A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

A Novel In Vitro Assay Correlates Insulin Receptor Autoantibodies With Fasting Insulin in Type B Insulin Resistance

CONTEXT

Severe insulin resistance (IR) in the presence of insulin receptor autoantibodies (InsR-aAb) is known as type B insulin resistance (TBIR). Considerable progress in therapy has been achieved, but diagnosis and monitoring of InsR-aAb remains a challenge.

OBJECTIVE

This work aimed to establish a robust in vitro method for InsR-Ab quantification.

METHODS

Longitudinal serum samples from patients with TBIR at the National Institutes of Health were collected. A bridge-assay for InsR-aAb detection was established using recombinant human insulin receptor as bait and detector. Monoclonal antibodies served as positive controls for validation.

RESULTS

The novel assay proved sensitive, robust, and passed quality control. The measured InsR-aAb from TBIR patients was associated with disease severity, decreased on treatment, and inhibited insulin signaling in vitro. Titers of InsR-aAb correlated positively to fasting insulin in patients.

CONCLUSION

Quantification of InsR-aAb from serum samples via the novel in vitro assay enables identification of TBIR and monitoring of successful therapy.

Application of Machine Learning Algorithms to Predict Uncontrolled Diabetes Using the All of Us Research Program Data

There is a paucity of predictive models for uncontrolled diabetes mellitus. The present study applied different machine learning algorithms on multiple patient characteristics to predict uncontrolled diabetes. Patients with diabetes above the age of 18 from the All of Us Research Program were included. Random forest, extreme gradient boost, logistic regression, and weighted ensemble model algorithms were employed. Patients who had a record of uncontrolled diabetes based on the international classification of diseases code were identified as cases. A set of features including basic demographic, biomarkers and hematological indices were included in the model. The random forest model demonstrated high performance in predicting uncontrolled diabetes, yielding an accuracy of 0.80 (95% CI: 0.79-0.81) as compared to the extreme gradient boost 0.74 (95% CI: 0.73-0.75), the logistic regression 0.64 (95% CI: 0.63-0.65) and the weighted ensemble model 0.77 (95% CI: 0.76-0.79). The maximum area under the receiver characteristics curve value was 0.77 (random forest model), while the minimum value was 0.7 (logistic regression model). Potassium levels, body weight, aspartate aminotransferase, height, and heart rate were important predictors of uncontrolled diabetes. The random forest model demonstrated a high performance in predicting uncontrolled diabetes. Serum electrolytes and physical measurements were important features in predicting uncontrolled diabetes. Machine learning techniques may be used to predict uncontrolled diabetes by incorporating these clinical characteristics.

Cardiovascular Risk Among Patients with Controlled and Uncontrolled Type 2 Diabetes: A Sub-Cohort Analysis from the Heart Health Promotion (HHP) Study

Objective

This study aimed to estimate the risk of cardiovascular disease (CVD) among patients with and without diabetes mellitus (DM) using the Framingham risk score (FRS) and to investigate the effect of DM control on CVD risk.

Methodology

A total of 2432 participants who had their glycosylated hemoglobin (HbA1c) measured within the last three months were included in this study. The study cohort was divided into three categories: non-diabetic, participants with controlled DM (HbA1c<7%), and uncontrolled DM (HbA1c≥7%). The World Health Organization's stepwise approach to chronic disease risk factor Surveillance-Instrument v2.1 was used in this study to collect the anthropometric and biochemical measurements. The Framingham Coronary Heart Risk Score (FRS) was used to calculate the 10-year cardiovascular risk (CVR). The groups were compared concerning the prevalence of metabolic, socioeconomic, and cardiac risks.

Results

Out of 2432 participants, 149 had controlled DM (6.1%), 286 had uncontrolled DM (11.8%), and 1997 participants were normoglycemic (82.1%). Compared to healthy participants, diabetic participants showed more high-risk characteristics across all CVR parameters. Uncontrolled diabetic patients had a graver laboratory and clinical profiles compared to the controlled DM group. As measured by FRS, nearly half of patients with controlled DM (49.9%) and two-thirds of patients with uncontrolled DM (63.3%) were classified as intermediate and high-risk compared to 4.6% of the healthy participants. Compared to healthy participants, patients with controlled DM showed a threefold increased CVR (OR = 3.02, 95% C.I. = 1.41-7.24) while this risk catapulted to 13 times among those with uncontrolled DM (OR = 13.57, 95% C.I. = 6.99-26.36).

Conclusion

Participants with DM are at moderate to high CVR. Individuals with uncontrolled DM showed higher CVR profiles as measured by FRS and have a higher prevalence of obesity, unhealthy diet, and physical inactivity.

Loosening of Teeth, an Unusual Presentation of Mucormycosis in COVID-19 Infected Patients

Aim of our study was to report unusual presentation of mucormycosis in patients, who were recovered from COVID-19 infection. This was a prospective observational study, undertaken at Ravindra Nath Tagore Medical College, Udaipur, India, over a period of last 3 months (April-June 2021). All patients with maxillofacial and dental mucormycosis were included in the study. All patients either have COVID-19 infection or recovered from it. Eight (40%) patients had history of use of corticosteroids for COVID1-19 infection, fifteen patients had either known case of diabetes or newly diagnosed diabetes with uncontrolled blood sugar at the time of presentation, three (15%) patients were in pre-diabetic state with HbA1c between 6.0 and 6.5% and two patients had no diabetes. None of patients had diabetic ketoacidosis and only one patient reported complete loss of vision with dental symptoms. There was unusual presentation of mucormycosis in form of loosening of teeth in uncontrolled diabetes. Injudicious use of steroids and uncontrolled diabetes are two main risk factors, so eyes should be kept on both of these.

Endogenous Endopthalmitis in Disseminated Methicillin-Sensitive Staphylococcus aureus (MSSA) Bacteremia

Endogenous endophthalmitis (EE) is an ocular infection resulting from hematogenous spread from the remote primary source. Risk factors include endocarditis, bacteria meningitis, immunosuppressive state, and invasive procedures in patients with sepsis. We present a case of a 43-year-old gentleman with poorly controlled diabetes mellitus who was admitted for bilateral nasoseptal cellulitis with a right nasal wall abscess and right vocal cord palsy. At presentation, he just had preseptal cellulitis without any posterior segment involvement. He underwent incision and drainage under the Otorhinolaryngology team. Unfortunately, postoperatively he developed sepsis with a hematogenous spread of infection systemically involving his right eye (endophthalmitis) and his heart valve (infective endocarditis). Blood culture revealed Methicillin Sensitive Staphylococcus Aureus (MSSA) infection. He had six weeks of intravenous cloxacillin and three times intravitreal injections of vancomycin and ceftazidime with complete resolution of signs and symptoms. In the case of a poorly controlled diabetic patient with an extensive regional infection, the presence of ocular symptoms and signs that are suggestive of EE must be taken seriously and warrant a complete eye examination as early detection and treatment of EE is crucial for better prognosis.

Clinical profile of COVID-19-associated mucormycosis patients and the clinical suspects: a descriptive audit

Background

India witnessed a massive surge of rhino orbital cerebral mucormycosis (ROCM) cases during the second wave of COVID-19, recording the highest number of cases in the world, indeed, an epidemic within the pandemic.

Objectives

To describe the clinical profile of patients with COVID-19-associated mucormycosis (CAM) and the clinical suspects for mucormycosis.

Methods

This single-center descriptive, observational study/audit was done at Indira Gandhi Medical College, Pondicherry, South India. This study is about the clinical profile of 7 CAM patients and 14 COVID-19 patients who were suspects of CAM, based on their risk factors and clinical symptoms, and were referred to the ENT department.

Statistical analysis

All the descriptive variables were summarized as mean, frequency, and percentages for qualitative data.

Results

All 7 CAM patients were COVID-19 positive and were not vaccinated against COVID-19, All 7 were known diabetic, all 7 had steroid therapy for their COVID status, and 5 out of 7 (71%) had uncontrolled diabetes mellitus at the time of diagnosis. Facial pain, nasal discharge, and eye swelling were the presenting symptoms of CAM. Maxillary and ethmoid sinuses were the most commonly involved para nasal sinuses. Four out of seven (57.1%) CAM patients survived after 16 months of follow-up, after surgical and medical treatment for CAM. Of the 14 clinical suspects who were negative for CAM, 2 were negative for COVID-19, their risk factors were brought under control, 3 expired due to COVID complications, and 9 patients are alive till date.

Conclusion

Uncontrolled diabetes is a risk factor for ROCM/CAM, another possible risk factor is steroid therapy, and we hypothesize that COVID infection could also be a possible risk factor that needs to be studied more extensively in a larger sample. Early clinical suspicion, withdrawal of steroids, rapid control of diabetes mellitus, appropriate investigations, and early surgical intervention combined with medical treatment offers better outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43163-023-00430-2.

Usefulness of continuous glucose monitoring of blood glucose control in patients with diabetes undergoing hemodialysis: A pilot study

Background

Blood glucose stability has recently been considered important in the treatment of diabetes. Both hypoglycemia and hyperglycemia can frequently occur in patients with diabetes undergoing hemodialysis. This study aimed to determine the usefulness of continuous glucose monitoring (CGM) for glycemic control and glycemic variability stabilization in patients with diabetes undergoing hemodialysis.

Materials and methods

Eighteen patients aged ≥18 years with type 1 or 2 diabetes and ≥3 months on hemodialysis at the Eulji Medical Center, Daejeon, Republic of Korea between November 2021 and May 2022 were included. Patients underwent 7 days CGM twice: the baseline study period (T0) and the follow-up study period (T1), at a 12 weeks interval. Physicians modified the treatment strategy according to the T0 results, and then patients conducted T1. As indicators of glycemic control, the mean glucose levels, glycated hemoglobin A1c (HbA1c), and time in range were measured. As indicators of glycemic variability, standard deviation (SD) and % coefficient variation (%CV) were measured.

Results

Data from 18 patients were analyzed. The mean glucose levels, HbA1c, SD, and %CV improved in T1 compared to T0 (P < 0.05). During T0, the mean glucose level was significantly lower on a day with hemodialysis than on a day without (P < 0.05), and SD and %CV were significantly higher on a day with hemodialysis than on a day without (P < 0.05). After the physicians modified the treatment according to the T0 results, there were no differences in the mean glucose levels, SD, and %CV between days with and without hemodialysis during T1.

Conclusion

Continuous glucose monitoring could be a promising tool for individualizing treatment strategies in patients with diabetes undergoing hemodialysis.

Clinicopathological Study of Mucormycosis in COVID-19 Patients: Experience From a Tertiary Care Center in South India

Background: The coronavirus disease 2019 (COVID-19) pandemic has taken the world to different dimensions. With the surge of the second wave in India, the number of cases with mucormycosis has increased. Mucormycosis is a potentially life-threatening, opportunistic, invasive, fungal infection that can occur in immunocompromised states. The aim of the study is to analyze the clinicopathological parameters of patients with mucormycosis in the surge of the second wave of COVID-19.

Materials and Methods: All cases of mucormycosis reported in the Department of Pathology in a tertiary care centre in South India from March 2021 to June 2021 were included in the study. The patient details were retrieved from the Medical Records section. The patient characteristics, location, associated comorbidities, management and treatment outcomes were analyzed and compared to similar studies reported worldwide.

Results: Of 58 cases, 38 (65%) were males and 20 (35%) were females. The ages ranged from 34 to 77 years. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in 46 patients in reverse transcription polymerase chain reaction (RT-PCR) with high-resolution computed tomography (HRCT) Chest changes noted in 54 patients. Associated comorbidities were noted in 52 patients, with uncontrolled diabetes mellitus (46 patients; 88%) being the most common. Location was commonly in nasal and paranasal sinuses (43%), followed by orbital (2%), cerebral (10%) and pulmonary (8%) areas. Among the paranasal sinuses, the maxillary sinus was commonly involved. Mixed fungal infections (Aspergillus sp. and Candida sp.) were noted in eight (14%) cases. Oxygen therapy was given in 85% of cases; 30% of cases needed ventilator support; corticosteroid therapy was initiated in 49 patients, tocilizumab in six patients as treatment for mucormycosis. Amphotericin B was administered in 59% of patients based on clinical findings alone. After histopathological confirmation, 90% of them received amphotericin. Functional endoscopic sinus surgery (FESS) was done in 96% of cases, among them 45% underwent extensive surgical debridement and 15% underwent orbital decompression. Orbital exenteration (2%) was the other modality of management.

Conclusion: Detailed analysis of clinicopathological features suggests the possibilities of immunosuppression (due to diabetes and use of corticosteroids in treatment of COVID-19) and COVID-19 (endothelial damage, cytokine storm) being the pathogenesis associated with the sudden surge of mucormycosis.

Adherence to Clinical Guidelines on STATIN Prescribing Among Diabetic Patients Aged 40-75 Years Old in a Primary Care Setting: A Cross-Sectional Study

BACKGROUND

Diabetes mellitus (D.M.) is a chronic metabolic disease caused by decreased insulin secretion, which increases the risk of cardiovascular diseases. Evidence has shown that statins reduce cardiovascular risk in patients with diabetes; moreover, most clinical guidelines recommend statins.

OBJECTIVE

This study aimed to assess the level and status of adherence to guidelines on statin prescription in patients with diabetes mellitus in a primary care setting in Palestine.

METHODS

A retrospective cross-sectional descriptive study was conducted at an ambulatory center in Palestine. Data were collected by auditing prescription records and reviewing medical charts of patients with diabetes who visited the clinic from February 15 to March 17, 2021. The collected data included patient characteristics, comorbidities, lipid profiles, and statin prescription. A chi-square test was used to evaluate the appropriateness of the prescribed statins with different demographic and clinical variables. Statistical significance was set at p < 0.05. Statistical Package for Social Sciences (SPSS) version 22 was used to analyze the data.

RESULTS

Out Of 262 diabetic patients included in the analysis, 74% were prescribed appropriate statin therapy according to the American Diabetes Association (ADA) guidelines, and 24% of patients had inappropriate statin therapy or needed statins. Furthermore, 82.8% were on high-intensity statins, while 11% were not taking any statins. More than 60% of patients had uncontrolled diabetes and hypertension.

CONCLUSION

Most guidelines recommend statin therapy in diabetic patients owing to its benefits in preventing cardiovascular complications. In this study, most patients were on appropriate STATIN therapy; however, 50% of diabetic patients had LDL of more than 100 mg/dl, and 25% were not prescribed statins, increasing their risk of ASCVD. Therefore, we recommend strict adherence to the established guidelines on statins prescribed to patients with diabetes to prevent cardiovascular complications, save lives, and reduce healthcare costs.

Successful long-term therapy of mucormycosis with isavuconazole

We present a case of a 55-year-old poorly controlled diabetic who presented to the hospital with facial pain, ophthalmoplegia, vision changes, and diabetic ketoacidosis and was diagnosed with rhinocerebral mucormycosis due to Rhizopus microsporus. He was started on liposomal amphotericin B and micafungin and went for nasal endoscopy and debridement, but the infection had progressed through the base of the skull and he received the maximum tolerated debridement. Posaconazole was added and discontinued due to elevated liver chemistry tests and was replaced with oral isavuconazole. After 6 weeks of therapy with liposomal amphotericin B and isavuconazole, he was switched to oral isavuconazole monotherapy. He underwent 30 sessions of hyperbaric oxygen therapy. Imaging showed improvement with subsequent biopsies that were negative for mucormycosis. At 13 months of therapy, his monotherapy was discontinued. He continues to have long-term sequelae including left facial droop and inability to close his left eye.

A Comparative Study Evaluating Implant Success and Bone Loss in Diabetes and Nondiabetes

BACKGROUND

Diabetes is seen to be associated with increased rate of failure of implants. The implant failure can be categorized as ailing, failing, and failed implants. The review of literature did not form any consensus on the effect of diabetes on the implant success rates. The reason we found was many confounding factors and nonconsideration of glycemic status of diabetic patients. Hence, in our study, we eliminated the confounding factors and took glycemic index in consideration.

MATERIALS AND METHODS

Forty-six participants were included in this study, out of which 26 were nondiabetic and 20 diabetic. Diabetics were further divided into two groups based on the HBA1C values, as controlled and uncontrolled diabetics.

RESULTS

We found that the uncontrolled diabetics had highest rate of implant failure as compared to other two groups. Furthermore, the controlled diabetics and nondiabetics had similar implant successes and failure rates.

CONCLUSION

This suggests that controlled diabetics are comparable to nondiabetics in terms of implant success rates.

Prevalence and Incidence Rate of Diabetes, Pre-diabetes, Uncontrolled Diabetes, and Their Predictors in the Adult Population in Southeastern Iran: Findings From KERCADR Study

Background: Diabetes mellitus is among the most serious health challenges worldwide. We assessed the prevalence of pre-diabetes (pre-DM) and diabetes (DM), the effectiveness of diabetes management, the 5-year incidence rate, and associated variables in the adult population in southeastern Iran. Methods: In a random cluster household survey (2014-2018), 9,959 adult individuals aged 15-80 years were assessed for coronary artery disease risk factors, including diabetes mellitus in Kerman (KERCADRS, phase 2). Among these people, 2,820 persons had also participated in phase 1 of the study 5 years earlier (2009-2011). Univariable and multivariable survey logistic regression models were used to identify the potential predictors of diabetes and pre-diabetes. Results: The prevalence of pre-DM was 12% (males 13.2% vs. females 11.1%), steadily increasing from 7.1% in the 15-24 years group to 18.4% in the 55-64 years group. The prevalence of DM was 10.2% (male and female, 7.9 and 10.8%, respectively), of which 1.9% were undiagnosed. DM was diagnosed in 10.6% of educated and 15.1% of illiterate people. The prevalence of diagnosed DM was lower in smokers (5.2 vs. 8.7%) and dependent opium users (5.4 vs. 8.8%). The prevalence of uncontrolled DM (HbA1c > 7%) was 48.8%, increasing with age. The frequency of uncontrolled DM among people without and with treatment was 32 and 55.9%, respectively. Illiterate people had worse uncontrolled DM (55.6 vs. 39.6%). The 5-year incidence rate (persons/100 person-years) was 1.5 for pre-DM and 1.2 for DM, respectively. The lowest and the highest incidence rate of DM belonged to the 15-34 years old group (0.5) and dependent opium users (2.4). The incidence rate was found to have a direct relationship with BMI and a reverse relationship with physical activity. Conclusion: Pre-DM and DM affected 22.2% of the population. One-third of patients with diabetes had undiagnosed DM, and in 55.9% of people with diagnosed DM, treatment had been ineffective. Appropriate health interventions are needed to reduce the prevalence and health consequences of diabetes in the region.

Prevalence and Risk Factors for Resistant Hypertension: Cross-Sectional Study From a Tertiary Care Referral Hospital in South India

Background Around 10% patients with hypertension have resistant hypertension (RH). Older age, Black race, obesity, diabetes mellitus (DM) and chronic kidney disease (CKD) are the common risk factors for RH. The present study was done to find out the prevalence and factors associated with RH. Methods This cross-sectional study was done between December 2018 and February 2020. Adult patients registered with the hypertension clinic and on care for more than three months were included in the study. History was noted and blood pressure (BP) was measured using standard precautions. The patients were divided into two groups - resistant and non-resistant hypertension. Chi-square test was done to check the significance of the differences between the two groups. Binary logistic regression was done for the risk factors with a p-value < 0.2 in the Chi-square test. Results A total of 275 patients were included. The mean age was 56 ± 10 years and 61% were females. The mean duration of hypertension was 7 ± 5 years; 77% of patients were overweight or obese. A family history of hypertension was present in 30% and 18% had diabetes mellitus. History suggestive of secondary hypertension was present in 13%. BP was controlled (<130/80 mm of hg) in 145 (53%), uncontrolled in 130 (47%) and resistant hypertension was seen in 31 [(11%) 95% CI 8-16%] patients. Duration of hypertension, obesity, and elevated fasting blood sugar were significantly associated with RH.  Conclusions RH was found in 11% of hypertensive patients. Longer duration of hypertension, obesity, and higher fasting blood glucose were associated with RH.

The Impact of Financial Incentives on Behavior and Self-Management of Uncontrolled Type 2 Diabetes: Pre- and Post-Quasiexperimental Study

Introduction

Noncommunicable diseases are one of the main challenges that affect health worldwide and have been found to be increasing in both low- and middle-income countries compared with high-income countries. The aim of this study was to assess the impact of financial incentives and a comprehensive care program focusing on patients' behavior and self-management of uncontrolled type 2 diabetes (glycosylated hemoglobin [HbA1c] ≥ 7), as well as modifiable risk factors for disease complications in a Saudi Arabian population.

Methods

This quasiexperimental study, using a pre- and postevaluation approach, was used to compare the level of HbA1c among patients with uncontrolled diabetes before and after the financial incentives and comprehensive care program were implemented. Financial awards were given to patients who achieved a significantly greater decrease in HbA1c levels with his/her responsible physician. The study population included 702 Saudi Arabian patients with type 2 diabetes from 14 regions and 34 primary healthcare centers in the Kingdom of Saudi Arabia. All of these patients (≥ 15 years old) with uncontrolled type 2 diabetes who attended local primary healthcare centers in Saudi Arabia for a follow-up visit from February to October 2018.

Results

The mean age, in years, of the sample was 56.14 (± SD = 9.909); slightly more than half of the patients 401 (57.1%) were females. Most of the participants 645 (91.9%) were married, and 381(54.3%) patients were housewives. Linear mixed modeling revealed that all groups showed improvements over time in the primary outcome of HbA1c levels (p = 0.009), Including the secondary outcomes of body mass index and systolic and diastolic blood pressure (p = 0.04, < 0.001, 0.019 respectively).

Conclusions

Patient behavior was improved, which was reflected by decreases in HbA1c, body mass index, and blood pressure levels. A comprehensive care program is recommended by healthcare providers to increase awareness among patients with diabetes to reduce other risk factors. These kinds of interventions positively motivate patients with diabetes to control their health measurements and to adopt a healthy lifestyle.

A Rare Case Report of Non-toxigenic Corynebacterium diphtheriae Bloodstream Infection in an Uncontrolled Diabetic With Peripheral Vascular Disease

Corynebacterium diphtheriae usually causes respiratory diphtheria, which is considered as a disease of toxemia but never bacteremia. Over the last few decades, cutaneous diphtheria has been increasingly reported owing to the emergence of the non-toxigenic strain, which causes locally necrotic and ulcerative lesions. Bacteremia is very rare, but the existing evidence in the literature suggests that the organism can rarely cause invasive infections such as septicemia, endocarditis, and osteoarthritis. Here, we present a rare case of C. diphtheriae causing bloodstream infections in an elderly diabetic with peripheral vascular disease, which was diagnosed incidentally on routine blood culture owing to automated identification systems viz matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) confirmed with conventional methods, and susceptibility was performed using automated VITEK 2 system (BioMérieux, Marcy-l'Étoile, France), which has aided in the timely management.

Impact of Non-Tailored One-Way Automated Short Messaging Service (OASMS) on Glycemic Control in Type 2 Diabetes: A Retrospective Feasibility Study

Short message service (SMS) is easily accessible and potentially an ideal platform for delivering patient-targeted messages. However, an effective SMS dosing strategy is not well established. Our purpose was to evaluate the impact of diabetes self-care promoting messages via non-tailored one-way automated SMS (OASMS) on glycemic control in type 2 diabetes (T2DM). The change in hemoglobin A1c (HbA1c) was compared between patients who received the service and those who did not. This retrospective quasi-experimental pre-post feasibility study was conducted at an academic medical center endocrinology clinic. English-speaking adults (≥18 years) with uncontrolled T2DM (HbA1c ≥ 8%) were included. A total of 69 patients (intervention n = 34; control n = 35) met the inclusion criteria. The mean (±SD) baseline HbA1c values were 10.2% (±1.9%) and 9.9% (±1.7%) in the intervention and control arms, respectively. Median follow-up was 3.3 months (IQR = 3-4.2). An ANCOVA model adjusted for baseline HbA1c and age showed an estimated HbA1c reduction difference of -0.97% (95% CI, -1.73 to -0.20%, p = 0.014), favoring the intervention arm. Inverse propensity score weighting confirmed the ANCOVA results. Our study suggests that adding diabetes self-care promoting messages via non-tailored OASMS to usual care improves glycemic control in poorly controlled T2DM. Larger and longer studies are needed to evaluate different features of the non-tailored OASMS strategy.

Breaking Bad: a case of Lactobacillus bacteremia and liver abscess

We present a case of a 46-year-old Hispanic male with a past medical history significant for uncontrolled diabetes presenting with abdominal pain, nausea and vomiting and found to have Lactobacillus bacteremia and liver abscess. A PubMed and Clinical Key literature review of the other known cases of Lactobacillus liver abscess was performed. Through examination of previous case reports, the patient presented in this paper, and the associated risk factors of Lactobacillus liver abscess it is likely that the incidence of this rare condition will increase and would therefore be prudent to further study Lactobacillus as a pathogenic bacteria so that its complications may be better treated and prevented.

A qualitative exploration of barriers to medication adherence among patients with uncontrolled diabetes in Qatar: integrating perspectives of patients and health care providers

PURPOSE

To develop an in-depth understanding of the barriers to medication adherence among patients with uncontrolled diabetes attending primary health care (PHC) centers in Qatar by exploring and integrating patients' and health care providers' perspectives.

PARTICIPANTS AND METHODS

A descriptive qualitative methodology was used in this study. A trained researcher conducted semi-structured face-to-face interviews at two PHC centers. Patients with uncontrolled diabetes (with varied sociodemographic characteristics) and their respective health care providers (physicians, pharmacists, nurses, dieticians, and others) were purposively selected from the two PHC centers. All interviews were audio recorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Thirty interviews (14 patients and 16 health care providers) were conducted. A number of barriers to medication adherence were identified and classified broadly under three main themes: 1) patient-related factors, which included patients' individual characteristics and patients' perception, attitude, and behavior; 2) patient-provider factors, which included communication and having multiple health care providers caring for the patient; and 3) societal and environmental factors, which included social pressure and traveling to visit friends and relatives.

CONCLUSION

Patients with uncontrolled diabetes face multiple barriers to medication adherence. Similar themes emerged from both patients and their care providers. This research highlights the need for concerted multidimensional efforts and series of interventions to overcome these barriers. One vital intervention is expanding the scope of pharmacists' role within the PHC centers through providing medication reconciliation, patient-tailored medication counseling, and medicines use review, which may improve treatment outcomes among patients with diabetes.

Epidemiology of diabetes mellitus, pre-diabetes, undiagnosed and uncontrolled diabetes and its predictors in general population aged 15 to 75 years: A community-based study (KERCADRS) in southeastern Iran

BACKGROUND

The goal of this research was to measure the age-sex standardized prevalence of pre-diabetes (pre-DM) and diabetes (DM), and the effectiveness of diabetes management (using HbA1C as the indicator) in an urban area in Iran.

METHODS

Using a randomized cluster household survey, we recruited 5900 individuals whose age ranged from 15 to 75 from Kerman for assessing coronary artery disease risk factors (KERCADRS) including diabetes. In 2010 and 2011, all of the participants were interviewed by trained staff for medical history and physical activities, and were then examined for blood pressure and anthropometric measures. Venus blood sample was also collected for fasting plasma glucose and HbA1c.

RESULTS

The age-sex standardized prevalence of pre-diabetes, diagnosed and undiagnosed was 18.7%, 6.3% and 2.7%, respectively. Diabetes increased by age (from 14.7% in the 15-24 years old group to 28.4% in the 65-75 years old group), particularly after 40 years. Occasional opium users had the highest prevalence of Pre-DM (34.6%). Seventy-nine percent of the depressed and 75.5% of the anxious participants with diagnosed-DM were identified as uncontrolled-DM. More than 60% of diagnosed diabetic cases had impaired HbA1c. Overweight and obesity (adjusted odds ratio (AOR) 1.6) and low physical activity (AOR 1.5) were the most preventable risk factors associated with diabetes.

CONCLUSION

Considerable prevalence of diabetes, susceptibility in progressing to diabetes and uncontrolled diabetes among individuals living in Kerman, suggested ineffective prevention and treatment of diabetes in urban areas in Iran. Successful experience regarding primary health-care in rural areas should be expanded to urban settings.

Where to Go Now With V-Go?

V-Go is a mechanical continuous insulin delivery device releasing a basal amount of rapid acting insulin that also allows the user the ability to deliver discrete meal time or correction doses. This analysis reviews available published literature on the technology, and discusses a recent article comparing the V-Go system with multiple daily insulin injection therapy. Finally, suggestions for future studies are provided.

Rhinocerebrocutaneous mucormycosis caused by Mucor species: A rare causation

Rhinocerebral mucormycosis is the most common form of mucormycosis occurring commonly in patients of diabetic ketoacidosis. Fungi of the order Mucorales belong to six families, among whom Rhizopus is the most common, while Mucor is a rare cause. We report a 45-year-old female with uncontrolled diabetes mellitus diagnosed to have rhinocerebrocutaneous mucormycosis caused by Mucor species. The diagnosis was confirmed on histology and culture. A high-index of suspicion is required for early diagnosis and timely initiation of therapy to optimize the outcome. Our patient succumbed to her infection.

Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To assess the effect glycemic control has on perioperative morbidity and mortality in patients undergoing elective degenerative lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Diabetes mellitus (DM) is a prevalent disease of glucose dysregulation that has been demonstrated to increase morbidity and mortality after spine surgery. However, there is limited understanding of whether glycemic control influences surgical outcomes in patients with DM undergoing lumbar spine procedures for degenerative conditions.

METHODS

The Nationwide Inpatient Sample was analyzed from 2002 to 2011. Hospitalizations were isolated on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery and diagnoses codes for degenerative conditions of the lumbar spine. Patients were then classified into 3 cohorts: controlled diabetic, uncontrolled diabetic, and nondiabetic. Patient demographic data, acute complications, and hospitalization outcomes were determined for each cohort.

RESULTS

A total of 403,629 (15.7%) controlled diabetic patients and 19,421 (0.75%) uncontrolled diabetic patients underwent degenerative lumbar spine surgery from 2002 to 2011. Relative to nondiabetic patients, uncontrolled diabetic patients had significantly increased odds of cardiac complications, deep venous thrombosis, and postoperative shock; in addition, uncontrolled diabetic patients also had an increased mean length of stay (approximately, 2.5 d), greater costs (1.3-fold), and a greater risk of inpatient mortality (odds ratio=2.6, 95% confidence interval=1.5-4.8, P<0.0009). Controlled diabetic patients also had increased risk of acute complications and inpatient mortality when compared with nondiabetic patients, but not nearly to the same magnitude as uncontrolled diabetic patients.

CONCLUSION

Suboptimal glycemic control in diabetic patients undergoing degenerative lumbar spine surgery leads to increased risk of acute complications and poor outcomes. Patients with uncontrolled DM, or poor glucose control, may benefit from improving glycemic control prior to surgery.

LEVEL OF EVIDENCE

3.

Necrosis of maxilla, nasal, and frontal bone secondary to extensive rhino-cerebral mucormycosis

Mucormycosis is an opportunistic fulminant fungal infection caused by zygomycetes. This fungus can cause a variety of infections in human beings, particularly in the uncontrolled diabetes mellitus. Zygomycetes impinge into the vascular network, resulting in thrombosis and necrosis of the surrounding hard and soft tissues. The infection begins in the nose and paranasal sinuses due to inhalation of fungal spores and spread to orbital and intracranial structures either by direct invasion or through the blood vessels. Sinus mucormycosis is often accompanied by a poor prognosis and a high mortality rate. Hence, aggressive surgical intervention with antifungal therapy is usually necessary. Early diagnosis and prompt treatment can reduce the mortality and morbidity of this lethal fungal infection. We report a case of aggressive rhino-cerebral mucormycosis in a 58-year-old female patient with uncontrolled diabetes mellitus.