DIABETES TECHNOLOGY & THERAPEUTICS

Volume 25, Supplement 1, 2023

ª Mary Ann Liebert, Inc.
DOI: 10.1089/dia.2023.2501

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ORIGINAL ARTICLE

Virtual Clinics for Diabetes Care

Satish K. Garg , Abdulhalim M. Almurashi , and Erika Rodriguez

Introduction

T elehealth or virtual clinics have been present for delivering care to patients
with a wide variety of illnesses, especially for patients with diabetes. Currently in the
West (Europe and the United States) and many other emerging economies, virtual care that
is based on their needs is available to the majority of patients with diabetes. In March of
2020, the COVID-19 pandemic forced many hospitals and clinical care facilities to be
locked down for a period ranging from a few weeks to a few months. Since patients with
diabetes, especially those with new onset type 1 diabetes (T1D), those with diabetic
ketoacidosis (DKA), and other high-risk individuals, needed to be cared for during the
lockdown, many clinics were forced to develop telehealth or virtual clinics to deliver care.
In part, virtual care development was also facilitated by the emergency authorization by
the regulators to practice medicine across the states in the United States; the reimburse-
ments for such care were kept similar to in-person patient visits. We have learned a lot in
the past 2.5 years from virtual clinics, and we think that such care, especially for people
with diabetes, is here to stay in some form. Virtual care for patients with diabetes was in
part expedited by development of remote glucose monitoring with the use of continuous
glucose monitors (CGM) and hybrid closed-loop systems (HCL) that could be initiated
remotely. We are delighted to author this critical article on virtual diabetes clinics in this
year’s Advanced Technologies and Treatments for Diabetes (ATTD) 2022 Yearbook.
It is well known and reported in literature that people with diabetes and hypertension
are at high risk of morbidity and mortality from COVID-19 infections. It is particularly
true for patients whose glucose control is suboptimal (HbA1c > 8.5%). The United
Kingdom National Health Service data showed a 3.5-fold increased risk of death from
COVID-19 infections in patients with type 1 diabetes. Many parts of diabetes care can be
effectively delivered remotely and virtually. Doing so has several advantages for both the
patients and the providers. For example, patients don’t need to travel for their clinic visits
and can save money related to travel (e.g., parking, gas, etc.). Most patients and providers
have appreciated the availability of telehealth. We hope that the reimbursement rate for
virtual care will continue to be similar to that for in-person care, like during the pandemic.
It is known that *70% of diabetes care visits could be effectively accomplished
remotely. It is true that there are situations when patient will need to be seen in person,
such as when patients need laser surgery for proliferative diabetic retinopathy, when
they need dialysis for end-stage kidney disease, and when patients with diabetes have
high-risk pregnancies. Every visit cannot be accommodated by virtual clinics through
phone calls, videos, emails, and text messages. Thus, we see a future for diabetes care
that will include a combination of virtual diabetes clinics and in-person clinic visits.
The frequency of these two options will vary based on a patient’s needs.

Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.

S-2
VIRTUAL CLINICS FOR DIABETES CARE S-3

There are different aspects of virtual clinics that include patients having direct access to
their digital data and being guided with different algorithms to adjust their medication
themselves to improve their glucose control. For the providers, it is important to have
patient’s glucose data shared for video visits and remote monitoring for different aspects of
diabetes care. It was difficult to choose only 14 out of about 10,000 abstracts we reviewed
in this area, and thus unfeasible to cover all aspects of virtual clinics. The 14 abstracts for
this article were divided into the following four categories: virtual clinics for type 1
diabetes, virtual clinics for type 2 diabetes, virtual clinics for obesity, and virtual clinics for
the newly emerging cardiovascular complications associated with COVID-19. We hope
readers find this article helpful for facilitating virtual clinics in their own settings.

Key Articles Reviewed

Is Telemedicine the Preferred Visit Modality in Patients with Type 1 Diabetes?

Kirzhner A, Zornitzki T, Ostrovsky V, Knobler H, Schiller T
Exp Clin Endocrinol Diabetes 2022;130: 462–467
Impact of the COVID-19 Pandemic on Management of Children and Adolescents
with Type 1 Diabetes
Choudhary A, Adhikari S, White PC
BMC Pediatr 2022;22: 124
Current Provision and HCP Experiences of Remote Care Delivery and Diabetes
Technology Training for People with Type 1 Diabetes in the UK During the
COVID-19 Pandemic
Forde H, Choudhary P, Lumb A, Wilmot E, Hussain S
Diabet Med 2022;39: e14755
Telemonitoring, Telemedicine and Time in Range During the Pandemic:
Paradigm Change for Diabetes Risk Management in the Post-COVID Future
Danne T, Limbert C, Domingo MP, Del Prato S, Renard E, Choudhary P, Seibold A
Diabetes Ther 2021;12: 2289–2310
Telemedicine and COVID-19 Pandemic: The Perfect Storm to Mark a Change in
Diabetes Care. Results from a World-Wide Cross-Sectional Web-Based Survey.
Giani E, Dovc K, Dos Santos TJ, Chobot A, Braune K, Cardona-Hernandez R, De Beaufort C,
Scaramuzza AE; ISPAD Jenious Group
Pediatr Diabetes 2021;22: 1115–1119
Type 2 Diabetes Management, Control and Outcomes During the COVID-19
Pandemic in Older US Veterans: An Observational Study
Aubert CE, Henderson JB, Kerr EA, Holleman R, Klamerus ML, Hofer TP
J Gen Intern Med 2022;3: 870–877
Reliability of Virtual Physical Performance Assessments in Veterans During
the COVID-19 Pandemic
Ogawa EF, Harris R, Dufour AB, Morey MC, Bean J
Arch Rehabil Res Clin Trans 2021;3: 100146
Long-term Effectiveness of the Time Intervention to Improve Diabetes Outcomes
in Low-Income Settings: A 2-Year Follow-Up
Vaughan EM, Johnson E, Naik AD, Amspoker AB, Balasubramanyam A, Virani SS,
Ballantyne CM, Johnston CA, Foreyt JP
J Gen Intern Med 2022;37: 3062–3069
Management of Obesity Using Telemedicine During the COVID-19 Pandemic
Wang-Selfridge AA, Dennis JF
Mo Med 2021;118: 442–445
S-4 GARG ET AL.

In-person and Virtual Multidisciplinary Intensive Lifestyle Interventions Are

Equally Effective in Patients with Type 2 Diabetes and Obesity
Al-Badri M, Kilroy CL, Shahar JI, Tomah S, Gardner H, Sin M, Votta J, Phillips-Stoll A,
Price A, Beaton J, Davis C, Rizzotto J, Dhaver S, Hamdy O
Ther Adv Endocrinol Metab 2022;13: 20420188221093220

Cardiovascular Risk Factors and Clinical Outcomes Among Patients Hospitalized

with COVID-19: Findings from the World Heart Federation COVID-19 Study
Prabhakaran D, Singh K, Kondal D, Raspail L, Mohan B, Kato T, Sarrafzadegan N, Talukder SH,
Akter S, Amin MR, Goma F, Gomez-Mesa J, Ntusi N, Inofomoh F, Deora S, Philippov E,
Svarovskaya A, Konradi A, Puentes A, Ogah OS, Stanetic B, Issa A, Thienemann F, Juzar D,
Zaidel E, Sheikh S, Ojji D, Lam CSP, Ge J, Banerjee A, Newby LK, Ribeiro ALP, Gidding S,
Pinto F, Perel P, Sliwa K, on behalf of the World Heart Federation COVID-19 Study
Collaborators
Glob Heart 2022;17: 40

COVID-19-Associated Coagulopathy and Antithrombotic Agents—Lessons After

1 Year
Leentjens J, van Haaps TF, Wessels PF, Schutgens REG, Middeldorp S
Lancet Haematol 2021;8: e524–e533

Pulmonary Vascular Thrombosis in COVID-19 Pneumonia

De Cobelli F, Palumbo D, Ciceri F, Landoni G, Ruggeri A, Rovere-Querini P, D’Angelo A,
Steidler S, Galli L, Poli A, Fominskiy E, Grazia Calabrò M, Colombo S, Monti G, Nicoletti R,
Esposito A, Conte C, Dagna L, Ambrosio A, Scarpellini P, Ripa M, Spessot M, Carlucci M,
Montorfano M, Agricola E, Baccellieri D, Bosi E, Tresoldi M, Castagna A, Martino G, Zangrillo A
J Cardiothorac Vasc Anesth 2021;35: 3631–3641

Prevalence, Characteristics, and Outcomes of COVID-19-Associated Acute

Myocarditis
Ammirati E, Lupi L, Palazzini M, Hendren NS, Grodin JL, Cannistraci CV, Schmidt M,
Hekimian G, Peretto G, Bochaton T, Hayek A, Piriou N, Leonardi S, Guida S, Turco A, Sala S,
Uribarri A, Van de Heyning CM, Mapelli M, Campodonico J, Pedrotti P,
Barrionuevo Sánchez MI, Ariza Sole A, Marini M, Vittoria Matassini M, Vourc’h M,
Cannatà A, Bromage DI, Briguglia D, Salamanca J, Diez-Villanueva P, Lehtonen J, Huang F,
Russel S, Soriano F, Turrini F, Cipriani M, Bramerio M, Di Pasquale M, Grosu A, Senni M,
Farina D, Agostoni P, Rizzo S, De Gaspari M, Marzo F, Duran JM, Adler ED, Giannattasio C,
Basso C, McDonagh T, Kerneis M, Combes A, Camici PG, de Lemos JA, Metra M
Circulation 2022;145: 1123–1139

VIRTUAL CLINICS: TYPE 1 DIABETES
Is Telemedicine the Preferred Visit Modality
in Patients with Type 1 Diabetes?
Kirzhner A, Zornitzki T, Ostrovsky V, Knobler H,
Schiller T
Department of Endocrinology, Diabetes and Metabolic
Disease, Kaplan Medical Center and Faculty of Medicine,
Hebrew University of Jerusalem, Israel
Exp Clin Endocrinol Diabetes 2022;130: 462–467
Introduction
The COVID-19 pandemic limits access to diabetes clinics. In
the last few years, remote communication has been con-
ducted through phone calls and WhatsApp messages. How-
ever, to avoid in-person visits, more robust media are needed
for telemedicine. Insufficient data exist to determine whether
virtual meetings are preferable to conventional office visits
for patients with type 1 diabetes (T1D).
Materials and Methods
T1D patients who are followed in a hospital-affiliated dia-
betes clinic were asked to fill a structured questionnaire
aimed to determine their attitude towards telemedicine and
their preference between virtual and conventional visits. The
questionnaire was offered to consecutive T1D patients who
visited the clinic between August 2020 and October 2020.
Results
Seventy-one T1D patients who fulfilled the questionnaire
were included. The median age was 38 years, 39% were male,
and the median duration of diabetes was 18 years. Fourteen
percent of the participants preferred only virtual visits, 24%
preferred only conventional visits, and 62% preferred a
combination of these modalities. Sex, origin, education,
VIRTUAL CLINICS FOR DIABETES CARE
duration of diabetes, mode of insulin treatment, and distance
from the clinic were not associated with patients’ preference,
but older patients ( ‡ 61 years) tended to prefer conventional
visits. Sixty-six percent felt confident in their ability to
download data from their personal medical devices.
Conclusion
Patients from a wide range of treatment modalities are willing
to use telemedicine. However, virtual meetings cannot fully
replace conventional visits for patients with T1D, especially
in the older age group.
Impact of the COVID-19 Pandemic on Management
of Children and Adolescents with Type 1 Diabetes
Choudhary A, Adhikari S, White PC
Division of Pediatric Endocrinology, Department of Pe-
diatrics, University of Texas Southwestern Medical Center,
Dallas, TX
BMC Pediatr 2022;22: 124
Introduction
The COVID-19 pandemic affected the health of a wide range
of people. We studied some of the effects on type 1 diabetes
patients at a large urban pediatric teaching hospital.
Materials and Methods
Approximately 1600 patients were included in the study.
COVID-related restrictions were implemented on March 15,
2020; the ‘‘2019’’ data were gathered during the 1-year period
before this date, and the ‘‘2020’’ data were gathered during the
1-year period after this date. We compared patient character-
istics, glycemic control, Patient Health Questionnaire (PHQ)-9
depression screen scores, in-person and virtual outpatient en-
counters, hospitalizations, and continuous glucose monitor
(CGM) use between the 2019 and 2020 periods.
Results
In a generalized linear model, increasing age, noncommercial
insurance, being Black, being Hispanic, and nonuse of CGMs
were all associated with higher hemoglobin A1c (HbA1c), but
there was no difference between the 2019 and 2020 groups. The
time CGM users were in range was lower in noncommercial
insurance patients and in Black and Hispanic patients; the in-
range time improved slightly from 2019 to 2020. CGM use by
patients with noncommercial insurance (93% of such patients
were in government programs, 7% were uninsured or ‘‘other’’)
increased markedly. In 2020, patients with commercial insur-
ance (i.e., private pay or provided by an employer) had fewer
office visits, but insurance status did not influence use of the
virtual visit platform. There was no change in hospitalization
frequency from 2019 to 2020 in either commercially or non-
commercially insured patients, but patients with noncommer-
cial insurance were hospitalized at markedly higher frequencies
in both years. PHQ-9 scores were unchanged.
Conclusion
Hospitalization frequency, glycemic control, and depression
screening scores were unchanged in our large urban pediatric
S-5
teaching hospital during the COVID pandemic. Increased use
of CGM and rapid adoption of telemedicine may have ame-
liorated the impact of the pandemic on disease management.
Current Provision and HCP Experiences of Remote
Care Delivery and Diabetes Technology Training
for People with Type 1 Diabetes in the UK During
the COVID-19 Pandemic
Forde H1, Choudhary P1, Lumb A 2,3, Wilmot E 4,5,
Hussain S 6,7,8
1
Leicester Diabetes Research Centre, Leicester General
Hospital, Leicester, UK; 2Oxford Centre for Diabetes En-
docrinology and Metabolism, Oxford, UK; 3NIHR Oxford
Biomedical Research Centre, Oxford, UK; 4Department of
Diabetes, University Hospitals of Derby and Burton NHS
FT, Derby, UK; 5School of Medicine, Nottingham Uni-
versity, Nottingham, UK; 6Department of Diabetes and
Endocrinology, Guy’s and St Thomas’ NHS Trust, Guy’s
Hospital, London, UK; 7Department of Diabetes, School of
Life Course Sciences, King’s College London, London, UK;
8
Institute of Diabetes, Endocrinology and Obesity, King’s
Health Partners, London, UK
Diabet Med 2022;39: e14755
Introduction
In response to the COVID-19 pandemic, remote care meth-
ods have been quickly implemented for patients with type 1
diabetes in the United Kingdom. We studied current modes of
care delivery, experiences of health-care professionals, and
impact on insulin-pump training in type 1 diabetes care in the
United Kingdom.
Materials and Methods
The UK Diabetes Technology Network designed a 48-
question survey aimed at health-care professionals providing
care in type 1 diabetes.
Results
A total of 143 health-care professionals (48% diabetes physi-
cians, 52% diabetes educators, and 88% working in adult ser-
vices) from approximately 75 UK centers (52% university
hospitals, 46% general and community hospitals) responded to
the survey. Care was delivered mainly via telephone calls.
Video consultations took longer than telephone calls (P < .001).
Common barriers to remote consultations were patient famil-
iarity with technology (72%) and access to patient device data
(67%). Effects were also seen on insulin pump training. Re-
duction in total new pump starts (73%) and renewals (61%)
were highlighted. Common barriers to insulin training included
patient digital literacy (61%), limited health-care professional
experience (46%), and time required per patient (44%). Pump
starts and renewals in larger insulin-pump services were less
impacted by the pandemic than were those of smaller services.
Conclusion
This survey highlights UK health-care professional experi-
ences of remote care delivery. Although the results support
the use of virtual care, several of the highlighted factors,
S-6
especially patient digital literacy, need to be addressed to
improve virtual care delivery and device training.
Telemonitoring, Telemedicine and Time in Range
During the Pandemic: Paradigm Change for Diabetes
Risk Management in the Post-COVID Future
Danne T1, Limbert C 2,3, Domingo MP 4, Del Prato S 5,
Renard E 6,7, Choudhary P 8,9, Seibold A10
1
Diabetes Center for Children and Adolescents, Kinder- und
Jugendkrankenhaus AUF DER BULT, Hannover, Germany;
2
Unit for Paediatric Endocrinology and Diabetes, CHULC,
Hospital Dona Estefania, Lisbon, Portugal; 3NOVA Medical
School, Lisbon, Portugal; 4Endocrinology and Nutrition
Service, Department of Medicine, Germans Trias I Pujol
Research Institute and Hospital, Universitat Autònoma de
Barcelona, Barcelona, Spain; 5Department of Clinical and
Experimental Medicine, University of Pisa, Pisa, Italy;
6
Department of Endocrinology, Diabetes, Nutrition, Mon-
tpellier University Hospital, Montpellier, France; 7Depart-
ment of Physiology, Institute of Functional Genomics,
CNRS, INSERM, University of Montpellier, Montpellier,
France; 8Department of Diabetes and Nutritional Sciences,
Kin’s College London, London, UK; 9Diabetes Research
Centre, University of Leicester, Leicester, UK; 10Abbott
Diabetes Care, Wiesbaden, Germany
Diabetes Ther 2021;12: 2289–2310
Introduction
People with diabetes are at greater risk for negative outcomes
from COVID-19. Though this risk is multifactorial, poor gly-
cemic control before and during admission to hospital for
COVID-19 is likely to contribute to the increased risk. The
COVID-19 pandemic and restrictions on mobility and interac-
tion can also be expected to impact daily glucose management
of people with diabetes. During the pandemic, glucose levels
have been telemonitored for many people with diabetes, in-
cluding adults and children with type 1 diabetes (T1D), al-
lowing the effects of COVID-19 on glycemic control to be
examined inside and outside the hospital setting. Periodic vir-
tual visits allow people with diabetes to receive care while
limiting the need for in-person attendance at diabetes clinics.
Reports that sustained hyperglycemia and early-stage diabetic
ketoacidosis may go untreated because of the lockdown and
concerns about the risk of exposure argue for wider access to
glucose telemonitoring. Therefore, in this paper we have criti-
cally reviewed reports concerning use of telemonitoring in the
acute hospitalized setting as well as during daily diabetes
management. Furthermore, we discuss the indications and im-
plications of adopting telemonitoring and telemedicine in the
present challenging time, as well as their potential for the future.
Materials and Methods
To date, 27 studies including 69,294 individuals with T1D
have reported the effect of glycemic control during the
COVID-19 pandemic.
Results
Despite restricted access to diabetes clinics, glycemic control
did not worsen for 25/27 cohorts and improved in 23/27 study
GARG ET AL.
groups. Significantly, time in range (TIR; 70–180 mg/dL
[3.9–10 mmol/L]) increased across 19/27 cohorts with a
median 3.3% ( - 6.0% to 11.2%) change. Thirty percent of the
cohorts with TIR data reported an average clinically signifi-
cant TIR improvement of 5% or more, possibly as a conse-
quence of more accurate glucose monitoring and improved
connectivity through telemedicine.
Conclusion
Periodic virtual visits allow people with diabetes to receive
care without having to visit diabetes clinics as often. Because
the lockdown may prevent sustained hyperglycemia and early-
stage diabetic ketoacidosis from being treated and because in-
person visits can increase the risk of infection, glucose tele-
monitoring should be more widely accessible. Therefore, in
this paper we have critically reviewed reports concerning use
of telemonitoring in the acute hospitalized setting as well as
during daily diabetes management. Furthermore, we discuss
the indications and implications of adopting telemonitoring
and telemedicine in the present challenging time as well as the
future potential of these care modes.
Telemedicine and COVID-19 Pandemic: The Perfect
Storm to Mark a Change in Diabetes Care. Results
from a World-Wide Cross-Sectional Web-Based
Survey
Giani E1, Dovc K 2, Dos Santos TJ 3,4, Chobot A 5,6,
Braune K 7, Cardona-Hernandez R 8, De Beaufort C 9,
Scaramuzza AE10; ISPAD Jenious Group
1
Department of Biomedical Sciences, Humanitas University,
Milan, Italy; 2Department of Pediatric Endocrinology, Dia-
betes and Metabolic Diseases, UMC - University Children’s
Hospital, Ljubljana, Slovenia, and Faculty of Medicine,
University of Ljubljana, Ljubljana, Slovenia; 3Pediatric
Unit, Vithas Almerı́a, Instituto Hispalense de Pediatrı́a,
Almerı́a, Spain; 4Department of Public Health, and Epide-
miology, School of Medicine, Universidad Autónoma de
Madrid, Madrid, Spain; 5Department of Pediatrics, In-
stitute of Medical Sciences, University of Opole, Opole,
Poland; 6Department of Pediatrics, University Clinical
Hospital, Opole, Poland; 7Department of Pediatric En-
docrinology and Diabetes, Charité - Universitätsmedizin
Berlin, Berlin, Germany; 8Division of Pediatric En-
docrinology, Hospital Sant Joan de Déu, Barcelona, Spain;
9
DECCP, Clinique Pédiatrique/CH de Luxembourg, Lux-
embourg, GD de, Luxembourg; 10Division of Paediatrics,
Pediatric Diabetes, Endocrinology and Nutrition, ASST
Cremona, Cremona, Italy
Pediatr Diabetes 2021;22: 1115–1119
Introduction
During the COVID-19 pandemic, many of the usual barriers
to care for people with diabetes (PwD) were circumvented by
using telemedicine. During this time, the proportion of PwD
receiving care via telemedicine grew quickly in many
countries. The goals of this study were to learn about health-
care professionals’ (HCPs) experiences with using tele-
medicine for diabetes care and about the changes and chal-
lenges with doing so.
VIRTUAL CLINICS FOR DIABETES CARE
Materials and Methods
A cross-sectional electronic survey was distributed through the
global network of Juniors in Educational Networking and In-
ternational Research Opportunities United States ( JENIOUS)
members of the International Society for Pediatric and Ado-
lescent Diabetes (ISPAD). Respondents’ professional and
practice profiles, clinic sizes, their country of practice, and data
regarding local telemedicine practices during COVID-19
pandemic were investigated.
Results
Answers from 209 HCPs from 33 countries were analyzed.
During the pandemic, the proportion of PwD receiving tele-
medicine visits increased from < 10% (65.1% of responders) to
> 50% (66.5%). There was an increase in specific privacy re-
quirements for remote visits (37.3% to 75.6%), data protection
policies (42.6% to 74.2%), and reimbursement for remote care
(from 41.1% to 76.6%). Overall, 83.3% HCPs reported to be
satisfied with the use of telemedicine. Some concerns (17.5%)
about the complexity and heterogeneity of the digital platforms
to be managed in everyday practice remain, feeding the need for
unifying and making the tools for remote care interoperable.
Also, 45.5% of professionals reported feeling stressed by the
need for extra time for telemedicine consultations.
Conclusion
Telemedicine was rapidly and broadly adopted during the
pandemic globally. Some issues related to its use were
promptly addressed by local institutions. Challenges with the
use of different platforms and for the need of extra time still
need to be solved.
Comments
The five abstracts listed above highlight the rapid and broad
adoption of telehealth and virtual clinics during the
COVID-19 pandemic globally. Many manuscripts also
reveal the challenges facing virtual clinics. The abstract
from the United Kingdom surveying UK health-care pro-
fessionals’ experiences of remote care delivery highlighted
the issues related to patient digital literacy; these issues
need to be addressed for effective virtual care delivery and
device training. The abstract from the study in Germany
went further than many other abstracts in making tele-
medicine and telemonitoring an aspiration goal for diabetes
management during the COVID-19 pandemic and beyond.
Telemedicine clearly is an option for a subset of patients
who are digitally literate and have access to technology.
However, many patients with diabetes may have difficulty
with this format. Thus, implementation for all patients with
diabetes may not be possible. The authors highlighted that
receiving care through virtual clinics was easier for the
patients who were more experienced and confident in
working with diabetes health-care technologies and creat-
ing their own diabetes health ecosystems. Many of those
patients happened to be in the pediatric age groups.
The abstract from Israel highlighted that virtual care
cannot fully replace conventional in-person visits for
patients with T1D, especially those in the older age
S-7
groups. Only about 60% of the adult patients were
confident of their ability to download data from their
personal medical devices. Although technologies for
patients with diabetes have come a long way, manufac-
turers need to make every attempt to make the data
available in a much easier platform for all age groups.
An abstract reported that hospitalization frequency,
glycemic control, and depression screening were un-
changed in a large urban pediatric hospital in the United
States during the COVID-19 pandemic. The researchers
recognized that increased use of continuous glucose
monitoring (CGM) and rapid adoption of telemedicine
may have ameliorated the impact of the pandemic on
disease management, especially on individuals who had
noncommercial insurance, were underinsured, or were
Black or Hispanic. Due to increased authorization of
diabetes-related technology during the COVID-19 pan-
demic, CGM use increased. This allowed digital data to
be better managed through virtual clinics.
The future of virtual care for people for T1D will
depend on reimbursement challenges and wider adop-
tion of such care. As indicated previously, this may need
to be individualized based on the patients’ needs. It is
clear that the use of virtual clinics does break many
ethnic and socioeconomic barriers, but the reimburse-
ment and cost challenges will need to be addressed.
VIRTUAL CLINICS: TYPE 2 DIABETES
Type 2 Diabetes Management, Control and
Outcomes During the COVID-19 Pandemic in Older
US Veterans: An Observational Study
Aubert CE1,2,3,4, Henderson JB 3,5, Kerr EA 3,4,6,
Holleman R 3, Klamerus ML 3, Hofer TP 3,4,6
1
Department of General Internal Medicine, Bern University
Hospital, Inselspital, University of Bern, Bern, Switzerland;
2
Institute of Primary Health Care, University of Bern, Bern,
Switzerland; 3Center for Clinical Management Research,
Veterans Affairs Ann Arbor Healthcare System, Ann Arbor,
MI; 4Institute for Healthcare Policy and Innovation, Uni-
versity of Michigan, Ann Arbor, MI; 5Consulting for Sta-
tistics, Computing & Analytics Research, University of
Michigan, Ann Arbor, MI; 6Department of Internal Medi-
cine, University of Michigan, Ann Arbor, MI
J Gen Intern Med 2022;3: 870–877
Introduction
The medical care of vulnerable patients may have adversely
been affected by the COVID-19–related change from in-
person to virtual visits. The aim of this study was to examine
changes in management, control, and outcomes in older
people with type 2 diabetes (T2D) that were associated with
the shift from in-person to virtual visits.
Materials and Methods
In veterans aged ‡ 65 years with T2D, we assessed the rates
of visits (in person, virtual), A1c measurements, antidiabetic
S-8
deintensification/intensification, emergency room visits and
hospitalizations (for hypoglycemia, hyperglycemia, other
causes), and A1c level, in March 2020 and from April 2020 to
November 2020 (pandemic period). We used negative bi-
nomial regression to assess change over time (reference:
prepandemic period, July 2018 to February 2020), with re-
spect to baseline Charlson Comorbidity Index (CCI; > 2 vs
£ 2) and A1c level.
Results
Among 740,602 veterans (mean age 74.2 [SD 6.6] years),
there were 55% (95% CI, 52%–58%) fewer in-person visits,
821% (95% CI, 793%–856%) more virtual visits, 6% (95%
CI, 1%–11%) fewer A1c measurements, and 14% (95% CI,
10%–17%) more treatment intensification relative to base-
line during the pandemic. Patients with CCI > 2 had a 14%
(95% CI 12%–16%) smaller relative increase in virtual
visits than those with CCI £ 2. We observed a seasonality of
A1c level and treatment modification, but no association of
either with the pandemic. After a decrease at the beginning
of the pandemic, there was a rebound in other-cause (but not
hypoglycemia- or hyperglycemia-related) emergency room
visits and hospitalizations from June 2020 to November
2020.
Conclusion
No changes in A1c level or short-term T2D-related outcomes
were observed, even though A1c measurements occurred less
often and virtual visits replaced most in-person visits. This
finding indicates that virtual visits are adequate for T2D care.
Further studies should assess the longer-term effects of
shifting to virtual visits in different populations to help in-
dividualize care, improve efficiency, and maintain appro-
priate care while reducing overuse.
Reliability of Virtual Physical Performance
Assessments in Veterans During the COVID-19
Pandemic
Ogawa EF1,2, Harris R1, Dufour AB 3,4, Morey MC 5,6,
Bean J1,2,7
1
Geriatric Research, Education, and Clinical Center/
Veterans Affairs Boston Healthcare System, Boston, MA;
2
Physical Medicine and Rehabilitation, Harvard Medical
School, Boston, MA; 3Hinda and Arthur Marcus Institute
for Aging Research, Hebrew Senior Life, Boston, MA;
4
Department of Medicine, Harvard Medical School, Boston
MA; 5Geriatric Research, Education, and Clinical Center/
Veterans Affairs Healthcare System, Durham, NC;
6
Department of Medicine, Duke University Center for
Aging/Claude D. Pepper Older Americans Independence
Center, Durham, NC; 7Physical Medicine and Rehabilita-
tion, Spaulding Rehabilitation Hospital, Boston, MA
Arch Rehabil Res Clin Trans 2021;3: 100146
Introduction
The purpose of this study was to determine the reliability of
three physical performance tests that older veterans took via a
telehealth visit (30-second arm curl test, 30-second chair
stand test, 2-minute step test).
GARG ET AL.
Materials and Methods
Design: Cross-sectional study.
Setting: Virtual.
Participants: Veterans (N = 55; mean age 75 years) who en-
rolled in Gerofit, a virtual group exercise program.
Interventions: Not applicable.
Main outcome measures: Each of the 55 participants per-
formed each test once and was observed by two assessors at
the same time. The intraclass correlation coefficient (ICC)
with 95% confidence intervals and Bland-Altman plots were
used as measures of reliability. To assess generalizability,
ICCs were further evaluated by health conditions (type 2
diabetes, arthritis, obesity, depression).
Results
The ICC was above 0.98 for all three tests across health
conditions, and Bland-Altman plots indicated that there were
no significant systematic errors in the measurement.
Conclusion
The three tests (30-second arm curl test, 30-second chair
stand test, 2-minute step test) yielded highly reliable results in
a virtual setting, and the findings are generalizable across
health conditions among veterans. Thus, these tests are reli-
able for evaluating physical performance in older veterans
during virtual visits.
Long-Term Effectiveness of the Time Intervention
to Improve Diabetes Outcomes in Low-Income
Settings: A 2-Year Follow-Up
Vaughan EM1,2, Johnson E 3, Naik AD 4,5, Amspoker AB 4,5,
Balasubramanyam A 6, Virani SS1,4,5, Ballantyne CM1,
Johnston CA 7, Foreyt JP1
1
Division of Atherosclerosis and Vascular Medicine, De-
partment of Medicine, Baylor College of Medicine (Baylor),
Houston, TX; 2Division of General Internal Medicine,
Baylor, Houston, TX; 3School of Health Professions, Baylor,
Houston, TX; 4Houston Center for Innovations in Quality,
Effectiveness, and Safety, Houston, TX; 5Michael E. De-
Bakey VA Medical Center, Houston, TX; 6Division of Dia-
betes, Endocrinology and Metabolism, Baylor, Houston, TX;
7
Department of Health and Human Performance, University
of Houston, Houston, TX
J Gen Intern Med 2022;37: 3062–3069
Introduction
We previously found that a 6-month multidimensional dia-
betes program called Telehealth-Supported Integrated Com-
munity Health Workers Medication-Access (TIME) resulted
in improved clinical outcomes. The purpose of this study was
to follow TIME participant clinical outcomes for 24 months.
Materials and Methods
Participants: Low-income Latino(a) patients with type 2 diabetes
Design and Intervention: We collected postintervention
clinical data for five cohorts (N = 101, mean n = 20/cohort)
who participated in TIME programs from 2018 to 2020 in
Houston, Texas.
VIRTUAL CLINICS FOR DIABETES CARE
We gathered HbA1c (primary outcome), weight, body
mass index (BMI), and blood pressure data at baseline, 6
months (intervention end), and semiannually thereafter until
24 months after baseline to assess sustainability. We also
evaluated participant loss to follow-up until 24 months.
Results
Participants decreased HbA1c levels during the intervention
(P < .0001) and maintained these improvements at each time
point from baseline to 24 months (P range: < .0001 to .015).
Participants reduced blood pressure levels during TIME and
maintained these changes at each time point from baseline
until 18 months (systolic P range, < .0001 to .0005; diastolic
P range, < .0001 to .008) but not at 24 months (systolic
P = .065; diastolic P = .85). There were no significant weight
changes during TIME or after intervention (weight P range,
.07 to .77; BMI P range, .11 to .71). Attrition rates (loss to
follow-up during the postintervention period) were 5.9% (6
months), 24.8% (12 months), 35.6% (18 months), and 41.8%
(24 months).
Conclusion
Multidimensional intervention does indeed allow vulnerable
populations to achieve and maintain improvements in gly-
cemic levels and blood pressure. Although attrition rates
became higher over the course of the study, most of the
postintervention data were collected during the COVID-19
pandemic, when it was more difficult for low-income people
to receive health care; hence, there is potential for these rates
to improve in the future. Future studies are needed to evaluate
longitudinal outcomes of diabetes interventions conducted by
local clinics rather than research teams.
Comments
The three articles above illustrate the reliability of
virtual clinics for assessments and similar health out-
comes in comparison to traditional in-person clinic
visits. In an observational study conducted in the Unites
States, virtual visits were adequate to maintain diabetes
care in older veteran populations. The study exhibited
that type 2 diabetes (T2D) control and outcomes re-
mained the same as they were before COVID and did
not affect hypoglycemic- and hyperglycemic-related
hospitalizations.
The second abstract examined the reliability of
converting the Veterans Affairs (VA’s) Gerofit program
into virtual classes due to the COVID-19 pandemic.
Gerofit is a geriatric and extended care program that
includes lessons, exercise classes, and physical assess-
ments. Since COVID-19 reduced the possibility for in-
person clinic visits, it became necessary to evaluate the
reliability of physical assessments in a virtual setting. The
study demonstrated that physical performance exams
conducted virtually had high reliability when compared
with in-person assessments in a VA setting. Physical
assessments conducted virtually have implementation
challenges; however, with continued technology and
telemonitoring improvements, assessments across many
medical disciplines can be effectively conducted virtually.
S-9
The final abstract touched on the importance of
targeting underserved populations as they face many
barriers to accessing equitable health care. This was a
2-year follow up to a targeted intervention study called
the Telehealth-Supported, Integrated Community Health
Workers, and Medication-Access (TIME) intervention
program. The follow-up aimed to examine the efficacy
of long-term maintenance and health outcomes under
this program. At the 6-month mark, the intervention
group demonstrated significantly better diabetes out-
comes (A1c, blood pressure, and medical adherence)
than did the control group. At the 2-year follow-up,
participants maintained A1c improvements at each set
time point, up to the 24-month mark. However, blood
pressure improvements were significant only through the
18-month mark. No significant changes were seen in
weight management. It was noted that attrition rates rose
over time, so, to maintain these health improvements,
there needs to be a multidimensional intervention model
that continues to engage these patients in remote
settings.
Although these abstracts show promise in the efficacy
of virtual clinics in maintaining health outcomes, it is
apparent that these visits need to be an adjunct to
traditional visits.
VIRTUAL CLINICS: OBESITY
Management of Obesity Using Telemedicine During
the COVID-19 Pandemic
Wang-Selfridge AA1, Dennis JF 2
1
Kansas City University College of Osteopathic Medicine,
Joplin Campus, Joplin, MO; 2Department of Anatomy,
Kansas City University College of Osteopathic Medicine,
Joplin Campus, Joplin, MO
Mo Med 2021;118: 442–445
Introduction
The number of telemedicine visits increased because of
measures to reduce the risk of infection during the COVID-19
pandemic.
Methods
To evaluate the role of telemedicine in obesity management
during COVID-19, we conducted a systematic review to
identify barriers in using this approach to patient care.
Results
While necessary, the management of obesity through tele-
medicine was met with patient-specific and health-care-
specific barriers.
Conclusion
Increased awareness of these barriers may allow physicians
to better understand patient interactions via virtual medical
visits.
S-10
In-Person and Virtual Multidisciplinary Intensive
Lifestyle Interventions Are Equally Effective in
Patients with Type 2 Diabetes and Obesity
Al-Badri M, Kilroy CL, Shahar JI, Tomah S, Gardner H,
Sin M, Votta J, Phillips-Stoll A, Price A, Beaton J, Davis C,
Rizzotto J, Dhaver S, Hamdy O
Joslin Diabetes Center, Affiliated with Harvard Medical
School, Boston, MA
Ther Adv Endocrinol Metab 2022;13: 20420188221093220
Introduction
Intensive lifestyle intervention (ILI) is critical in the man-
agement of diabetes. The Weight Achievement and Intensive
Treatment (Why WAIT) program is a 12-week multidisci-
plinary weight management program that has been im-
plemented in real-world clinical practice since 2005. Why
WAIT has been shown to be effective in allowing partici-
pants to maintain long-term weight loss, as measured both 5
and 10 years later. In response to the COVID-19 pandemic,
the program became virtual: telemedicine and mobile health
applications replaced in-person visits. We conducted a ret-
rospective pilot study to assess the effectiveness of a virtual
model of a diabetes and weight management program that
was already established and has been successful since 2005.
Materials and Methods
We evaluated 38 patients with diabetes and obesity enrolled
in the Why WAIT program between February 2019 and
December 2020. Sixteen participants were enrolled in the
virtual program (VP) and were compared with 22 participants
who completed the latest two physical programs (PPs) before
COVID-19. Changes in the following parameters were
evaluated: body weight, A1c, blood pressure (BP), and lipid
profile after 12 weeks of ILI.
Results
Body weight decreased by - 7.4 – 3.6 kg from baseline in the
VP group and by - 6.8 – 3.5 kg in the PP group (P = 0.6 be-
tween groups). A1c decreased by - 1.03% – 1.1% from
baseline in the VP group and by - 1.0% – 1.2% in the PP
group (P = .9 between groups). BP, lipid profile, and all other
parameters improved in both groups with no significant dif-
ferences between the two groups.
Conclusion
Virtual multidisciplinary ILI is as effective as the in-person
intervention program in improving body weight, A1C, BP, and
lipid profile and in reducing the number of antihyperglycemic
medications. Results from our study suggest that scaling the
Why WAIT program in a virtual format to a larger population
of patients with diabetes and obesity is feasible and is poten-
tially as successful as the in-person program.
Comments
Telemedicine has been used by the National Aeronautics
Space Association (NASA) since 1960, and the first
GARG ET AL.
abstract highlights the need for its continued develop-
ment. This review displayed the benefits of telemedicine
to reduce barriers to bariatric surgery programs. Many
informational sessions and eligibility criteria question-
naires can be done virtually. It is suggested that traditional
in-person bariatric consultations are not successful be-
cause of the lengthy process that patients have to go
through in order to get cleared for surgery. It is a com-
plicated and, at times, discouraging process. Less than 1%
of eligible bariatric surgery patients make it through the
traditional process and undergo surgery. This is unfortu-
nate because it has been shown that bariatric surgery is
one of the most effective ways to treat obesity and its
comorbidities. Although the investigators addressed some
of the limitations and barriers to patient access to tele-
medicine, such as differences in reimbursement between
commercial and noncommercial insurers, overall, virtual
care was shown to be as effective as in-person visits.
The second abstract evaluated intensive interventions
for diabetes management using telehealth. The Why
WAIT program is a 12-week multidisciplinary weight
management program that has been used by physicians
since 2005. In this pilot study, the researchers reported
significant weight loss and a significant improvement in
glucose control (BP and lipid profile). The virtual format of
the Why WAIT program needs to be considered for larger
patient populations with diabetes and obesity because it has
been shown to be successful and cost-effective.
VASCULAR COMPLICATIONS ASSOCIATED
WITH COVID-19
Cardiovascular Risk Factors and Clinical
Outcomes Among Patients Hospitalized with
COVID-19: Findings from the World Heart
Federation COVID-19 Study
Prabhakaran D1, Singh K 2,3, Kondal D 4, Raspail L 5,
Mohan B 6, Kato T 7,8, Sarrafzadegan N 9, Talukder SH10,
Akter S11, Amin MR12, Goma F13, Gomez-Mesa J14, Ntusi
N15, Inofomoh F16, Deora S17, Philippov E18, Svarovskaya
A19, Konradi A 20, Puentes A 21, Ogah OS 22, Stanetic B 23,
Issa A 24, Thienemann F 25, Juzar D 26,27, Zaidel E 28, Sheikh
S 29, Ojji D 30, Lam CSP 31,32, Ge J 33, Banerjee A 34, Newby
LK 35, Ribeiro ALP 36, Gidding S 5, Pinto F 37, Perel P 38,
Sliwa K 39, on behalf of the World Heart Federation
COVID-19 Study Collaborators
1
Public Health Foundation India, Centre for Chronic Disease
Control, World Heart Federation, London School of Hygiene
& Tropical Medicine, UK; 2Public Health Foundation of
India, Gurugram, Haryana, India, and Centre for Chronic
Disease Control, New Delhi, India; 3Heidelberg Institute of
Global Health, University of Heidelberg, Germany; 4Centre
for Chronic Disease Control, New Delhi, India; 5World Heart
Federation, Geneva, Switzerland; 6Department of Cardiol-
ogy, Dayanand Medical College, Ludhiana, Punjab, India;
7
Department of Clinical Research, National Hospital Orga-
nization Tochigi Medical Centre, Tochigi, Japan; 8Depart-
ment of Cardiovascular Medicine, Dokkyo Medical Uni-
versity School of Medicine, Mibu, Tochigi, Japan; 9Isfahan
VIRTUAL CLINICS FOR DIABETES CARE S-11

Cardiovascular Research Center, Cardiovascular Research Introduction

Institute, Isfahan University of Medical Sciences, Isfahan,
Limited data exist on the cardiovascular manifestations and
Iran & School of Population and Public Health, University of
risk factors in people hospitalized with COVID-19 from low-
British Columbia, Vancouver, Canada; 10Kuwait Bangladesh
and middle-income countries. This study aims to describe
Friendship Government Hospital, Dhaka, Bangladesh;
11 cardiovascular risk factors, clinical manifestations, and out-
National Coordinator, Eminence, Bangladesh; 12Dhaka
comes among patients hospitalized with COVID-19 in low
Medical College Hospital, Bangladesh; 13Centre for Primary
(LICs), lower-middle (LMICs), upper-middle-income
Care Research/Levy Mwanawasa University Teaching Hos-
(UMICs), and high-income countries (HICs).
pital, Lusaka, Zambia; 14Cardiology Service, Fundación
Valle del Lili, Cali, Colombia; 15Division of Cardiology,
Materials and Methods
Department of Medicine and Cape Heart Institute, Faculty of
Health Sciences, University of Cape Town and Groote Schuur Through a prospective cohort study, data on demographics
Hospital, South Africa; 16Internal Medicine Department, and preexisting conditions at hospital admission, clinical
Olabisi Onabanjo University Teaching Hospital, PMB 2001, outcomes at hospital discharge (death, major adverse car-
Sagamu, Nigeria; 17Department of Cardiology, All India In- diovascular events [MACEs], renal failure, neurological
stitute of Medical Sciences, Jodhpur, India; 18Ryazan State events, and pulmonary outcomes), 30-day vital status, and
Medical University, Ryazan Emergency Hospital, Ryazan, rehospitalization were collected. Descriptive analyses and
Russia; 19Cardiology Research Institute, Tomsk National multivariable log-binomial regression models, adjusted for
Research Medical Center, Russian Academy of Sciences, age, sex, ethnicity/income groups, and clinical characteris-
Russia; 20Almazov National Medical Research Centre, St. tics, were performed.
Petersburg, Russia; 21ISSSTE Clı́nica Hospital de Guana-
juato, Cerro del Hormiguero S/N, Maria de la Luz, Guana- Results
juato, Gto., Mexico; 22Department of Medicine, College of
Forty hospitals from 23 countries recruited 5313 patients with
Medicine, University of Ibadan, and University College
COVID-19 (LIC = 7.1%, LMIC = 47.5%, UMIC = 19.6%,
Hospital Ibadan, Nigeria; 23Department of Cardiology,
HIC = 25.7%). Mean age was 57.0 ( – 16.1) years and 59.4%
University Clinical Centre of the Republic of Srpska, Bosnia
were male; preexisting conditions included hypertension
and Herzegovina; 24Instituto Nacional de Cardiologia, Rio de
(47.3%), diabetes (32.0%), coronary heart disease (10.9%),
Janeiro, Brazil; 25Cape Heart Institute, Department of
and heart failure (5.5%). The most frequently reported car-
Medicine, Faculty of Health Sciences, University of Cape
diovascular discharge diagnoses were cardiac arrest (5.5%),
Town, South Africa and Department of Internal Medicine,
acute heart failure (3.8%), and myocardial infarction (1.6%).
University Hospital Zurich, University of Zurich, Switzer-
The rate of in-hospital deaths was 12.9% (N = 683), and the
land; 26National Cardiovascular Center Harapan Kita Hos-
rate of death 30 days after discharge was 2.6% (N = 118)
pital, Jakarta, Indonesia; 27Department of Cardiology & Vas-
(overall death rate 15.1%). The most common causes of death
cular Medicine, University of Indonesia, Indonesia;
28 were respiratory failure (39.3%) and sudden cardiac death
Cardiology Department, Sanatorio Güemes, and Pharma-
(20.0%). The predictors of overall mortality included older
cology Department, School of Medicine, University of Buenos
age ( ‡ 60 years), male sex, preexisting coronary heart dis-
Aires, Acuña de Figueroa 1228 (1180AAX), Buenos Aires,
ease, renal disease, diabetes, intensive care unit admission,
Argentina; 29Department of Clinical Research, Tabba Heart
oxygen therapy, and higher respiratory rates (P < 0.001 for
Institute. ST-1, Block 2, Federal B Area, Karachi, Pakistan;
30 each). Compared to White people, people who were Asian,
Department of Medicine, Faculty of Clinical Sciences, Uni-
Black, or Hispanic had almost 2 to 4 times higher risk of
versity of Abuja, and University of Abuja Teaching Hospital,
death. Further, the risk of death was 2 to 3 times higher for
Nigeria; 31National Heart Center Singapore and Duke-
people from LICs, LMICs, UMICs than for those from HICs.
National University of Singapore, Singapore; 32Department of
Cardiology, University Medical Center Groningen, University
Conclusion
of Groningen, Groningen, the Netherlands; 33Department of
Cardiology, Zhongshan Hospital, Fudan University, Shanghai There are insufficient data on people with COVID-19 in
Institute of Cardiovascular Diseases, Shanghai, China; 34Uni- LICs, LMICs, and UMICs. In this study, we provide data on
versity College London, UK; 35Duke Clinical Research In- the outcomes of COVID-19 in these countries. The results of
stitute, Duke University School of Medicine, Durham, NC; this study can be used in future planning for the pandemic in
36
Cardiology Service and Telehealth Center, Hospital das countries of all income levels.
Clı́nicas, and Department of Internal Medicine, Faculdade de
Medicina, Universidade Federal de Minas Gerais, Belo Hor- COVID-19-Associated Coagulopathy and
izonte, Brazil; 37Santa Maria University Hospital, CAML, Antithrombotic Agents—Lessons After 1 Year
CCUL, Faculdade de Medicina da Universidade de Lisboa,
Lisbon, Portugal; 38Department of Non-communicable Disease Leentjens J1, van Haaps TF 2, Wessels PF 3,4, Schutgens
Epidemiology, London School of Hygiene & Tropical Medicine, REG 5, Middeldorp S1
World Heart Federation, Switzerland; 39Cape Heart Institute, 1
Department of Internal Medicine, Radboud Institute for
Department of Medicine & Cardiology, Groote Schuur Hos- Health Sciences, Radboud University Medical Centre, Nij-
pital, Faculty of Health Sciences, University of Cape Town, megen, Netherlands; 2Department of Vascular Medicine,
South Africa, World Heart Federation, Switzerland Amsterdam University Medical Centers, Amsterdam, Neth-
Glob Heart 2022;17: 40 erlands; 3Department of Medical Oncology, University of
S-12
Pretoria, Pretoria, South Africa; 4Ampath Laboratories,
Pretoria, South Africa; 5Van Creveldkliniek, University
Medical Center Utrecht, University Utrecht, Utrecht,
Netherlands
Lancet Haematol 2021;8: e524–e533
Introduction
COVID-19 is associated with a high incidence of thrombotic
complications, which can be explained by the complex and
unique interplay between coronaviruses and endothelial
cells, the local and systemic inflammatory responses, and the
coagulation system.
Materials and Methods
In current practice, intensified doses of medication are being
used to prevent thrombosis in patients admitted to hospital
with COVID-19. Several guidelines for these prophylactic
measures have been published, but because there is not en-
ough high-quality, direct evidence, current recommendations
may not be strong enough. In this Viewpoint, we summarize
the pathophysiology of COVID-19 coagulopathy in the
context of patients who are ambulant, admitted to hospital,
and critically ill or noncritically ill, and have been discharged
from hospital. We also review data from randomized con-
trolled trials of antithrombotic therapy in the past year in
patients who are critically ill.
Results
These data provide the first high-quality evidence on optimal
use of antithrombotic therapy in patients with COVID-19.
Pharmacological thromboprophylaxis is not routinely re-
commended for patients who are ambulant and have been
discharged. A first-ever trial in noncritically ill patients who
were admitted to hospital has shown that a therapeutic dose of
low-molecular-weight heparin might improve clinical out-
comes in this population. In critically ill patients, this same
treatment does not improve outcomes, and prophylactic-dose
anticoagulant thromboprophylaxis is recommended.
Conclusions
In the upcoming months, we expect numerous data from the
ongoing antithrombotic COVID-19 studies to guide clini-
cians at different stages of the disease.
Pulmonary Vascular Thrombosis in COVID-19
Pneumonia
De Cobelli F1,2, Palumbo D1,2, Ciceri F1,3, Landoni G1,4,
Ruggeri A 3, Rovere-Querini P1,5, D’Angelo A1,6, Steidler
S 2, Galli L 7, Poli A 7, Fominskiy E 4, Grazia Calabrò M 4,
Colombo S 4, Monti G 4, Nicoletti R 2, Esposito A1,4, Conte
C1,5, Dagna L1,8, Ambrosio A 9, Scarpellini P 6, Ripa M 6,
Spessot M10, Carlucci M11, Montorfano M12, Agricola E1,13,
Baccellieri D14, Bosi E1,15, Tresoldi M10, Castagna A1,6,
Martino G1,16, Zangrillo A1,4
1
Vita-Salute San Raffaele University, Milan, Italy; 2Radi-
ology Department, Experimental Imaging Center, IRCCS
San Raffaele Scientific Institute, Milan, Italy; 3Hematology
and Bone Marrow Transplantation, IRCCS San Raffaele
GARG ET AL.
Scientific Institute, Milan, Italy; 4Department of Anesthesia
and Intensive Care, IRCCS San Raffaele Scientific Institute,
Milan, Italy; 5Division of Immunology, Transplantation and
Infectious Diseases, IRCCS San Raffaele Scientific Institute,
Milan, Italy; 6Coagulation Service and Thrombosis Re-
search Unit, IRCCS San Raffaele Scientific Institute, Milan,
Italy; 7Unit of Infectious Diseases, IRCCS, San Raffaele
Scientific Institute, Milan, Italy; 8Unit of Immunology,
Rheumatology, Allergy, and Rare Diseases, IRCCS San
Raffaele Scientific Institute, Milan, Italy; 9Clinical Gov-
ernance, IRCCS San Raffaele Scientific Institute, Milan,
Italy; 10Unit of General Medicine and Advanced Care,
IRCCS San Raffaele Scientific Institute, Milan, Italy;
11
Emergency Department, IRCCS San Raffaele, Milan,
Italy; 12Interventional Cardiology Unit, IRCCS San Raffaele
Scientific Institute, Milan, Italy; 13Cardiovascular Imaging
Unit, Cardio-Thoracic-Vascular Department, IRCCS San
Raffaele Scientific Institute, Milan, Italy; 14Cardio-
Thoracic-Vascular Department, San Raffaele Scientific In-
stitute, Milan, Italy; 15Unit of General Medicine, Endocrine
and Metabolic Diseases, IRCCS San Raffaele Scientific In-
stitute, Milan, Italy; 16Division of Neuroscience, Institute of
Experimental Neurology, IRCCS San Raffaele Scientific
Institute, Milan, Italy
J Cardiothorac Vasc Anesth 2021;35: 3631–3641
Introduction
During severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection, dramatic endothelial cell damage
with pulmonary microvascular thrombosis has been hypoth-
esized to occur. The aim of this study was to assess whether
pulmonary vascular thrombosis (PVT) is due to recurrent
thromboembolism from peripheral deep vein thrombosis or
to local inflammatory endothelial damage with a super-
imposed thrombotic late complication.
Materials and Methods
Design: Observational study.
Setting: Medical and intensive care unit wards of a teaching
hospital.
Participants: The authors report a subset of patients included
in a prospective institutional study (CovidBiob study) with
clinical suspicion of pulmonary vascular thromboembolism.
Interventions: Computed tomography pulmonary angiogra-
phy and evaluation of laboratory markers and coagulation
profile.
Results
Twenty-eight of 55 (50.9%) patients showed PVT, with a
median time interval of 17.5 days from symptom onset. Si-
multaneous multiple PVTs were identified in 22 patients,
with bilateral involvement in 16, mostly affecting segmental/
subsegmental pulmonary artery branches (67.8% and
96.4%). Patients with PVT had significantly higher ground
glass opacity areas (31.7% [95% CI 22.9–41] vs 17.8% [95%
CI 10.8–22.1], P < .001) compared with those without PVT.
Remarkably, in all 28 patients, ground glass opacities areas
and PVT had an almost perfect spatial overlap. D-dimer level
at hospital admission was predictive of PVT.
VIRTUAL CLINICS FOR DIABETES CARE S-13

Conclusion mèdica de Bellvitge, L’Hospotalet del Llobregat, Barcelona,

Spain; 17Cardiology Division, Cardiovascular Department,
The results revealed a specific radiologic pattern for COVID-19
Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona
pneumonia: there was almost a complete spatial overlap between
Umberto I-GM Lancisi-G Salesi, Ancona, Italy; 18Department
PVT and ground glass opacities. These findings support the idea
of Anesthesiology and Surgical Intensive Care, Hôpital Laen-
that COVID-19 lung inflammation and PVT are pathogeneti-
nec, University Hospital of Nantes, France; 19School of Medi-
cally related. The results did not match prior ideas about pul-
cine, UPRES EA 3826, Thérapeutiques Cliniques et Expéri-
monary embolism associated with COVID-19 pneumonia.
mentales des Infections, IRS2 Nantes Biotech, France; 20School
of Cardiovascular Medicine and Sciences, King’s College
Prevalence, Characteristics, and Outcomes London British Heart Foundation Centre of Excellence, James
of COVID-19-Associated Acute Myocarditis Black Centre, UK; 21Department of Cardiology, King’s College
Hospital London, UK; 22Mater Domini Humanitas Hospital,
Ammirati E1, Lupi L 2, Palazzini M1, Hendren NS 3,
Castellanza, Italy; 23Cardiology Department, Hospital Uni-
Grodin JL 3, Cannistraci CV 4,5, Schmidt M 6, Hekimian G 6,
versitario De La Princesa, Madrid, Spain; 24Heart and Lung
Peretto G 7, Bochaton T 8, Hayek A 8, Piriou N 9, Leonardi S10,
Center, Department of Cardiology, Helsinki University Hospi-
Guida S10, Turco A10, Sala S 7, Uribarri A11,12,
tal, Finland; 25Service de Cardiologie, Hôpital Foch, Suresnes,
Van de Heyning CM13, Mapelli M14,15, Campodonico J14,15,
France; 26Ospedale Civile di Baggiovara, Modena, Italy;
Pedrotti P1, Barrionuevo Sánchez MI16, Ariza Sole A16, 27
Department of Histopathology, Niguarda Hospital, Milano,
Marini M17, Vittoria Matassini M17, Vourc’h M18,19,
Italy; 28Cardiovascular Department, ASST Papa Giovanni
Cannatà A 20,21, Bromage DI 20,21, Briguglia D 22,
XXIII, Bergamo, Italy; 29Institute of Radiology, Department of
Salamanca J 23, Diez-Villanueva P 23, Lehtonen J 24,
Medical and Surgical Specialties, Radiological Sciences, and
Huang F 25, Russel S 25, Soriano F1, Turrini F 26, Cipriani M1,
Public Health, University of Brescia, Italy; 30Cardiovascular
Bramerio M 27, Di Pasquale M 2, Grosu A 28, Senni M 28,
Pathology Unit, Azienda Ospedaliera, Department of Cardiac,
Farina D 29, Agostoni P14,15, Rizzo S 30, De Gaspari M 30,
Thoracic, Vascular Sciences and Public Health, University of
Marzo F 31, Duran JM 32, Adler ED 32, Giannattasio C1,33,
Padua, Italy; 31Department of Cardiology, Infermi Hospital,
Basso C 30, McDonagh T 20,21, Kerneis M 34, Combes A 6,
Rimini, Italy; 32Division of Cardiology, Department of Medi-
Camici PG 7, de Lemos JA 3, Metra M 2
cine, University of California San Diego; 33Department of
1
De Gasperis Cardio Center and Transplant Center, Niguarda Health Sciences, University of Milano-Bicocca, Monza, Italy;
Hospital, Milano, Italy; 2Institute of Cardiology, Department 34
Sorbonne Université, ACTION Study Group, Institut National
of Medical and Surgical Specialties, Radiological Sciences, de la Santé et de la Recherche Médicale UMRS1166, Institute of
and Public Health, University of Brescia, Italy; 3Division of CardioMetabolism and Nutrition, Institut de Cardiologie, Hô-
Cardiology, Department of Internal Medicine, University of pital Pitié-Salpêtrière (AP-HP), Paris, France
Texas Southwestern Medical Center, Dallas, TX; 4Center for Circulation 2022;145: 1123–1139
Complex Network Intelligence, Tsinghua Laboratory of Brain
and Intelligence, Department of Computer Science, Depart- Introduction
ment of Biomedical Engineering, Tsinghua University, Beij-
ing, China; 5Center for Systems Biology, Dresden, Germany; Although there have been case reports of acute myocarditis
6
Sorbonne Université, UMRS 1166, Institute of Cardiometa- (AM) in patients with COVID-19, insufficient data exist on
bolism and Nutrition, Service de Médecine Intensive- what is thought to be a rare complication of the disease. In
Réanimation, Institut de Cardiologie, Assistance Publique- this retrospective study with patients from 23 hospitals in the
Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, France; 7San United States and Europe, we will report the prevalence,
Raffaele Hospital and Vita Salute University, Milano, Italy; baseline characteristics, in-hospital management, and out-
8
Urgences et Soins Critiques Cardiologiques, Hôpital Cardi- comes for patients with COVID-19-associated AM.
ologique, Hospices Civils de Lyon, Bron, France; 9Université
Nantes, CHU Nantes, Centre National de la Recherche Sci- Materials and Methods
entifique, Institut National de la Santé et de la Recherche
A total of 112 patients with suspected AM from 56,963
Médicale, l’Institut du Thorax, France; 10University of Pavia
hospitalized patients with COVID-19 were evaluated be-
and Fondazione Istituto di Ricovero e Cura a Carattere Sci-
tween February 1, 2020, and April 30, 2021. Inclusion criteria
entificio Policlinico S. Matteo, Italy; 11Departamento de
were hospitalization for COVID-19 and a diagnosis of AM
Cardiologı́a, Hospital Clı́nico Universitario, Valladolid,
based on endomyocardial biopsy or increased troponin level
Spain; 12Centro de Investigación Biomédica en Red de En-
plus typical signs of AM on cardiac magnetic resonance
fermedades Cardiovasculares, Instituto de Salud Carlos III,
imaging. We identified 97 patients with possible AM, and
Madrid, Spain; 13Department of Cardiology, Antwerp Uni-
among them, 54 patients with definite/probable AM sup-
versity Hospital, and Genetics, Pharmacology and Physio-
ported by endomyocardial biopsy in 17 (31.5%) patients or
pathology of Heart, Blood Vessels and Skeleton Research
magnetic resonance imaging in 50 (92.6%). We analyzed
Group, Antwerp University, Belgium; 14Centro Cardiologico
patient characteristics, treatments, and outcomes among all
Monzino Istituto di Ricovero e Cura a Carattere Scientificio,
COVID-19-associated AM.
Milano, Italy; 15Department of Clinical Sciences and Commu-
nity Health, Cardiovascular Section, University of Milano,
Results
Italy; 16Cardiology Department, Bellvitge University Hospital,
Bioheart, Grup de Malalties Cardiovasculars, Institut d’In- AM prevalence among hospitalized patients with COVID-19
vestigació Biomèdica de Bellvitge, Institut d’Investigació Bio- was 2.4 per 1000 hospitalized patients with definite/probable
S-14
AM and 4.1 per 1000 with possible AM. The median age of
definite/probable cases was 38 years, and 38.9% were female.
On admission, chest pain and dyspnea were the most frequent
symptoms (55.5% and 53.7%, respectively). Thirty-one cases
(57.4%) occurred in the absence of COVID-19 associated
pneumonia. Twenty-one (38.9%) had a fulminant presentation
requiring inotropic support or temporary mechanical circulatory
support. The composite of in-hospital mortality or temporary
mechanical circulatory support occurred in 20.4%. At 120 days,
estimated mortality was 6.6%; mortality was 15.1% in patients
with associated pneumonia versus 0% in patients without
pneumonia (P = .044). During hospitalization, left ventricular
ejection fraction, assessed by echocardiography, improved from
a median of 40% on admission to 55% at discharge (n = 47;
P < .0001) similarly in patients with or without pneumonia.
Corticosteroids were frequently administered (55.5%).
Conclusion
Estimates of AM in patients hospitalized for COVID-19 are
between 2.4 and 4.1 per 1000 patients. AM usually occurs in
patients who do not have pneumonia and often becomes
worse when blood flow is unstable. AM is a rare complication
in patients hospitalized for COVID-19, with an outcome that
differs with the presence of concomitant pneumonia.
Comments
We took the liberty of including these four abstracts in
vascular complications associated with COVID-19 since
these are relatively new findings. The first abstract reports
limited data on cardiovascular manifestations and risk
factors associated with COVID-19 from low- and middle-
income countries. The authors looked at major cardiovas-
cular events, renal failure, neurological events, pulmonary
outcomes, 30-day vital status, and rehospitalizations. The
predictors of overall mortality included older age, male
sex, preexisting coronary heart disease, renal disease, di-
abetes, and intensive care unit (ICU) admissions. Patients
from low-income, lower-middle-income, or upper-middle-
income countries had 2 to 3 times higher risk of death than
did patients from high-income countries. It is possible that
the development of virtual care might eliminate these
differences based on socioeconomic status.
Pulmonary vascular thrombosis and different coagulo-
pathy have been reported with COVID-19 infections.
Different pharmacological approaches (the second abstract)
might emerge over time for treating patients with COVID-
19 inflection and vascular thrombosis. The third abstract
identified a specific radiological pattern of COVID-19
pneumonia with unique spatial distribution of pulmonary
vascular thrombosis with areas of ground glass opacities.
The last abstract provides prevalence, characteristics,
and outcomes for patients with COVID-19 and acute
myocarditis (AM). Since AM is a rare complication of
COVID, minimal reports are available beyond the case
reports the authors used. A retrospective cohort from 23
hospitals in the United States and Europe was analyzed. A
total of 112 patients with suspected AM from nearly
57,000 patients with COVID were evaluated for AM. It
appears that the prevalence of AM in hospitalized patients
GARG ET AL.
with COVID is about 2.4 per 1000 hospitalized patients.
The median age of these patients is 38 years and about 40%
are women. Patients usually present with chest pain and
dyspnea. At 120 days the estimated mortality was 6.6% for
all patients with AM and 15.1% in patients with associated
pneumonia. This abstract highlights that mortality rates are
significantly higher if pneumonia is associated with AM.
Conclusions and Summary
Virtual clinics are not a new concept, but the emergence of
COVID-19 required the quick adoption, implementation, and
improvement of these services. The COVID-19 pandemic lim-
ited in-person visits because of lockdowns, and clinics responded
by offering remote diabetes management visits via phone calls,
videos, emails, and text messages. Since COVID-19 remains a
global public health threat, it is critical that we assess the efficacy
of telehealth services. Telehealth can be an opportunity to break
long-standing barriers to equitable access to health care. It is well
known that health disparities exist because of differences in race,
ethnicity, sex, gender, socioeconomic status, location, age, and
sexual orientation and because of the way those differences in-
tersect. However, telemedicine has shown promise in improving
access to health services for all. We hope that these 14 abstracts
will shed some light on a few successful strategies for the im-
plementation of these virtual clinics and its reliability and value
in future health-care settings.
When selecting abstracts for this article we came across a
common theme: in many cases, virtual clinics are comparable
to traditional in-person visits. As expected, there are many
caveats to this observation, which range from health-care
specific barriers, such as insurance reimbursement issues and
the reliability of virtual physical exams. Many barriers to tel-
ehealth access are patient specific, such as lack of digital lit-
eracy or technology, being in an older age group, living in rural
areas, socioeconomic status, and belonging to minority racial
or ethnic groups. Although there are numerous obstacles for
equitable access to virtual health services, when they are
available, they are most beneficial to these specific populations.
As the COVID-19 pandemic continues, clinics and hos-
pitals need to expand and improve their virtual services.
Converting in-person visits for prevention and monitoring to
a virtual setting can reduce cost, travel time, wait times for
appointments, and loss of work time. However, telehealth
visits cannot replace traditional care in emergent or compli-
cated health issues and in certain populations.
We also wanted to highlight cardiovascular complications
that are associated with COVID-19 infection, as they have
been prominent in this year’s literature and are a growing
concern among health-care providers. We continue to see
prominent cardiovascular risk factors among patients with
COVID-19. There have been numerous cases of COVID-19-
associated coagulopathy and pulmonary vascular thrombosis
complications, developments that stress the importance of
provider awareness. Although virtual clinics cannot, at this
time, completely replace in-person visits, telehealth is here to
stay and we, as providers, need to adapt to this shift.
Author Disclosure Statement
The authors have nothing to disclose.