Household Consumption of Thiamin-Fortified Fish Sauce Increases Erythrocyte Thiamin Concentrations among Rural Cambodian Women and Their Children Younger Than 5 Years of Age: A Randomized Controlled Efficacy Trial.

OBJECTIVES: To assess whether ad libitum consumption of thiamin-fortified fish sauce over 6 months yields higher erythrocyte thiamin diphosphate concentrations (eTDP) among women of childbearing age and their children aged 12-59 months compared with control sauce containing no thiamin. STUDY DESIGN: In this double-blind, randomized controlled efficacy trial, 276 nonpregnant, nonlactating women (18-45 years of age) and their families in Prey Veng, Cambodia, were randomized to receive 1 of 3 fish sauce formulations: low thiamin concentration (low, 2 g/L), high thiamin concentration (high, 8 g/L), or a control (no thiamin) fish sauce. Baseline (t = 0) and endline (t = 6 months) eTDP were measured with the use of high-performance liquid chromatography with a fluorescence detector. RESULTS: Fish sauce consumption did not differ between treatment groups (P = .19). In intent-to-treat analysis, women's baseline-adjusted endline eTDP (mean; 95% CI) was higher among women in the low (259; 245-274 nmol/L) and high (257; 237-276 nmol/L) groups compared with control (184; 169-198 nmol/L; P < .001); low and high groups did not differ (P = .83). Similarly, children's baseline-adjusted eTDP was higher in the low (259; 246-271 nmol/L) and high (257; 243-270 nmol/L) groups compared with control (213; 202-224 nmol/L; P < .001). CONCLUSION: Fortified fish sauce appears to be an efficacious means of improving biochemical thiamin status in nonpregnant, nonlactating women and their children (1-5 years of age) living in rural Cambodia. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02221063.

Successful implementation of virtual care to overcome the challenges of managing gestational diabetes during the COVID-19 pandemic: a quality improvement project.

At the start of the COVID-19 pandemic, the Jim Pattison Diabetes and Pregnancy (JP DAP) clinic quickly switched from in-person to virtual care for patients with gestational diabetes (GDM) to reduce the risk of viral transmission. Poor glycaemic control in pregnancies increases the risk of maternal-fetal complications and thus women with GDM require education, frequent follow-up and treatment to reduce these risks. Delays in care could potentially result in increased maternal-fetal complications. We conducted a prospective, single-centre quality improvement (QI) study of women with GDM who attended the JP DAP clinic and delivered between 1 September 2019 and 31 March 2021. 2123 singleton pregnancies between 1 September 2019 and 31 March 2021 with GDM were analysed for this study. The time of referral to see the endocrinologist was lower than baseline in the first wave but rose significantly in the second wave. No-shows for appointments increased in the first wave but were lower than baseline after the implementation of time slots. There was no special cause variation for maternal-fetal complications pre pandemic, first wave or during the second wave. A patient satisfaction survey reported that 93% of respondents strongly agreed or agreed with the statement 'I was satisfied with the care provided to me over the telephone appointments'. The GDM education package, online educational videos in Hindi and English and the glucometer smartphone application helped to maintain the time of referral to first endocrinologist appointment in the first wave and therefore were considered an effective substitute for in-person education. Despite the delays in care seen in the second wave, there was no increase in maternal-fetal complications. Our clinic plans to continue using virtual tools for the foreseeable future.

Improving the efficiency of virtual insulin teaching for patients admitted to hospital through the COVID-19 pandemic: a quality improvement initiative.

BACKGROUND: Throughout the COVID-19 pandemic, many areas of medicine transitioned to virtual care. For patients with diabetes admitted to hospital, this included diabetes education and insulin teaching. Shifting to a virtual model of insulin teaching created new challenges for inpatient certified diabetes educators (CDE). OBJECTIVE: We advanced a quality improvement project to improve the efficiency of safe and effective virtual insulin teaching throughout the COVID-19 pandemic. Our primary aim was to reduce the mean time between CDE referral to successful inpatient insulin teach by 0.5 days. DESIGN, SETTING, PARTICIPANTS: We conducted this initiative at two large academic hospitals between April 2020 and September 2021. We included all admitted patients with diabetes who were referred to our CDE for inpatient insulin teaching and education. INTERVENTION: Alongside a multidisciplinary team of project stakeholders, we created and studied a CDE-led, virtual (video conference or telephone) insulin teaching programme. As tests of change, we added a streamlined method to deliver insulin pens to the ward for patient teaching, created a new electronic order set and included patient-care facilitators in the scheduling process. MAIN OUTCOME AND MEASURES: Our main outcome measure was the mean time between CDE referral and successful insulin teach-back. Our process measure was the percentage of successful insulin pen deliveries to the ward for teaching. As balance measures, we captured the percentage of patients with a successful insulin teach, the time between insulin teach and hospital discharge, and readmissions to hospital for diabetes-related complications. RESULTS: Our tests of change improved the efficiency of safe and effective virtual insulin teaching by 0.27 days. The virtual model appeared less efficient than usual in-person care. CONCLUSIONS: In our centre, virtual insulin teaching supported patients admitted to hospital through the pandemic. Improving the administrative efficiency of virtual models and leveraging key stakeholders remain important for long-term sustainability.

Successful multidisciplinary treatment of Doege-Potter syndrome: hypoglycaemia caused by paraneoplastic IGF-2 production by a metastatic haemangiopericytoma.

Hypoglycaemia due to insulin-like growth factor (IGF)-2 secretion is a paraneoplastic complication of malignancy with significant morbidity that can often go unrecognised due to its uncommon presentation. We report on a case of a 51-year-old man with metastatic haemangiopericytoma presenting with refractory hypoglycaemia, requiring continuous dextrose 10% infusion while in hospital. IGF-2 levels were significantly elevated, in keeping with a rare entity associated with solitary fibrous tumours, known as Doege-Potter syndrome. The patient was managed using uncooked cornstarch in conjunction with debulking of the hepatic tumour burden with bland IR-guided transarterial embolisation, and eventual surgical resection to treat his non-islet cell tumour hypoglycaemia (NICTH). The case highlights this rare paraneoplastic phenomenon that should be included in the differential for hypoglycaemia, especially if a history of a solitary fibrous tumour is elicited. Our case is the first to document a successful approach to treating the hypoglycaemia using preoperative transarterial bland embolisation.