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Most deaths from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection occur in older subjects. We assessed the utility of serum inflammatory markers interleukin-6 (IL-6), C reactive protein (CRP), and ferritin (Roche, Indianapolis, IN), and SARS-CoV-2 immunoglobulin G (IgG), immunoglobulin M (IgM), and neutralizing antibodies (Diazyme, Poway, CA). In controls, non-hospitalized subjects, and hospitalized subjects assessed for SARS-CoV-2 RNA (n = 278), median IgG levels in arbitrary units (AU)/mL were 0.05 in negative subjects, 14.83 in positive outpatients, and 30.61 in positive hospitalized patients (PPP = 1.00 x 10−12). Antibody or ferritin levels did not add significantly to predicting hospitalization. Antibody testing in family members and contacts of SARS-CoV-2 RNA positive cases (n = 759) was invaluable for case finding. Persistent IgM levels were associated with chronic COVID-19 symptoms. In 81,624 screened subjects, IgG levels were positive (≥1.0 AU/mL) in 5.21%, while IgM levels were positive in 2.96% of subjects. In positive subjects median IgG levels in AU/mL were 3.14 if P = 2.96 x 10−38). Our data indicate that: 1) combined IL-6 ≥10 pg/mL and CRP ≥10 mg/L identify SARS-CoV-2 positive subjects requiring hospitalization; 2) IgG levels were significantly correlated with neutralizing antibody levels with a wide range of responses; 3) IgG levels have significant utility for case finding in exposed subjects; 4) persistently elevated IgM levels are associated with chronic symptoms; and 5) IgG levels are significantly higher in positive older subjects than their younger counterparts.

Women with a history of gestational diabetes are at high risk for developing type 2 diabetes mellitus. In studies with long periods of follow-up, diabetes incidence of up to 70% has been reported. The appropriate follow-up of women following a pregnancy complicated by gestational diabetes has not been studied. Published guidelines recommend that obstetrician/gynaecologists, who are often the de facto primary care physicians for these otherwise healthy young women, incorporate glucose monitoring in the post-partum period into their annual examinations. In reality, reported rates of screening have been low. There is also no clear evidence for any beneficial interventions to prevent diabetes in patients with prior history of gestational diabetes. Lifestyle intervention programmes for diabetes prevention among these patients yielded disappointing results. Metformin, pioglitazone, liraglutide, and bariatric surgery are possible options but based on inadequate data. There remains a need for randomized, placebo-controlled studies to evaluate various pharmacologic treatments, with and without lifestyle interventions, to prevent type 2 diabetes mellitus in women with a history of gestational diabetes.

This commentary constitutes the opinions of the endocrinologists whose names are appended. The commentary is based on articles published in peer-reviewed journals as listed in the cited references, as well as cumulative experience in treating patients with type 1 diabetes mellitus (T1DM). This commentary applies only to patients with T1DM, and does not apply to patients with type 2 DM who are being treated with insulin even though the principles may be similar. The recommendations outlined also do NOT apply to the pregnant woman with T1DM, who should not fast. Additionally, this commentary does not preclude an individual from directing any questions having to do with religious observance to a competent Rabbi. For example, with regard to fingerstick blood glucose testing, which requires the use of an electronic meter, we have received written council from Rabbi Yosef Shalom Eliashiv and Rabbi Joseph Efrati (Jerusalem, Israel), and Rabbi M. Weissmandl and Rabbi Mordechai Willig (NY) that the procedure is permissible when performed appropriately for the patient's welfare and health while fasting on Yom Kippur.

Patients with diabetes may undergo an approximately 24-h fast for a voluntary religious observance or in preparation for a medical procedure. Commonly, patients will manage their diabetes before and during such fasting without guidelines from their doctors, often because they did not ask for advice. The physician should therefore take the lead in advising patients how to fast safely, in order to avoid the situation wherein the patient manages medication changes on his/her own. Furthermore, it sends a message to the patient that having diabetes does not preclude living a reasonably ‘normal’ life, even when it comes to religious observances. Copyright © 2011 John Wiley & Sons, Ltd.

Editor’s comment : The commentary by Dr. Grajower has such important clinical relevance that responses were invited from the three pharmaceutical companies that supply insulin in the U.S. and the American Diabetes Association, and all of these combined in this commentary. The commenting letter and individual responses were authored separately and are completely independent of each other. Diabetic patients treated with insulin, whether for type 1 or type 2 diabetes, are prone to often unexplained swings in their blood glucose. These swings can vary from dangerously low to persistently high levels. Most diabetic patients, and most physicians, will adjust insulin regimens so as to avoid hypoglycemia at the expense of hyperglycemia. Among the “textbook” reasons for variable glucose responses to any given insulin regimen are 1 ) site of administration, 2 ) exercise, 3 ) bottles not adequately mixed before drawing the insulin (for NPH, Lente, or Ultralente), and 4 ) duration of treatment with insulin (1). A new insulin was marketed by Aventis Pharmaceuticals about 1 year ago, insulin glargine (Lantus). The manufacturer seemed to stress that patients not use a started bottle of this insulin for >28 days (2). Two patients of mine highlighted this point. L.K. is a 76-year-old woman with type 2 diabetes, diagnosed at 55 years of age, and treated with insulin since age 56. Her insulin regimen was changed to Lantus at night together with Novolog before meals. She monitors her blood glucose four times a day. She used a bottle of Lantus until it ran out; therefore, a bottle lasted for 2 months. Her recent HbA1c was 7.6%. I retrospectively analyzed her home glucose readings by averaging her fasting blood glucose levels for the first 15 days of a new bottle and the last 15 days of that same bottle. The results were 137 ± …

The concentration of hepatic nuclear T3 receptors was measured in isolated nuclei from athyreotic mice bearing thyrotrophic tumors and intact rats with Walker 256 carcinoma. Receptor concentration was reduced in all tumor-bearing animals. The mean receptor capacity of the Walker tumor-bearing rats [0.31 +/- 0.05 (SEM) ng/mg DNA] was significantly decreased from simultaneously assayed controls (0.47 +/- 0.04 ng/mg DNA; P less than 0.01). No change in the apparent equilibrium association constant was observed. In individual rats, the magnitude of the decrease in nuclear T3 receptor concentration was highly correlated with the decrease in tumor-free body weight. Additional studies showed that the decrease in nuclear receptors was not due to delayed equilibration of added T3 with nuclear sites in vitro or to an increase in endogenous hepatic T3 concentration. The plasma concentration of total and free T4 and T3 was decreased in tumor-bearing rats. Plasma TSH concentration, however, remained unchanged. Thus, these transplantable neoplasms seem to be associated with decreased hepatic nuclear receptors and low concentrations of plasma thyroid hormones. The unchanged plasma TSH suggests that the animals remained euthyroid.

The activity of hepatic α-glycerophosphate dehydrogenase (α-GPD) and malic enzyme (ME) was measured in rats bearing the Walker 256 carcinoma to assess the relationship between the reduction in the nuclear L-T3 (T3) receptor concentration which occurs in tumor-bearing (T) rats and the biological effects of thyroid hormones. T3 receptor concentration was uniformly decreased when tumors exceeded 9.5% of body weight. No change in basal α-GPD activity was observed, but ME activity was decreased to between 29–61% of control. The decrease in ME activity did not appear to be related to decreased nuclear T;) receptor concentration since ME was also decreased in T rats with tumors that were too small to effect a decrease in the concentration of nuclear T3 receptors or plasma T4 and T3. The response of both ME and α-GPD to T3 administration in T rats was comparable to that of control despite reduced nuclear T3 receptor and plasma hormone concentrations. When non-T rats were subjected to food restriction to simulate ...

Excerpt To the editor: I write to add to the report of Dat and Sontag (1) with a brief description of another family with pancreatic carcinoma. I treated an 80-year-old white man who presented with...