Diabetology, Volume 5, Issue 6 (November 2024) – 8 articles

Background: Handheld cameras may increase access to teleretinal diabetic retinopathy screenings (TDRS), as they are more economical and nimbler than traditional desktop cameras. However, their use in safety net clinical settings is less understood. Methods: The Los Angeles County Department of Public Health collaborated with the Los Angeles County Department of Health Services (DHS) to pilot the use of handheld cameras in DHS’s TDRS program. This study assessed screening metrics and interviewed TDRS coordinators and photographers about their experiences using these cameras. Results: Handheld cameras were harder to operate and performed less optimally on key screening metrics (e.g., image quality) compared to desktop cameras. However, this challenge appeared to be linked to the selected model rather than to all handheld cameras. The adoption of handheld cameras in DHS was aided by their integration into an existing agency infrastructure that already supported the use of desktop cameras; these operational supports included an established workflow, a data platform, and experienced photographers. Conclusions: The use of handheld cameras for TDRS is a promising practice for assuring equitable access to screenings. Handheld cameras are portable, smaller in size, and lower in cost than desktop cameras. Future projects should invest in and assess the performance of higher-quality models of these cameras, especially their use in safety net clinical settings. Full article

Background: Studies of pharmacists’ clinical programs have demonstrated improvements in controlling chronic diseases. However, significantly less data are available regarding pharmacist impact in a value-based Patient-Centered Medical Home (PCMH). The present study assessed a population health initiative to incorporate pharmacists for the management of type 2 diabetes (T2D), hypertension, and hyperlipidemia in a PCMH. Methods: This was a single-center retrospective cohort study of patients with T2D and baseline glycated hemoglobin (HbA1c) greater than 9%. Patients were excluded if they received care from an endocrinology provider or were lost to follow-up during the observation window of 1 January 2023 through 31 July 2023. Patients were analyzed in two cohorts: (1) patients who received any outpatient care from a clinical pharmacist (pharmacist cohort) and (2) patients who did not receive any outpatient care from a clinical pharmacist (usual care cohort). The primary outcome was the proportion of patients achieving an HbA1c of less than 8%. Secondary outcomes included blood pressure control and receipt of guideline-directed statin therapy. Results: Ninety-one patients were identified, twenty-nine in the pharmacist cohort and sixty-two in the usual care cohort. The overall population was older (mean age ~66 years), 59% female, and racially diverse (<50% Caucasian). HbA1c less than 8% was achieved in 34% of patients in the pharmacist cohort and 29% of patients in the usual care cohort (p = 0.001). A blood pressure goal of less than 140/90 mmHg was achieved more frequently in the pharmacist cohort (90% vs. 61%, p = 0.006), but guideline-directed statin therapy was similar between groups (90% vs. 79%, p = 0.215). Conclusions: Pharmacists can play an integral role within a PCMH to improve value-based measures for HbA1c and blood pressure control. Further research is needed to assess the impact of pharmacist care on statin use and economic outcomes. Full article

Background/Objectives: Individuals with diabetes often experience discrimination and barriers at work and are confronted with the challenge of deciding whether to disclose their health status in their workplace. This study explores the disclosure of diabetes in the workplace. The research was based on a previously developed questionnaire. Methods: Two hundred and five persons with diabetes who were employed in Greece participated in the research. Results: The majority of the participants chose to disclose. Demographic characteristics influenced their disclosure decision, with the diabetes type and the employment sector showing a more significant impact. The majority of the participants showed a strong preference for early disclosure. Conclusions: The main reasons for disclosure were the belief that there was no reason to conceal it and the need to know in an emergency. In contrast, the main reasons for concealment were the fear of being fired or not being hired, the belief that disclosure was unnecessary, and concerns about being treated differently. The present research brings to light the reality of employed people with diabetes in Greece. Future research could focus on a deeper understanding of the disclosure issues of people with diabetes and other non-visible disabilities. Full article

Background/Objectives: Diabetic ketoacidosis (DKA) is an acute and potentially life-threatening complication characterized by the accumulation of ketone bodies in the blood, primarily occurring in patients with type 1 diabetes and occasionally in those with type 2 diabetes under certain conditions. DKA presents with symptoms such as polyuria, polydipsia, polyphagia, and, in severe cases, mental status changes. Identifying the triggering factor is crucial to prevent complications and effectively manage this medical emergency. Methods: This report describes the case of a 58-year-old male patient with stage IIIb nodular melanoma, diagnosed in November 2022. Results: After receiving five cycles of pembrolizumab, the patient developed de novo DKA, presenting with blurred vision, asthenia, adynamia, polyuria, and polydipsia. He was admitted to the emergency department with a blood glucose level of 764 mg/dL, confirming hyperglycemia and metabolic acidosis. He was transferred to the intensive care unit for fluid resuscitation and insulin infusion. After adequate clinical evolution and meeting the criteria for DKA resolution, possible autoimmune endocrinopathies secondary to immunotherapy were considered. Due to this complication, the oncological treatment was changed. Finally, the patient was discharged with the need to continue insulin therapy and oral hypoglycemic agents, along with thyroid hormone supplementation. Conclusions: The novelty of this case lies in the presentation of DKA as an immune-mediated complication induced by pembrolizumab, highlighting the importance of closely monitoring patients receiving immune checkpoint inhibitors to detect and manage emerging autoimmune endocrinopathies. It is essential to adjust oncological treatment according to the patient’s response and promptly manage autoimmune endocrinopathies to improve clinical outcomes and the patient’s quality of life. Full article

Aims: The accurate prediction of blood glucose (BG) levels is critical for managing Type-1 Diabetes (T1D) in pediatric patients, where variability due to factors like physical activity and developmental changes presents significant challenges. Methods: This work explores the application of foundational models, particularly the encoder–decoder model TimeGPT, for BG forecasting in T1D pediatric patients. Methods: The performance of TimeGPT is compared against state-of-the-art models, including ARIMAX and LSTM, and multilayer perceptron (MLP) architectures such as TiDE and TSMixer. The models were evaluated using continuous glucose monitoring (CGM) data and exogenous variables, such as insulin intake. Results: TimeGPT outperforms or achieves comparable accuracy to the state of the art and MLP models in short-term predictions (15 and 30 min), with most predictions falling within the clinically safe zones of the Clarke Error Grid. Conclusions: The findings suggest that foundational models like TimeGPT offer promising generalization capabilities for medical applications and can serve as valuable tools to enhance diabetes management in pediatric T1D patients. Full article

Aims: This study aims to assess the perspective of doctors and nurses regarding the clinical settings and barriers to implementing opportunistic diabetic retinopathy screening with handheld fundus cameras. Design: This study was a cross-sectional, online questionnaire study. Methods: An online survey was distributed to doctors and nurses working in Portuguese primary care units and hospitals between October and November 2021. The survey assessed current fundus observation practices, potential contexts, and barriers to using handheld fundus cameras. Results: We received 299 eligible responses. About 87% of respondents (n = 255) believe in the clinical utility of handheld fundus cameras to increase patients’ access to diabetes-related retinopathy screening, and 74% (n = 218) attribute utility to identify other eye or systemic diseases. More than a third of participants (37%, n = 111) envisioned using such devices multiple times per week. The main potential barriers identified included limited time (n = 90), equipment cost (n = 48), or the lack of skills in retinal image acquisition (n = 47). Most respondents (94%, n = 275) expected a follow-up recommendation to accompany the telemedicine diagnosis. Conclusions: Doctors and nurses support the use of handheld fundus cameras. However, to optimize their implementation, some strategies should be considered, including training, telemedicine-based diagnosis, and support for follow-up through accessible, user-friendly, and efficient information systems. Full article

Introduction: Limited studies have explored the impact of cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulators on glucose tolerance and insulin secretion in patients with CF, yielding varied results. This study aims to assess alterations in glucose metabolism and insulin secretion over 24 and 52 weeks following CFTR modulator initiation in a cohort of pediatric and adult patients with CF. Materials and Methods: A prospective longitudinal study conducting oral glucose tolerance test (OGTT) with C-peptide and insulin levels. The insulin secretion rate at 60 min (ISR60) and the insulinogenic index (IGI) were calculated during the first 60 and 30 min of the OGTT, respectively. Glucose metabolism status was categorized as normal (NGT), indeterminate (INDET), impaired glucose tolerance (IGT), or cystic fibrosis-related diabetes (CFRD). Additionally, continuous glucose monitoring (CGM) was performed for 14 days at each visit. We employed a repeated-measures general linear model to assess changes in insulin secretion and CGM metrics, with glucose tolerance status as the between-subjects factor and visit (baseline, 24 and 52 weeks) as the within-subjects factor. Results: The study comprised 25 patients (11 adults and 14 pediatrics). At baseline, 2 patients (8%) had NGT, 8 (32%) had INDET, 10 (40%) had IGT, and 5 (20%) had CFRD. Overall, there were no significant changes in insulin and C-peptide area under the curve (AUC), IGI and DI after 52 weeks. However, we observed an increase in ISR60 among NGT patients (mean change: 1.766; 95% CI: 1.414; 2.118, p < 0.001). Consistently, average glucose exhibited a significant decrease in NGT patients between 24 and 52 weeks (mean change: −5.645; 95% CI: −4.233; −10.866, p = 0.028). Conclusions: Treatment with CFTR modulators potentially enhances insulin secretion in patients with CF NGT. Early initiation of treatment, as evaluated through long-term prospective trials, is essential to further investigate whether decreased glucose control is preventable or reversible. Full article

(1) Background: Prediabetes represents reversible glycemic abnormalities between normal glucose regulation and diabetes. Indonesia has a high burden of non-communicable diseases, such as diabetes. This study aims to evaluate the impact of lifestyle changes on prediabetes and diabetes in rural and urban populations. (2) Methods: This is a repeated cross-sectional study, and data were obtained from Basic Health Research (RISKESDAS) in 2013 and 2018. (3) Results: The study found that urban populations who ate >3 days/week of vegetables had a lower proportion of prediabetes and diabetes. Rural populations with 2 days/week of vegetable consumption had a higher risk of prediabetes in 2018. From 2013 to 2018, urban and rural populations consumed excessive amounts of sweet food/drink, salty food, fatty/cholesterol/fried food, and meat/chicken/fish-based food with preservatives. In 2018, urban and rural populations who consumed sweet food/drink more than once daily had a higher risk of prediabetes and diabetes. The prevalence of active physical activity declined in normoglycemic individuals, while it increased in prediabetes and diabetes in urban and rural areas. In 2013, physical activity was a protective factor for prediabetes. (4) Conclusions: Lifestyle changes impacted prediabetes and diabetes prevalence. Further research is needed to promote healthy diets and lifestyle modifications. Full article