Importance Patients with diabetes are known to be at increased risk for infections including severe coronavirus disease 2019 (COVID-19) but the relationship between COVID-19 severity and specific pre-infection glucose levels is not known. Objective To assess the differential effects of pre-infection glucose levels on the risk for severe COVID-19 amongst patients with and without diabetes. Design Population based historical cohort study. Setting National state-mandated HMO. Patients All adult patients with a positive SARS-COV2 test between March-October 2020. Exposure Recent fasting blood glucose (FBG) and glycated hemoglobin (HBA1C), age, gender, body mass index (BMI) and diagnoses of diabetes, hypertension, ischemic heart disease. Outcome Risk for severe COVID-19, defined as resulting in ≥10 hospitalization days, ICU admission or death. Results 37,121 patients with a positive SARS-COV2 test were identified; 707 defined as severe (1.9%). Unadjusted risk factors for severe disease were age (OR = 1.1 for every year increase; 95% CI 1.09–1.11, p < 0.001), male gender (OR = 1.34, 95% CI 1.06–1.68, p = 0.012); BMI (OR = 1.02 for 1 kg/m2 increase, 95% CI 1.00–1.04, p = 0.025). Controlling for these factors, we found an association between pre-infection FBG and the risk of severe COVID-19, with a differential effect in patients with and without a diagnosis of diabetes. For patients without diabetes, elevated FBG in the pre-diabetes range (106–125 mg/dl) was associated with severe COVID-19 (OR 1.55 95% CI 1.04–2.26 p = 0.027). For patients with a diagnosis of diabetes, we found a J-shaped association between pre-infection glucose control and the risk for severe COVID-19 where the lowest risk for was for patients with FBG 106–125 mg/dl; the risk increased with higher pre-infection glucose levels but strikingly also for patients with a low pre-infection FBG (<100mg/dl) or HbA1C (<5.7%). Conclusions and relevance Elevated pre-infection blood glucose is a risk factor for severe COVID-19 even in non-diabetics. For patients with a diagnosis of diabetes both high as well as low pre-infection glucose levels are risk factors for severe COVID-19. Further research is required to assess whether these associations are causal, but we believe these findings can already have clinical implications for COVID-19 risk assessment and stratification.

Background: The success of Helicobacter pylori (H. pylori) eradication depends on several host and treatment factors. Serum vitamin D levels may be associated with H. pylori infection and eradication rates. We investigated the association between vitamin D and H. pylori infection and eradication, using a large electronic database based on medical records from a population-based health maintenance organization. Methods: Data regarding adults who underwent H. pylori testing and had vitamin D measurements within one month of H. pylori testing were collected. H. pylori infection was ascertained using urea breath or stool antigen tests. A negative H. pylori test following a positive result implied eradication. Multivariate regression models were constructed to assess associations between H. pylori infection, eradication, and vitamin D. Results: Among 150,483 members who underwent H. pylori testing from 2009 to 2018, 27,077 (18%) had vitamin D measurements. Vitamin D levels were inversely associated with H. pylori infection, p < 0.001. The odds of a positive H. pylori test were 31% higher among patients with vitamin D levels <20 ng/mL, compared with those with levels ≥20 ng/mL (OR 1.31, 99% CI 1.22–1.4, p < 0.001). Purchase of vitamin D supplements was associated with a negative subsequent H. pylori test (p < 0.001). Mean vitamin D levels were moderately higher in those with successful vs. failed H. pylori eradication (19.34 ± 9.55 vs. 18.64 ± 9.61, p < 0.001). Conclusions: Vitamin D levels are associated with H. pylori infection. Increased vitamin D levels are associated with successful H. pylori eradication. Vitamin D may have a role in H. pylori eradication.

Background Being on the COVID-19 frontline could negatively impact healthcare workers mental health. We examined smoking behavior changes and the association with changes in stress levels and sleeping patterns among hospital workers during the pandemic. Methods An online survey was conducted among employees of a large tertiary medical center in Israel. Data collected included socio-demographic characteristics, smoking status, changes in smoking behavior (for smokers only), stress levels, and sleeping duration during the pandemic, perceptions of risk for COVID-19 infection and disease severity, presence of a chronic illness, COVID-19 exposure and infection status, and involvement in treating COVID-19 patients, Multi-nominal logistic regression modeling assessed the effects of covariates on smoking behavior change. Results Overall, 920 healthcare workers participated. More than half (59%) reported an increase in stress and 28% reported changes in sleep duration. Thirty-five percent of current smokers (n=132), reported smoking more. Increased stress was associated with an increase in smoking (OR=3.45; 95% CI 1.2-9.4, p=0.016), and an increase in sleeping hours was significantly associated with a decrease in smoking (OR=6.62, 95% CI 1.2-32. p=0.02). Among smokers who reported perceived levels of stress to be the same or slightly higher than pre-pandemic, a strong inverse association was observed between sleep and smoking. Conclusions The mental health consequences of the pandemic, specifically for health workers, could lead to negative changes in smoking behaviors. Together with offering stress-management skills and coping strategies, mental health support should target smoking behaviors and sleep disturbances. Implications A high proportion of healthcare employees working in a large tertiary medical centre in Israel reported increased stress levels during the COVID-19 pandemic. Among smokers, increased stress levels were associated with increased smoking, suggesting that smoking may be a coping mechanism for COVID-19 related stress. Offering stress-management skills and coping strategies can mitigate the negative impact on health workers' smoking behaviour, and reduce stress-related increases in smoking behaviour.