Endocrinology and Diabetes

Is this Acute Manifestation of Adrenal Crisis? (2025)

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Type of publication:

Journal article

Author(s):

*Nwaneri C.

Citation:

Acta Medica International. 12(1) (pp 66-71), 2025. Date of Publication: 01 Jan 2025.

Abstract:

Adrenal crisis is a life threatening complication of both primary and secondary adrenocortical insufficiency. The diagnosis of adrenal crisis requires a high index of suspicion, such as circulatory collapse, refractory hypotension, and metabolic acidosis. The clinical features are because of both mineralocorticoid and glucocorticoid deficiencies. The primary and initial treatment is intravenous cortisol therapy, and saline (sometimes glucose). Case presentation was used in this 43 year old woman who presented with dizziness, anorexia, vomiting, generalized weakness, and lethargy. She had a history of recent tuberculosis infection and was commenced on antituberculosis therapy, rifampicin. Her biochemical profile was suggestive of impending adrenal crisis. Her chest X ray and computed tomography were grossly normal. The patient recovered completely and was discharged home with the resolution of her deranged metabolic and electrolyte derangements. Appropriate specialist care is vital in patients with adrenal crisis, coupled with initial aggressive fluid resuscitation and acid base balance and good intensive care.

DOI: 10.4103/amit.amit_89_24

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Is Hybrid Closed Loop Continuous Subcutaneous Insulin Infusion Beneficial in Adults with Type 1 Diabetes(T1D) on Continuous Glucose Monitoring: A Reallife District General Hospital Perspective (2024)

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Type of publication:

Conference abstract

Author(s):

*Jones A.; *Basavaraju N.; *Cane C.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A275-A276), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: Hybrid closed loop(HCL) continuous subcutaneous insulin infusion(CSII) and continuous glucose monitoring(CGM) have made significant improvements in management of T1D.We studied benefits of Hybrid closed loop(HCL) over non-closed loop(NCL) CSII in a cohort of adults with T1D. Method(s): We analysed a live database of patients managed in a single District General Hospital (DGH) service on CSII from 2011 onwards. %Time in range (TIR), %hypoglycaemia (%hypo) and HbA1c were analysed with independent samples T-Test (SPSS software). Result(s): 302 patients were included: mean age was 44 years (range 19-81), female:male 57:43, diabetes duration 25years (range 2-61), and mean pre-CSII HbA1c 63mmol/mol. 218 were on HCL, 21 partial closed loop(PCL) and 63 were NCL. All patients were either on real-time(rt)CGM or intermittently scanned( is)CGM. HCL users were on Medtronic 780G with Guardian G4 sensor or Tandem T-Slim with Dexcom G6 sensor and NCL patients mostly on Omnipod DASH with rtCGM or isCGM. For HCL vs NCL systems, mean HbA1c (52 vs 57mmol/mol, p < 0.005), TIR (71% vs 62%, p < 0.005) were significantly improved on HCL. There was a trend to reduced %hypo (1.64% vs 2.64%,p = 0.08) but not statistically significant. Conclusion(s): This analysis demonstrates significantly better glycaemic control, in both HbA1c and TIR parameters, in HCL CSII users compared to NCL CSII in T1D. Hypoglycaemia was reduced but did not achieve statistical significance, possibly due to overall low rate of hypoglycaemia in the entire cohort. We speculate patients would have been responding to CGM alarm warnings to abort actual hypoglycaemic events.

Is Continuous Glucose Monitoring (CGM) the Critical Technological Intervention in Adults with Type 1 Diabetes(T1D) on Continuous Subcutaneous Insulin Infusion (CSII) Therapy? (2024)

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Type of publication:

Conference abstract

Author(s):

*Jones A.; *Basavaraju N.; *Cane C.; *Kumar A.; *Moulik P.;

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A230), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: We assessed impact of CGM in existing CSII patients with T1D switching to hybrid closed loop (HCL), partial closed loop (PCL) or remaining on non-closed loop (NCL) CSII. Method(s): Outcomes of patients with T1D on CSII in an adult service from 2011 were reviewed. Analysis of %Time in range (%TIR), %hypoglycaemia (%hypo) and HbA1c was done with SPSS. Result(s): 302 patients were included. 183 were on Tandem T-Slim(T-Slim), 58 Omnipod Dash(DASH), 39 Medtronic780G(780G), 11 Medtronic670G(670G), and 7 Medtronic640G(640G). 218 were on HCL, 21 PCL and 63 NCL. All were on either real-time (rt)CGM (DexcomG6, GuardianG3 or GuardianG4) or intermittently scanned (is)CGM (Freestyle Libre2). T-Slim, DASH, 780G, 670G, 640G showed mean HbA1c of 53.8, 55.6, 53.0, 62, 52.8mmol/mol; %TIR of 70, 64, 72, 61, 56%; and %hypo of 1.7, 1.8, 2.0, 1.4, 4.0% respectively. Post-hoc analysis only showed statistically significant benefits with HbA1c for T-Slim over 670G, and 780G over 670G; %TIR for 780G over 640G and %hypo for T-Slim over 640G. Mean HbA1c and %TIR were significantly better on HCL vs NCL and PCL, but not %hypo. PCL did not show benefit over NCL in HbA1c, %TIR or %hypo. Conclusion(s): We propose CGM confers the most important interventional benefit in patients already on CSII. HCL provided additional benefits in improving glycaemia, both TIR and HbA1c, but not hypo in patients on CGM. PCL does not provide additional benefits over NCL in patients on CGM. QOL indices, however, may show additional benefits both in HCL and PCL.

Does Age Influence Clinical and Patient Satisfaction Outcomes in Adults with Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion (CSII) And Continuous Glucose Monitoring (CGM)? (2024)

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Type of publication:

Conference abstract

Author(s):

*Jones A.; *Basavaraju N.; *Cane C.; *Kumar A.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A124), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: There is a possibility of subconscious bias towards using complex technology in young adults. Patient perceptions towards treatment may be influenced by age. We explored outcomes and patient experiences in various age groups with Type 1 Diabetes(T1D). Method(s): Database of patients within a single adult pump service was analysed for HbA1c, %time in range(%TIR), %hypoglycaemia(%hypo). Additionally, for Hybrid closed-loop patients Diabetes Treatment Satisfaction Questionnaire (DTSQ), Type 1 Diabetes Distress score(T1DDS), Hypoglycaemia fear survey(HypoFS) and Insulin dosing systems, perceptions, ideas, reflections, and expectations (INSPIRE)scores were analysed in different age groups. Result(s): 302 patients were included: mean age 44 years (range 19-81), 57% females, mean diabetes duration 25years (range 2- 61), and mean pre-CSII HbA1c 63mmol/mol. 218 users had hybrid closed-loop(HCL), 21 partial closed-loop and 63 non-closed-loop CSII. All were on CGM. Only 2 patients were aged above 75years and excluded from statistical analysis. Compared to the entire cohort, 19-25-year-olds had worse mean HbA1c(53.8vs58.8%), TIR(68.7vs59%) and %hypo(1.79vs2.33%), of which only %hypo was not statistically significant. Clinical outcomes were similar in all other groups. Positive Correlation(r) with age was noted with TIR(r = 0.263,p <0.001), DTSQ(r = 0.143, p = 0.03), and negative correlation with %hypo(r = -0.127, p = 0.028), HypoFS(r = -0.309, p <0.001), T1DDS(r = -0.244,p <0.001), and INSPIRE(r = – 0.146,p = 0.038). HypoFS were worse in younger individuals with progressive improvement with increasing age. Conclusion(s): Young adults (19-25 years) had worse clinical outcomes compared to other adults on CSII. Diabetes distress, fear of hypoglycaemia was higher in younger individuals. Use of complex technology including HCL was equally embraced across all age groups, though younger patients may have greater acceptance.

Hybrid-Closed Loop Pump in Type 1 Diabetes (T1D) Improves Clinical Outcome More Than Quality of Life (QoL) Compared to Nonclosed Loop Pumps Supported By CGM (2024)

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Type of publication:

Conference abstract

Author(s):

*Basavaraju N.; *Jones A.; *Cane C.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A327), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: Hybrid closed loop(HCL) continuous subcutaneous insulin infusion(CSII) and continuous glucose monitoring(CGM) have made significant improvements in management of T1D. We studied benefits of Hybrid closed loop(HCL) over non-closed loop(NCL) CSII in a cohort of adults with T1D. Method(s): We analysed a live database of patients managed in a single centre on CSII. Clinical parameters assessed included %Time in range(TIR), %hypoglycaemia(%hypo) and HbA1c. QOL was assessed with Diabetes Treatment Satisfaction Questionnaire( DTSQ), Hypoglycaemia Fear Survey(HFS), Type 1 Diabetes Distress score(T1DDS). Data was analysed using the SPSS software. Result(s): Data on 281 patients were included, mean age was 44 years(range 19-81), 57% females. 218 were on HCL (Medtronic 780G with Guardian G4 sensor or Tandem T-Slim with Dexcom G6 sensor) and 63 (Omnipod DASH with Dexcom G6 or Freestyle Libre 2). For HCL vs NCL systems, clinical parameters improved with mean HbA1c (52 vs 57mmol/mol, p < 0.005), TIR (71% vs 62%, p < 0.005) and %hypo (1.64% vs 2.64%, p = 0.08). QOL improvement favoured HCL, but were non-significant with mean DTSQ (36.3 vs 35.5, p = 0.21), HFS (33.6vs34.9, p = 0.71) and T1DDS (47.2 vs 49.3, p = 0.40). There was no significant difference in clinical or QOL parameters between Medtronic 780G and Tandem T-Slim HCL systems. Conclusion(s): HCL systems studied had clear benefits in terms of clinical outcome parameters compared to NCL, but this was not reflected in improved patient perceptions on QOL. All patients on NCL being on CGM may be a possible explanation, with the reassurance of CGM making the biggest impact on patients perceived QOL.

Effect of Long Disease Duration on Clinical and Patient Perceived Satisfaction Outcomes in Patients with Type 1 Diabetes (T1DM) on CSII And CGM (2024)

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Type of publication:

Conference abstract

Author(s):

*Jones A.; *Basavaraju N.; *Cane C.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A326), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: Patients with longstanding T1DM tend to have more glycaemic variability. Patient perceptions towards chronic disease change over time. We examined outcomes in patients on CSII with different DM durations. Method(s): A single adult service outcome database of T1DM patients was analysed for Hba1c, %Time in range(%TIR), %hypoglycaemia(%hypo). For Hybrid closed loop(HCL) patients, Diabetes Treatment satisfaction Questionnaire(DTSQ), Type 1 Diabetes Distress score(T1DDS), Hypoglycaemia fear survey(HypoFS) and Insulin dosing systems, perceptions, ideas, reflections and expectations(INSPIRE) scores were analysed. Results were compared across different disease duration groups. Result(s): A cohort of 302 patients with T1DM were studied. 218 were on HCL, 21 partial closed loop and 63 were nonclosed loop CSII. All were on CGM. Mean diabetes duration was 25 years (range 2-61), male:female 43:57. Mean Hba1c(53.8mmol/mol), %TIR(68.7%) and %hypo(1.79%) were similar except 21-30year duration group who had better Hba1c and TIR. Correlation(r) for Hba1c(r = -0.111,p = 0.055), TIR(r = 0.206, p < 0.001) and %hypo(r = -0.106, p = 0.067) suggest better outcomes with longer duration of diabetes. HypoFS(r = -0.169,p = 0.016) and T1DDS(r = -0.192,p = 0.006) scores correlated inversely, DTSQ(r = 0.148, p = 0.035) positively and INSPIRE(r = -0.127, p = 0.069) did not correlate with diabetes duration. Conclusion(s): CSII and CGM glycaemic outcomes were similar in patients with all diabetes durations, highest in the 20- 30 years duration group. Reasons for this remains uncertain. Longer duration correlated with better outcomes on Hba1c, TIR and satisfaction scores. Hypo fear and diabetes distress was greater with shorter duration though hypo frequency was not statistically correlated to diabetes duration. These may be due to human factors, better disease acceptance and perceptions with longer duration.

Clinical and Patient Satisfaction Outcomes in People with Type 1 Diabetes from Different Social Background Treated with CSII and CGM (2024)

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Type of publication:

Conference abstract

Author(s):

*Jones A.; *Basavaraju N.; *Cane C.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: Advanced Techologies and Treatments for Diabetes Conference, ATTD 2024. Virtual. 26(Supplement 2) (pp A326-A327), 2024. Date of Publication: 01 Feb 2024.

Abstract:

Background and Aims: There may be a bias towards use of expensive technological innovations in people from higher socioeconomic classes. We explored patient experiences and outcomes in different socioeconomic backgrounds with T1diabetes( T1DM) treated with insulin pumps. Method(s): Index of Multiple Deprivation (IMD), an official statistic based on income, education, employment, health, housing, crime and living environment was used to stratify patients into quintiles based on socioeconomic status. HbA1c, time in range(%TIR), %hypoglycaemia(%hypo), Diabetes Treatment Satisfaction Questionnaire (DTSQ), Type 1 Diabetes Distress score (T1DDS), Hypoglycaemia fear survey (HypoFS) and Insulin dosing systems, perceptions, ideas, reflections and expectations (INSPIRE) scores in different IMD quintiles were analysed. Result(s): 302 patients were included: mean age 44 years (range 19-81), male:female 43:57 diabetes duration 25years (range 2- 61). 218 were on hybrid closed-loop, 21 partial closed-loop and 63 on non-closed-loop CSII. All were on CGM. Mean HbA1c (53.7vs52.6mmol/mol, correlation r = -0.059,p = 0.3), %TIR (67.7vs70.1%,r = -0.053,p = 0.36) and %hypo (2.29vs1.58%,r = -0.117,p = 0.043) had a trend to be worse in lower socioeconomic classes but correlation was not statistically significant apart from in %hypo. Mean DTSQ and INSPIRE scores were similar between social classes but mean T1DDS (52.8vs41.8,r = -0.189,p = 0.007) and HypoFS (41.7vs29.9,r = -0.145,p = 0.038) scores were worse in lowest compared to highest social quintile. Conclusion(s): Outcomes on CSII and CGM were broadly similar across all social backgrounds. There was statistically significant correlation, albeit low, between lower socioeconomic class and hypoglycaemia. This may explain the higher greater diabetes distress and hypoglycaemia fear in lower socioeconomic classes. Diabetes treatment satisfaction including with HCL were similar.

Altered body image, disordered eating, and suboptimal glycaemic control in type 1 diabetes: Is technology and GLP1 agonists an option? (2024)

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Type of publication:
Conference abstract

Author(s):
*Basavaraju N.; *Jones M.; *Moulik P.

Citation:
British Journal of Diabetes. Conference: ABCD Diabetes Update. Loughborough United Kingdom. 24(1) (pp 112-113), 2024. Date of Publication: June 2024.

Abstract:
Introduction: Disordered eating in type 1 diabetes (T1DM) is associated with diabetes distress and suboptimal glycaemic control. We present a case of T1DM with binge eating disorder, discussing the benefits of GLP-1 analogues with continuous subcutaneous insulin infusion (CSII) therapy. Case: A 35-year-old female was diagnosed with T1DM in 2012, at 24 years of age, and commenced on basal bolus insulin. She had two pregnancies over the next seven years with good glycaemic control. There was pronounced dawn phenomenon post-pregnancy which was reflected in her erratic Freestyle Libre glucose readings. CSII therapy with Tandem T-slim was commenced a year later, in October 2020. Over the next 12-18 months, she was diagnosed with depression and hypertension, missed her outpatient diabetes clinic appointments, and struggled with diabetes management and fear of hypoglycaemia. During mid-2022 she developed mental health issues, with hallucinations and binge eating and a likely diagnosis of bipolar personality disorder. Later in the year, she was commenced on Tandem T-slim CSII and Dexcom G6 with Basal IQ technology. There was no evidence of retinopathy or neuropathy on annual diabetes screening. During outpatient diabetes review in February 2023, there was recurrent insulin pump auto-suspend followed by rebound hyperglycaemia and hence overnight basal insulin was reduced. Six months later, her weight had increased and glycaemic control worsened due to continued binge eating, missing pre-meal boluses, and she continued to be under the mental health liaison team. Her insulin was changed from Novorapid to Lyumjev (after discussion with the patient due to licensing criteria with the insulin pump) to accommodate binge eating hyperglycaemia and she was supported by motivational interviewing whilst awaiting review by eating disorders services. A month later, in October 2023, after CSII MDT discussion, she was commenced on control IQ – hybrid closed loop (HCL). In November 2023, her GMI (Glucose Management Indicator) improved, and she was commenced on dulaglutide after full discussion and patient consent including licensing criteria in T1DM. A month later, her food cravings reduced, she felt more positive about diabetes self-management and her insulin requirement reduced from 108 units to 98 units (basal 38%, bolus 62%). Her weight, BMI, HbA1c and ambulatory glucose profile data are shown in the Table. Discussion(s): HCL helped to improve glycaemic control by increasing TIR and reducing HbA1c. GLP-1 analogues have shown positive effects on reducing binge eating and weight loss. The combination of HCL and GLP-1 analogue in this patient resulted in lower insulin doses, positive attitude towards diabetes self-management along with improved clinical parameters and patient satisfaction. Binge eating disorders are associated with obesity and increase in cardiovascular risk. GLP-1 analogues in obese T1DM patients improve metabolic profile, weight, HbA1c and insulin requirement, with no increase in incidence of diabetic ketoacidosis or hypoglycaemia. There are no reported cases of T1DM with binge eating disorder on GLP-1 analogues in the literature and hence further studies are warranted.

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A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus (2024)

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Type of publication:
Journal article

Author(s):
White, Billy; Ng, S M; Agwu, J C; Barrett, T G; Birchmore, N; Kershaw, M; Drew, J; Kavvoura, F; Law, J; Moudiotis, C; Procter, E; Paul, P; Regan, F; Reilly, P; Sachdev, P; *Sakremath, R; Semple, C; Sharples, K; Skae, M; Timmis, A; Williams, E; Wright, N; Soni, A.

Citation:
BMC Medicine. 22(1):144, 2024 Apr 02.

Abstract:
BACKGROUND: Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS: Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION: Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS: This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

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Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance (2024)

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Type of publication:
Journal article

Author(s):
Lauri, Chiara; Noriega-Alvarez, Edel; *Chakravartty, Riddhika M; Gheysens, Olivier; Glaudemans, Andor W J M; Slart, Riemer H J A; Kwee, Thomas C; Lecouvet, Frederic; Panagiotidis, Emmanouil; Zhang-Yin, Jules; Martinez, Jose Luis Lazaro; Lipsky, Benjamin A; Uccioli, Luigi; Signore, Alberto.

Citation:
European Journal of Nuclear Medicine & Molecular Imaging. 2024 Mar 27.

Abstract:
PURPOSE: Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS: This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS: Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION: These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

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