Severe Hypoglycemic Episodes Research Articles

Evaluation of severe hypoglycemia management in children and adolescents with type 1 diabetes in a Belgian tertiary pediatric care center: impact of intranasal glucagon and cost analysis.

To evaluate the management and costs of severe hypoglycemia (SH) in children and adolescents with type 1 diabetes (T1D) in our Belgian tertiary pediatric care center. In the EPI-GLUREDIA study, clinical parameters from children and adolescents with T1D were retrospectively analyzed from July 2017 to June 2024. The characteristics of SH and its treatment were collected during the medical consultation following the SH episode. Between July 2017 and June 2024, 208 cases of SH were recorded in 113 children and adolescents with T1D, with an average age of 13.6years and T1D duration of 6.2years. Oral glucose was the most common treatment (47.4%), while glucagon was used in only 25.4% of cases and more frequently in boys (30.8%) than in girls (18.7%). Notably, only 43% of SH episodes were treated according to international guidelines. A significant increase in glucagon use was observed after reimbursement of its intranasal form in Belgium in January 2022. After 2022, glucagon use significantly increased (28/81 vs. 25/129; p = 0.013), particularly among teachers and educators (18/49 vs. 10/78; p = 0.002). The average direct cost of treating SH was €187.9, with costs ranging from €0 to €1092.5 depending on the treatment method.Conculusion: Our study underscores the difficulty in managing SH in young people with T1D, with only 43% being treated as per guidelines. Since 2022, the increased use of the intranasal form of glucagon in Belgium led to reduced healthcare costs and improved care of patients experiencing SH.

Assessing prevalence and predictors of impaired awareness of hypoglycemia in type 2 diabetes patients with chronic kidney disease

BackgroundThis study aims to determine the prevalence of impaired awareness of hypoglycemia (IAH) across all chronic kidney disease stages in patients with type 2 diabetes mellitus and to identify predictors of impaired awareness of hypoglycemia within these patients.MethodsClinical and laboratory data were extracted from patient medical records. Participants were interviewed using validated modified Clarke’s questionnaire and Gold score to assess impaired awareness of hypoglycemia.ResultsCross sectional study included 480 participants diagnosed with chronic kidney disease and type 2 diabetes. The overall prevalence of impaired awareness of hypoglycemia (IAH) was 34.6% (166 patients) according to the Clarke questionnaire and 34.4% by the Gold Score (165 patients). This prevalence varied significantly across different CKD stages, with higher rates in stage 3 (P value = 0.001). The mean impaired awareness of hypoglycemia scores were 3.98 ± 1.34 (Clarke) and 3.92 ± 1.52 (Gold), with advanced CKD stages showing statistically significant elevated scores (p value ≤ 0.05). In the 166 patients with impaired awareness of hypoglycemia, a statistically significant higher incidence of severe hypoglycemia was observed in hemodialysis patients (p value = 0.01). Most of patients with impaired awareness of hypoglycemia aged > 60 years, had more prevalent hypertension and had lower HbA1c levels (P value ≤ 0.05). However, Multivariate logistic regression analysis found that age > 60 years was a significant independent risk factor with an 8% higher risk for IAH (P = 0.01), (OR 1.08, 95% CI 1.01–1.16).ConclusionThe present study is unique in investigating impaired awareness of hypoglycemia (IAH) across the full spectrum of chronic kidney disease (CKD) stages, including patients on hemodialysis. Approximately one-third of CKD patients with type 2 diabetes mellitus exhibited a general lack of awareness of hypoglycemia. Patients with stage 3 CKD showed the highest prevalence of IAH. Those already experiencing IAH and receiving hemodialysis faced more severe hypoglycemic episodes. Age over 60 years was an independent risk factor for hypoglycemia unawareness in this patient group. Larger wide scale studies are needed to further validate these results.

Evaluating the impact of severe hypoglycaemia definition wording on severe hypoglycaemia history assessment.

Several wordings of the definition of severe hypoglycaemia (SH) exist. This study aims to evaluate how different SH definition wordings affect SH history assessment. In this cross-sectional study, surveys were emailed to registrants of the T1D Exchange, a U.S. national type 1 diabetes patient registry. Participants' demographic information was collected. Six-month SH history was evaluated with questionnaires including SH definition wordings from either (1) professional societies, (2) a diabetes community website, or (3) a hypoglycaemia research questionnaire. Analyses included the McNemar test, pairwise Wilcoxon signed-rank test, logistic regression analysis, Kappa statistics, and Spearman correlation. A total of 1580 valid responses were obtained from participants (52% female; mean ± SD age: 46 ± 15 years; 95% White; mean ± SD diabetes duration: 25 ± 16 years). Questionnaires with four different SH definition wordings yielded significant variations in the prevalence of SH (i.e., having developed at least one episode of SH) and the number of SH episodes: the ADA/ENDO 2013 definition wording yielded the highest results on both metrics, whereas HypoA-Q and ADA 2023 yielded the lowest. Among participants reporting at least one SH episode, the number of episodes identified with the different SH definition wordings was poorly correlated (Rs: 0.09-0.37; p < 0.001). Race, education level, and household income were associated with higher odds of discrepancies in SH history (p < 0.05). This U.S. national survey with individuals living with type 1 diabetes demonstrated significant discrepancies in SH history when assessed with different SH definition wordings. Race and socioeconomic status were associated with these discrepancies.

Performance of a safety protocol for scuba diving in people with type 1 diabetes: 20years of "Diabete Sommerso®" experience.

Scuba diving for people with diabetes was discouraged due to hypoglycemia risks. However, evolving guidelines now enable safe diving for people with diabetes. Among them, the Diabete Sommerso® safety protocol. This study aims to describe data from 20years of DS activities and evaluate the performance of the protocol in avoiding metabolic complications. During DS camps, participants are trained to monitor glycemia before and immediately after diving, aiming for stable levels between 150-250mg/dl. Since 2004, glycemic data from dives conducted with DS/independently by its members have been collected. DS issued diving licenses to 74 type 1 diabetic people. Data are available for 68: median age was 32years (IQR 22 yrs), diabetes duration 18years (IQR 16 yrs), HbA1c 7% (IQR 1%). 34 used insulin pumps, 43 continuous glucose monitoring. A total of 1179 dives were analyzed, showing a median reduction in glycemia of -38mg/dl during dives (IQR 92mg/dl, p<0.0001). Post-dive hypoglycemia occurred in 23 cases, 45% of which involved protocol non-adherence. Hypoglycemia prevalence was 1.7% when the protocol was followed. No severe hypoglycemic episodes occoured during/after diving. Data from 1179 dives indicate that, with adherence to the safety protocol, scuba diving is safe and poses no risk of severe hypoglycemia for people with type 1 diabetes.

How Might We Tell if Advances in Diabetes Care and Technology are Helping People to Feel Less Constrained? Introducing the Diabetes Constraints Scale.

Recent advances in diabetes care and technology, such as real-time continuous glucose monitoring, can help people live more freely, with more flexibility and fewer constraints, thereby enhancing quality of life (QOL). To date, there has been no validated means for measuring this key psychological dimension. We developed the Diabetes Constraints Scale (DCS) to assess perceived constraints pertaining to diabetes self-management. Six items were developed from qualitative interviews (20 adults with type 2 diabetes [T2D], 8 adults with type 1 diabetes [T1D]). Items were included in one study with T2D adults (N = 458) and one with T1D adults (N = 574). Scale reliability was analyzed for each study using exploratory factor analyses. Associations between DCS and key psychosocial and glycemic variables were assessed. In both studies, factor analyses revealed a single factor, with adequate internal reliability (Cronbach's alpha >.80). Both studies demonstrated significant associations in the expected direction between DCS and overall well-being, diabetes-specific QOL, and diabetes distress (all P < .001). In both studies, DCS was positively linked with the number of missed insulin boluses and the frequency of severe hypoglycemic episodes (T1D both P < .001; T2D both P < .005) and-in the T1D group only-with HbA1c (P < .001). The DCS is a reliable and valid method to determine the degree to which adults with diabetes feel constrained or limited by the disease. It may serve as a useful tool for assessing how new interventions can help individuals feel freer in the face of the demands of diabetes.

Severe hypoglycaemia and diabetic ketoacidosis in adults presenting to a hospital emergency department: Adverse prognostic markers for survival in type 2 diabetes and the role of SGLT2 inhibitors.

To determine the prognosis associated with severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA) in adults presenting to a hospital emergency department (ED). Medical records of adults with type 1 (T1D) and type 2 (T2D) diabetes who attended the ED with SH and DKA between 1 January 2019 and 30 June 2023, were reviewed for comorbidities, long-term survival, mortality and causes of death. A total of 429 episodes of DKA occurred in 293 people and 643 episodes of SH in 515 people. DKA predominated in T1D (77.6%) and SH in T2D (54.3%). In T2D, 32.3% of DKA events were associated with sodium-glucose cotransporter-2 inhibitor (SGLT2-i) medication. In both SH and DKA, patients with T2D were older and had more comorbidities than T1D, particularly cardiorenal disease, heart failure, cognitive impairment and cancer (all p < 0.005). Compared with T1D, mortality was higher in T2D after SH (48.4% vs. 19.9%, p < 0.005) and after DKA (30.8% vs. 13.4%, p = 0.001) with shorter median times to fatal outcome (SH: 134 vs. 511 days; DKA: 43 vs. 266 days, both p < 0.005). Long-term survival was lower (p < 0.005) and mortality risk was higher in T2D after index presentation with SH (HR 3.43 [95% CI: 2.43-4.84], p < 0.005) and DKA (HR 3.00 [95% CI: 1.77-5.10], p < 0.005). Irrespective of diabetes type, most causes of death in SH and DKA were non-cardiovascular. SH and DKA events requiring hospital treatment herald a poor prognosis with greater mortality in T2D adults with multimorbidity. A significant number of DKA episodes in T2D occurred in people receiving SGLT2-i medication.

Cardiovascular, Metabolic, and Safety Outcomes with Semaglutide by Baseline Age: Post Hoc Analysis of SUSTAIN6 and PIONEER6.

The high risk of cardiovascular events in people with type2 diabetes increases with age. The cardiovascular effects of once-weekly subcutaneous and once-daily oral semaglutide versus placebo in people with type2 diabetes at high cardiovascular risk were investigated in the SUSTAIN6 and PIONEER6 cardiovascular outcomes trials, respectively. It is unknown whether the effects of semaglutide are age dependent. This post hoc analysis evaluated cardiovascular, metabolic, and safety outcomes with semaglutide versus placebo in age subgroups (≤ 60; > 60 to ≤ 65; > 65 to ≤ 70; and > 70years) pooled from SUSTAIN6 and PIONEER6. Major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), changes from baseline in glycated hemoglobinA1c (HbA1c) and body weight, and adverse events were analyzed. Semaglutide reduced major adverse cardiovascular events and its components versus placebo across age subgroups (most hazard ratios < 1.0; pinteraction > 0.05). The treatment difference in HbA1c reduction was greater in those aged ≤ 60years than in older subgroups (pinteraction = 0.01). Reductions in body weight with semaglutide versus placebo were consistent across agesubgroups (pinteraction = 0.124). Serious adverse events or severe hypoglycemic episodes did not differ between semaglutide and placebo across age subgroups. Semaglutide consistently reduced major adverse cardiovascular events and body weight versus placebo across age subgroups; its safety profile did not differ with age. These results suggest that relaxing HbA1c targets based solely on age may not always be required for people with type2 diabetes. SUSTAIN6 (NCT01720446) and PIONEER6 (NCT02692716) are registered at ClinicalTrials.gov.

Characterising impaired awareness of hypoglycaemia and associated risks through HypoA-Q: findings from a T1D Exchange cohort.

We aimed to: (1) externally validate the five-item Hypoglycaemia Awareness Questionnaire (HypoA-Q) impaired awareness subscale (HypoA-Q IA); (2) examine how impaired awareness of hypoglycaemia (IAH) relates to the risk of severe hypoglycaemia and level 2 hypoglycaemia; and (3) identify factors associated with IAH. Nationwide survey of T1D Exchange registrants was conducted to collect data on demographics, 6 month severe-hypoglycaemia history, hypoglycaemia awareness status (via HypoA-Q IA, the Gold instrument and the Clarke instrument) and continuous glucose monitor (CGM) measures. The Clarke hypoglycaemia awareness factor (Clarke-HAF) was calculated to exclude severe-hypoglycaemia history items. Analyses included Cronbach's α, Spearman correlations and logistic regression. Valid survey responses were collected from N=1580 adults with type 1 diabetes (median age, 44 years; 52% female participants; median HbA1c, 48 mmol/mol [6.5%]). Of these, 94% of participants were using CGMs and 69% were using hybrid closed-loop (HCL) systems; 30% had at least one severe-hypoglycaemia episode in the past 6 months. The HypoA-Q IA had satisfactory internal reliability (α=0.79) and construct validity. Higher HypoA-Q IA scores were independently associated with greater risk of severe hypoglycaemia (p<0.001), performing comparably to the Gold instrument and the Clarke-HAF instrument. HypoA-Q IA-determined IAH was independently associated with 88% higher odds of developing severe hypoglycaemia (p<0.001) and twofold higher odds for spending ≥1% of time in level 2 hypoglycaemia (p=0.011). Higher age and longer diabetes duration were associated with higher IAH risk (p<0.001). CGM and HCL use was associated with lower IAH risk (p<0.001). The HypoA-Q IA is a brief, valid and reliable tool for assessing IAH in today's technology-oriented era. IAH was independently associated with severe hypoglycaemia and level 2 hypoglycaemia in a cohort with high prevalence of advanced diabetes technology use and HbA1c within the recommended range. CGM and HCL use was related to lower IAH risk.

Hypoglycaemia Prevention, Awareness of Symptoms, and Treatment (HypoPAST): protocol for a 24-week hybrid type 1 randomised controlled trial of a fully online psycho-educational programme for adults with type 1 diabetes

BackgroundManagement of type 1 diabetes (T1D) requires the use of insulin, which can cause hypoglycaemia (low blood glucose levels). While most hypoglycaemic episodes can be self-treated, all episodes can be sudden, inconvenient, challenging to prevent or manage, unpleasant and/or cause unwanted attention or embarrassment. Severe hypoglycaemic episodes, requiring assistance from others for recovery, are rare but potentially dangerous. Repeated exposure to hypoglycaemia can reduce classic warning symptoms (‘awareness’), thereby increasing risk of severe episodes. Thus, fear of hypoglycaemia is common among adults with T1D and can have a negative impact on how they manage their diabetes, as well as on daily functioning, well-being and quality of life. While advances in glycaemic technologies and group-based psycho-educational programmes can reduce fear, frequency and impact of hypoglycaemia, they are not universally or freely available, nor do they fully resolve problematic hypoglycaemia or associated worries. This study aims to determine the effectiveness of a fully online, self-directed, scalable, psycho-educational intervention for reducing fear of hypoglycaemia: the Hypoglycaemia Prevention, Awareness of Symptoms, and Treatment (HypoPAST) programme.MethodsA 24-week, two-arm, parallel-group, hybrid type 1 randomised controlled trial, conducted remotely (online and telephone). Australian adults (≥ 18 years) with self-reported T1D and fear of hypoglycaemia will be recruited, and allocated at random (1:1) to HypoPAST or control (usual care). The primary outcome is the between-group difference in fear of hypoglycaemia (assessed using HFS-II Worry score) at 24 weeks. A sample size of N = 196 is required to detect a 9-point difference, with 90% power and allowing for 30% attrition. Multiple secondary outcomes include self-reported psychological, behavioural, biomedical, health economic, and process evaluation data. Data will be collected at baseline, 12 and 24 weeks using online surveys, 2-week ecological momentary assessments, website analytics and semi-structured interviews.DiscussionThis study will provide evidence regarding the effectiveness, cost-effectiveness and acceptability of a novel, online psycho-educational programme: HypoPAST. Due to the fully online format, HypoPAST is expected to provide an inexpensive, convenient, accessible and scalable solution for reducing fear of hypoglycaemia among adults with T1D.Trial registrationAustralian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000894695 (21 August 2023).

6567 Novel Indication of GLP-1 Receptor Agonists Beyond Weight Loss: Addressing Post-Gastric Bypass Late Dumping Syndrome

Abstract Disclosure: G. Arevalo: None. S. Gra Menendez: None. D. Soliman: None. R.J. Galindo: Consulting Fee; Self; Novo Nordisk, Eli Lilly &amp; Company, Sanofi, Bayer, Inc., Boehringer Ingelheim, Pfizer, Inc., Abbott Laboratories. Grant Recipient; Self; National Institute of Diabetes and Digestive and Kidney Diseases (2P30DK111024), National Institute of Diabetes and Digestive and Kidney Diseases (K23DK123384). Other; Self; Novo Nordisk, Eli Lilly &amp; Company, Dexcom. Background: Late dumping syndrome, characterized by postprandial hyperinsulinemic hypoglycemia (PHH), represents a complex clinical challenge in post-bariatric patients. GLP-1 receptor agonists are being explored as an effective therapeutic option. Clinical Case: A 47-year-old overweight (BMI of 29.86 kg/m²) woman, with a medical history of scleroderma and esophageal dysmotility, underwent a gastric sleeve gastrectomy later requiring conversion to Roux-en-Y gastric bypass to improve esophageal motility. Eleven months post-bypass, she began experiencing recurrent episodes of hypoglycemia (venous glucose 49-70 mg/dL, n &amp;gt;70 mg/dL) accompanied by sweating, palpitations, drowsiness, and weakness. Initial tests were consistent with postprandial hyperinsulinemic hypoglycemia: serum insulin (13.5 µIU/mL, n &amp;lt; 3 µIU/mL), and c-peptide (4.1 ng/mL, n &amp;lt; 0.6 ng/mL). The Sigstad score and the Arts dumping severity score were positive for late dumping syndrome with a score of 26 and 14, respectively. During glucagon administration, the patient's blood glucose level increased by up to 50 mg/dL within 10 minutes of administration. Both sulfonylurea screening and insulin antibody tests were negative. Real-time CGM measurements showed patterns of postprandial hyperglycemic peaks, up to 160-180 mg/dL (n &amp;lt;140 mg/dL), approximately 30 to 60 min after meals, followed by rapidly declining glucose (1-2 hours later), resulting in hypoglycemic events as low as 49 mg/dL. Initial management with dietary changes and pharmacological treatment was unsuccessful due to poor medication tolerability of acarbose and diazoxide, and low adherence to the prescribed diet due to her esophageal dysmotility. The CGM patterns and symptom presentation raised suspicion that late dumping syndrome was triggered by rapid hyperglycemic responses after oral ingestions of typical meals, resulting in the desynchronization of hormonal responses (insulin and GLP-1), and post-prandial hypoglycemia. Hence, the consideration for a GLP-1 receptor agonist emerged. A weekly subcutaneous injection of a long-acting GLP-1 receptor agonist, semaglutide 0.25 mg exhibited marked improvement in her glycemic profile: fewer episodes of postprandial hyperglycemia, and the subsequent descents in blood glucose were less pronounced. The patient demonstrated a favorable response with no severe hypoglycemic episodes reported during a follow-up period of three months. Conclusion: This is the first case to demonstrate semaglutide's efficacy as a standalone treatment for PHH in post-bariatric patients. In this case, semaglutide effectively controlled glycemia and improved the patient's quality of life, presenting a promising therapeutic option for such complex cases. Presentation: 6/1/2024

Lantidra: Cell Therapy for Treatment of Type 1 Diabetes Mellitus

The more recent cell treatment for type 1 Diabetes is called lantidra. Lantidra has recently received approval to treat type 1 Diabetes mellitus. The first allogeneic (deceased donor) pancreatic islet cell therapy, lantidra (donislecel), was approved by the FDA Centre for Biologics Evaluation and Research (CBER) on June 28, 2023. It is intended to treat adults with type 1 diabetes who, despite current management, do not achieve target glycosylated hemoglobin levels due to recurrent episodes of severe hypoglycemia. The editorial’s goal is to draw attention to the growing impact of type 1 diabetes on the world’s health, discuss earlier attempts at pancreatic transplant techniques, and announces the first regulatory approval of a revolutionary transplant strategy called allogeneic pancreatic islet beta cell infusion.

Safety of Options to "Boost" (Enhancing Insulin Infusion Rates) and "Ease-Off" (Reducing Insulin Infusion Rates) in CamAPS FX Hybrid Closed-Loop System: A Real-World Analysis.

The usage and safety of the Boost and Ease-off features in the CamAPS FX hybrid closed-loop system were analyzed in a retrospective analysis of real-world data from 7,464 users over a 12-month period. Boost was used more frequently than Ease-off, but for a shorter duration per use. Mean starting glucose was above range for Boost (229 ± 51 mg/dL), and within range for Ease-off (114 ± 29 mg/dL). Time spent below 70 mg/dL was low during Boost periods [median (interquartile range; IQR) 0.0% (0.0, 0.5%)], and lower than during no Boost periods [2.1% (1.2, 3.4%)], while time spent above 180 mg/dL was lower during Ease-off periods (15 ± 14%) compared with no Ease-off periods (25 ± 12%). There were no episodes of severe hypoglycemia or diabetic ketoacidosis attributed to Boost or Ease-off use. Boost and Ease-off allow users to engage safely with CamAPS FX to manage their glucose levels during periods of more-than-usual and less-than-usual insulin needs.

Initiation or switch to insulin degludec/insulin aspart in adults with type 2 diabetes in India: Results from a prospective, non-interventional, real-world study.

To investigate clinical outcomes in adults with type 2 diabetes (T2D) after insulin degludec/insulin aspart (IDegAsp) treatment in a real-world setting. The 26 weeks study involved 1102 adults with T2D who were either initiated with or switched to IDegAsp according to local practice in six countries. It was an open-label, non-interventional study. The primary endpoint was the change in glycosylated haemoglobin (HbA1c) levels from baseline to the end of study (EOS). From India, 185 adults participated in this study with mean age of 58.1 (10.3) years and 14.4 (8.1) years of mean duration of T2D. Mean HbA1c decreased from 9.8% (1.8) at baseline to 8.2% (0.1) at the EOS; change in HbA1c from baseline [95% CI]: -1.6% (0.1) [-1.8; -1.4], P < 0.0001. There was a significant reduction in mean fasting plasma glucose (FPG) level from 190.0 (65.8) mg/dl at baseline to 141.9 (4.3) mg/dl at EOS; change in FPG from baseline [95% CI]: -52.2 (4.3) mg/dl [-60.7; -43.7], P < 0.0001. There was a numerical reduction in resource utilization related to diabetes and its complications and hypoglycaemic episodes. From baseline to EOS, the participants with outpatient visits (72 to 32) and workdays missed (2 to 0) decreased. Additionally, the number of patient-reported non-severe hypoglycaemic (47 to 8) and severe hypoglycaemic (4 to 1) episodes decreased as well. Initiation or switching to IDegAsp led to improvement in glycaemic control in real-world population of Indian adults with T2D. This was accompanied by a numerical reduction in resource utilization and patient-reported hypoglycaemia. Clinical trial registration: NCT04042441.

Optimizing Physical Activity for Glycemic Control in Type 1 Diabetes: Strategies and Risks

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune condition characterized by the destruction of insulin-producing beta cells in the pancreas, necessitating lifelong insulin therapy. This study explores the impact of physical activity on glycemic control and overall health in individuals with T1DM. Despite its proven benefits, including improved cardiovascular health, lower HbA1c levels, and reduced insulin requirements, over 60% of T1DM patients do not engage in regular exercise. Different types of physical activities—such as aerobic, anaerobic, and high-intensity interval training (HIIT)—affect metabolic responses differently. Aerobic exercises and HIIT have shown significant improvements in health-related quality of life (HRQoL) and reduced incidence of severe complications, such as diabetic ketoacidosis. However, exercise-induced hypoglycemia remains a significant risk, especially if exercise follows recent severe hypoglycemic episodes. Proper management strategies include adjusting insulin doses, monitoring glucose levels, and carbohydrate intake. The study highlights the importance of tailored exercise plans and preventive measures to mitigate risks such as nocturnal hypoglycemia and elevated ketones. Ultimately, effective integration of physical activity into diabetes management can lead to enhanced overall health and quality of life for individuals with T1DM.

Insulin-Related Suicide Attempt in Non-Diabetic Pediatric Patient

Insulin analogs are basic drugs that are widely used in the treatment of diabetes around the world. Suicides with their use are described as rare, occurring mainly in the population of diabetic patients due to their easy access to the drug and knowledge of its properties. Among non-diabetic people, insulin is used for suicidal purposes mainly by adults with medical education. A case of a 15-year-old girl found unconscious by her mother at night was described. The patient was immediately transported to the hospital, where she was diagnosed with her first severe hypoglycemic episode of unknown origin. Once conscious and in a better state, the patient admitted to having taken insulin, which she had stolen from her diabetic mother, for suicidal purposes. The patient had no history of mental illness or self-destructive behavior. The patient was referred to psychiatric care. Suicides and suicide attempts involving insulin are usually observed among people with chronic diabetes. Moreover, such attempts are made by adults who know the mechanism of action of the drug. In the pediatric group without diabetes, such cases are extremely rare. Additionally, the issue of similar behaviors becomes very important due to the increasing popularity and availability of insulin therapy and the possibilities of obtaining information about using it to commit suicide from the Internet. Particular vigilance is required in pediatric emergency departments when a patient is identified as having a first episode of severe hypoglycemia of unknown origin.

A case study on the implementation of quality and comprehensive indicators set in routine diabetes care

IntroductionType 2 diabetes is a major public health issue in Mexico due to its high prevalence and its projection for the coming years for this disease. Findings on multidisciplinary care related to chronic diseases have proven effective, based on measurement of patient-centered outcomes, The Center of Comprehensive Care for Patients with Diabetes (CAIPaDi) is a multidisciplinary program focused on reducing diabetes complications. This case study aims to illustrate the results of implementing health outcomes measurements and demonstrate the beneficial effects of establishing a comprehensive model of care through a patient-centered approach.MethodsA descriptive analysis of the comprehensive care indicators of patients with type 2 diabetes treated in the CAIPaDi program between 2013 and 2023 was conducted. The results were structured according to the standard set of outcomes for diabetes proposed by the International Consortium for Health Outcomes Measurements (ICHOM).ResultsThe baseline and prospective registration of consultations was completed for five years, complying with 25 of the 26 indicators of the ICHOM set. In diabetes control, 56.5% of patients had A1c ≤ 7%, 87.9% had BP ≤ 130/80 mmHg, 60.9% had LDL-cholesterol < 100 mg/dl, and obesity rates decreased from 42.19% to 30.6% during annual consultations. Fewer years of diagnosis before the first visit is key to overall improvement in program adherence (P = 0.02).In acute events, a hyperglycemic crisis occurred in only two cases and severe hypoglycemia episodes in 8 patients. For chronic complications, no lower limb amputations occurred. Cardiovascular outcomes occurred in < 1%. Periodontal disease was analyzed, and periodontitis decreased from 82.9% to 78.7%. Mortality reports were low, with COVID-19 being the main cause of death. Patient-reported outcomes demonstrated reductions in anxiety, depression, and diabetes distress during follow-up.ConclusionRegistering quality-of-care indicators is feasible in a comprehensive care program. It allows improving the medical, mental health, and lifestyle outcomes of patients with type 2 diabetes and provides relevant data for planning health programs. A quick diagnosis before program adherence is crucial for overall improvement in patients.

Diabetes Stigma and Clinical Outcomes: An International Review.

Diabetes stigma is the social burden of living with diabetes. People with diabetes may experience or perceive an adverse social judgment, prejudice, or stereotype about living with diabetes at work, school, in healthcare settings, popular culture, or relationships. This review describes the methods that have been used to assess diabetes stigma, and explores the prevalence of diabetes stigma, associated sociodemographic and socioeconomic factors, cultural factors, and how diabetes stigma is associated with clinical outcomes, including HbA1c levels, diabetic ketoacidosis, severe hypoglycemia, and chronic complications, in addition to psychosocial complications in youth, adolescents, and adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). The prevalence of diabetes stigma has been reported as high as 78% in adults with T1D, 70% in adults with T2D, 98% in youth and adolescents with T1D, and is unknown in youth and adolescents with T2D. Diabetes stigma has been associated with lower psychosocial functioning, decreased self-care behaviors, higher HbA1c levels, and higher frequency of diabetes complications in adults with T1D and T2D. In adolescents and young adults with T1D, diabetes stigma is associated with lower psychosocial functioning, higher HbA1c levels, and higher frequency of diabetic ketoacidosis and severe hypoglycemia episodes in addition to chronic complications. In youth and adolescents with T2D, one study demonstrated an association of diabetes stigma with lower psychosocial functioning, higher HbA1c levels, and presence of retinopathy. Gaps exist in our understanding of the mechanisms of diabetes stigma, particularly in youth and adolescents with T2D.

Continuous Glucose Monitoring Among Patients with Type 1 Diabetes in Rwanda (CAPT1D) Phase I: Feasibility Study.

The development of minimally invasive continuous glucose monitoring systems (CGMs) has transformed diabetes management. CGMs have shown clinical significance by improving time in the euglycemic range, decreasing rates of hypoglycemia, and improving HbA1c. In Rwanda, CGMs are currently not in routine use, and no clinical studies of CGM use were identified in the literature. To determine impact and feasibility of real-time CGM use among people living with T1D in Rwanda, through assessment of sensor usage, time in range, rates of hypo-and-hyperglycemia, HbA1c and rates of diabetes-related hospitalizations over time. The Continuous Glucose Monitoring Among Patients with Type 1 Diabetes in Rwanda (CAPT1D) study is a single-arm prospective observational study conducted at the Rwandan Diabetes Association (RDA) clinic in Kigali, Rwanda, aiming to assess the impact and feasibility of CGM use in Rwanda. A cohort of 50 participants diagnosed with T1D were enrolled. Participants were at least 21 years old, undergoing multiple daily insulin therapy, and not currently pregnant. Phase I of the study was conducted over 12 months, using the Dexcom G6 CGM. Phase II and Phase III extended CGM use for an additional 6 months respectively, using the next generation, Dexcom G7 CGM. Here we report the quantitative results of the Phase I study. Participants used the sensor for >80% of the time throughout the study period. A significant increase in time in range was observed within 3 months, and sustained over 12 months. HbA1c decreased significantly in 3 months and stayed lower throughout the 12-month period. Mean HbA1c levels decreased by 2.8% at 6 months (p<0.01) and 3.2% at 12 months (p<0.01) A total of 12 diabetes-related hospitalizations were reported during the study period. No cases of DKA or episodes of severe hypoglycemia occurred. Significant and meaningful improvements in key glycemic indices indicate the potential feasibility and impact of CGM among people living with T1D in Rwanda. Future studies could be designed to include pre- and post-intervention analysis to determine the effectiveness in terms of complications and costs.

Effect of recurrent severe insulin-induced hypoglycemia on the cognitive function and brain oxidative status in the rats

BackgroundEpisodes of recurrent or severe hypoglycemia can occur in patients with diabetes mellitus, insulinoma, neonatal hypoglycemia, and medication errors. However, little is known about the short-term and long-term effects of repeated episodes of acute severe hypoglycemia on the brain, particularly in relation to hippocampal damage and cognitive dysfunction.MethodsThirty-six wistar rats were randomly assigned to either the experimental or control group. The rats were exposed to severe hypoglycemia, and assessments were conducted to evaluate oxidative stress in brain tissue, cognitive function using the Morris water maze test, as well as histopathology and immunohistochemistry studies. The clinical and histopathological evaluations were conducted in the short-term and long-term.ResultsThe mortality rate attributed to hypoglycemia was 34%, occurring either during hypoglycemia or within 24 h after induction. Out of the 14 rats monitored for 7 to 90 days following severe/recurrent hypoglycemia, all exhibited clinical symptoms, which mostly resolved within three days after the last hypoglycemic episode, except for three rats. Despite the decrease in catalase activity in the brain, the total antioxidant capacity following severe insulin-induced hypoglycemia increased. The histopathology findings revealed that the severity of the hippocampal damage was higher compared to the brain cortex 90 days after hypoglycemia. Memory impairments with neuron loss particularly pronounced in the dentate gyrus region of the hippocampus were observed in the rats with severe hypoglycemia. Additionally, there was an increase in reactive astrocytes indicated by GFAP immunoreactivity in the brain cortex and hippocampus.ConclusionRecurrent episodes of severe hypoglycemia can lead to high mortality rates, memory impairments, and severe histopathological changes in the brain. While many histopathological and clinical changes improved after three months, it seems that the vulnerability of the hippocampus and the development of sustained changes in the hippocampus were greater and more severe compared to the brain cortex following severe and recurrent hypoglycemia. Furthermore, it does not appear that oxidative stress plays a central role in neuronal damage following severe insulin-induced hypoglycemia. Further research is necessary to assess the consequences of repeated hypoglycemic episodes on sustained damage across various brain regions.

Once-weekly insulin icodec compared with daily basal insulin analogues in type 2 diabetes: Participant-level meta-analysis of the ONWARDS 1-5 trials.

To perform a participant-level post hoc meta-analysis of Phase 3a trials in type 2 diabetes (T2D) to characterize the hypoglycaemia safety and glycaemic efficacy of once-weekly insulin icodec (icodec). All ONWARDS 1-5 randomized participants were pooled as overall T2D, insulin-naive, an insulin-experienced subgroups, and by once-daily trial comparator (degludec or glargine U100). The main outcomes included incidence and rates of clinically significant and severe hypoglycaemia. Additional endpoints included change in glycated haemoglobin (HbA1c) from baseline and HbA1c target achievement without clinically significant or severe hypoglycaemia. The meta-analysis comprised 3765 participants (1882 icodec vs. 1883 comparators). In the overall T2D pool, clinically significant hypoglycaemia incidence was similar in the icodec group versus the comparator group (17.9% vs. 16.2%, odds ratio [OR] 1.14, 95% confidence interval [CI] 0.94, 1.38); however, rates were low but significantly higher in the icodec group (1.15 vs. 1.00 episodes/participant-year of exposure, estimated rate ratio 1.51 [95% CI 1.24, 1.85]). Fewer severe hypoglycaemic episodes occurred with icodec than with comparators (8 vs. 18). A greater reduction in HbA1c occurred with icodec versus comparators, irrespective of subgroup (estimated treatment difference range [-0.10 to -0.29%]; all p < 0.05). Across subgroups, except for the insulin-experienced subgroup, the odds of achieving HbA1c <53 mmol/mol (7.0%) without clinically significant or severe hypoglycaemia were greater with icodec than with comparators (OR range 1.30-1.55; all p < 0.05). Icodec was associated with a similar incidence but higher rates of clinically significant hypoglycaemia (equating to one additional hypoglycaemic episode every 6 years) and fewer severe hypoglycaemic episodes versus comparators. Our findings also confirmed the greater efficacy of icodec that was demonstrated in the ONWARDS trial programme.