key: cord-1040328-fl4thj5g authors: Elbarbary, Nancy Samir; dos Santos, Tiago Jeronimo; de Beaufort, Carine; Agwu, Juliana Chizo; Calliari, Luis Eduardo; Scaramuzza, Andrea Enzo title: COVID‐19 outbreak and pediatric diabetes: perceptions of health care professionals worldwide date: 2020-07-20 journal: Pediatr Diabetes DOI: 10.1111/pedi.13084 sha: 1d1baae11f5887f95299a111be617b5dbbed81d0 doc_id: 1040328 cord_uid: fl4thj5g BACKGROUND: COVID‐19 is an infectious disease that started in Wuhan, China in late 2019 and later spread around the world. Diabetes has been recognized as a possible risk factor for COVID‐19 complications. OBJECTIVE: ISPAD investigated perceptions, challenges and experience of healthcare professionals (HCP) taking care of children and young people with diabetes world‐wide during COVID‐19 pandemic. METHODS: From 21(st) April to 17(th) May 2020, during COVID‐19 pandemic, a web‐based survey was sent to ISPAD members and former participants of ISPAD conferences by email. RESULTS: Responders from 215 diabetes centres from 75 countries completed the survey. Majority were from UK (35; 16.3%), USA (20; 9.3%) and India (15; 7%). HCP were mostly pediatric endocrinologists (64%). During COVID‐19 pandemic, 16.5% of responders continued face‐to‐face consultation while most changed to telephone (32%) or video (18%) consultations. 19% reported a shortage of medical supplies. 22% reported a delay in diagnosis of patients with new‐onset diabetes, while 15% reported a higher incidence of DKA. 12% reported having one or more patients with COVID‐19. Most of the 86 children and adolescents with diabetes and COVID‐19 had only mild/moderate symptoms, while 5 required admission to an intensive care unit. No deaths were reported. CONCLUSIONS: This large global survey during COVID‐19 pandemic showed that many HCP adapted to the pandemic by resorting to telemedicine. One fourth of HCP reported delays in diagnosis and an increased rate of DKA. The emergence of COVID‐19 pandemic had an important impact on family's behaviour that might have led to increase in DKA presentation. This article is protected by copyright. All rights reserved. Coronaviruses are a large family of viruses that can cause disorders ranging from a mild cold to severe diseases. In December 2019, a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of COronaVIrus Diasease . Typical symptoms of COVID-19 include fever, cough, shortness of breath, and muscle pain [1] . In the time frame studied, a large cohort with COVID-19 from China showed that illness severity can range from mild (81%), severe (14%) to critical (5%). All deaths occurred among patients with critical illness and the overall case fatality rate was 2.3% [2] .Moreover, pooled rates of ICU admission, acute respiratory distress syndrome and mortality reported in another systematic review and meta-analysis were 10.9%, 18.4% and 4.3%, respectively [3] . Several data suggest that most people with COVID-19 may have comorbidities, the most prevalent of which are diabetes, cardiovascular disease, and hypertension [4] . In England, a nationwide analysis demonstrates that all types of diabetes are independently associated with a significant increased risk of in-hospital death with COVID-19 [ 5] . However, it is reassuring to hear that, at least according to some reports, young people, with or without diabetes, are coping better with COVID-19 infection [6] . Of 2,572 laboratoryconfirmed cases aged 18 years or younger in the US, none had type 1 nor type 2 diabetes but had other condition such as chronic lung disease and cardiovascular disease [7] or no chronic conditions at all [8] . This article is protected by copyright. All rights reserved. COVID-19 pandemic has forced dramatic changes in the delivery of healthcare landscape, and healthcare professionals (HCP) are making unprecedented modifications to healthcare systems, social services as well as attitude and management of children living with diabetes.To the best of our knowledge, we do not have established guidelines for managing COVID-19 in children, adolescents and young adults with diabetes. Therefore, we conducted this survey to gain an understanding of the patterns of practice of HCP registered in the database of the International Society for Pediatric and Adolescent Diabetes (ISPAD), who are likely to be taking care of children and adolescents with diabetes. This survey should help to identify different management strategies, challenges, knowledge and practice of HCP caring for pediatric patients with diabetes during COVID-19 pandemic so we can guide our future educational activities toward improving the management in this area. This article is protected by copyright. All rights reserved. This is a cross-sectional electronic survey conducted over a four-week period from 21st April to 17th May 2020 under the auspices of ISPAD. The answers were entered into a web-based commercial software (Google Forms, Google LLC, California, United States) which is a collaborative web survey software created by Google. A Google Form is automatically connected to a spreadsheet, responses can be saved there and subsequently analysed. The target population was identified from the ISPAD HCP database (ISPAD members and former participants of ISPAD conferences and post-graduate courses). Respondents were asked to describe themselves concerning specialties, and volume of practice. They all received an initial invitation by e-mail that explained the rationale and what was required from the responders, followed by two reminder e-mails over 3 weeks for non-responders. If responders belong to the same centre, this was considered as a single response. All subjects provided explicit informed consent electronically to voluntary participate before they could proceed to the survey questions. The voluntary nature and the strict confidentiality in which data were analysed and reiterated. Responses were collected automatically, stored electronically, and interpreted via linkage to spreadsheet. Summary statistics were prepared for responses to each question. This article is protected by copyright. All rights reserved. The survey questions were developed by six pediatric endocrinologists. The survey was sent to about 2,300 HCP. A direct electronic link of the survey and consent was sent to the HCP by email and also via social media platforms (Facebook, Twitter, and LinkedIn). The completion of the survey took no more than twenty minutes. It was created in an online format with 47 questions divided into five sections. The first section concerns targeted HCP consent to participate in the survey and confirm their voluntary participation, and the following section included responders' professional and practice profiles. Three questions were aimed to define the professional profile of the responders, size of their clinic and their country of practice. To further understand challenges and changes that HCP have had to make in caring for children and adolescents with diabetes during the pandemic, the next section included a set of questions focused on diabetes management. The questions covered the HCP's perceptions and practices including medication prescriptions, their availability, how they managed education sessions, acute complications seen, special considerations on use of concomitant drugs, blood glucose measurement, parents' beliefs and psychological aspects faced. The last two sections included questions sought to characterise the profile of patients who tested positive for SARS-CoV-2 virus, including their characteristics, clinical presentation, diagnosis and treatment (the full version of the survey is available as a supplemental material). Analysis of data was performed using Google Sheets. Descriptive statistics were used to present demographic data and to evaluate knowledge, attitudes and perceptions of HCP during COVID-19 pandemic. Quantitative variables were described in the form of mean and This article is protected by copyright. All rights reserved. standard deviation, and qualitative variables were described as number and percentage. Some questions were open-ended questions. In total we received 303 responses to the survey. Since for some center more than one response was received, we merged all the responders from the same center and considered it as one response. A convenient sample of 215 diabetes centers from 75 countries participated in the study. The majority of participants were form UK (35; 16.3%), followed by US (20; 9.3%) and India (15; 7%). Among the responders 193 (64%) were pediatric endocrinologists, 46 (15%) pediatricians with interest in diabetes, 26 (9%) nurse practitioners. The remaining were dietitians, trainee, diabetes educator and adult physicians. Majority of the participants (72.5%) had clinic size of more than 100 children with diabetes [ Table 1 ]. During COVID-19 pandemic, face-to-face consultation has been maintained by 16.7% of responders, and only once adequate personal protective equipment has been provided. Most of the HCP offered only phone call (32%) and video consultations (18%) for existing patients. However, for patients with new onset diabetes, a majority of HCP (38%) offered face-to-face education wearing appropriate personal protective equipment followed by phone calls (25.5%) and video consultations (22%) [ Table 1 ]. We asked if any shortage of supply has been perceived as a result of COVID-19 where there previously had not been shortages. There is very wide variation in insulin and supply refill prescription duration, varying from 1 month to always [ Table 1 ]. Scarcity of any diabetes supply has been observed only by 19%, while 65% had not had any shortage of supplies, and This article is protected by copyright. All rights reserved. 16% of them were not aware of any challenging situation. Main shortage of diabetes care supplies have been glucose test strips (26%), basal and bolus insulins (22% each), glucose sensors (10.5%). Immune stimulants have been prescribed only by one fourth of the responders, most of them, however, at less than 50% of their pediatric diabetes population [ Table 1 ]. Twenty-two percent of responders reported a potentially delayed diagnosis of children with new onset diabetes mellitus during the pandemic and 15% reported a higher incidence of DKA in their practice. [ Table 2 ]. Coming to the potential fear of COVID-19, most participants (68%) had the feeling that caregivers/families avoided contact with the diabetes team during pandemic because of this fear. Twelve percent of HCP reported caring for one or more patients with COVID-19 [ Table 2 ]. Most of responders reported using RT-PCR SARS-CoV-2 as method to confirm the diagnosis (78%), using both nasal (56%) and oropharyngeal (37%) swab, while serologic tests and bronchi alveolar lavage were used in very few patients [ Table 2 ]. Only a small number of pediatric patients with positive testing for COVID-19 were reported in this global survey: 61 with type 1 diabetes mellitus and 25 with type 2. This article is protected by copyright. All rights reserved. Their clinical characteristics and symptoms (generally mild or moderate, with just 5 patients admitted to ICU) have been summarized in [ Table 2 ]. No deaths were reported. Most of them reported a contact with family member with a confirmed positive test, or clinical suspicion (50%), while in 12.5% of cases the caregiver was a healthcare worker confronted with a positive case. In 7.5% travel or residence in a location reporting cases during the last 2 weeks was described. In 30% of COVID-19 positive patients the source of contagion remains unknown [ Table 2 ]. During the COVID-19 outbreak paracetamol was the most antipyretic drug used (81%), while very few used ibuprofen (4%) or a combination of both (12%). The responders reported that majority of patients did not observe false readings with continuous glucose monitoring (CGM) (93%). Among the ones who reported false readings, the most used intermittent scanned or real time CGM was FreeStyle Libre™ (43%), followed by Dexcom G6™ (27%) and Dexcom G5™ (24%) respectively. Regarding continuing to use of angiotensin-converting enzyme inhibitors (ACEi) drugs in patients with nephropathy and/or hypertension, only 25% of people using the drug (about 50% of the sample), have been advised to interrupt the ACEi. Patients (12%) who continued ACEi did not report any complications. Anxiety and parental stress were the most reported psychological problems faced so far (31% and 24%, respectively) while few patients (15%) did not face any. This is the first study to quantitatively investigate the perceptions, challenges and experience of HCP for children and adolescents with diabetes mellitus during COVID-19 pandemic. Since its outbreak in Wuhan, China, in December 2019 COVID-19 has spread to more than 200 countries and has been labeled as pandemic [9] . Epidemiologic studies have consistently demonstrated that children are at lower risk of developing severe symptoms or critical illness compared with adults [10, 11] . Despite many uncertainties, the COVID-19 pandemic recommendations in most countries include people with diabetes within the 'at risk' population. ISPAD guidance for HCP reassured people from anecdotal reports coming from Wuhan, China, and Italy, stating that children with diabetes have not shown a different disease pattern compared to their peers and that children in general had less severe clinical manifestations than adults [12] . Diabetic ketoacidosis is an acute, major, life-threatening complication of diabetes. Early diagnosis of type 1 diabetes is essential to allow treatment to start as soon as possible. Although, 15% of responders reported increased incidence of DKA in children in their centers, delayed diagnosis and admission to hospital were seen in 22% of the centers. This would suggest that for a significant number of centers, newly diagnosis of type 1 diabetes would be postponed, and possibly they would be facing a similar rate of DKA during the pandemic, but with more severe DKA due to the delay of the diagnosis. In the midst of the COVID-19 pandemic, people are sheltering in place and practicing social distancing. Parents and caregivers are delaying seeking emergency help out of fear of being infected in the hospital or due to the reduced service for non-COVID-19 care. Moreover, delayed diagnosis of new cases of type 1 diabetes could be due to the front-line health workers focusing on respiratory symptoms of the unwell child (with DKA), without considering type 1 diabetes as a potential diagnosis. Thus, anecdotal reports have suggested that as a result of delay in seeking medical attention, affected individuals have presented with more severe DKA [13] . The importance of following public health measures of containment in addition to standard diabetes mellitus care and, whenever needed, the sick day management guidelines of ISPAD should be emphasized [14] . Emergency department doctors should remember general pediatric evaluation in the time of a pandemic, such as recently observed, to avoid the need for hospitalization and emergency. Pediatric diabetes teams should be informed immediately to avoid complications; recommendations should be produced as soon as possible to allow appropriate treatment to start [12] . We recommend that every opportunity should be taken to raise awareness of the symptoms of diabetes amongst parents, caregivers, school staff, and the general population. It is the role of HCP to urge experiencing symptoms to seek care for these life-threatening events. COVID-19 pandemic has forced a majority of the diabetologists to adapt to providing diabetes mellitus care remotely through telehealth. However, healthcare disparities continue to challenge availability of diabetes technologies for underprivileged communities. In a recent two case series, DKA was prevented via telemedicine by shared glucose data through Clarity™ or the share feature of CGM, and frequent insulin dose adjustments. Clinical outcomes were similar without any hospital admissions, thus saving significant cost [15] . Telemedicine and digital medicine also offer critically important approaches to improve This article is protected by copyright. All rights reserved. access, efficacy, efficiency, and cost-effectiveness of medical care for people with diabetes. It will be important to include these measures as well after the pandemic. Telemedicine, technology and digital healthcare have demonstrated their role in diabetes mellitus care during a period of crisis, and this experience may be used to convince payers and policy makers of the lasting benefits for this high-risk population, and to systemize them [16] . It is strongly encouraged to upgrade telehealth services by institutions to continue caring for patients, as well as protect the healthcare workers and community. Face-to-face consultation, with appropriate personal protective equipment, was used at 16.5% of the centers. This pandemic is bringing healthcare systems worldwide to the brink of collapse based on the rapidly increasing number of new severe infections, including the high rate of infections among frequently exposed healthcare professionals. Telemedicine or another virtual diabetes clinic can be a useful tool to ease data exchange between patients and HCP, as well as to reduce the number of physician-patient contacts. However, it is of note that even for newly diagnosed patients (for whom usually the face-to face education is the gold standard) more than 50% of patients received education via telehealth systems. Consequences of the lockdown for persons with diabetes could be absent or major, based on less exercise, changes in dietary habits (e.g., increased snacking, consumption of 'comfort' dense-calorie foods), restrictions in routine visits to the physician, and decreased availability of insulin and/or oral hypoglycemic agents. Although HCP kept insulin available for almost three months ahead and all insulin and technology companies announced that they did not anticipate disruptions of the medical supply line, 19% of responders had shortage in basic diabetes supplies: blood glucose test strips, basal and bolus insulins, as well as sensors for This article is protected by copyright. All rights reserved. CGM. This is an alarming fact that might lead to uncontrolled glycemia or worsening status of comorbid diseases in some region of the world. It should be emphasized to urge companies on providing all diabetes medical supplies around the globe. A link to their on-line shop for supplies should also be provided. Telehealth consultations should be supported, and virtual training sessions should be readily available. In our survey, 12% reported on COVID -19 positive patients. These were mainly type 1 and type 2 diabetes patients. In type 1 diabetes patients mean HbA1c was 7.6%, diabetes duration range 1-5 years, while for type 2 was 7.8% and diabetes duration range 3-10 years. It seems that most of cases were well controlled with standard therapy, and just few needed ICU admission; two adolescents with type 2 diabetes admitted to ICU required intubation and ventilation. Fortunately, no death was reported. A study from China reported that adults with diabetes had a significantly higher risk than people without, of severe pneumonia, release of tissue injury-related enzymes, excessive uncontrolled inflammatory responses, and hypercoagulable state associated with dysregulated glucose metabolism [17] . A recent study reported that a higher HbA1c level is associated with inflammation, hypercoagulability, and low oxygen saturation in COVID-19 patients, leading to a higher mortality rate [18] . As cardiovascular diseases and diabetes are strongly associated with elevated adipose tissue mass and low grade inflammation, a higher body mass index might be an important risk factor for a more severe course of the disease, particularly of pneumonia, in these people [19] . It is notable that the only ones who underwent intubation and ventilation were 2 adolescents with type 2 diabetes. Knowledge about insulin resistance is also important, because it is among the strongest determinants of impaired metabolic health and cardiac This article is protected by copyright. All rights reserved. dysfunction. Measurement of anthropometrics and metabolic parameters is crucial as both might be useful in a hospital setting to assess the risk of a complicated course of disease in patients with positive COVID-19 tests [20] . Current knowledge suggests the virus can be transmitted through droplets, direct contact and aerosols. Droplets transmission may occur when respiratory droplets of an infected person, are ingested or inhaled by individuals nearby [21] . This is also been reported in our survey, as 50% of respondents reveal direct contact with confirmed case among family members in previous two weeks. Though, 30% responded that the source of infection was unknown. Fecal shedding may be another source of transmission [ 22] . The clinical spectrum of COVID-19 is very heterogeneous. The most commonly reported symptoms were fever, cough, and hypo/hyperglycemia. However, shortness of breath. headache, myalgia, upper respiratory symptoms (e.g., sore throat and rhinorrhea) and gastrointestinal symptoms (e.g., nausea and diarrhea) can also occur, as recently reported [4, 23] . Caution should be taken to potential hypoglycemic events either from severe illness and lack of food intake, ibuprofen should be handled with care as it could increase the hypoglycemic effect of insulin [24] and with the use of chloroquine in these subjects. Patient tailored therapeutic strategies, rigorous glucose monitoring and careful consideration of drug interactions seem to reduce adverse outcomes [25] . Another issue during this COVID-19 pandemic has been the use of immunostimulants to help preventing the disease. To date there is insufficient evidence to conclude that children with type 1 diabetes are immunocompromised. The evidence indicates that an immunocompromised state occurs only in the context of poor glycemic control and/or with This article is protected by copyright. All rights reserved. severe complications, such as DKA or in adults with vasculopathy and chronic kidney disease [26] . The link between catching COVID-19 infection and diabetes was explored in this survey and 75% of HCP responded that parents did not ask for immunostimulant treatments. Interestingly, about the 25% who were asked for immunostimulant supplement, there is not a specific region of the world where this habit is consistent, but it was spread in several countries. It is important to note that immune supporting effects of supplements and vitamins, in the context of the COVID-19, are not proven. Furthermore, attention to nutrition, protein intake and vitamin status is important for individuals with diabetes at any time and thus as well during this pandemic [1] . Although a few studies recommend vitamin C supplementation as an antioxidant [27] and higher doses of vitamin D in elderly in the first few weeks of COVID-19 infection [28] or those with vitamin deficiency [29] , neither vitamin D nor vitamin C supplementation appears to have any effect in protecting from COVID-19. Of all respondents 81% used paracetamol as antipyretic, in line with some non-confirmed recommendations which hypothesized that ibuprofen or other non-steroidal antiinflammatory drugs could be harmful for patients with COVID-19 [30] . A low percentage of responders reported false positive elevated CGM reading (7%), especially among FreeStyle Libre™ users, perhaps due to acetaminophen interference [31] ; this kind of interference has been previously reported for several CGM systems, including FreeStyle Libre™ [32] . In the lower respiratory tract, it appears that decreased angiotensin-converting enzyme 2 (ACE2), which binds to the receptor binding domain of SARS-CoV-2 virus, could portend a higher risk of developing severe acute respiratory distress and lung injury [5, 33] . For this reason, 25% of responders advised their patients to interrupt ACEi in advance. No substantial increase in the likelihood of a positive test for COVID-19 or in the risk of severe was reported in association with five common classes of antihypertensive medications [34] . In fact, the American Heart Association and other major associations recommend their continued use [35] . Achieving glycemic targets should be the goal, no matter which drugs are being used. Anxiety and parenting stress were the most commonly seen psychological problems among our responders. Living with diabetes and managing the condition on a day-to-day basis are associated with heightened levels of anxiety and distress [36, 37] . In a recent study, 25% It is important to prioritize mental health in these stressful days for both patients and their families, which can have a big impact on diabetes control and blood glucose levels. People with diabetes are two to three times more likely to have depression. Use of technology to stay connected to friends and family; trying an online meeting or calling a friend may lessen the stress patients might experience. Strengths of our study are the global sourcing (215 centers in 75 countries) among HCP with a focus on pediatric diabetes and the timeliness of the survey, which was initiated very This article is protected by copyright. All rights reserved. shortly after substantial lockdown in most countries due to the COVID-19 pandemic. Although SARS-CoV-2 infection in adults includes persons with diabetes in the vulnerable, high risk population, our report suggests that children with diabetes do not belong to the high risk group. This might have some important implications for children with diabetes and the restart of school, since does not seem they have to be more cautious than their healthy peers. Limitations of the survey may be that we present observational data from some countries but not all where COVID-19 spread out, even if the most interested ones (by numbers of infected people and deaths) are all represented. While 15% reported a higher incidence of DKA, only registry data prospectively will show accurately any impact on the rates of DKA presentation. However, we acknowledge that the missed countries could have had different experience or knowledge in handling these patients. Relating to this issue we would like also to highlight that out of approximately 2300 emails sent, we received only 303 responses (13%). Even if in line with the answer rate to similar surveys, these low numbers could be due either to the pandemic itself and much less time to manage usual daily workload, and the fact that some of the email addresses could have been changed or not active anymore. Follow up survey could be of utmost importance to improve our knowledge and to evaluate the effects of COVID-19 over time. In conclusion, this large global survey, done with HCP coming from centers treating children and adolescents with diabetes, showed how HCP adapted their current practices during COVID-19 pandemics. Social isolation highly influenced patients care around the world, favoring remote consultation through telehealth/telemedicine as an option to maintain This article is protected by copyright. All rights reserved. assistance to patients with diabetes, in comparison to traditional face-to-face consultation. The great majority of centers did not have diabetes children COVID-19 positive, and from those who had, the majority had just mild/moderate disease course. The emergence of COVID-19 pandemic had an important impact on family's behavior that might be associated with increase in DKA at diagnosis and delaying new onset diagnosis. This article is protected by copyright. All rights reserved. (9) 13 (4) 15 (5) 3 (1) 37 (12) (31) 118 (24) 73 (15) 40 (8) 33 (7) 31 (6) 20 (4) 18 ( Any family member as a confirmed or probable case in the last 14 days Caregiver is a health care worker where a case had been diagnosed This article is protected by copyright. All rights reserved. Clinical considerations for patients with diabetes in times of COVID-19 epidemic Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention Risk Factors of Severe Disease and Efficacy of Treatment in Patients Infected with COVID-19: A Systematic Review, Meta-Analysis and Meta Regression Analysis Effects of hypertension, diabetes and coronary heart disease on COVID-19 diseases severity: a systematic review and meta-analysis. medRxiv 2020; published online March 30 Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a whole population study. version posted CDC COVID-19 Response Team Coronavirus disease 2019 in children-United States COVID-19, type 1 diabetes, and technology: why paediatric patients are leading the way Pediatric Life-Threatening Coronavirus Disease 2019 With Myocarditis Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study Summary of recommendations regarding COVID-19 in children with diabetes: Keep Calm and Mind your Diabetes Care and Public Health Advice Unintended consequences of COVID-19: remember general pediatrics ISPAD Clinical Practice Consensus Guidelines 2018: Sick day management in children and adolescents with diabetes The Silver Lining to COVID-19: Avoiding Diabetic Ketoacidosis Admissions with Telehealth Managing New-Onset Type 1 Diabetes During the COVID-19 Pandemic: Challenges and Opportunities Diabetes is a risk factor for the progression and prognosis of COVID-19 Glycosylated hemoglobin is associated with systemic inflammation, hypercoagulability, and prognosis of COVID-19 patients Obesity and impaired metabolic health in patients with COVID-19 Endocrine and metabolic link to coronavirus infection Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review COVID-19: faecal-oral transmission? Clinical features of patients infected with 2019 novel coronavirus in Wuhan Coronavirus and Type 1 Diabetes: What You Need to Know COVID-19 and diabetes: Knowledge in progress Are children with type 1 diabetes immunocompromised? A new clinical trial to test high-dose vitamin C in patients with COVID-19. Crit Care Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths Potential interventions for novel coronavirus in China: A systematic review Mieke Van Hemelrijck. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting? Ecancer medical science Resistance to Acetaminophen Interference in a Novel Continuous Glucose Monitoring System Continuous glucose monitor interference with commonly prescribed medications: a pilot study Should anti-diabetic medications be reconsidered amid COVID-19 pandemic? Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19 HFSA/ACC/AHA statement addresses concerns re: using RAAS antagonists in COVID-19 Diabetes distress in adults with type 1 diabetes: prevalence, incidence and change over time