COVID-19, and low SES has been linked to obesity. OBJECTIVES: Our goal was to better understand the important relationship between body weight and sociodemographic variables affecting the COVID-19 burden. METHODS: We conducted a cross-sectional study of subjects presenting to Israel's largest emergency department and their odds for positive SARS-CoV-2 virus PCR testing during the first wave of the pandemic. RESULTS: We found that as BMI rises, as compared to normal weight, it is associated with increasing odds for testing positive, independently of age, gender, SES and population density (BMI 25-29.9 kg/m2: OR = 1.42, 95% CI 1.07 - 1.90; BMI 30-34.9 kg/m2: OR = 1.50, 95% CI 1.06 - 2.11; BMI ≥ 35 kg/m2: OR = 1.61, 95% CI 1.02 - 2.46). Furthermore, male gender, low SES and high population density are also associated with excess risk for positive test results independently of body weight. CONCLUSIONS: Understanding these risk factors for infection and how they might interplay can help the medical community develop approaches to protect at-risk groups from infection and severe disease secondary to seasonal and pandemic viral infections.

Unannounced Meal Challenges Using an Advanced Hybrid Closed-Loop System.

Background: The advanced hybrid closed-loop (AHCL) algorithm combines automated basal rates and corrections yet requires meal announcement for optimal outcomes. We aimed to compare the performance of the MiniMed™ 780G AHCL algorithm with and without meal announcement. Methods: In a single-arm study involving 14 adults with type 1 diabetes, we evaluated the safety and efficacy of AHCL when meals were not announced. Participants stayed at a supervised environment for 5 days, during which the outcomes of not announcing meals (≤80 g of carbohydrate) were assessed. Next, participants entered a 90-day at-home "unannounced" phase, during which all meals (≤80 g of carbohydrate) were unannounced, followed by a 90-day at-home phase in which all meals were announced. Results: Time in range (TIR 70-180 mg/dL) was lower in the unannounced versus announced periods (67.5% ± 12.5% vs. 77.7% ± 9.5%; P < 0.01, respectively), with more time spent in hyperglycemia range 180-250 mg/dL (22.7% ± 7.7% vs. 15.7% ± 7.2%) and >250 mg/dL (7.9% ± 6.4% vs. 3.6% ± 2.7%), but less time in hypoglycemia range 54-70 mg/dL (1.6% ± 1% vs. 2.8% ± 1.8%) and <54 mg/dL (0.3% ± 0.4% vs. 0.7% ± 0.9%). Not announcing meals containing up to 60 g of carbohydrate did not lead to increase in postprandial extreme dysglycemia >250 mg/dL, and up to 20 g of unannounced carbohydrates did not significantly change the TIR 70-180 mg/dL compared with full announcement. Conclusion: The AHCL system is optimized for use with meal announcement. While not announcing meals of ≤80 g carbohydrates appears to be safe, it results in suboptimal postprandial glycemic control, especially with high-carbohydrate meals. Not announcing small meals (≤20 g carbohydrate) does not deteriorate glycemic control. Clinical Trial Registration number: NCT04479826.

Obesity in late adolescence and incident type 1 diabetes in young adulthood.

AIMS/HYPOTHESIS: Studies in children have reported an association between increased BMI and risk for developing type 1 diabetes, but evidence in late adolescence is limited. We studied the association between BMI in late adolescence and incident type 1 diabetes in young adulthood. METHODS: All Israeli adolescents, ages 16-19 years, undergoing medical evaluation in preparation for mandatory military conscription between January 1996 and December 2016 were included for analysis unless they had a history of dysglycaemia. Data were linked with information about adult onset of type 1 diabetes in the Israeli National Diabetes Registry. Weight and height were measured at study entry. Cox proportional models were applied, with BMI being analysed both as a categorical and as a continuous variable. RESULTS: There were 777 incident cases of type 1 diabetes during 15,819,750 person-years (mean age at diagnosis 25.2±3.9 years). BMI was associated with incident type 1 diabetes. In a multivariable model adjusted for age, sex and sociodemographic variables, the HRs for type 1 diabetes were 1.05 (95% CI 0.87, 1.27) for the 50th-74th BMI percentiles, 1.41 (95% CI 1.11, 1.78) for the 75th-84th BMI percentiles, 1.54 (95% CI 1.23, 1.94) for adolescents who were overweight (85th-94th percentiles), and 2.05 (95% CI 1.58, 2.66) for adolescents with obesity (≥95th percentile) (reference group: 5th-49th BMI percentiles). One increment in BMI SD was associated with a 25% greater risk for incidence of type 1 diabetes (HR 1.25, 95% CI 1.17, 1.32). CONCLUSIONS: Excessively high BMI in otherwise healthy adolescents is associated with increased risk for incident type 1 diabetes in early adulthood.

[PATIENT INVOLVEMENT IN THE DESIGN OF RESEARCH AND PRACTICES IN HEALTHCARE].

INTRODUCTION: The integration and involvement of patients in shaping research, processes and policies in the health care system is a new trend, which is gaining momentum in many countries around the world. Although participatory processes have existed for many years, systematic and organized mechanisms have only begun maturing in recent years. The first expression of this trend is in aspects related to research, including: accessibility to information about experiments; patient participation in research as research subjects; participation in the design and management of research. The second area in which patients are involved is priority setting in research, drug approval processes and policy making. The third subject of patient involvement is the formation of therapeutic practices in healthcare quality improvement, healthcare routine, and the development of assessment tools. In this article, we review participatory processes, which are initiated by the authorities via mandatory standardization or participatory practices embedding, and also by patient organizations and public representatives working alongside, or as part of healthcare organizations. We present the global picture and then present examples from the Israeli context.

Managing Obesity in Lockdown: Survey of Health Behaviors and Telemedicine.

Since the outbreak of COVID-19, billions of people have gone into lockdown, facing pandemic related challenges that engender weight gain, especially in the obese. We report the results of an online survey, conducted during Israel's first quarantine, of 279 adults treated in hospital-based obesity clinics with counseling, medications, surgery, endoscopic procedures, or any combination of these for weight loss. In this study, we assessed the association between changes in dietary and lifestyle habits and body weight, and the benefits of receiving weight management care remotely through telemedicine during lockdown. Compared to patients not receiving obesity care via telemedicine, patients receiving this care were more likely to lose weight (OR, 2.79; p = 0.042) and also to increase participation in exercise (OR, 2.4; p = 0.022). While 40% of respondents reported consuming more sweet or salty processed snacks and 33% reported less vegetables and fruits, 65% reported more homemade foods. At the same time, 40% of respondents reported a reduction in exercise and 52% reported a decline in mood. Alterations in these eating patterns, as well as in exercise habits and mood, were significantly associated with weight changes. This study highlights that lockdown affects health behaviors associated with weight change, and advocates for the use of telemedicine to provide ongoing obesity care during future quarantines in order to promote weight loss and prevent weight gain.

Stemness in human thyroid cancers and derived cell lines: the role of asymmetrically dividing cancer stem cells resistant to chemotherapy.

CONTEXT: Cancer stem cells (CSCs) have the ability to self-renew through symmetric and asymmetric cell division. CSCs may arise from mutations within an embryonic stem cell/progenitor cell population or via epithelial-mesenchymal transition (EMT), and recent advances in the study of thyroid stem cells have led to a growing recognition of the likely central importance of CSCs in thyroid tumorigenesis. OBJECTIVE: The objectives of this study were to establish the presence of a stem cell population in human thyroid tumors and to identify, isolate, and characterize CSCs in thyroid cancer cell lines. RESULTS: 1) Human thyroid cancers (n = 10) and thyroid cancer cell lines (n = 6) contained a stem cell population as evidenced by pluripotent stem cell gene expression. 2) Pulse-chase experiments with thyroid cancer cells identified a label-retaining cell population, a primary characteristic of CSCs, which at mitosis divided their DNA both symmetrically and asymmetrically and included a population of cells expressing the progenitor marker, stage-specific embryonic antigen 1 (SSEA-1). 3) Cells positive for SSEA-1 expressed additional stem cell markers including Oct4, Sox2, and Nanog were confirmed as CSCs by their tumor-initiating properties in vivo, their resistance to chemotherapy, and their multipotent capability. 4) SSEA-1-positive cells showed enhanced vimentin expression and decreased E-cadherin expression, indicating their likely derivation via EMT. CONCLUSIONS: Cellular diversity in thyroid cancer occurs through both symmetric and asymmetric cell division, and SSEA-1-positive cells are one form of CSCs that appear to have arisen via EMT and may be the source of malignant thyroid tumor formation. This would suggest that thyroid cancer CSCs were the result of thyroid cancer transformation rather than the source.

Clinical review: The emerging cell biology of thyroid stem cells.

CONTEXT: Stem cells are undifferentiated cells with the property of self-renewal and give rise to highly specialized cells under appropriate local conditions. The use of stem cells in regenerative medicine holds great promise for the treatment of many diseases, including those of the thyroid gland. EVIDENCE ACQUISITION: This review focuses on the progress that has been made in thyroid stem cell research including an overview of cellular and molecular events (most of which were drawn from the period 1990-2011) and discusses the remaining problems encountered in their differentiation. EVIDENCE SYNTHESIS: Protocols for the in vitro differentiation of embryonic stem cells, based on normal developmental processes, have generated thyroid-like cells but without full thyrocyte function. However, agents have been identified, including activin A, insulin, and IGF-I, which are able to stimulate the generation of thyroid-like cells in vitro. In addition, thyroid stem/progenitor cells have been identified within the normal thyroid gland and within thyroid cancers. CONCLUSIONS: Advances in thyroid stem cell biology are providing not only insight into thyroid development but may offer therapeutic potential in thyroid cancer and future thyroid cell replacement therapy.