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BackgroundA multi-country outbreak caused by monkeypox virus (MPXV) has been unfolding across endemic and non-endemic countries since May 2022. Throughout April and May 2022, Nigeria reported 31 MPXV cases, of which 11 were confirmed via testing. In May 2022, three internationally exported cases of MPXV, presumed to have originated in Nigeria, were reported, suggesting that a larger than reported outbreak might be occurring in the country.MethodsWe used previously established methods to estimate the true size of the MPXV outbreak in Nigeria. We estimated the incidence rate of exported MPXV cases among all outbound international air travellers from Nigeria during the time period of April and May 2022, using forecasted air traveller volumes. We then applied this incidence rate to the entire population of Nigeria during April and May 2022 assuming that the rate of infection was the same in Nigeria for both travellers and the resident population. Information on the subset of population that were considered to be travellers was obtained from the United Nations World Tourism Organization (UNWTO).ResultsWe estimated that there were approximately 4000 (N = 4013; 95% CI: 828–11 728) active cases of MPXV in Nigeria in April and May 2022. This is approximately 360-fold greater than the confirmed number and approximately 130-fold greater than the reported number of cases in Nigeria.ConclusionOur findings suggest that a larger outbreak than is appreciated may be ongoing in Nigeria. The observed international spread of MPXV offers important insights into the scale of the epidemic at its origin, where clinical detection and disease surveillance may be limited. These findings highlight the need to expand and support clinical, laboratory, and public health capacity to enable earlier detection of epidemics of international significance.

Objective To summarize and quantitatively evaluate sleep outcomes of dry eye disease (DED) patients. Design A systematic review and meta-analysis. Participants DED patients were individuals with dry eye symptoms or primary Sjogren’s syndrome (pSS). Controls were healthy, non-pSS, or non-DED patients. Methods A systematic search of MEDLINE, EMBASE, PsycINFO, and grey literature was conducted. Studies were screened using Covidence software. Outcomes included sleep quality, duration, daytime sleepiness, prevalence/incidence/severity of sleep disorders, and sleep disturbances. Meta-analysis was conducted using STATA 13.0. The weighted mean difference (WMD) was calculated as the effect size for continuous scale outcomes. Random-effects models were developed based on the presence of heterogeneity. Results Seventeen full-text articles (16 370 subjects) and 2 conference abstracts (571 763 subjects) were included. Compared to controls, DED patients score higher on the Pittsburgh Sleep Quality Index (WMD = 1.69, 95% CI: 0.82, 2.56; I2 = 88.8%, p Conclusion DED patients may have poorer sleep quality, greater daytime sleepiness, less sleep, more sleep disturbances, increased prevalence, incidence, and severity of sleep disorders compared to non-DED patients. Further research is needed to identify potential causes of these outcomes given the paucity and heterogeneity of included studies. It may be worthwhile to consider sleep in the clinical management of DED.

A significant rise of SARS-CoV-2 transmission in Arizona in June 2020 prompted the need to evaluate potential dispersion to other regions in the United States. We evaluate the potential for domestic dissemination of SARS-CoV-2 from Arizona using mobile device-location and scheduled flights data.

Minimizing hypoglycemia is a key clinical goal for healthcare providers (HCPs) in the care of patients with T1DM and T2DM as the associated morbidity and mortality of hypoglycemia is well understood. Yet, there is a paucity of literature regarding the impact of reported hypoglycemia on HCPs. Using qualitative data from the InHypo-DM Study, Canada’s largest mixed methods study of hypoglycemia to date, we explored the emotional impact of patients’ hypoglycemia on HCPs. Our research team conducted semi-structured interviews lasting 30-45 minutes. Interviews were transcribed verbatim. An iterative and interpretative process was used during both individual and team analysis to identify the main themes. A purposive sample of twenty HCPs was interviewed including endocrinologists (4), family physicians (4), nurse practitioners (3), and diabetes educators (9). Three themes emerged in the analysis: (1) a sense of professional responsibility with the subsequent feeling that the HCP must have failed or inadequately fulfilled their professional duties; (2) a mix of personal emotions including sadness, “feeling bad,” guilt and distress; and (3) the desire to act on these emotions through a “call to action” expressed as a strong desire to identify potential causes of patients’ hypoglycemia and ways in which to help prevent future events. This qualitative study highlights the emotional impact on HCPs as they care for patients at risk of hypoglycemia. While it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected to discover that these responses often became personal emotions. Clinical strategies that support HCPs in their efforts to optimize hypoglycemia detection and prevention should be promoted. Such strategies could help facilitate not only reductions in hypoglycemia among patients, but also lessen the emotional burden experienced by diabetes care providers over the span of their careers. Disclosure S.M. Reichert: Advisory Panel; Self; Abbott, AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Novo Nordisk Inc., Sanofi, Servier. Consultant; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; Canadian Institutes of Health Research. Other Relationship; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Novo Nordisk Inc., Sanofi. J.B. Brown: None. Y. Valliere: None. C. McLachlan: None. S. Webster-Bogaert: None. A. Ratzki-Leewing: Consultant; Self; Eli Lilly and Company, Novo Nordisk A/S. Research Support; Self; Sanofi. B.L. Ryan: None. N.H. Au: None. S.B. Harris: Advisory Panel; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Consultant; Self; Abbott, AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; AstraZeneca, Canadian Institutes of Health Research, Eli Lilly and Company, Health Canada/First Nations and Inuit Health Branch, Janssen Pharmaceuticals, Inc., JDRF, Lawson Foundation, Novo Nordisk Inc., Sanofi. Other Relationship; Self; AstraZeneca, Eli Lilly and Company, Novo Nordisk Inc., Sanofi. Funding Sanofi Canada

The aim of this study was to estimate the real-world incidence of self-reported non-severe hypoglycemia (NSH) and its related sociodemographic and clinical risk factors in a general population of Canadian adults with type 2 diabetes mellitus (T2DM) taking insulin and/or secretagogues.Data for this study were obtained from the InHypo-DM Study. Self-reported data on the frequency of NSH (past 30 days) as well as sociodemographic and clinical characteristics were collected through an online questionnaire. Risk factors for any, daytime and nocturnal NSH were identified using multivariable negative binomial regression with backward selection.Among 432 adults with T2DM (43.8% female, mean age of 53.1 years), 53.9% (95% confidence interval [CI], 49.2% to 58.6%) reported ≥1 event of any (i.e. daytime or nocturnal) NSH in the past 30 days. The 30-day incidence rate of any NSH was 2.3 events per 30 person-days (95% CI, 2.1 to 2.4). Risk factors associated with the increased rate of any NSH were younger age, lower annual household income, being employed, longer duration of diabetes, higher glycated hemoglobin and presence of comorbidity. Risk factors were generally similar for daytime NSH (except for the exclusion of diabetes duration and addition of diabetes medication type) and nocturnal NSH (except for the exclusion of being employed).This is the largest Canadian investigation to estimate the real-world frequency and distribution of self-reported NSH in T2DM. Events were alarmingly frequent and recurrent. Numerous sociodemographic and clinical risk factors were elucidated. These results highlight the importance of identifying high-risk individuals to minimize future occurrences of hypoglycemia.

Impaired awareness of hypoglycemia (IAH) has been linked to an increased rate of severe hypoglycemia (SH) in T1DM. Yet, few investigations have focused on quantifying this relationship in the context of T2DM, particularly from a pragmatic epidemiological lens. This study leverages the value of self-reported SH data to explore the real-world, population-based effect of IAH severity on SH rates in T2DM. A validated questionnaire (InHypo-DMPQ) was administered online to a nationally representative panel comprising Canadians (≥18 years) with T2DM using insulin and/or secretagogues. Data were collected on respondents’ socio-demographic/clinical traits; self-reported incidence of SH (in the past year); and IAH severity, trisected by no, moderate, and severe impairment. Multivariable negative binomial regression (NBR) analysis was used to isolate the effect of IAH on SH. A directed acyclic graph was devised to identify the minimally sufficient adjustment set. Of the 452 complete respondents (mean age: 53.2 (SD: 14.7) years; male: 56%), 6% were classified with severe IAH, 67% with moderate IAH, and 27% with no IAH. Those with severe IAH had the highest crude annual SH rate (5.89 events/person-year, 95% CI: 5.01-6.88), which over doubled and tripled the SH rate in people with moderate IAH (p This real-world, population-based study provides timely insight into the high prevalence of moderate and severe IAH in people with T2DM using insulin and/or secretagogues. The marked impact of IAH on increased SH rates underscores a pressing need for the clinical prioritization of IAH assessment and management in T2DM. Disclosure A. Ratzki-Leewing: None. S.B. Harris: Advisory Panel; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Consultant; Self; AstraZeneca, Janssen Pharmaceuticals, Inc., Lilly/Boehringer Ingelheim, Merck & Co., Inc., Novo Nordisk Inc., Sanofi. Research Support; Self; Abbott, AstraZeneca, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Other Relationship; Self; Canadian Diabetes Association, Canadian Institutes of Health Research, The Lawson Foundation. N.H. Au: None. S. Webster-Bogaert: None. J.B. Brown: None. S.M. Reichert: Advisory Panel; Self; Abbott, AstraZeneca, Novo Nordisk Inc., Sanofi, Servier. Research Support; Self; Canadian Institutes of Health Research. Speaker's Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi. B.L. Ryan: None. Funding Sanofi Canada

While sulfonylureas (SUs) are known to induce hypoglycemia, their low cost and ease-of-use has made them a mainstay therapy for T2DM. Second-generation SUs (SGSUs), compared to first-generation SUs (FGSUs), have been successful at reducing these events. Pragmatic evidence substantiating this association remains limited; this study leverages data from the population-based InHypo-DM study to describe the real-world patterns of SU use and impact on hypoglycemia incidence in Canada. A validated questionnaire (InHypo-DMPQ) was administered online to a nationwide panel consisting of adults with SU-treated T2DM. Questions related to respondents’ past hypoglycemia events, as well as socio-demographic and clinical traits. Negative binomial regression (NBR) was used to test the effect of SU type (FGSUs (chlorpropamide/tolbutamide) vs. SGSUs (glyburide/gliclazide/glimepiride)) on the annual rate of any hypoglycemia. A directed acyclic graph was constructed to identify the adjustment set. Of the 255 adults with SU-treated T2DM (56% male, mean age: 53.1 (SD: 14.4) years), 10.6% were on FGSUs (chlorpropamide: 7.5%, tolbutamide: 3.1%) and 89.5% on SGSUs (glyburide: 27.5%, gliclazide: 54.9%, glimepiride: 7.1%). Annualized crude event frequencies revealed that those on FGSUs, vs. SGSUs, were 1.57 times as likely to have ≥1 event; this group also experienced an average of 2.70 more events/person-year. Based on the NBR, FGSUs vs. SGSUs was associated with a 2.76 (95% CI: 1.07-7.11, p=0.035) factor increase in the rate of hypoglycemia, adjusting for drug coverage, T2DM duration, income, and clinician type. These results confirm that FGSUs induce a dangerous, real-world risk for hypoglycemia. It exposes a worrying trend for the continued use of outdated SUs for T2DM, despite the availability of safer alternatives in Canada. Our study serves as a pressing call-to-action to ensure that clinicians provide the safest and most effective therapeutic management for patients with T2DM. Disclosure N.H. Au: None. A. Ratzki-Leewing: None. B.L. Ryan: None. S. Mequanint: None. J.E. Black: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation.

Many patients fail to report severe hypoglycemia (SH) events to their healthcare provider (HCP). This limits the ability of HCPs to adjust treatment regimens and optimize glycemia. This study aimed to explore the independent association between patients’ disclosure of SH events to their HCP and self-reported rates of SH. Data were obtained from the InHypo-DM population-based study, Canada’s largest hypoglycemia-specific survey. To indicate SH disclosure, patients at risk for hypoglycemia rated how often they reported their SH events (using ADA definitions) to their HCP on a scale from Never to Always. Univariable analyses identified significant clinical or demographic confounders (p≤0.2). Based on the distribution of SH events, zero-inflated negative binomial (ZINB) regression was used to test the relationship between hypoglycemia disclosure and the retrospective incidence of SH events. A total of 552 people with T1DM (17%) or T2DM (83%) completed the InHypo-DM survey. Forty percent of respondents reported at least one or more SH events. The overall incidence rate of SH was 2.45 events/person-year. Thirty-four percent of respondents indicated that they always report SH events. Results of the ZINB model showed that the odds of experiencing any event was not significantly associated with disclosure behaviour (p=0.86). However, the rate of repeated events was almost double (IRR=1.9, 95% CI: 1.2 to 3.0, p=0.004) among individuals who under-reported their SH as compared to those who did not. These results persisted after adjusting for age, medication type, income, most recent HbA1c, and presence of comorbidities. This population-based study revealed a nearly two-fold higher rate of SH among those who under-report to their HCP. Thus, HCPs should be aware that patient reporting may not be a true reflection of SH events and make efforts to elicit accurate information regarding SH events from their patients, especially for those at risk for repeated SH. Disclosure A. Ratzki-Leewing: None. J.E. Black: None. S. Mequanint: None. N.H. Au: None. B.L. Ryan: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation.

Insight into the self-reported frequency of third-party assisted severe hypoglycemia (SH) is critical for the therapeutic optimization of type 2 diabetes (T2D). This study presents real-world epidemiological evidence on the self-reported incidence and related risk indicators of SH. A validated questionnaire (InHypo-DMPQ) was administered to a population-based panel of adult Canadians with T2D treated with insulin and/or secretagogues. Questions pertained to respondents’ past hypoglycemia events as well as socio-demographic and clinical characteristics, including hypoglycemia unawareness. Univariable analyses (p≤0.20) followed by a multivariable zero-inflated negative binomial (ZINB) analysis were performed to explore the influence of potential risk indicators on the occurrence of any and repeated SH events. The current evaluation is based on a cohort of 436 respondents (mean age: 53 years; male: 54%). Among these individuals, 37.8% (95% CI: 33.3%-42.4%) self-reported at least one SH event in the past year; the incidence rate was 2.4 events (95% CI: 2.26-2.55) per person-year. Based on the ZINB analysis, only non-severe (NH) hypoglycemia was independently associated with SH, holding other indicators constant. Among respondents who reported ≥1 (vs. zero) NH events, the odds of never experiencing an SH event decreased by 82% (95% CI: 39.3%-94.7%, p=0.006). Likewise, a history of NH, among those who had a chance of experiencing SH, increased the expected rate of SH by a factor of 4.29 (95% CI: 2.25-8.17, p Real-world estimates of SH in T2D are often limited by sub-optimal reporting and gaps in clinical practice. To help clarify the true frequency of SH, this large, population-based study leveraged the value and clinical relevance of self-reported hypoglycemia data. The results of this study suggest that the burden of third-party assisted SH is substantial in people with T2D. Clinical strategies to prevent NH may reduce the risk of any/repeated SH events and resulting sequelae. Disclosure A. Ratzki-Leewing: None. S. Harris: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Amgen Inc., Lilly/Boehringer Ingelheim, Abbott, Janssen. Consultant; Self; Novo Nordisk A/S, Sanofi, Merck, AstraZeneca, Lilly/Boehringer Ingelheim, Abbott, Janssen. Research Support; Self; Novo Nordisk A/S, Sanofi, Merck, Abbott, AstraZeneca, Janssen. Other Relationship; Self; CIHR, CDA, The Lawson Foundation. S. Mequanint: None. N.H. Au: None. J.E. Black: None. S.M. Reichert: Other Relationship; Self; Novo Nordisk Inc., Sanofi, Abbott, AstraZeneca. Advisory Panel; Self; Servier. Speaker's Bureau; Self; Eli Lilly and Company. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Merck & Co., Inc., Janssen Pharmaceuticals, Inc.. J.B. Brown: None. B.L. Ryan: None.