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Purpose: To evaluate the effectiveness and safety of a pharmacist-managed protocol for transitioning critically ill patients from intravenous (iv) to subcutaneous insulin compared with a provider-managed process. Method(s): This single-center, retrospective, observational study included patients admitted to the medical or surgical/trauma intensive care unit who received a continuous infusion of iv insulin from January 2019 to April 2021. Patients were excluded if they were less than 18 years of age, pregnant, incarcerated, or received iv insulin for the diagnosis of diabetic ketoacidosis, hyperglycemic hyperosmolar state, calcium channel blocker or beta blocker overdose, or hypertriglyceridemia. The primary outcome was the percentage of blood glucose (BG) concentrations within the target range of 70-150 mg/dL from 0 to 48 h following transition to subcutaneous insulin. Secondary outcomes included percentage of BG concentrations within goal range following transition at 0-12 h and 12-24 h, incidence of hypo- and hyperglycemia, and percentage of patients requiring dose adjustments after initial transition. Result(s): A total of 110 unique patients were included with 70 patients in the provider-managed group and 40 patients in the pharmacist-managed group. On average, pharmacists transitioned patients to 63% basal insulin based on their 24-h total day dose of insulin. The pharmacist-managed group achieved glycemic control in 53% of transitions at 12 h, 40% at 24 h, and 47% from 0 to 48 h, while the provider group achieved glycemic control in 25% of transitions at 12 h, 12% at 24 h, and 18% from 0 to 48 h (p < 0.001 for all time points). As for safety end points, the pharmacist-managed group demonstrated lower rates of hypoglycemia (p = 0.001), severe hypoglycemia (p = 0.332), hyperglycemia (p < 0.001), and severe hyperglycemia (p < 0.001) compared with the provider-managed group. Conclusion(s): Pharmacists can effectively and safely transition critically ill patients from iv to subcutaneous insulin utilizing a standardized protocol.Copyright © 2023 Pharmacotherapy Publications, Inc.
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BACKGROUND: The coronavirus pandemic has had an extremely negative impact on the patients with diabetes mellitus (DM both in terms of a more severe course of COVID -19 and an increased risk of death. AIM: Analysis of risk factors for death due to COVID -19 in patients with DM type 1 and type 2 (DM1 and DM2). MATERIALS AND METHODS: Retrospective analysis of the database of the national diabetes register (NDR), which included DM patients with COVID-19 and reported virus infection outcome (recovery/or death) in 15 712 DM1 and 322 279 DM2 patients during a 2-year follow-up period (01/02/2020 to 03/04/2022) (discharge date)). RESULT(S): Case fatality rate in patients with DM, who underwent COVID -19 was 17.1% (DM1-8.8%;DM2-17.5%). As a result of multivariate regression analysis of seven significant factors in DM1 and thirteen in DM2 (evaluated by univariate anlisys), a number of the most important predictors of risk for fatal outcome were identified: in DM1 these were age >=65 years (OR =4.01, 95% CI: 1.42-11.36), presence of arterial hypertension (AH) (OR =2.72, 95% CI: 1.03 -7.16) and diabetic foot syndrome (DFS) (OR = 7.22, 95% CI: 1.98-26.29);for T2DM: age >= 65 years (OR =2.53, 95% CI: 1.96-3.27), male (OR =1.51, 95% CI: 1.23-1.84), duration DM >=10 years (OR =2.01, 95% CI: 1.61-2.51), BMI >= 30 kg/m2 (OR =1.26, 95% CI: 1.02-1.55), ASCVD/CKD (OR =1.49, 95% CI: 1.01-2.04), history of diabetic coma (OR =12.97, 95% CI: 1.89-88.99) and presence of disability (OR =1.40, 95% CI: 1.14-1.73). In T2DM, the type of antidiabetic therapy (ADT) prior to COVID -19 (last visit before the development of infection) had a significant impact: Insulin therapy (OR = 1.64, 95% CI: 1.30-2.07), sulfonylureas (SU) (OR =1.51, 95% CI: 1.23-1.84));dipeptidyl peptidase-4 inhibitor (iDPP-4) therapy (OR =0.57, 95% CI: 0.39-0.83) and sodium-glucose cotransporter-2 inhibitor (iSGLT2) therapy (OR =0.64, 95% CI: 0.46-0.88). Vaccination was the most important protective factor in both types of DM: DM1 OR =0.19, 95% CI: 0.06-0.59;SD2 OR =0.20, 95% CI: 0.16-0.26. CONCLUSION(S): The common risk factor for fatal outcome in both DM1 and DM2 was age >=65 years;in DM1 - history of hypertension and DFS, in DM2 - male sex, diabetes duration >=10 years, BMI >=30 kg/m2, history of ASCVD/CKD and diabetic coma, disability. In T2DM, significant differences in risk were observed depending on the type of ADT: insulin and SU therapy were factors that increased the risk of death, whereas therapy with iDPP-4 and iSGLT2 reduced the risk of death. Vaccination reduced the risk of death in DM1 and DM2 by 5.2 and 5-fold, respectively.Copyright © Endocrinology Research Centre, 2022.
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Background and Aims: The burden of uncontrolled DM amongst insulin users in Malaysia is great. Structured Self- Monitoring of Blood Glucose (SMBG) that are stored in cloud, simplified into visual charts, graphs coupled with a diabetes management system (DMS) that allows remote insulin titration can lead to improvement of glycemic control. Method(s): 124 Type 2 DM outpatients with HbA1C > 8% on intensive insulin therapy were recruited in this 26 weeks, multicenter, double arm, randomized controlled study. The patients were randomized to control arm which used traditional logbook and intervention arm which received remote insulin titration with a Bluetooth glucometer coupled with a DMS. The primary objective was to compare reduction of HbA1C and the secondary objective was to compare the change in Diabetes Distress Scale (DDS) between the control and intervention arm. Result(s): There was significantly higher mean reduction of HbA1C in the intervention group ;-2.016+/-1.60 versus - 1.326+/-1.51 in the control group (p = 0.027) by week 14 and was maintained till Week 26. There was no significant difference between the reduction of DDS between both groups. The mean frequency of SMBG in the intervention group was significantly higher than the control group;339.656+/-171.14 (intervention) versus 216.716+/-96.40 (control) [p < 0.001]. Conclusion(s): Remote insulin titration has been proven effective especially during COVID-19 whereby there was imminent need for reduction of physical visits to the hospital. This has led to improvement of glycemic control but could translate to lesser waiting time and reduction of cost in the long term.
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Background and Aims: During the SARS COV 2 pandemic, the number of cases of unrecognized diabetes increased in those hospitalized for pneumonia. It has been hypothesized that some forms of diabetes not classified as classic are attributable to SARS COV 2 infection. Method(s): We studied the prevalence of diabetes in those admitted to our Covid Hospital from January 2021 to September 2022. A total of 1200 subjects studied by cross-analysis of hospital discharge forms with diabetes mellitus and final therapy as research item. Result(s): The prevalence of diabetes mellitus was 2.16%. Of the subjects diagnosed with diabetes, 26.9% were not classifiable as type 1 or type 2 and the condition of diabetes mellitus was not previously known. HbA1c values were not statistically (7,86+/-0,95 vs 8,1+/-1,1 p = NS) different among subjects with diabetes and autoimmune markers were not present. Fasting C-peptide levels (ng/ml) were significantly lower (0,8- 0,23 vs 2,36+/-0,8 p < 0.05) in those with not previously known diabetes, 57.2% were discharged on insulin therapy. and continued it after 92- 18 days of follow-up. Conclusion(s): The interrelationship between COVID-19 and diabetes remain uncertain and researchers hope to understand whether Covid-19 causes a new form of diabetes or more simply a stress response that triggers classic diabetes. In our experience those individuals with fasting C-peptide levels lower than usual obeserved in Type 2 diabetic subjects continued insulin theraphy for a limited time. They could be a new entity of diabetes classification but longitudinal data are further required to confirm what we can call DIabCovid.
Subject(s)
Diabetes Mellitus, Type 1 , Humans , Adult , Child , Adolescent , Diabetes Mellitus, Type 1/epidemiology , Insulin , Hypoglycemic AgentsABSTRACT
BACKGROUND: The coronavirus pandemic has had an extremely negative impact on the patients with diabetes mellitus (DM both in terms of a more severe course of COVID -19 and an increased risk of death. AIM: Analysis of risk factors for death due to COVID -19 in patients with DM type 1 and type 2 (DM1 and DM2). MATERIALS AND METHODS: Retrospective analysis of the database of the national diabetes register (NDR), which included DM patients with COVID-19 and reported virus infection outcome (recovery/or death) in 15 712 DM1 and 322 279 DM2 patients during a 2-year follow-up period (01/02/2020 to 03/04/2022) (discharge date)). RESULT(S): Case fatality rate in patients with DM, who underwent COVID -19 was 17.1% (DM1-8.8%;DM2-17.5%). As a result of multivariate regression analysis of seven significant factors in DM1 and thirteen in DM2 (evaluated by univariate anlisys), a number of the most important predictors of risk for fatal outcome were identified: in DM1 these were age >=65 years (OR =4.01, 95% CI: 1.42-11.36), presence of arterial hypertension (AH) (OR =2.72, 95% CI: 1.03 -7.16) and diabetic foot syndrome (DFS) (OR = 7.22, 95% CI: 1.98-26.29);for T2DM: age >= 65 years (OR =2.53, 95% CI: 1.96-3.27), male (OR =1.51, 95% CI: 1.23-1.84), duration DM >=10 years (OR =2.01, 95% CI: 1.61-2.51), BMI >= 30 kg/m2 (OR =1.26, 95% CI: 1.02-1.55), ASCVD/CKD (OR =1.49, 95% CI: 1.01-2.04), history of diabetic coma (OR =12.97, 95% CI: 1.89-88.99) and presence of disability (OR =1.40, 95% CI: 1.14-1.73). In T2DM, the type of antidiabetic therapy (ADT) prior to COVID -19 (last visit before the development of infection) had a significant impact: Insulin therapy (OR = 1.64, 95% CI: 1.30-2.07), sulfonylureas (SU) (OR =1.51, 95% CI: 1.23-1.84));dipeptidyl peptidase-4 inhibitor (iDPP-4) therapy (OR =0.57, 95% CI: 0.39-0.83) and sodium-glucose cotransporter-2 inhibitor (iSGLT2) therapy (OR =0.64, 95% CI: 0.46-0.88). Vaccination was the most important protective factor in both types of DM: DM1 OR =0.19, 95% CI: 0.06-0.59;SD2 OR =0.20, 95% CI: 0.16-0.26. CONCLUSION(S): The common risk factor for fatal outcome in both DM1 and DM2 was age >=65 years;in DM1 - history of hypertension and DFS, in DM2 - male sex, diabetes duration >=10 years, BMI >=30 kg/m2, history of ASCVD/CKD and diabetic coma, disability. In T2DM, significant differences in risk were observed depending on the type of ADT: insulin and SU therapy were factors that increased the risk of death, whereas therapy with iDPP-4 and iSGLT2 reduced the risk of death. Vaccination reduced the risk of death in DM1 and DM2 by 5.2 and 5-fold, respectively. Copyright © Endocrinology Research Centre, 2022.
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Introduction: Maturity onset diabetes of young (MODY) is a group of monogenic disorders characterized by AD inherited, accounting for approximately 1% to 6% of all pediatric diabetic patients. Sulfonylurea has been successfully used in MODY type 1 and 3;insulin therapy is needed for other types of MODY, including type 5. GLP-1RAs, Liraglutide daily injection, has been successfully used in one report, after which the patient was off insulin therapy. Objective(s): To present a case of MODY Type 5 that showed a great response to weekly treatment of GLP-1RAs (Semagutide). Method(s): A case report, Consent were obtained. Result(s): In our case report, an 18-years old girl known to have MODY type 5 HNFA1b mutation required both long and short-acting insulin (0.6 units/kg/ day). She had a history of high, low glucose readings and frequent hypoglycemia attacks. Therefore, once weekly, GLP-1RA (Semaglutide) was tried for 3 months. The dose was gradually increased from 0.25 mg to a maximum of 0.5 mg subcutaneously weekly. Insulin therapy was weaned, and then off insulin after the 6th dose;glucose readings were monitored via Dexcom CGM, which confirmed a significant improvement (Figure 1). Moreover, there was a disappearance of hypoglycemic attacks, a reduction of insulin doses approximately to zero, an improvement of time in range (TIR) to about 100%, enhanced glucose variability, and a reduction in the serum HbA1c from 6.1% to 5.6%, which was the lowest record since the diagnosis and finally injections number dropped from 28 per week to only one. However, the medication was stopped as the patient could not tolerate its gastric side effects after she was infected with COVID-19. Conclusion(s): Semaglutide is effective and superior to insulin therapy for MODY type 5 and can be considered to replace insulin therapy. In addition, CGM showed an excellent success that helped safely transfer the patient from intensive insulin therapy to the GLP-1RAs trial. Further studies are needed in MODY type 5.
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AIMS: To conduct a study on glycemic control improvement by appropriate re-education on the self-injection technique (SIT) in patients with diabetes mellitus undergoing insulin therapy. METHODS: Patients who received appropriate SIT and were treated with insulin for more than a year were re-educated. For the observation period of six months, the subjects' SIT was checked, and hemoglobin A1c (HbA1c) levels were measured at each visit. HbA1c levels, insulin doses, and behavioral changes in SIT were investigated at baseline and at the end of the observation period. RESULTS: In the per-protocol set population, the HbA1c level decreased by 0.2 % (2.0 mmol/mol) on average, showing a significant difference (p = 0.009). No significant difference was observed in the proportion of subjects with decreased HbA1c levels, changes in total daily insulin doses, or blood glucose levels. Four of the six SIT items covered by re-education were improved. CONCLUSIONS: Providing re-education on insulin SIT was considered effective in reducing HbA1c levels and improving adherence to proper SIT.
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COVID-19 , Diabetes Mellitus, Type 2 , Diabetes Mellitus , Self Administration , Humans , Blood Glucose , Diabetes Mellitus/drug therapy , Diabetes Mellitus/chemically induced , Diabetes Mellitus, Type 2/drug therapy , Glycated Hemoglobin , Glycemic Control , Hypoglycemic Agents , Insulin , Insulin, Regular, Human/therapeutic use , PandemicsABSTRACT
Background: Studies of mobile diabetes applications (apps) have demonstrated improvements in glycemia, and patient-reported outcomes (PROs). In addition, shift to shorter pen needles (PN) and guidance on proper injection techniques have shown the potential for reduced glycemic variability. The purpose is to determine the impact of using a diabetes mobile app plus a novel 4 mm PN on PROs and glycemic outcomes in type 2 diabetes mellitus (T2DM) for multiple daily injection (MDI) insulin users. Materials and methods: In this 8-week prospective, parallel-group, randomized controlled trial, subjects either received (1:1) intervention (BD Diabetes Care [DC] App + BD Nano TM 2nd Gen PN) or control therapy. Controls used their current PN and did not use diabetes apps. Results: Fifty-eight subjects were randomized. Fifty-seven completed the study (intervention n = 27, control n = 30). At study end, there were no significant differences in PROs between groups, except improved medication adherence (ARMS-D) in controls. From flash glucose monitoring (fGM) data, there were no significant differences in most glycemic measures between groups except for a trend for improved glycemic variability [mean amplitude of the glycemic excursions (MAGE)] in the Intervention (p = 0.06). Controls had significantly reduced time spent in hypoglycemia but had 2 to 3-fold higher incidence at baseline. In general, Intervention subjects reported satisfaction with both the app and PN. Conclusions: This is the first BD DC App study, in combination with BD Nano TM 2nd Gen PN, to assess glycemic outcomes. This combination intervention shows promising results for reduced glycemic variability and the potential to positively impact self-management.
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Background and Aims: The burden of uploading diabetes device shifted from clinic staff to those living with T1D as a result of virtual encounters for COVID-19. Unfortunately, many patients were not familiar with the upload process, causing incomplete data availability. This study compared patients with device data available at the start of their routine virtual clinical visits vs. those that did not. Methods: Data was collected from individuals <23 years old, with T1D, who received virtual care at a network of tertiary pediatric diabetes clinics in the Midwest USA from 3/2020 to 11/ 2021. Successfully uploading any device data or having cloudconnected streaming data was defined as having engaged in data sharing. Results: Observations from 946 telehealth encounters were analyzed. Only 52.9% (n = 383) had device data uploaded before their visit. Mean HbA1c (9.5% vs 8.5%, p-value <0.001), and mean time in range (44.7% vs 35.7%, p-value <0.001) were lower in those that had uploaded/streamed their data before their clinic encounter. Those with a longer duration of diabetes, selfidentifying as Black or African American, and those with public insurance were less likely to have data available at the start of their visit. Conclusions: Data from diabetes devices are integral to routine, effective, and safe management of insulin therapy. Statistically significant differences in access to device data were noted in those with public insurance and those who self-identify as African American. HbA1c and TIR were also lower. This study highlights the importance of equitable access to diabetes devices and continued advancement in auto-data streaming technologies.
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Background and Aims: During the recent COVID-19 pandemic, telemedicine has been used in type 1 diabetic patients to monitor and check metabolic balance, through specific platforms for downloading data. Aim of our study is to describe the experience of remote training, initiation and one-year follow-up of insulin pump therapy and continuous glycemic monitoring in four poorly controlled type 1 diabetic patients, presenting several hypoglycemic episodes. Methods: In April 2020 four patients were determined to be CSII therapy candidates, primarily to reduce hypoglycemic episodes. The remote training consisted of 3 or 4 sessions focused on self-management of advanced insulin therapy and technical aspects of pumps. They occurred in patients' homes using Skype™ for synchronous teleconferencing. After the training, two patients transitioned to the MiniMed 670G system, one to Omnipod and one to Accu-Chek Solo. Insulin pump informations and CGM data were remotely downloaded, and follow-up telemedicine visits were scheduled. Results: As early as two weeks after the insulin pump has been implanted, a hypoglycemic episode reset was recorded in all patients and the time in range (TIR) was greater than 90% in three of the four patients. During one-year remote follow-up, all patients maintained a satisfactory %TIR and glycemic variability, with a limited number of hypoglycemic events. One patient had COVID-19 disease and one became pregnant: these conditions were well managed by telemedicine service. Conclusions: These findings support the effectiveness of telemedicine for remote training, initiation, and follow-up of insulin pump therapy, ensuring a positive control of glycometabolic outcomes.
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Case Report Introduction Patients with mild to moderate diabetic ketoacidosis (DKA) can be safely treated with subcutaneous, rapidacting insulin analogs on the medical floor or in the emergency department. Here we describe a case of COVID pneumonia with DKA, effectively treated with a subcutaneous insulin regimen with anion gap closure in 4 hours since the presentation on medical floors. Case The patient is a 64-year-old male with no medical history, has not been in follow-up with a primary care physician for the past 20 years presents to the emergency department [ED] with a 2-week history of generalized weakness and fatigue. Reports feeling very thirsty and dehydrated with increased frequency of urination. On arrival he was noted to be saturating at 88 to 89% on room air, was switched to non 2 Litres nasal cannula with improvement in saturation to 94%, sinus tachycardia at 110 beats per minute, blood pressure 110/72 mmHg. Blood glucose was noted to be at 486 mg/dL with anion gap greater than 24 mEq/L, bicarbonate less than 10 mEq/L, creatinine at 1.62 mg/dL. Arterial blood gas analysis showed pH of 7.39, partial pressure of carbon dioxide at 16, partial pressure of oxygen at 61, bicarbonate of 10 suggestive of metabolic acidosis with respiratory compensation. He received a bolus of 0.3 units/kg [21 units] of subcutaneous insulin lispro (rapid-acting). Then was switched to 0.2 units/kg [14 units] subcutaneous insulin every 2 hours, the basic metabolic panel was done every 2 hours. Anion gap was closed in 4 hours. For transition, we calculated 0.5 units/kg [35 units] which was divided into basal - insulin glargine 17 units and bolus - sliding scale insulin lispro before meals and bedtime (insulin naive patient). His anion gap remained closed thereafter. He was treated with remdesivir and dexamethasone for COVID pneumonia. He was discharged after 5 days with improvement in his respiratory status from COVID pneumonia with outpatient follow-up. Discussion Subcutaneous insulin protocols are being used with increasing frequency to treat selected patients with mild to moderate DKA. Especially during this COVID pandemic, this helps to decrease the exposure frequency of staff (health care workers especially doctors and nursing staff) to patients given insulin dosing and lab frequency of 2-4 hours (compared with hourly checks for insulin intravenous drip), decreases the use of personal protective equipment (PPE), decreases the upgrade to intensive care units (ICU) that in turn helps with effective resources management in ICU for more critical patients. This protocol has not been studied in severe DKA yet but has similar efficacy and safety in mild or moderate DKA patients when compared to IV insulin therapy.
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Background and Aims: Both corticosteroids and covid- 19 infection can impair glucose metabolism resulting in significant hyperglycaemia. A trust-wide guidance was issued following alert from the National Inpatient Diabetes covid-19 Response Group, highlighting the need to use insulin instead of oral glucose-lowering agents. Owing to this, a higher number of patients were being initiated and discharged on insulin. Methods: All adult patients who were new to insulin were given a pre-packed 'Insulin initiation bundle' by the diabetes educators. This was a new initiative. It included consumables to last for two weeks and standardised patient information leaflets. All the patients discharged home on insulin were booked follow-up in a diabetes educator-led telephone clinic. A protocol was developed outlining the process above and each staff member's role. This was communicated widely. Results: The standardisation of insulin initiation safety bundles removed the need for the diabetes educators to write additional letters to the GP and improved efficacy of the discharge process. The virtual follow up on discharge ensured safe titration or withdrawal of insulin treatment until they completed their course of steroids and insulin. Conclusions: We believe this was an innovative practice. It universalised the approach to safe discharge from the hospital for patients who were newly started on insulin. This also ensured that patients had enough supplies to last them for two weeks post-discharge. We also found that the structured protocol for booking patients onto a virtual clinic list facilitated safe and early discharges at a time of increased pressure on hospital beds and ensured safe follow up.
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Introduction: The Coronavirus Disease 2019 (COVID-19) epidemic is caused by SARS-CoV-2, a recently discovered virus that causes severe acute respiratory syndrome. Influenza-related mortality poses an important risk factor for COVID-19, and comorbidity with diabetes is another important factor. Aim: The present study evaluated the biochemical features of COVID-19 positive patients with and without diabetes mellitus was admitted in DMWIMS Hospital Wayanad, Kerala state. Materials and Methods: Demographic, clinical, laboratory, treatments, complications, and clinical outcomes data of 194 patients were extracted from hospital management software and compared between diabetes (n=64) and non-diabetes (n=130) groups. The biochemical parameters such as D-Dimer, CRP, HbA1C, serum Potassium and albumin values were obtained from the Laboratory management software -medical records of the patients were analysed. Results: Compared with non-diabetic patients, diabetic patients had higher levels of S. Potassium (p=.014), C-reactive protein (p=.008), HbA1C (p<.01), and D-dimer (p=.033), and lower levels albumin (p=.035). Conclusion: COVID-19 is associated with diabetes as an independent risk factor. Diabetes patients, especially those who require insulin therapy, need more attention when it comes to prevention and treatment.
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Introduction: The aim of this study was to improve treatment of corticosteroid induced hyperglycaemia in patients critically unwell with COVID-19. Management with high dose steroids reduces mortality and has become standard practice. However, high dose glucocorticoid therapy impairs glucose metabolism in patients already at risk of insulin resistance and impaired insulin production, resulting in increased incidence of hyperglycaemia [1]. Methods: A retrospective audit was undertaken, collecting data on steroid use, glycaemic control, and insulin treatment in 100 patients admitted to the Royal Cornwall Hospital Intensive Care Unit with COVID-19. A standard operating procedure (SOP) for the treatment of steroid induced hyperglycaemia was created, based on guidelines from the National Inpatient Diabetes COVID-19 Response Group [1]. Results: Of 100 patients, 91 received high dose steroids. The majority (64.8%) experienced glycaemic control issues, defined as one episode of blood sugar > 12 mmol/l. Of the patients treated with 6 mg dexamethasone 52% experienced hyperglycaemia, compared to 71% of those treated with higher steroid doses. There was no significant difference in the highest blood sugar level of either cohort (t54 = - 0.450, p = 0.654). The average time between first episode of hyperglycaemia and commensal of insulin was 76 h. There was a lack of consensus in management of steroid-induced hyperglycaemia-no treatment was administered in 37% of patients. In those who were treated, 19 different combinations of insulin were given. Sliding scale insulin was administered in most patients who experienced no further hyperglycaemia. Conclusions: These results highlight a necessity for consensus management of steroid induced hyperglycaemia. In line with these findings, the devised SOP recommends initial therapy with rapid acting insulin and administration of a sliding scale if hyperglycaemia persists.
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Background: The early reports of COVID-19 came from Wuhan, China in early December, 2019 with clusters of cases of severe pneumonia (1). Since then, reports of new onset diabetes (NODM) and diabetic ketoacidosis have been published (2, 3). This study aims to estimate the incidence of NODM among patients with COVID-19 admitted to a hospital in Basra, southern Iraq. Material(s) and Method(s): This was a retrospective crosssectional study conducted at Al-Mawani Hospital from October to December 2020 on 1011 patients. Data were extracted from records of patients admitted to COVID-19 wards and ICU. Patients were diagnosed as having NODM according to the American Diabetes Association (ADA) criteria (4). Place of admission (isolation wards or ICU), patients' outcome (alive or dead), plasma glucose and insulin use were documented. Result(s): Males represent 58.4% of the participants. Mean age was 55.6 years. Approximately, 1/5 (20.5%) of the participants were managed at ICU. NODM was reported in 26.7% of the patients (44.8% of those who do not have past history of diabetes). Preexisting diabetes was reported in 40.4%. Accordingly, 679 (67.1%) were having diabetes both known and NODM. Mean plasma glucose for those with diabetes was = 334 mg/dL. Insulin therapy was used in 444 (65.3% of those with diabetes). Mortality rate was 24.3%. Those with NODM were more likely to be admitted to the isolation ward rather than ICU compared to those without (21.3% vs 18.5%, p=0,0005). In contrast, those with pre-existing diabetes were more likely to be admitted to ICU (22.4% vs 19.2%, p=0.0005). Mortality rate was higher among those with pre-existing diabetes than those with NODM (27.6% vs 21.1%, p=0.0005). Mortality rate among those with diabetes was more than those without (25% vs 22.8%, p=0005). Conclusion(s): A high incidence rate of NODM and prevalence rate of diabetes were reported in this cohort of patients. Quarter of patients admitted to the hospital for moderate-severe COVID-19 died. Inpatients insulin therapy was suboptimal. Future studies which include pre-admission data on glucose profile as well studies on the incidence of NODM among mild-moderate cases of COVID19 are required. Further prospective studies with a long follow up period are needed to better understand the outcome of NODM post COVID-19. Health Care Providers should screen for diabetes in all patients with COVID-19.
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Introduction: The coronavirus (COVID-19) pandemic of 2020 had a major impact on NHS services. From the 23rd of March 2020, the Urology Department in Basingstoke initiated telephone-led consultation clinics instead of face-to-face outpatient appointments, in accordance with U.K. guidance. Objectives: To evaluate patient experience and satisfaction following the introduction of remote (telephone) consultations during the COVID-19 pandemic. Patients and methods: The first 200 remote patient appointments between the 30th of March 2020 and the 16th of April 2020 were sent a postal questionnaire (19 questions relating to their experience and level of satisfaction with the interaction). Telephone consultations were conducted by 6 consultants, 3 registrars, and 2 specialist nurses. The patients were not prewarned to expect a questionnaire after the remote ap-pointment. The associated cost saving resulting from a switch from face-to-face appointments to remote telephone appointments was also calculated. Results: 100 out of the 200 patients responded within 1 month (response rate 50%). A total of 44% of the patients were new referrals, while 56% were follow-ups. Overall, the feedback was positive regarding the telephone consultation, with 88% rating the care received as excellent or very good. In addition, 90% would recommend a telephone consultation to family and friends. However, 35% would prefer in the future to have another telephone consultation rather than face-to-face consultation, with 46% preferring a face-to-face appointment in the future and 19% unsure. For new patients, the proportion wishing to have a face-to-face appointment, in the end, was unsurprisingly higher than it was for those undergoing a follow-up (39% vs. 7 %). In these 2 weeks, the cost reduction to the NHS from shifting from face-to-face consultation to telephone consultation was estimated to be £6500. Conclusions: Telephone urology clinics are a satisfactory alternative to face-to-face appointments for many of our patients now and beyond the COVID-19 pandemic. They are efficient, cost-effective, and feasible to undertake urological consultation and can be implemented successfully in selected patients. The feedback from this questionnaire would suggest that priority should be given to face-to-face appointments for new patients and for complex follow-up appointments. Telephone follow-up appointments, however, are a good approach for the majority of patients.
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Introduction: Neonatal diabetes mellitus (NDM) is a rare monogenic form of diabetes occurring mainly in the first 6 months of life. Approximately 30% of transient NDM cases have an activating mutation in the KATP channel genes ABCC8 and KCNJ11. The majority of transfers from insulin to sulfonylureas in patients with KCNJ11 mutations are done inside the hospital. Objectives: To report a case of transient neonatal diabetes mellitus (TNDM) where precision medicine, defining treatment based on molecular diagnosis and technology (intermittent continuous glucose monitoring-iCGM) allowed to make treatment adjustments with the patient safely at home, in times of COVID-19 pandemic. Methods: Case report of a patient with TNDM in use of iCGM. Results: A boy with transient NDM due to the p.E227K mutation in the KCNJ11 gene. Diabetes remitted at 30 months and relapsed at 6 years of age. Insulin was initiated and soon transition to glibenclamide was proposed with the use of iCGM, which allowed the patient to safely stay at home during the transition, especially important in the context of the COVID-19 pandemic. The data was uploaded to an online platform that allowed the medical team to perform remote daily checks on glucose levels and suggest treatment changes. During insulin therapy, the device's 14-day analysis revealed a glucose management index (GMI) of 7,2% and 72% of time in range (TIR). Patient's glucose profile improved rapidly after SU was initiated so that insulin therapy was discontinued. After four months of SU treatment, GMI was 6,2% with 93% of TIR (Figure 1). Conclusions: NDM is a model of a genetic disease that can benefit from precision medicine, where treatment is defined after molecular diagnosis, and that iCGM is a valuable tool that should be considered to monitor glucose, increase safety and speed up dose adjustments in outpatient transition from insulin to glibenclamide. As far as we understand the use of iCGM was not reported in this situation previously.
ABSTRACT
Introduction: The coronavirus disease 2019 (COVID-19) affected countless peoples' lives including pediatric patients with type 1 diabetes. Dasman Diabetes Institute, as a specialized diabetes center, collected routine patient clinical data from 2018 to date to improve quality of care and optimize outcomes. Objectives: We aim to investigate the impact of COVID-19 on glycemic control, diabetic ketoacidosis (DKA) occurrences, and diabetes management. Methods: Body mass index (BMI), blood pressure (BP), hemoglobin A1C (HbA1c), DKA and insulin treatment modality were analyzed in 152, 154 and 53 pediatric patients aged <18 years from March to December in the pre-pandemic years 2018, 2019 and during the pandemic in 2020. In March 2020, a nation-wide total lockdown was implemented. Glycemic control was defined as an HbA1c <7%. DKA occurrence was self-reported in the past 12 months. Chi-squared test for trend was used to assess differences between the years. Results: Most patients in 2018 (99.3%) and 2019 (99.3%) had at least 1 value of HbA1c, BP and BMI recorded, however in 2020, only 32.1% had at least 1 value of HbA1c and BMI and none had BP recorded (p<0.0001). Glycemic control was found in 15.8%,12% and 7.7% of the patients consulted in 2018, 2019 and 2020, respectively. DKA occurred in 6.5%, 3.2% and 5.7% of the patients in those years too. Of the 112 clinic visits in 2020, 99 (88.4%) were virtual consultations. Over time, pump use was 44.7%, 48.7% and 54.7% and continuous glucose monitoring remained the same in 21.1%, 20.8% and 20.8% of the study population from 2018-2020. Conclusions: COVID-19 interrupted access to care due to nation-wide lockdowns and curfews which led to a decrease in patient follow up and poor data monitoring. Despite the decrease in patient follow-up, markers of care were not different before and during COVID-19. The steep decrease in follow-up and lack of difference in quality of care could potentially be due to patients seeking medical care elsewhere. (Table Presented).