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There is wide variation in mortality among patients hospitalized with COVID-19. Whether this is related to patient or hospital factors is unknown.To compare the risk of mortality for patients hospitalized with COVID-19 and to determine whether the majority of that variation was explained by differences in patient characteristics across sites.An international multicenter cohort study of hospitalized adults with laboratory-confirmed COVID-19 enrolled from 10 hospitals in Ontario, Canada and 8 hospitals in Copenhagen, Denmark between January 1, 2020 and November 11, 2020.Inpatient mortality. We used a multivariable multilevel regression model to compare the in-hospital mortality risk across hospitals and quantify the variation attributable to patient-level factors.There were 1364 adults hospitalized with COVID-19 in Ontario (n = 1149) and in Denmark (n = 215). In Ontario, the absolute risk of in-hospital mortality ranged from 12.0% to 39.8% across hospitals. Ninety-eight percent of the variation in mortality in Ontario was explained by differences in the characteristics of the patients. In Denmark, the absolute risk of inpatients ranged from 13.8% to 20.6%. One hundred percent of the variation in mortality in Denmark was explained by differences in the characteristics of the inpatients.There was wide variation in inpatient COVID-19 mortality across hospitals, which was largely explained by patient-level factors, such as age and severity of presenting illness. However, hospital-level factors that could have affected care, including resource availability and capacity, were not taken into account. These findings highlight potential limitations in comparing crude mortality rates across hospitals for the purposes of reporting on the quality of care.

OBJECTIVE Maintaining healthy glucose levels is critical for the management of type 1 diabetes (T1D), but the most efficacious and cost-effective approach (capillary self-monitoring of blood glucose [SMBG] or continuous [CGM] or intermittently scanned [isCGM] glucose monitoring) is not clear. We modeled the population-level impact of these three glucose monitoring systems on diabetes-related complications, mortality, and cost-effectiveness in adults with T1D in Canada. RESEARCH DESIGN AND METHODS We used a Markov cost-effectiveness model based on nine complication states for adults aged 18–64 years with T1D. We performed the cost-effectiveness analysis from a single-payer health care system perspective over a 20-year horizon, assuming a willingness-to-pay threshold of CAD 50,000 per quality-adjusted life-year (QALY). Primary outcomes were the number of complications and deaths and the incremental cost-effectiveness ratio (ICER) of CGM and isCGM relative to SMBG. RESULTS An initial cohort of 180,000 with baseline HbA1c of 8.1% was used to represent all Canadians aged 18–64 years with T1D. Universal SMBG use was associated with ∼11,200 people (6.2%) living without complications and ∼89,400 (49.7%) deaths after 20 years. Universal CGM use was associated with an additional ∼7,400 (4.1%) people living complications free and ∼11,500 (6.4%) fewer deaths compared with SMBG, while universal isCGM use was associated with ∼3,400 (1.9%) more people living complications free and ∼4,600 (2.6%) fewer deaths. Relative to SMBG, CGM and isCGM had ICERs of CAD 35,017/QALY and 17,488/QALY, respectively. CONCLUSIONS Universal use of CGM or isCGM in the Canadian T1D population is anticipated to reduce diabetes-related complications and mortality at an acceptable cost-effectiveness threshold.

Objective: Maintaining healthy glucose levels is critical for the management of type 1 diabetes (T1D), but the most efficacious and cost-effective approach (capillary self-monitoring of blood glucose [SMBG], continuous or intermittently-scanned glucose monitoring [CGM, isCGM]) is not clear. We modelled the population-level impact of these three glucose-monitoring systems on diabetes-related complications, mortality, and cost-effectiveness in adults with T1D in Canada. Research Design and Methods: We used a Markov cost-effectiveness model based on 9 complication states for adults aged 18-64 years with T1D. We performed the cost-effectiveness analysis from a single payer health care system perspective over a 20-year horizon; assuming a willingness-to-pay threshold of $50,000 per quality adjusted life year (QALY). Primary outcomes were the number of complications and deaths, and the incremental cost-effectiveness ratio (ICER) of CGM and isCGM relative to SMBG. Results: An initial cohort of 180,000 with baseline HbA1c of 8.1% was used to represent all Canadians aged 18-64 with T1D. Universal SMBG use was associated with ~11,200 people (6.2%) living without complications and ~89,400 (49.7%) deaths after 20 years. Universal CGM use was associated with an additional ~7,400 (4.1%) people living complication-free and ~11,500 (6.4%) fewer deaths compared to SMBG, while universal isCGM use was associated with ~3,400 (1.9%) more people living complication-free and ~4,600 (2.6%) fewer deaths. Relative to SMBG, CGM and isCGM had ICERs of $35,017/QALY and $17,488/QALY, respectively. Conclusions: Universal use of CGM or isCGM in the Canadian T1D population is anticipated to reduce diabetes-related complications and mortality at an acceptable cost-effectiveness threshold.

ImportanceDiabetes has been reported to be associated with an increased risk of death among patients with COVID-19. However, available studies lack detail on COVID illness severity and measurement of relevant comorbidities.Design, Setting, and ParticipantsWe conducted a multicenter, retrospective cohort study of patients over the age of 18 years who were hospitalized with COVID-19 between January 1, 2020 and November 30, 2020 in Ontario, Canada and Copenhagen, Denmark. Chart abstraction emphasizing co-morbidities and disease severity was performed by trained research personnel. The association between diabetes and death was measured using Poissson regression.Main Outcomes and Measureswithin hospital 30-day risk of death.ResultsOur study included 1018 hospitalized patients with COVID-19 in Ontario and 305 in Denmark, of whom 405 and 75 patients respectively had pre-existing diabetes. In both Ontario and Denmark, patients with diabetes were more likely to be older, have chronic kidney disease, cardiovascular disease, higher troponin levels, and to receive antibiotics compared with adults who did not have diabetes. In Ontario, the crude mortality rate ratio among patients with diabetes was 1.60 [1.24 – 2.07 95% CI] and in the adjusted regression model was 1.19 [0.86 – 1.66 95% CI]. In Denmark, the crude mortality rate ratio among patients with diabetes was 1.27 (0.68 – 2.36 95% CI) and in the adjusted model was 0.87 (0.49 – 1.54 95% CI)]. Meta-analyzing the two rate ratios from each region resulted in a crude mortality rate ratio of 1.55 (95% CI 1.22,1.96) and an adjusted mortality rate ratio of 1.11 (95% CI 0.84, 1.47).ConclusionsPresence of diabetes was not strongly associated with in-hospital COVID mortality independent of illness severity and other comorbidities.

Compare the self-reported prevalence of severe hypoglycemia (level-3-H) in people with type 1 diabetes (PWT1D) according to two wording of definition: by the International Hypoglycemia Study Group (IHSG) and an alternate simplified version developed by patient-partners (PP).Cross-sectional study (PWT1D = 14 years) self-reporting risk factors, patient-year incidence and annual prevalence of level-3-H were defined according to either IHSG's wording (low sugar levels requiring help from another person, or use of glucagon, or hospitalization, or loss of consciousness) or with an alternative simpler wording developed by PP (low sugar levels that you would have been unable to treat).Among 1430 eligible participants, in the last 12 months, the annual prevalence of level-3-H (IHSG: 242/100 vs. PP: 231/100 patient-years, p = 0.229) and median number of episodes (IHSG: 2.0 [1-3] vs. PP: 1.0 [1-3], p = 0.359) were similar. The prevalence of participants reporting hypoglycemia in the past year was higher with IHSG wording (13.5% vs. 10.5%; p 0.001); this difference was significantly (p 0.001) larger among patients with impaired awareness of hypoglycemia. Association of both definitions with level-3-H risk factors was comparable.The level-3-H episodes by PP and IHSG wording were comparable. The simplicity of PP wording may allow better mutual understanding between patients and healthcare team.NCT03720197 (registered on October 19th 2018).

Section 303(d) of the Clean Water Act (CWA) and the US Environmental Protection Agency’s (USEPA’s) supporting regulations in 40 CFR Part 130.7 require states to develop lists of waterbodies impaired by a pollutant and needing a Total Maximum Daily Load (TMDL) (i.e., the Section 303(d) list) and to prepare a TMDL for each waterbody/pollutant combination. USEPA’s regulations also recognize that other pollution control requirements may obviate the need for a TMDL. These alternatives to TMDLs are commonly referred to as Category 4b waters as described in USEPA’s Integrated Reporting Guidance for Sections 303(d), 305(b), and 314 of the CWA. For the 2008 reporting cycle, the Kansas Department of Health and Environment (KDHE) assigned 11 nonpoint source atrazine impaired stream segments in the Little Arkansas River subbasin to Category 4b. The foundation of KDHE’s Category 4b demonstration is the Little Arkansas Watershed Restoration and Protection Strategy (WRAPS) and supplemental information. The WRAPS process grew out of the Section 319 program to foster watershed management for water quality. The process encompasses four stages: development of a stakeholder leadership team; assessment of watershed conditions; planning to identify goals, priorities and applicable programs for the watershed; and implementation of activities to improve water quality. The Little Arkansas WRAPS, completed in 2004, outlines restoration and protection goals and actions for the surface and groundwater of the Little Arkansas River subbasin. The WRAPS was developed by a stakeholder leadership team consisting of agency advisors (including Kansas State University [KSU] Research and Extension, Natural Resource Conservation Service [NRCS], local County Conservation Districts, and KDHE) and local agricultural producers and atrazine applicators that ultimately implement the voluntary BMP practices. The leadership team is currently focusing implementation of the WRAPS strategies on atrazine impairments in selected sub-watersheds within the Little Arkansas drainage. The elevated atrazine levels are associated with agricultural nonpoint sources: there are no point source dischargers of atrazine in the subbasin. Key components of implementing the WRAPS for atrazine include (1) an outreach/education program for the agricultural community (i.e., producers) on atrazine application rates, timing, alternatives, and label instructions; (2) an atrazine BMP program that includes BMP demonstration sites and on-farm visits by KSU extension staff to promote voluntary atrazine BMPs; and (3) incentive payments to producers that sign up and employ the voluntary BMPs. Based on the schedule for implementing the proposed controls, KDHE expects

Diabetes mellitus is a common condition and diabetics are prone to develop a spectrum of neuropathic complications ranging from symmetric and diffuse to asymmetric and focal neuropathies that may be associated with significant morbidity. Diabetic sensorimotor polyneuropathy is the most common of these complications, occurring in patients with type 1 and 2 diabetes mellitus, as well as in those with prediabetes and glucose intolerance. In this review, the authors discuss the wide variety of neuropathies that can present in the context of diabetes, including the clinical manifestations, diagnostic features, and approach to management.

Glomerular hemodynamics and the renin-angiotensin system in patients with type 1 diabetes mellitus.BackgroundMany studies have reported that blocking the renin-angiotensin-system (RAS) with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker in the patient with diabetes mellitus leads to an increase in renal plasma flow (RPF), no change in glomerular filtration rate (GFR), and a fall in filtration fraction. This constellation is generally attributed to predominant efferent arteriolar dilation.MethodsThis study examined the renal hemodynamic response to blocking the RAS with both captopril and candesartan on separate days in 31 patients with type 1 diabetes mellitus.ResultsThere was a wide range of changes in RPF and GFR in response to the two agents, each administered at the top of its dose-response range. The RPF response to the two agents was strongly concordant (r = 0.65; P < 0.001), as was the GFR response (r = 0.81; P < 0.001). Moreover, there was a strong correlation between the RPF response and the change in GFR with each agent (r = 0.83 and 0.66; P < 0.01). A significant rise in RPF was followed by a rise in GFR. The RPF dependency of GFR in the type 1 diabetics suggests strongly that glomerular filtration equilibrium exists in the glomeruli of the diabetic kidney: Simple notions of local control based on afferent:efferent arteriolar resistance ratios are too simplistic.ConclusionOur data suggest that the intrarenal RAS is activated in over 80% of patients with type 1 diabetes mellitus. Abundant evidence suggests that this activation predisposes to diabetic nephropathy.

Electrophysiologic studies provide objective data concerning nerve and muscle function. This information enables the diagnosis of disease states and monitoring of disease progression. This chapter describes the changes in electrophysiologic function in both prediabetes and diabetes and discusses the utility of this testing in patients with diabetes. Both the strengths and limitations of electrophysiology are discussed.

To develop a scientifically sound and clinically relevant evidence-based guideline for the treatment of painful diabetic neuropathy (PDN).We performed a systematic review of the literature from 1960 to August 2008 and classified the studies according to the American Academy of Neurology classification of evidence scheme for a therapeutic article, and recommendations were linked to the strength of the evidence. The basic question asked was: "What is the efficacy of a given treatment (pharmacological: anticonvulsants, antidepressants, opioids, others; and non-pharmacological: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others) to reduce pain and improve physical function and quality of life (QOL) in patients with PDN?"Pregabalin is established as effective and should be offered for relief of PDN (Level A). Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulphate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B). Other treatments have less robust evidence or the evidence is negative. Effective treatments for PDN are available, but many have side effects that limit their usefulness, and few studies have sufficient information on treatment effects on function and QOL.