Hypoglycemia Unawareness and Recurrent Severe Hypoglycemia in an Individual With Type 1 Diabetes Mellitus on Insulin.

Background/Objective: Hypoglycemia unawareness is a complication of recurrent hypoglycemia that can complicate diabetes management and impact quality of life. We present the case of an individual with type 1 diabetes with hypoglycemia unawareness and recurrent severe hypoglycemia requiring emergency intervention. Case Report: A 55-year-old man with type 1 diabetes was referred for hypoglycemia unawareness and recurrent hypoglycemia with seizures. Over the prior 4 years he had >400 paramedic responses with 56 hospitalizations. Blood glucose levels ranged between 0.7 and 2.4 mmol/L during these episodes and presenting Hemoglobin A1c (HbA1c) was 4.6% (28 mmol/mol). He was taking insulin glargine daily and aspart with meals via insulin pens with no alternative etiology for his hypoglycemia was identified. The patient expressed difficulty with self-management, social instability, and limited appointment attendance. He was provided a continuous glucose monitor, educational support, and glycemic targets were broadened. After 6 months, HbA1c was 4.6% (28 mmol/mol) and he had 65 paramedic responses. A multidisciplinary team was organized for biweekly follow-up, community outreach, remote technological support, and psychological counseling. After 2 years, the patient had 2 emergency responses and HbA1c was 7.2% (55.2 mmol/mol). Discussion: Permissive hyperglycemia, educational interventions, and continuous glucose monitoring are validated strategies for prevention of hypoglycemia. Limiting hypoglycemia is crucial to restore hypoglycemia awareness, and in severe cases may require high intensity follow-up, community outreach, and psychosocial support. Conclusion: Hypoglycemia unawareness can complicate hypoglycemia prevention. Severe refractory cases are often multifaceted and may warrant a multidisciplinary approach to identify and target patient-specific needs.

Patient Perspectives on Virtual Care for Diabetes Management in the Era of COVID-19.

OBJECTIVE: The aim of this study was to characterize patient perspectives on the quality of diabetes care at The Ottawa Hospital Endocrinology and Metabolism multidisciplinary clinic delivered virtually during the COVID-19 pandemic. METHODS: An online survey was developed to collect quantitative and qualitative data on patients' experiences with virtual diabetes clinic visits between March 2020 and April 2021. RESULTS: A total of 333 patients were included in this study; 45% were female and had a mean age of 60 years. Seventy-nine percent were born in Canada and 87% identified as Caucasian. Thirty-six percent were treated for type 1 diabetes and 62% for type 2 diabetes. Eighty-seven percent of virtual visits occurred by phone, with 12% of these on Zoom. Overall, 83% were "very satisfied" or "satisfied" with their virtual care experience. Most respondents perceived all treatment-related factors to be equally well addressed virtually as in person, except for physical examination. Auxiliary factors like travel, cost, and time spent were rated more favourably with virtual care. Qualitative findings provided further contextualization and identified gaps in virtual care delivery. For future visits, 44% wanted in-person visits only as needed, 36% wanted a hybrid of in-person and virtual appointments, and 11% preferred in-person appointments only. CONCLUSIONS: Patients perceive that virtual care provides high-fidelity diabetes management while reducing their pandemic risks as well as minimizing travel and time associated with in-person care. Virtual care is an important medium for diabetes care delivery that should be used according to patient preference and intermixed with in-person appointments.

Effects of Prediabetes on Long-term Risk of Developing Cardiac Events in Patients Presenting With Acute Coronary Syndrome.

OBJECTIVES: The aim of this work was to identify the long-term risk associated with prediabetes and developing subsequent cardiac events in patients presenting with acute coronary syndrome (ACS) at a tertiary health-care centre. METHODS: In this retrospective cohort study, we analyzed patients admitted with ACS between January and December 2013. Two hundred thirty patients with prediabetes were matched to a comparison cohort of patients with no diabetes based on age, sex, and diagnosis code of the International Statistical Classification of Diseases and Related Health Problems---10th revision. The primary outcome was incidence of ACS readmission over a 5-year period. RESULTS: There were 46 (20%) readmissions for ACS in the prediabetes cohort and 33 (14.3%) in the no-diabetes cohort. Univariable conditional logistic regression showed that prediabetes was not a significant risk factor for ACS readmission (odds ratio, 1.481; 95% confidence interval, 0.909 to 2.414; p=0.115). After accounting for other major risk factors for coronary disease, prediabetes was not shown to be a significant risk factor for ACS readmission (odds ratio, 1.333; 95% confidence interval, 0.795 to 2.233; p=0.276). CONCLUSIONS: Among patients presenting with ACS, prediabetes was not associated with increased risk of readmission for subsequent cardiac events compared with patients with no diabetes after 5 years of follow-up. A longer follow-up duration is needed.

Comparing the content of traditional faxed consultations to eConsults within an academic endocrinology clinic.

OBJECTIVE: To compare the content of traditional faxed referrals and electronic consultations (eConsults) and determine how many questions sent by traditional referral could be successfully addressed using eConsult. METHODS: We conducted a cross-sectional, qualitative study of eConsults and faxed referrals sent to a tertiary diabetes and endocrinology clinic in Ottawa, Ontario. A convenience sample of 300 faxed referrals sent between March and July 2017 and 300 eConsults submitted between January and December 2017 were selected and coded using an established taxonomy to determine question type. Two endocrinologists reviewed the faxed referrals to assess whether they could have been addressed using eConsult. Responses to a mandatory closeout survey were reviewed for all eConsults, assessing the case's outcome, impact on decision to refer, and educational value. RESULTS: Most faxed consultations were requests for shared care in diabetes mellitus, whereas most eConsults requested help in diagnostic test interpretation. 25-27% of faxed consults were felt to be potentially amenable to eConsult. Referring provider behaviour was changed in 45.3% of eConsult cases through avoidance of face-to-face consultation. CONCLUSION: eConsult is a promising tool for PCPs to improve access to specialist opinion without necessitating a face-to-face visit.

Real-World Patient Experience of Long-Term Hybrid Closed-Loop Insulin Pump Use.

OBJECTIVES: Understanding of patient experiences and adaptations to hybrid closed-loop (HCL) pumps beyond the confines of short-term clinical trials is needed to inform best practices surrounding this emerging technology. We investigated long-term, real-world patient experiences with HCL technology. METHODS: In semistructured interviews, 21 adults with type 1 diabetes at a single Canadian tertiary diabetes centre discussed their transition to use of Medtronic MiniMed 670G auto-mode. Interviews were audio-recorded, transcribed and analyzed iteratively to identify emerging themes. RESULTS: Participants' mean age was 50±13 years, 12 of the 21 participants were female, baseline glycated hemoglobin (A1C) was 7.9±1.0% and auto-mode duration was 9.3±4.6 months. Three had discontinued auto-mode. Most participants praised auto-mode for reducing hypoglycemia, stabilizing glucose overnight and improving A1C, while also reporting frustration with frequency of alarms and user input, sensor quality and inadequate response to hyperglycemia. Participants with the highest baseline A1Cs (8.8% to 9.8%) tended to report immense satisfaction and trust in auto-mode, meeting their primary expectations of improved glycemic control. In contrast, participants with controlled diabetes (A1C <7.5%) had hoped to offload active management but experienced significant cognitive and emotional labour associated with relinquishing control during suboptimal auto-mode performance. Participants were commonly aware of workarounds to "trick" the pump, and almost all participants with A1C <7.5% tried at least 1 workaround. CONCLUSIONS: In the real-world setting, patients' goals and satisfaction with auto-mode appeared to vary considerably with their baseline diabetes control. Patients with the most suboptimal glycemic control described the greatest benefits and easiest adaptation process, challenging commonly held assumptions for patient selection for pump therapy.

A Patient-Inspired Quality Improvement Initiative for Pituitary Adenoma Care.

BACKGROUND: Pituitary adenomas (PAs) are common and often require complex multidisciplinary care with multiple specialists. This may result in a healthcare system that is challenging for patients to navigate. Audits of care at our institution revealed opportunities for improvement to better align care with patients' needs. METHODS: A quality improvement initiative that incorporated a patient advisory committee of patients who had received treatment for PA at our center and their family members were used to help identify opportunities for improvement. The patient-identified gaps in care included the need to coordinate and minimize appointments and the desire for better communication and education. Based on this information, changes were implemented to the pituitary program, including increasing access to the Multidisciplinary Clinic and developing a standardized and centralized triage process. RESULTS: A pre- and post-intervention analysis consisting of retrospective chart reviews revealed that these changes had an impact on wait times for first assessment, and a significant shift in the location of this first visit - with a larger proportion of patients being seen in the Multidisciplinary Clinic after an intervention. CONCLUSIONS: We demonstrate that patient involvement, beyond individual patient-physician interactions, can lead to meaningful and observable changes, and can improve the quality of care for PA.

Sodium-glucose cotransporter 2 inhibitors and type 2 diabetes: clinical pearls for in-hospital initiation, in-hospital management, and postdischarge.

PURPOSE OF REVIEW: The aim of this article is to provide practical recommendations on safe initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors to in-patients as well as management of those who are already on SGLT2 inhibitors. RECENT FINDINGS: Robust data from stable outpatient cohorts indicate that the SGLT2 inhibitors are associated with clinically meaningful reductions in major adverse cardiovascular events, lower rates of hospitalization for heart failure, and a reduction in major kidney outcomes There is however a lack of information on how to initiate and manage SGLT2 inhibitors in an acute in-patient setting. SUMMARY: SGLT2 inhibitors may be cautiously appropriate for in-patients if all the criteria for safe use are met but good clinical judgment must prevail. Temporary withholding of SGLT2 inhibitors is appropriate in hospitalized patients during a period of stress and/or insulinopenia.

Does a Canadian diabetes curriculum work for future physicians in China? Lessons from the Ottawa Shanghai Joint School of Medicine.

BACKGROUND: The Ottawa Shanghai Joint School of Medicine (OSJSM) is a campus of the University of Ottawa Medical School in Shanghai, China. This collaboration allowed us to study whether a Canadian curriculum is suitable for the Chinese population. The aim of this study is to evaluate: 1) The OSJSM diabetes curriculum; and 2) The relevancy of the content for the Chinese population. METHODS: The diabetes curriculum content was evaluated using a curriculum comparison between the University of Ottawa, OSJSM, and the Shanghai Jiao Tong School of Medicine (SJTSM). A literature search compared the diabetes populations in Canada and China. Interviews determined how physicians and patients manage diabetes. RESULTS: The diabetes curriculum at the OSJSM is identical to that of the University of Ottawa. Canada and China have a similar diabetes prevalence, diagnostic criteria, and management. Although both countries utilize the same screening guidelines for diabetes and its complications, patients in Canada are more likely to adhere to these recommendations. CONCLUSION: This study suggests that the diabetes content of the University of Ottawa curriculum remains relevant in China. A greater emphasis on the importance of screening for disease complications in the curriculum may facilitate making this a priority for patients and healthcare providers in China.

Diabetes Canada Position Statement for People With Types 1 and 2 Diabetes Who Fast During Ramadan.

OBJECTIVE: Fasting from dawn to dusk during Ramadan, including abstaining from water and food, is 1 of the pillars of Islam and is observed by the majority of Muslims. Most research concerning diabetes and fasting during Ramadan originates from Middle Eastern or South Asian countries; however, differences exist in hours of work and fasting, pharmacotherapy and blood glucose monitoring between these countries and Canada. METHODS: An expert forum of 7 Canadian experts and 1 international expert collaborated to develop Canadian guidelines using the same evidence-based principles, with the exception of an independent methods review used for the Diabetes Canada clinical practice guidelines. Diabetes Canada scientific leadership and Canadian health-care providers performed independent external reviews. Religious leaders endorsed the position statement and provided letters of support. An informed patient participated in the position-statement development. Each recommendation was approved with 100% consensus of the expert forum. RESULTS: Recommendations for risk stratification, education, pharmacotherapy and blood glucose monitoring for adults with type 1 and type 2 diabetes who intend to fast during Ramadan have been developed. CONCLUSIONS: This is the first Canadian position statement on the topic of Ramadan fasting and diabetes. It was developed by an expert faculty and endorsed by Diabetes Canada, and provides guidance about pharmacotherapy and glucose monitoring for health-care providers so that they can assist Canadian Muslims living with diabetes to observe fasting during Ramadan safely.

Alemtuzumab Induced Thyroid Disease in Multiple Sclerosis: A Review and Approach to Management.

Alemtuzumab, an anti-CD52 monoclonal antibody, was recently approved for treatment of MS in Canada, having shown to significantly reduce relapses and disability in patients, particularly those who relapsed despite first line treatment. Offsetting its benefit however, is the development of novel secondary autoimmune disease, particularly affecting the thyroid gland in up to 36% of patients. The incidence of Alemtuzumab induced thyroid dysfunction (AITD) will likely rise as alemtuzumab becomes more widely used for treating MS. We review the clinical and investigational cues that help delineate the aetiology and management of thyrotoxicosis and hypothyroidism in ATID. AITD can be easily managed and we present a simple approach for its evaluation and management by neurologists that should be implemented prior to considering a referral to an internist or endocrinologist for further opinion or treatment.

Immune checkpoint inhibitor therapy associated hypophysitis.

Ipilimumab is a monoclonal antibody directed against CTLA4 T-lymphocyte antigen used as cancer therapy. Immune-related adverse events are common side effects and may include hypophysitis-related hypopituitarism. The clinical features of six patients with ipilimumab-induced hypophysitis (IH) are described. The clinical features of IH reported in clinical trials, including the incidence of IH by gender and the likelihood of adrenal axis recovery, are summarized. Following the development of IH, most patients remain on glucocorticoid replacement despite efforts to withdraw therapy. Analysis of gender information in published clinical trials suggests that men are more prone to developing IH than women, and few patients fully recover the pituitary-adrenal axis function. Ipilimumab and other drugs within its class are likely to be used to treat many forms of cancer. Endocrinologists should anticipate a significant increase in the incidence of autoimmune hypophysitis. Strategies for early detection of IH and long-term management should be considered.

Stability of the Bax (G)8 microsatellite in localized prostatic adenocarcinoma.

OBJECTIVES: Microsatellite instability has been found in a variety of tumors including prostate cancer. Bax, a pro-apoptotic protein from the Bcl-2 family of proteins, has a microsatellite composed of an eight deoxyguanine [(G)8] tract located in exon 3. Prostate carcinoma cells have increased proliferation indices and lower levels of apoptosis when compared to benign tissue. We investigated whether instability in the Bax (G)8 microsatellite contributes to loss of apoptotic control in localized prostate cancer. PATIENTS AND METHODS: Thirty-eight patients undergoing radical prostatectomy for localized prostate carcinoma participated in this study. Prostate carcinoma was microdissected, and polymerase chain reaction amplification of a region containing the (G)8 microsatellite was performed on DNA from peripheral blood leukocytes and tumors, followed by single strand conformational polymorphism (SSCP) analysis and direct DNA sequencing. RESULTS: SSCP analysis showed no alteration in the number of bands detected upon comparison of tumor tissue to leukocytes, suggesting no alterations in the microsatellite. This was confirmed by direct sequencing, which demonstrated a normal (G)8 sequence in each case. CONCLUSION: We conclude that the Bax (G)8 microsatellite is stable in localized stage T2 and T3 prostate cancer. Our findings argue against a mutator phenotype pathway leading to loss of apoptotic control in localized prostate cancer.