Self-isolation negatively impacts self-management of diabetes during the coronavirus (COVID-19) pandemic

Uptake of self-management education programmes for people with type 2 diabetes in primary care through the embedding package: a cluster randomised control trial and ethnographic study

BACKGROUND

Self-management education programmes are cost-effective in helping people with type 2 diabetes manage their diabetes, but referral and attendance rates are low. This study reports on the effectiveness of the Embedding Package, a programme designed to increase type 2 diabetes self-management programme attendance in primary care.

METHODS

Using a cluster randomised design, 66 practices were randomised to: (1) a wait-list group that provided usual care for nine months before receiving the Embedding Package for nine months, or (2) an immediate group that received the Embedding Package for 18 months. 'Embedders' supported practices and self-management programme providers to embed programme referral into routine practice, and an online 'toolkit' contained embedding support resources. Patient-level HbA1c (primary outcome), programme referral and attendance data, and clinical data from 92,977 patients with type 2 diabetes were collected at baseline (months - 3-0), step one (months 1-9), step 2 (months 10-18), and 12 months post-intervention. An integrated ethnographic study including observations, interviews, and document analysis was conducted using interpretive thematic analysis and Normalisation Process Theory.

RESULTS

No significant difference was found in HbA1c between intervention and control conditions (adjusted mean difference [95% confidence interval]: -0.10 [-0.38, 0.18] mmol/mol; -0.01 [-0.03, 0.02] %). Statistically but not clinically significantly lower levels of HbA1c were found in people of ethnic minority groups compared with non-ethnic minority groups during the intervention condition (-0.64 [-1.08, -0.20] mmol/mol; -0.06% [-0.10, -0.02], p = 0.004), but not greater self-management programme attendance. Twelve months post-intervention data showed statistically but not clinically significantly lower HbA1c (-0.56 [95% confidence interval: -0.71, -0.42] mmol/mol; -0.05 [-0.06, -0.04] %; p < 0.001), and higher self-management programme attendance (adjusted odds ratio: 1.13; 95% confidence interval: 1.02, 1.25; p = 0.017) during intervention conditions. Themes identified through the ethnographic study included challenges for Embedders in making and sustaining contact with practices and providers, and around practices' interactions with the toolkit.

CONCLUSIONS

Barriers to implementing the Embedding Package may have compromised its effectiveness. Statistically but not clinically significantly improved HbA1c among ethnic minority groups and in longer-term follow-up suggest that future research exploring methods of embedding diabetes self-management programmes into routine care is warranted.

TRIAL REGISTRATION

ISRCTN23474120, registered 05/04/2018.

Self-management challenges of adults with type 2 diabetes mellitus in Ekurhuleni district primary health care facilities amid COVID-19 lockdown

BACKGROUND

 Self-management is highly recommended in managing type 2 diabetes mellitus (T2DM). Amid the coronavirus disease 2019 (COVID-19) lockdown, many restrictions were imposed, which might have affected the continuum of care and self-management. However, little is known about how people with T2DM experienced self-management during COVID-19 lockdown within the primary health care (PHC) facilities.

AIM

 The study explored and described the self-management challenges of adults with T2DM in Ekurhuleni PHC facilities amid COVID-19 level 5 and 4 lockdowns.

SETTING

 The study was conducted in three community health centres in Ekurhuleni which are rendering PHC services.

METHODS

 A phenomenological, qualitative, exploratory, and descriptive design was utilised. Purposive sampling was used to select adult patients with T2DM. Data were collected telephonically between July 2022 and August 2022 using semi-structured interviews. Inductive content analysis was used to analyse data.

RESULTS

 Two themes emerged from the interviews, namely, uncontrolled blood glucose levels and financial challenges.

CONCLUSION

 The patients with T2DM experienced uncontrolled blood glucose levels and financial challenges during the COVID-19 lockdown. Guidelines to improve self-management programmes during restrictions are needed to promote good health during future pandemics to prevent complications and mortality. The telehealth model can be designed to monitor chronic patients at home during lockdown as a two-way communication.Contribution: More knowledge and insight into self-management and health promotion of patients with T2DM was provided by this study. Increased training needs arose for PHC nurses in managing and monitoring patients.

Impact of a Public Health Emergency on Behavior, Stress, Anxiety and Glycemic Control in Patients With Pancreas or Islet Transplantation for Type 1 Diabetes

A public health emergency such as the COVID-19 pandemic has behavioral, mental and physical implications in patients with type 1 diabetes (T1D). To what extent the presence of a transplant further increases this burden is not known. Therefore, we compared T1D patients with an islet or pancreas transplant (β-cell Tx; n = 51) to control T1D patients (n = 272). Fear of coronavirus infection was higher in those with β-cell Tx than without (Visual Analogue Scale 5.0 (3.0-7.0) vs. 3.0 (2.0-5.0), p = 0.004) and social isolation behavior was more stringent (45.8% vs. 14.0% reported not leaving the house, p < 0.001). A previous β-cell Tx was the most important predictor of at-home isolation. Glycemic control worsened in patients with β-cell Tx, but improved in control patients (ΔHbA1c +1.67 ± 8.74 vs. -1.72 ± 6.15 mmol/mol, p = 0.006; ΔTime-In-Range during continuous glucose monitoring -4.5% (-6.0%-1.5%) vs. +3.0% (-2.0%-6.0%), p = 0.038). Fewer patients with β-cell Tx reported easier glycemic control during lockdown (10.4% vs. 22.6%, p = 0.015). All T1D patients, regardless of transplantation status, experienced stress (33.4%), anxiety (27.9%), decreased physical activity (42.0%), weight gain (40.5%), and increased insulin requirements (29.7%). In conclusion, T1D patients with β-cell Tx are increasingly affected by a viral pandemic lockdown with higher fear of infection, more stringent social isolation behavior and deterioration of glycemic control. This trial has been registered in the clinicaltrials.gov registry under identifying number NCT05977205 (URL: https://clinicaltrials.gov/study/NCT05977205).

Increase in antibiotic resistance in diabetic foot infections among peruvian patients: a single-center cross-sectional study

Background

Diabetic foot is one of the most significant complications in individuals with diabetes and is closely associated with lower limb amputation. The antibiotic susceptibility patterns of these bacterial isolates play a critical role in guiding effective treatment strategies We aimed to determine the most common bacterial agents causing diabetic foot infections in a tertiary-care hospital in Peru.

Methods

Clinical and microbiological data were collected from 181 patients diagnosed with diabetic foot infections and positive microbiological culture results. All the samples were analyzed with the Vitek 2 compact system and the cut-off points were defined with the CLSI M100 guide. The data were segregated based on mono-microbial or poly-microbial cultures, bacterial types, and antibiotic susceptibility profiles.

Results

A total of 32 bacterial species were identified, predominantly Gram-negative (63%). The most frequent bacterial agents isolated were Staphylococcus aureus (19.9%), Escherichia coli (12.2%), Pseudomonas aeruginosa (8.3%), and Proteus vulgaris (6.6%). These bacteria commonly exhibited resistance to Ampicillin, Ciprofloxacin, Levofloxacin, Trimethoprim-sulfamethoxazole, and Cefuroxime. E. coli showed the highest antibiotic resistance (19 antibiotics), while Gentamicin, Tobramycin, and Levofloxacin demonstrated the highest sensitivity against the most prevalent bacteria. Gram-negative bacteria also exhibited notable antibiotic-susceptibility to Meropenem, Piperacillin/tazobactam, and Amikacin. Regarding the presence of Extended-Spectrum Beta-Lactamase, 54 isolates tested positive, with 35 (64.8%) and 14 (42.4%) of these being S. aureus and E. coli.

Conclusions

Bacterial agents causing diabetic foot infections pose a constant concern, particularly due to the increasing antibiotic resistance observed. This difficulty in treating the condition contributes to a higher risk of amputation and mortality. Further research on bacterial susceptibility is necessary to determine appropriate dosages for pharmacological treatment and to prevent the overuse of antibiotics.

A new emergency during the latest phase of the COVID-19 pandemic: access to healthcare services by patients with non-communicable diseases

Background

The aim of our study was to investigate the impact of the COVID-19 pandemic on the healthcare and the disease management of patients affected by non-communicable diseases (NCDs), by exploring, specifically, the obstacles encountered in the access to healthcare services during the latest phase of the pandemic.

Methods

This cross-sectional study was carried out among subjects attending the anti-SARS-CoV2 vaccination clinic in a Teaching Hospital of Southern Italy. To be included in the study, subjects had to be affected by at least one NCD, such as diabetes, hypertension, respiratory and heart diseases, renal and liver chronic conditions, immunodeficiency disorders due to cancer, or being kidney or liver transplant recipients.

Results

Among the 553 subjects who completed the questionnaire, the 39.4% (95% IC = 35.3-43.6) experienced obstacles in the access to healthcare services in the six months prior to the enrollment. The most frequent canceled/postponed healthcare services were the visits for routine checks for NCDs (60.6, 95% IC = 53.9-67), control visits of more complex diseases as cancer or transplantation (17.3, 95% IC = 12.6-22.8), and scheduled surgery (11.5, 95% IC = 7.7-16.4). The patients who experienced canceled/postponed healthcare services were significantly more likely to suffer from 3 or more NCDs (p = 0.042), to be diabetics (p = 0.038), to have immunodeficiency disorders (p = 0.028) and to have consulted GP at least once (p = 0.004).

Conclusion

Our results appear to be fundamental for guiding the choices of providers in order to concentrate organizational efforts to recover and reschedule missed appointments, where applicable, of the most fragile patients by virtue of age and chronic conditions.

Disparities in Food Security and Glycemic Control Among People with Type 2 Diabetes During the COVID-19 Pandemic

Background

Little is known about the differing impacts of food insecurity on HbA1c by race in type 2 diabetes (T2D). Predictions around increased food insecurity from COVID-19 exacerbating racial disparities led us to estimate its prevalence and associations with HbA1c by race during the COVID-19 pandemic.

Methods

Data came from medical records and surveys among a clinic-based sample of T2D patients. Linear regression models estimated associations between food insecurity and HbA1c and between change in food insecurity and change in HbA1c. Likelihood ratio tests and examination of stratum-specific estimates assessed effect modification by race.

Results

Our sample was 59% White, 59% female, and mean age was 60.8 ± 12.6. During the pandemic, food insecurity prevalence and HbA1c were significantly (p < .05) higher among non-Whites (39%, 8.4% ± 2.1) compared to Whites (15%, 7.8% ±1.6). HbA1c among those who were very food insecure was 1.00% (95% CI: 0.222, 1.762, p = .01) higher than those who were food secure. Those with increased food insecurity had a 0.58% (95% CI: 0.024, 1.128, p = .04) higher HbA1c increase than among those experiencing no change. No effect modification was detected.

Limitations

Convenience sampling in an endocrinology clinic, recall bias, and inadequate power may underlie null effect modification results.

Conclusion

Although effect modification was not detected, racial disparities in HbA1c and food insecurity warrant further investigation. These disparities, combined with the significant impact of food insecurity on HbA1c, suggest that prioritization of resources to high-risk populations should be considered early during public emergencies to minimize short- and long-term health consequences.

The impact of lockdown measures during the SARS-CoV-2 pandemic on the management of diabetes in a Northern Gauteng Region of South Africa

Introduction

coronavirus disease 2019 (SARS-CoV-2), a global pandemic, popularised the term "lockdown" due to its rapid spread around the world. "Lockdown" was used as an emergency measure to temporarily prevent people from entering or leaving their communities in an effort to reduce the spread of the virus. The effects of the "lockdown" measures on the management of chronic medical conditions in African populations have been inconsistent. This study aimed to assess the effects of the lockdown on glycaemic control in patients with diabetes.

Methods

retrospective study that examined metadata from 1st January 2019 to 31st December 2021, to assess the impact of the national SARS-CoV-2 response on the quantity and average level of haemoglobin A1c and random glucose in patients with diabetes at Dr. George Mukhari Academic Hospital. The data was retrieved from the National Health Laboratory Services corporate data warehouse.

Results

from 2019 to 2021, a total of 9,039 tests were performed, with females accounting for 63.21% (n = 5,714) and males for 36.08% (n = 3,261), while 0.7% (n = 70) did not have an assigned gender. Mean age was 49, with a standard deviation (SD) of 21.71. The testing rate (TR) in 2019 was 10.74 per day, 2020 had a TR of 6.07, and 2021 had a TR of 7.95. During the pandemic phase, all other age groups had TRs below 1.85, except the 50-59, 60-69, and 70+ year-old groups.

Conclusion

the study revealed that SARS-CoV-2 lockdown measures were linked to poor diabetes control in patients. As a result, the consequences of managing SARS-CoV-2 had a direct influence on diabetes management.

Investigating the Impact of COVID-19 Infection on Dry Eye Parameters

PURPOSE

This study aims to compare dry eye parameters before and after COVID-19 infection in dry eye patients.

METHODS

We included 44 dry eye patients (88 eyes) from our existing dry eye cohort, with 22 belonging to the post-COVID-19 group due to a prior COVID-19 infection and the other 22 forming the non-COVID-19 group as they had no history of COVID-19. We examined and compared the dry eye parameters of the post-COVID-19 group, including the ocular surface disease index (OSDI), Schirmer's test results (ST), non-invasive Keratography tear break-up time (NIKBUT), lipid layer thickness (LLT), Meibomian gland dysfunction (MGD), and the grading of papillae and follicles, both before and after the COVID-19 infection. We also compared the dry eye parameters difference of the post-COVID-19 group with the non-COVID-19 group.

RESULTS

The post-COVID-19 group was comprised of individuals with an average age of 38.36 ± 14.99 years, of which 82% were female. The time interval between the two tests was 16.92 ± 5.40 months, which did not differ significantly from the non-COVID-19 group. Compared to the pre-COVID-19 eyes, the post-COVID-19 eyes showed a significant decrease in the average LLT (52.86 ± 18.00 nm vs. 63.00 ± 22.40 nm, p < 0.001), as well as the maximum LLT (67.89 ± 20.81 nm vs. 78.48 ± 20.55 nm, p < 0.001). The MGD in both the upper (1.75 ± 0.84) and lower eyelids (1.43 ± 0.73) worsened after a COVID-19 infection. Additionally, the grading of papillae was worse following a COVID-19 infection (0.61 ± 0.69 vs. 0.16 ± 0.37, p < 0.001). The multivariate linear regression model revealed a negative association between COVID-19 infection and NIKBUT-average (β = -2.98, 95%CI: (-5.82, -0.15), p = 0.039), LLT-average (β = -14.12, 95%CI: (-22.66, -5.59), p = 0.001), and LLT max (β = -15.65, 95%CI: (-23.09, -8.20), p < 0.001).

CONCLUSION

From preliminary results, we concluded that dry eye patients who have been infected with COVID-19 appear to have a more severe dry eye condition, as evidenced by lower LLT, worse papillae and MGD, and shorter NIKBUT. It is important to raise awareness of this potential long-term symptom of COVID-19, especially among existing dry eye patients.

Effectiveness of Using the FreeStyle Libre® System for Monitoring Blood Glucose during the COVID-19 Pandemic in Diabetic Individuals: Systematic Review

BACKGROUND

Artificial Intelligence (AI) is an area of computer science/engineering that is aiming to spread technological systems. The COVID-19 pandemic caused economic and public health turbulence around the world. Among the many possibilities for using AI in the medical field is FreeStyle Libre^® (FSL), which uses a disposable sensor inserted into the user's arm, and a touchscreen device/reader is used to scan and retrieve other continuous monitoring of glucose (CMG) readings. The aim of this systematic review is to summarize the effectiveness of FSL blood glucose monitoring during the COVID-19 pandemic.

METHODS

This systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) and was registered in the international prospective register of systematic reviews (PROSPERO: CRD42022340562). The inclusion criteria considered studies involving the use of the FSL device during the COVID-19 pandemic and published in English. No publication date restrictions were set. The exclusion criteria were abstracts, systematic reviews, studies with patients with other diseases, monitoring with other equipment, patients with COVID-19, and bariatrics patients. Seven databases were searched (PubMed, Scopus, Embase, Web of Science, Scielo, PEDro and Cochrane Library). The ACROBAT-NRSI tool (A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies) was used to evaluate the risk of bias in the selected articles.

RESULTS

A total of 113 articles were found. Sixty-four were excluded because they were duplicates, 39 were excluded after reading the titles and abstracts, and twenty articles were considered for full reading. Of the 10 articles analyzed, four articles were excluded because they did not meet the inclusion criteria. Thus, six articles were included in the current systematic review. It was observed that among the selected articles, only two were classified as having serious risk of bias. It was shown that FSL had a positive impact on glycemic control and on reducing the number of individuals with hypoglycemia.

CONCLUSION

The findings suggest that the implementation of FSL during COVID-19 confinement in this population can be confidently stated to have been effective in diabetes mellitus patients.

Locked inside: Living with uncertainty in self-management for endometriosis during the COVID-19 pandemic

OBJECTIVE

A high symptom burden systemic inflammatory disorder, endometriosis typically entails both medical management and self-management strategies. The COVID-19 pandemic in Australia precipitated changes to healthcare provision, societal restrictions, and negative psychosocial outcomes particularly for those managing chronic illnesses (e.g., endometriosis). This study's objective was to address the following questions: "How have endometriosis self-management strategies changed since the outbreak of COVID-19, and what are the consequences of these changes?"

METHODS

In total, 21 respondents residing in Australia during the COVID-19 pandemic participated in a semi-structured interview following completion of an online survey advertised by Endometriosis Australia. In the survey, respondents provided demographic and clinical information, and psychological distress was assessed. Interviews were conducted online and recorded for transcribing. Transcribed data were thematically analyzed using the template method.

RESULTS

Qualitative analysis identified five themes: i) Maintaining Relationships with Health Professionals, ii) Altered Information Seeking Strategies, iii) More Autonomous Decision Making, iv) Diminished Self-Care and Behaviour Change, and v) Shifted Priorities. Respondents reported disruptions to, and uncertainties within, the healthcare system that precipitated adverse effects upon their ability to manage endometriosis and mental health.

CONCLUSIONS

These findings suggest that for many, COVID-19-related disruptions to the healthcare system and social isolation adversely impacted their endometriosis self-management. Targeted interventions are needed to address the consequences of these, including providing reliable information to support informed decision-making regarding endometriosis self-management, and assisting with mental health challenges arising from COVID-19-related social isolation.

Impact of COVID-19 pandemic on HbA1c management and results in pediatric and adult outpatients with diabetes

Objectives

Diabetes mellitus intensify the risks and complications related to COVID-19 infection. A major effect of the pandemic has been a drastic reduction of in-person visits. The aim of this study was to evaluate the impact of the COVID-19 pandemic on HbA_1c management and results among pediatric and adult outpatients with diabetes, considering the laboratory and point-of-care testing (POCT) HbA_1c measurements.

Methods

Observational retrospective study including patients from pediatric and adult diabetes units was conducted. HbA_1c results obtained in the laboratory and POCT over 3 years (2019-2021) were collected from the laboratory information system.

Results

After the lockdown, the number of HbA_1c plummeted. Children returned soon to routine clinical practice. The number of HbA_1c increased gradually in adults, especially in POCT. Globally, HbA_1c results were lower in children compared with adults (p<0.001). HbA_1c values in children (p<0.001) and adults (p=0.002) decreased between pre-pandemic and post-pandemic periods, though lower than the HbA_1c reference change value. The percentage of HbA_1c results above 8% remained stable during the study period.

Conclusions

Continuous glucose monitoring and a telemedicine have been crucial, even allowing for improvements in HbA_1c results. During the lockdown, patients with better metabolic control were managed in the laboratory whereas patients with poorer control or a severe clinical situation were attended in diabetes units by POCT. Adults returned to pre-pandemic management slowly because they were more susceptible to morbidity and mortality due to COVID-19. Coordination among all health professionals has been essential to offering the best management, especially in difficult scenarios such as the COVID-19 pandemic.

The relationship between social isolation, social support, and loneliness with cardiovascular disease and shared risk factors: A narrative review

BACKGROUND

Cardiovascular disease (CVD) is the greatest contributor to global morbidity and mortality. Poor social health plays a critical role in CVD incidence. Additionally, the relationship between social health and CVD may be mediated through CVD risk factors. However, the underlying mechanisms between social health and CVD are poorly understood. Certain social health constructs (social isolation, low social support and loneliness) have complicated the characterisation of a causal relationship between social health and CVD.

AIM

To provide an overview of the relationship between social health and CVD (and its shared risk factors).

METHOD

In this narrative review, we examined published literature on the relationship between three social health constructs (social isolation, social support, and loneliness) and CVD. Evidence was synthesised in a narrative format, focusing on the potential ways in which social health affects CVD, including shared risk factors.

RESULTS

The current literature highlights an established relationship between social health and CVD with a likelihood for bi-directionality. However, there is speculation and varied evidence regarding how these relationships may be mediated through CVD risk factors.

CONCLUSIONS

Social health can be considered an established risk factor for CVD. However, the potential bi-directional pathways of social health with CVD risk factors are less established. Further research is needed to understand whether targeting certain constructs of social health may directly improve the management of CVD risk factors. Given the health and economic burdens of poor social health and CVD, improvements to addressing or preventing these interrelated health conditions would have societal benefits.

Experiences of Filipino Americans with Type 2 Diabetes during COVID-19: A Qualitative Study

Little is known about the experiences of Filipino Americans with type 2 diabetes regarding their self-management during the early phase of the COVID-19 pandemic. We conducted a qualitative research study using semistructured interviews. In total, 19 interviews were recorded, transcribed, and analyzed by 4 independent coders. We situated our understanding of these results using three concepts from an indigenous Filipino knowledge system called Sikolohiyang Pilipino: Kapwa (shared identity), Bahala Na (determination), and Pakikibaka (spaces of resistance). The following three main themes emerged: (1) stressors of the pandemic, (2) coping behaviors (with two subthemes: emotional and lifestyle-focused responses), and (3) diabetes self-management outcomes. Participants experienced stresses, anxiety, and loneliness during the pandemic magnified by the complexities of self-management. Although many admitted the pandemic brought challenges, including burnout, they coped by using existing resources-support from family, friends, the use of technology, and various emotional coping mechanisms. Many said that they made few diabetes self-management changes.

Diabetes Control in a Student-Run Free Clinic During the COVID-19 Pandemic

Student run free health clinics (SRFCs) provide medical care to vulnerable populations in communities throughout the United States. The COVID-19 pandemic had a significant impact on the delivery of healthcare services and demanded a rapid adjustment in care delivery methods in both resource-rich and resource-poor settings. The aim of this study is to evaluate the impact of the pandemic on the management of chronic disease, specifically diabetes. Patients with diabetes who received care continuously throughout the pre-pandemic (face-to-face) and pandemic (telehealth) study periods at MedZou Community Health Center, a SRFC located in central Missouri, were evaluated. This sample of patients (n = 29) was evaluated on six quality measures including annual eye exams, blood pressure, hemoglobin A1c, chronic kidney disease monitoring, flu vaccination, and statin therapy. Overall diabetes care, as measured by the number of quality measures met per patient, decreased by 0.37 after the onset of the pandemic. The median COVID-era ranks were not statistically significantly different than the pre-pandemic ranks (z = 1.65, P = 0.099). Fewer patients received an influenza vaccination the year following the onset of the pandemic (10.3%) compared to the year before the pandemic (37.9%; difference in proportions 0.276, 95% CI 0.079, 0.473; p = 0.005). No other individual measures of diabetes care statistically differed significantly in the year after the pandemic began. Twenty-six (90%) patients received diabetes care using telehealth after the onset of the pandemic. Diabetes care using telehealth in a SRFC may be an acceptable alternative model when face-to-face visits are not feasible. Observed decreases in diabetes-related clinical quality measure performance warrant further study.