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We describe mortality-related risk factors of inpatients with diabetes and coronavirus disease 2019 (COVID-19) in Belgium.

Background: Adequate insulin injection technique (IIT) is crucial to optimize the efficacy of diabetes therapy. Widespread non-practice of injection-site rotation and frequent reuse of insulin pen needles (PN) promote high rates of lipohypertrophy (LH) among people living with diabetes (PwD). LH is associated with increased insulin requirement and suboptimal insulin absorption leading to worsened glycemic control and increased risk for hypoglycemia. Avoiding out-of-the-pocket patient costs of PN could reduce PN reuse, thereby limiting its contribution to LH occurrence. Objectives: A model was developed to compute the impact of a behavior shift in reuse on clinical and economic outcomes for type 1 and insulin-treated type 2 diabetes populations in Belgium. Methods: Patient populations were characterized by treatment-specific characteristics and grouped by their frequency of PN replacement. The intervention was modelled to cause a change in reuse frequency, with the effects propagating downstream of the model. Model and input parameters were based on literature research and expert opinions from a Delphi panel, since available data was found to be limited, incomplete or inconsistent and assumptions were needed. Results: Using the current situation as comparator, this analysis showed a reduction of healthcare expenditures following an improvement in IIT. Considering a 5-year time horizon, this study yields potential savings of 52.6 million euros (28.1–77.9 million euros) when 55% of PwD improve PN reuse behavior. Conclusion: Our model shows that even in an era of technological advances and established diabetes care, lack of adherence to correct IIT has an important impact on economic and health outcomes of PwD in Belgium.

Objective:A new compound, Debrichem (DEBx Medical BV, the Netherlands), a topical desiccation agent (TDA), is an active gel that contains an acidic species with a potent hygroscopic action. When in contact with microorganisms and necrosis, rapid desiccation and carbonisation of the proteins in these microorganisms, as well as of the extracellular matrix of biofilms and necrosis, occurs. The resulting ‘precipitate’ rapidly dislodges from the wound bed, resulting in a clean wound which granulates, which is a prerequisite for healing by secondary intention.Method:In a retrospective study, a series of mostly large and hard-to-heal lesions of different aetiologies were treated with a one-time application of the TDA, followed by weekly dressing changes.Results:Of the total of 54 lesions included in this case series, 22 were diagnosed as venous leg ulcers (VLUs), 20 as diabetic foot ulcers (DFUs), nine as post-traumatic, hard-to-heal lesions, two as vascular ulcers and one as an ischaemic ulcer. All of the VLUs, 75% of the DFUs and all of the other lesions reached complete granulation.Conclusion:The use of a TDA may contribute to the consistent, fast and easy removal of both biofilms and necrosis, and hence to wound healing.

ABSTRACTObjectiveRecent publications on Coronavirus Disease-2019 (COVID-19) report that diabetic people with or without co-morbidities are at higher risk of developing severe and/or fatal illnesses.Method and ResultWe report the first case of a 60-year-old man with a 27-year history of type 1 diabetes mellitus, infected by SARS-CoV-2 presenting with an euglycaemic ketoacidosis and an acute respiratory distress syndromeConclusionThis case report reminds us of the importance of adjusting more recent glucose-lowering drugs, including sodium-glucose cotransporter 2 inhibitors, in the overall management of type 1 diabetic individuals during the ongoing COVID-19 outbreak.AbbreviationsCOVID-19: Coronavirus disease 2019 (SARS-CoV-2) virus, T1DM: Type 1 diabetes mellitus, T2DM: Type 2 diabetes mellitus, SGLT2i: Sodium-glucose cotransporter 2 inhibitor, DKA: diabetic ketoacidosis, euDKA: euglycaemic diabetic ketoacidosis.

ObjectiveTo investigate the abundance and the prevalence of Dysosmobacter welbionisJ115T, a novel butyrate-producing bacterium isolated from the human gut both in the general population and in subjects with metabolic syndrome. To study the impact of this bacterium on host metabolism using diet-induced obese and diabetic mice.DesignWe analysed the presence and abundance of the bacterium in 11 984 subjects using four human cohorts (ie, Human Microbiome Project, American Gut Project, Flemish Gut Flora Project and Microbes4U). Then, we tested the effects of daily oral gavages with live D. welbionisJ115Ton metabolism and several hallmarks of obesity, diabetes, inflammation and lipid metabolism in obese/diabetic mice.ResultsThis newly identified bacterium was detected in 62.7%–69.8% of the healthy population. Strikingly, in obese humans with a metabolic syndrome, the abundance of Dysosmobactergenus correlates negatively with body mass index, fasting glucose and glycated haemoglobin. In mice, supplementation with live D. welbionisJ115T, but not with the pasteurised bacteria, partially counteracted diet-induced obesity development, fat mass gain, insulin resistance and white adipose tissue hypertrophy and inflammation. In addition, live D. welbionisJ115Tadministration protected the mice from brown adipose tissue inflammation in association with increased mitochondria number and non-shivering thermogenesis. These effects occurred with minor impact on the mouse intestinal microbiota composition.ConclusionsThese results suggest that D. welbionisJ115Tdirectly and beneficially influences host metabolism and is a strong candidate for the development of next-generation beneficial bacteria targeting obesity and associated metabolic diseases.

Purpose: This paper aims to provide insights into the internationalization strategic responses to the COVID-19 pandemic by higher education institutions (HEIs) in Latin America. Design/methodology/approach: This study is based on information from eight leading Latin American private universities. The data were obtained from official sources such as institutional communications and university administrators. Findings: The authors identify two main issues that HEIs should consider while responding to the pandemic. First, greater attention and resource allocation to the universities' main local stakeholders can affect traditional internationalization activities. Second, a focus on revitalizing foreign partnerships and strengthening “virtual internationalization” can help maintain and eventually increase international presence. Research limitations/implications: While this study analyses how these Latin American HEIs responded during the initial stages of the COVID-19 outbreak, it is important to conduct follow-up studies to shed light on how HEIs are adapting to the COVID-19 crisis as it continues to unfold. Originality/value: This study is based on unique information gathered from leading private, not-for-profit HEIs in Latin America, which, contrary to state-owned HEIs or other private institutions in developed economies, have exhibited different means and conditions to respond to the coronavirus outbreak. Finally, the authors contribute to the literature on the internationalization of HEIs by discussing the role of a significant disruptive event on the internationalization of higher education and, particularly, business schools. Propósito: Este artículo discute las respuestas estratégicas de internacionalización frente a la pandemia del COVID-19 implementadas por Instituciones de Educación Superior (IES) en América Latina. Diseño/metodología/aproximación: Este estudio se basa en información de ocho universidades privadas líderes en América Latina. La información fue obtenida de fuentes oficiales tales como comunicados institucionales y autoridades. Hallazgos: Identificamos dos temas principales que las IES deben considerar mientras responden al COVID-19. Primero, una mayor atención y reubicación de recursos hacia los principales grupos de interés local puede afectar las actividades tradicionales de internacionalización. Segundo, revitalizar las alianzas extranjeras y fortalecer la “internacionalización virtual” puede ayudar a mantener y eventualmente incrementar la presencia internacional. Limitaciones de investigación/implicaciones: Si bien este estudio analiza cómo un grupo de IES Latinoamericanas respondieron durante las etapas iniciales del COVID-19, es importante continuar analizando cómo las IES se siguen adaptando a medida que la crisis COVID-19 avanza. Originalidad/valor: Este estudio se basa en datos únicos obtenidos de IES privadas, sin fines de lucro, y líderes en América Latina que, al contrario de las universidades públicas u otras IES en economías desarrolladas, exhiben medios y condiciones diferentes para responder a la expansión del coronavirus. Finalmente, este trabajo contribuye a la literatura sobre internacionalización de IES mediante la discusión del rol de un evento disruptivo de escala mundial en la internacionalización de universidades y, particularmente, escuelas de negocios.

AbstractBackgroundNew recommendations call for lowering LDL-C < 55 mg/dL and non-HDL-C < 85 mg/dL in very-high cardiovascular risk (VH-CVR) patients with type 2 diabetes (T2DM). This study assessed the proportion of VH-CVR diabetics currently meeting these primary and secondary lipid targets, and which therapies/phenotypes predict combined goals achievement.MethodsWe analysed the cardiometabolic phenotype, use of lipid-modulatind drugs (LMD), pre- and post-LMD lipids levels, and CV complications among 1196 T2DM with high (n = 221; 18%) or VH-CVR (n = 975; 82%). Among the latter, the characteristics of combined lipid goal-achievers (n = 158) were compared to those of non-achievers (n = 817), with subgroup analyses of on-statin patients (n = 732) and those with established CVD taking statins (n = 362). Presence of statin-associated muscle symptoms (SAMS) was also recorded.Results75% of VH-CVR patients were on statins. Both LDL-C and non-HDL-C goals were achieved by 16.2% of all VH-CVR, 19.3% of on-statin VH-CVR, and 24.3% of patients with established CVD taking statins. Achieving both targets was associated with high-intensity statins, specifically rosuvastatin, [statin + ezetimibe] combination, lower baseline LDL-C, smaller LDLs, lower TG and lipoprotein(a), and reduced metabolic syndrome frequency. SAMS reporting did not differ between achievers and non-achievers.ConclusionsMore than 80% of patients are above targets. To bridge this gap, apart from treating more LMD-naive/refractory diabetics, one should consider for LDL-C to put most patients on high-intensity statins, more often with ezetimibe and, within statins, to switch preferably to rosuvastatin. As regards non-HDL-C, the off-target patients’ phenotype suggests that intensifying lifestyle measures against metabolic syndrome should supplement current therapies.

Biofilms play a central role in the chronicity of non-healing lesions such as venous leg ulcers and diabetic foot ulcers. Therefore, biofilm management and treatment is now considered an essential part of wound care. Many antimicrobial treatments, whether topical or systemic, have been shown to have limited efficacy in the treatment of biofilm phenotypes. The antimicrobial properties of iodine compounds rely on multiple and diverse interactions to exert their effects on microorganisms. An expert panel, held in Las Vegas during the autumn Symposium on Advanced Wound Care meeting in 2018, discussed these properties, with the focus on iodine and iodophors and their effects on biofilm prevention and treatment.

Diabetes is among the most frequently reported comorbidities in patients infected with COVID-19. According to current data, diabetic patients do not appear to be at increased risk of contracting SARS-CoV-2 compared to the general population. On the other hand, diabetes is a risk factor for developing severe and critical forms of COVID-19, the latter requiring admission to an intensive care unit and/or use of invasive mechanical ventilation, with high mortality rates. The characteristics of diabetic patients at risk for developing severe and critical forms of COVID-19, as well as the prognostic impact of diabetes on the course of COVID-19, are under current investigation. Obesity, the main risk factor for incident type 2 diabetes, is more common in patients with critical forms of COVID-19 requiring invasive mechanical ventilation. On the other hand, COVID-19 is usually associated with poor glycemic control and a higher risk of ketoacidosis in diabetic patients. There are currently no recommendations in favour of discontinuing antihypertensive medications that interact with the renin-angiotensin-aldosterone system. Metformin and SGLT2 inhibitors should be discontinued in patients with severe forms of COVID-19 owing to the risks of lactic acidosis and ketoacidosis. Finally, we advise for systematic screening for (pre)diabetes in patients with proven COVID-19 infection.

Objective:To assess the safety and efficacy of a surfactant-based technology for the management of burns.Method:In a retrospective review, paediatric patients with different types of burns were treated with the gel technology. In some patients, the treatment was combined with a topical antimicrobial agent. Primary objectives of the review were the assessment of healing, healing times and ease of use of the material.Results:The wounds of 15 paediatric patients with different types of burns, particularly with regard to depth and anatomical location, were evaluated using a retrospective chart review. It was found that the surfactant gel technology, with or without the topical antimicrobial agent, assisted in autolytic debridement, and that time to re-epithelialisation was short and within the range of those obtained with other established treatments.Conclusion:The number of patients and wounds in this evaluation is small but the study indicates that the gel technology provides a safe and effective way to treat smaller burns in paediatric patients.

ABSTRACTIntroduction: Glycated hemoglobin (A1c) is the measurement of choice to estimate the glycemic exposure over the last 3 months prior to sampling. The Free Style Libre® is a continuous glucose monitoring device which provides an estimated A1c(eA1c) from average interstitial glucose using Nathan’s ADAG equation. The objective of this study was to compare eA1c and A1cin type 1 diabetes patients (T1D) over a period of 3 months.Materials and methods: Data were collected from patient charts between July 2016 and October 2017. 3-months recordings with >70% of data available were analyzed. eA1c was recorded at each visit and the corresponding A1cvalue measured by high performance liquid chromatography in a single reference lab.Results: A total of 344 reports from 170 T1D were studied, 3 categories were identified: eA1c = A1c: 13% of reports. eA1c > A1c: 57% of reports, positive difference (eA1c – A1c) of +0.74 ± 0.5% (P < 0.0001). eA1c < A1c: 30% of reports, negative difference (eA1c – A1c) of −0.5 ± 0.3% (P < 0.0001).Conclusion: eA1c value was generally overestimated compared to measured A1cin this T1D cohort. This lesser concordance may result from differences in measured glucose source and/or frequency to calculate eA1c compared to ADAG, but also from using the reverse equation which is a source of potential bias. Another explanation could be a different rate of hypoglycemia between groups, or an asymmetric distribution of A1c patients’ phenotypes with differential hyper- or hypoglycation intrinsic propensity.

ABSTRACTObjectives: To document the frequency and predictors of low-density lipoprotein cholesterol (LDL-C) target value attainment among patients with coronary heart disease (CHD) in Belgium.Methods: The second Dyslipidemia International Study (DYSIS II) was an observational study of the prevalence of dyslipidemias and lipid target value attainment. Patients in this analysis were aged ≥ 18, had documented CHD, and had a full lipid profile. Use of lipid-lowering therapy (LLT), lipid profile, and LDL-C target value attainment (< 70 mg/dL) were assessed cross-sectionally at the enrollment visit. The distribution of LLTs was assessed among treated patients. Multivariate logistic regression was used to identify variables predictive of LDL-C target value attainment in treated patients.Results: We identified 409 patients with CHD in Belgium, 387 (94.6%) of whom were on LLT at the time of the lipid profile. Among treated patients, the rate of LDL-C target value attainment was 40.6%, and statin monotherapy was the most commonly used LLT (79.3%). Among users of statin monotherapy or combination therapy, simvastatin was the most commonly used treatment (41.6% of patients). Diabetes was associated with higher odds of LDL-C target value attainment (OR 2.29, 95% CI 1.33–3.93), and female gender was associated with lower odds (OR 0.48, 95% CI 0.24–0.97).Conclusion: Rates of LDL-C target value attainment are low in patients with CHD in Belgium. Intensifying statin therapy or combining it with non-statins is essential in Belgian patients for optimal LDL-C reduction.

The role of the dermis is essential for the proper orchestration of all phases of the normal wound healing process. Wounds with seriously damaged or even absent dermis consistently show seriously impaired wound healing and/or long-term complications such as hypertrophic scarring. Replacing a damaged dermis requires a dermal matrix that is compatible with, or even stimulates, the process of wound healing. Hyaluronic acid (HA), in an esterified form, is among the many matrices that are available. HA has been used in a number of indications, such as ulcers (ie, diabetic foot ulcers and venous leg ulcers), trauma, including burns, and for the repair of contractures and hypertrophic scars. The shorter healing time and the decrease of recurring hypertrophy demonstrate the efficiency of HA-derived matrices. Biopsies, taken up to 12 months post-reconstruction show a neodermis that histologically is largely comparable to normal skin, which probably is a function of HA playing such a pivotal role in normal, unwounded skin, as well as in the process of healing.

Metabolic syndrome is characterized by a constellation of comorbidities that predispose individuals to an increased risk of developing cardiovascular pathologies as well as type 2 diabetes mellitus1. The gut microbiota is a new key contributor involved in the onset of obesity-related disorders2. In humans, studies have provided evidence for a negative correlation between Akkermansia muciniphilaabundance and overweight, obesity, untreated type 2 diabetes mellitus or hypertension3–8. Since the administration of A. muciniphilahas never been investigated in humans, we conducted a randomized, double-blind, placebo-controlled pilot study in overweight/obese insulin-resistant volunteers; 40 were enrolled and 32 completed the trial. The primary end points were safety, tolerability and metabolic parameters (that is, insulin resistance, circulating lipids, visceral adiposity and body mass). Secondary outcomes were gut barrier function (that is, plasma lipopolysaccharides) and gut microbiota composition. In this single-center study, we demonstrated that daily oral supplementation of 1010A. muciniphilabacteria either live or pasteurized for three months was safe and well tolerated. Compared to placebo, pasteurized A. muciniphilaimproved insulin sensitivity (+28.62 ± 7.02%, P= 0.002), and reduced insulinemia (−34.08 ± 7.12%, P= 0.006) and plasma total cholesterol (−8.68 ± 2.38%, P= 0.02). Pasteurized A. muciniphilasupplementation slightly decreased body weight (−2.27 ± 0.92 kg, P= 0.091) compared to the placebo group, and fat mass (−1.37 ± 0.82 kg, P= 0.092) and hip circumference (−2.63 ± 1.14 cm, P= 0.091) compared to baseline. After three months of supplementation, A. muciniphilareduced the levels of the relevant blood markers for liver dysfunction and inflammation while the overall gut microbiome structure was unaffected. In conclusion, this proof-of-concept study (clinical trial no. NCT02637115) shows that the intervention was safe and well tolerated and that supplementation with A. muciniphilaimproves several metabolic parameters.

Background Patients with coronary heart disease (CHD) and survivors of acute coronary syndrome (ACS) are at very high risk for adverse cardiovascular events. Lowering low-density lipoprotein cholesterol (LDL-C) can reduce the risk, with effective lipid-lowering therapy (LLT) readily available; however, dyslipidemia remains prevalent throughout Europe.Design The observational Dyslipidemia International Study II (DYSIS II) aimed to identify unmet treatment needs in adult ACS and CHD patients. Data for the seven participating European countries are presented herein.Methods The study was carried out from December 2012 to November 2014. Use of LLT and attainment of European-guideline-recommended LDL-C targets were assessed. For ACS patients, changes in lipid levels and LLT were evaluated 4 months post-hospitalization.Results Of the 4344 patients enrolled, 2946 were attending a physician visit for the assessment of stable CHD, while 1398 had been hospitalized for an ACS event. In both patient sets, mean LDL-C levels were high (89.5 and 112.5 mg/dl, respectively) and <70 mg/dl target attainment extremely poor. The mean daily statin dosage (normalized to atorvastatin potency) was 27 ± 20 mg for CHD and 22 ± 17 mg for ACS patients. Treatment was intensified slightly for ACS subjects after hospitalization, with the dosage reaching 35 ± 24 mg/day. LDL-C target attainment was higher by the end of the 4-month follow up (30.9% and 41.5% for patients on LLT and without LLT at baseline, respectively; p< 0.05).Conclusion Elevated blood cholesterol levels are highly prevalent across Europe, with low numbers of coronary patients reaching their recommended LDL-C target. While use of LLT is widespread, there is significant scope for intensifying treatment.

Randomized controlled trials evaluating real-time continuous glucose monitoring (RT-CGM) patients with type 1 diabetes (T1D) show improved glycemic control, but limited data are available on real-world use.

AbstractObjectives:Most patients with type 2 diabetes mellitus (T2DM) have at least one comorbid chronic disease. These comorbidities increase disease burden and costs and may impact the selection of glucose-lowering therapies. The aim of our study was to describe the prevalence and co-prevalence of comorbidities in patients with T2DM in Belgium.Methods:This was a single centre, transversal, descriptive study performed at Saint-Luc University Hospital, Brussels, Belgium. T2DM patients aged >18 years presenting to the outpatient diabetes clinic and regularly followed (≥1 year) between July 2011 and 2016 were included in the database. Information on descriptive characteristics was collected and several comorbidities were assessed.Results:Overall, 778 patients were included. The median age was 68 years. The most frequently observed comorbidities were hypertension (85.5%), metabolic syndrome (MetS; 84.6%) and non-alcoholic hepatic steatosis (71.7%). 78.5% of the T2DM patients had ≥4 comorbidities. The highest co-prevalence of comorbidities was the combination of MetS and hypertension (75.8%), MetS and overweight (60.5%), and hypertension and overweight (56.6%).Conclusion:The observed prevalence and co-prevalence of comorbidities in T2DM Belgian patients was high, with 95.0% patients having at least two comorbid conditions.

The loss of extracellular matrix in combination with the exposure of structures such as bone and tendon pose a major challenge; the development of granulation tissue and subsequent reepithelialization over these structures is extremely slow and often may not happen at all. Replacement of the matrix has been shown to significantly increase the chances of healing since, with revascularization of the matrix, a wound bed is created that may either heal by secondary intention or via the application of a skin graft.

Obesity and type 2 diabetes are associated with low-grade inflammation and specific changes in gut microbiota composition. We previously demonstrated that administration of Akkermansia muciniphila to mice prevents the development of obesity and associated complications. However, the underlying mechanisms of this protective effect remain unclear. Moreover, the sensitivity of A. muciniphila to oxygen and the presence of animal-derived compounds in its growth medium currently limit the development of translational approaches for human medicine. We have addressed these issues here by showing that A. muciniphila retains its efficacy when grown on a synthetic medium compatible with human administration. Unexpectedly, we discovered that pasteurization of A. muciniphila enhanced its capacity to reduce fat mass development, insulin resistance and dyslipidemia in mice. These improvements were notably associated with a modulation of the host urinary metabolomics profile and intestinal energy absorption. We demonstrated that Amuc_1100, a specific protein isolated from the outer membrane of A. muciniphila, interacts with Toll-like receptor 2, is stable at temperatures used for pasteurization, improves the gut barrier and partly recapitulates the beneficial effects of the bacterium. Finally, we showed that administration of live or pasteurized A. muciniphila grown on the synthetic medium is safe in humans. These findings provide support for the use of different preparations of A. muciniphila as therapeutic options to target human obesity and associated disorders.

Background: Automated insulin calculators (AICs) with carbohydrate counting (CHC) have been shown to be effective in improving glycated haemoglobin (HbA1c) levels. By contrast, use of AICs without CHC, with predetermined prandial insulin doses modified according to a correction factor and modulated as a function of glycaemia, has not yet been investigated.Methods: This comparative, retrospective, observational and non-randomized study took place over a 6-month period of routine clinical practice. It evaluated the use of Free-style InsuLinx® and Free-style Neo® Abbott Diabetes Care (AIC) in easy mode (no CHC). All patients performed a basal–prandial insulin dosing schedule, and were not educated as to how to determine carbohydrate intake. Changes in HbA1cand capillary blood glucose levels, insulin therapy, frequency of blood glucose tests and body weight were analyzed 6 months prior to inclusion (T−6), at the time of inclusion (T0) and 6 months later (T+6). From T−6 to T0 (period A), patients used a standard blood glucose meter and adjusted their insulin doses themselves, and from T0 to T+6 (period B), each patient was provided with an AIC on easy mode function.Results: Of the 230 patients, 221 were retained at the end of the study (126 type 1 diabetes mellitus (T1DM) and 95 type 2 diabetes mellitus (T2DM)).At T−6, average (±standard error of mean) HbA1clevel was 8.3 ± 0.1%; T1DM: 8.5 ± 0.1% and T2DM: 8.0 ± 0.1%, respectively.At T0, the average HbA1clevel was 8.4 ± 0.1% (p = 0.02); T1DM: 8.5 ± 0.1% (ns) and T2DM: 8.2 ± 0.1% (p = 0.004).At T+6, with AIC in easy mode, average HbA1clevel decreased significantly to 7.7 ± 0.1% (p < 0.0001); T1DM: 8.0 ± 0.1% (p < 0.0001) and T2DM: 7.5 ± 0.1% (p < 0.0001).At T+6, in all diabetics, blood glucose monitoring frequency increased by 0.4/day (p < 0.0001). Insulin correction amounted to 14% of changes in predetermined prandial insulin doses.Conclusion: Routine clinical use of an AIC without CHC improved self-management of blood glucose and on average, decreased HbA1clevels by 0.52% in T1DM and 0.80% in T2DM after 6 months.