Following the COVID-19 Experience, Many Patients with Type 1 Diabetes Wish to Use Telemedicine in a Hybrid Format

Diabetes Care and Mental Health During the COVID-19 Pandemic: Perspectives of Adolescents with Diabetes, Parents, and Providers

This study explored ways in which the COVID-19 pandemic impacted adolescents' diabetes management and psychosocial functioning, and how adolescents, parents, and providers viewed telemedicine. We present data from three studies: (1) a comparison of psychosocial functioning and glycemic levels before and after pandemic onset (n = 120 adolescents; 89% with type 1 diabetes), (2) an online survey of parents about pandemic-related stressors (n = 141), and (3) qualitative interviews with adolescents, parents, and medical providers about the pandemic's impacts on adolescents' diabetes care and mental health (n = 13 parent-adolescent dyads; 7 medical providers). Results suggested some adverse effects, including disrupting routines related to health behaviors and psychosocial functioning and impairing adolescents' quality of life. Despite these challenges, most participants did not endorse significant impacts. Some even noted benefits, such as increased parental supervision of diabetes management that can be leveraged beyond the pandemic. Furthermore, telemedicine offers benefits to continuity of diabetes care but presents challenges to care quality. These findings underscore the varied and unique impacts of the COVID-19 pandemic on adolescents with diabetes.

Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt

The coronavirus disease (COVID-19) pandemic affected the management and follow-up of several chronic ailments, including pediatric type 1 diabetes mellitus (T1DM). Restricted access to healthcare and fear of contracting the virus during medical facility visits resulted in poor compliance, irregular follow-up visits, treatment, and delayed diagnosis of complications in pediatric diabetes such as diabetic ketoacidosis (DKA). As such, the incidence of complicated DKA in resource-limited settings is high due to delayed presentation, poor compliance with therapy, and associated comorbidities such as malnutrition and sepsis. The pandemic had only added to the woes. The increased surge in DKA, in the face of limited resources, prompted clinicians to find alternative solutions to manage these children effectively. In this narrative review, we discuss the key challenges faced globally while caring for children with T1DM and DKA during the COVID-19 pandemic, and the lessons learned thereof.

We Cannot Put This Genie Back in the Bottle: Qualitative Interview Study Among Family Medicine Providers About Their Experiences With Virtual Visits During the COVID-19 Pandemic

BACKGROUND

When a genie is freed from its bottle, things cannot be restored to the way they were before. At the beginning of the global COVID-19 pandemic, health care systems adjusted how they delivered care overnight. Primary care practices switched from seeing patients in person to virtual care applications, including video and phone visits, e-visits, e-consults, and messaging with clinicians. Prior to the pandemic, these applications were not as widely used, but discussions around their advantages and disadvantages in some settings were being explored. Emergency regulatory changes spurred by the pandemic freed this virtual care "genie" from its bottle. Wide-scale adoption of virtual care in family medicine has much potential, as primary care services are often a patient's first point of contact with the health care system.

OBJECTIVE

This study aims to analyze family medicine providers' experiences using virtual visits during the pandemic, perceived outcomes of the shift to virtual visits, and discusses its implications for the future of family medicine.

METHODS

This qualitative study took place at 3 academic primary care clinics between June and December 2020. Data were collected through one-on-one Zoom (version 5.2.1) interviews with family medicine clinical faculty who experienced the rapid transition of in-person visits to mostly "virtual" visits. The interviews were recorded, deidentified, and transcribed. We adopted a constructivist approach to qualitative content analysis to evaluate the results.

RESULTS

In total, 25 participants were eligible, and 20 individuals participated in this study (80% participation rate). The mean age was 43.4 years, and 85% (17/20) of the participants were female. We identified 3 main themes: the care process, patient engagement, and team-based care.

CONCLUSIONS

This study highlights the transition from in-person to virtual visits during the pandemic from the perspective of family medicine providers. Generally, family medicine providers' perceptions of the shift to virtual visits were positive, especially regarding team-based care. Challenges involved virtual inhibition, particularly for providers. Providers described ways they integrated virtual care with aspects of in-person care, creating a hybrid environment. The genie is out of the bottle-things will not be the same-but family medicine now has the opportunity to evolve.

Clinical Experience of Using Telemedicine for the Management of Patients Using Continuous Subcutaneous Insulin Infusion in a Highly Complex Latin American Hospital

INTRODUCTION

Continuous subcutaneous insulin infusion (CSII) has emerged as a potential solution for diabetes management during the pandemic, as it reduces the need for in-person visits and allows for remote monitoring of patients. Telemedicine has also become increasingly important in the management of diabetes during the pandemic, as it allows healthcare providers to provide remote consultations and support. Here, we discuss the implications of this approach for diabetes management beyond the pandemic, including the potential for increased access to care and improved patient outcomes.

METHODS

We performed a longitudinal observational study between 1 March 2020 and 31 December 2020 to evaluate glycemic parameters in diabetic patients with CSII in a telehealth service. Glycemic parameters were time in range (TIR), time above range, time below range, mean daily glucose, glucose management indicator (GMI), and glycemic variability control.

RESULTS

A total of 36 patients were included in the study, with 29 having type 1 diabetes and 6 having type 2 diabetes. The study found that the proportion of patients achieving target glucose variability and GMI remained unchanged during follow-up. However, in patients with type 2 diabetes, the time in target range increased from 70% to 80%, and the time in hyperglycemia decreased from 2% to 0%.

CONCLUSIONS

The results of this study suggest that telemedicine is a strategy for maintaining glycemic control in patients using CSII. However, the lack of access to the internet and adequate telemonitoring devices make it difficult to use on a large scale in emerging countries like ours.

Hybrid Clinics: A New Model for Ambulatory Care to Reduce Infection Risk

Objectives: To assess the viability of a hybrid clinic model combining in-person examination with video-based consultation to minimize viral transmission risk. Methods: Data were collected prospectively in a pediatric urology clinic for in-person visits from January to April 2018 ("classic") and hybrid visits from October to December 2020 of the COVID-19 pandemic ("hybrid"). Variables included provider, diagnosis, patient type, time of day, prior surgery, postoperative status, and decision-making for surgery. The primary outcome was "room time" or time in-person. The secondary outcome was "total time" or visit duration. Proportion of visits involving close contact (room time ≥15 min) was assessed. Univariate analyses were performed using the Wilcoxon rank-sum test and Fisher's exact test. Mixed models were fitted for visit approach and other covariates as fixed effects and provider as random effect. Results: Data were collected for 346 visits (256 classic, 90 hybrid). Hybrid visits were associated with less room time (median 3 min vs. 10 min, p < 0.001) but greater total time (median 13.5 min vs. 10 min, p = 0.001) as compared with classic visits. On multivariate analysis, hybrid visits were associated with 3 min less room time (95% confidence intervals [CIs]: -5.3 to -1.7, p < 0.001) but 3.8 min more total time (95% CI: 1.5-6.1, p = 0.001). Close contact occurred in 6.7% of hybrid visits, as compared with 34.8% of classic visits (p < 0.001). Conclusions: Hybrid clinic visits reduce room time as compared with classic visits. This approach overcomes the examination limitations of telemedicine while minimizing viral transmission, and represents a viable model for ambulatory care whenever close contact carries infection risk.

The future of telehealth in type 1 diabetes

PURPOSE OF REVIEW

Although telemedicine and telehealth services have been a part of type 1 diabetes (T1D) clinical care for several decades, the expansion of in-home telemedicine during the COVID-19 pandemic significantly increased interest in long-term use as part of routine care. This review highlights the current literature regarding telemedicine in T1D care as well as the benefits and barriers to use in a postpandemic world.

RECENT FINDINGS

Telemedicine has increased patient contact with healthcare providers, allowing for more frequent insulin dose adjustments and improvements in glycemic outcomes. In addition to routine clinical care, T1D device training and mental healthcare have been successful through telemedicine. Significant barriers to continued telemedicine care exist, including patient access and technology knowledge, language, and loss of face-to-face interaction. Healthcare providers additionally face unpredictable reimbursement and loss of continuity across state lines, and lack of resources and training for device downloads and telemedicine software.

SUMMARY

Telemedicine can be successfully used in T1D care and has the potential to significantly impact glycemic and long-term outcomes. Due to continued interest for in-person visits by people with T1D and providers, it is likely that long-term telemedicine use will include a hybrid format.

Driving Factors to Pursue Endocrinology Training Fellowship: Empirical Survey Data and Future Strategies

OBJECTIVE

There is a current and anticipated labor shortage of endocrinologists in the United States. Over the past decade, the number of applications to endocrinology fellowship programs has plateaued despite increased available positions, and interest in endocrinology has declined relative to other internal medicine subspecialty fields. The examination of driving factors for pursuit of endocrinology as a subspecialty career is needed.

METHODS

A 12-question online survey was developed to identify the primary reasons for current endocrinology fellows/trainees to pursue the field. This survey was sent to 152 U.S. endocrinology fellowship program directors for completion by their fellows between July and August 2021.

RESULTS

A total of 176 of 629 fellows (28.0%) completed the survey. The majority (57.4%) had decided to pursue endocrinology as a career during residency, while 27.3% had decided during medical school. The endocrinology rotation during residency was ranked by 79 fellows (44.9%) as the most influential factor, followed by having positive experiences with a clinical mentor (27.3%). Endocrinology exposure during medical school was sparse, with only 2.8% noting the availability of an endocrinology student interest group, while 59.7% reported inadequate endocrinology exposure during their medical school curriculum.

CONCLUSION

The majority of current endocrinology fellows/trainees report that exposure to the field during medical school was limited, and that their endocrinology elective and mentorship experiences during residency were the most influential factors for pursuing endocrinology as a subspecialty. Improved integration of endocrinology experiences between medical school and residency may enhance career interest in endocrinology.

Healthcare Utilization and Adherence to Treatment Recommendations among Children with Type 1 Diabetes in Poland during the COVID-19 Pandemic

Type 1 diabetes mellitus (T1D) is, next to obesity and asthma, the most common chronic disease in children in Poland. The results of T1D treatment strongly depend on the patient’s compliance with therapeutic recommendations, which entails the use of necessary health services. Based on a retrospective analysis of the data on health services provided in 2016–2020 to over 15.5 thousand patients with T1D in Poland, we assessed the compliance of the actual model of treatment of T1D in children with the current guidelines. It was found that only about 50% of patients received the number of diabetes consultations corresponding to the recognized standards, with about 15% of children with T1D remaining outside the public healthcare system. In the case of many outpatient services (ophthalmological, neurological, mental health), the number of consultations was extremely low—one order of magnitude lower than in general population and dropped even lower in 2020. This shows that the health needs of children with T1D are not being met within the public healthcare system. The COVID-19 pandemic caused significant limitations in access to healthcare in Poland. Compared to the pre-pandemic period there was a significant decrease (−27% compared to 2019) in the number of hospitalizations, and a substantial increase (+22% compared to 2019) in the number of diabetic ketoacidoses (DKA) cases. The proportion of hospitalizations caused by DKA rose to 8.9% compared to 7.3% in 2019.

The Impact of COVID-19 Lockdown on Glycemic Balance in Romanian Patients with Type 1 Diabetes Mellitus

INTRODUCTION

The COVID-19 pandemic has brought major changes not only at the economic and social level but especially in the medical system.

OBJECTIVE

To evaluate the impact of COVID-19 lockdown on the quality of glycemic control in Romanian patients with type 1 diabetes mellitus (T1DM).

MATERIAL AND METHOD

Our study group included 102 Romanian volunteers' patients with T1DM from both urban and rural areas. Data were collected during an interview, based on a structured questionnaire with multiple-choice questions about diabetes management during lockdown, how they interact with their diabetologist, how they accessed the treatment and what other factors influenced their diabetes management during the lockdown.

RESULTS

Blood glucose levels were significantly higher in the MDII group as a consequence of delayed administration of insulin corrections due to inadequate insulin dosing (60% vs 31.81%; χ ² = 5.51, p = 0.018). In addition, insulin pump users had improved response to stress and anxiety (ie, additional therapeutic safety being provided by use of insulin pump; in some devices, blood glucose being continuously monitored, leading to premature detection of important blood glucose excursions) compared to insulin pen users (χ ² = 5.09, p = 0.024). In the context of hypoglycemia, we observed that in the pen MDII group, more users have administered an excess of insulin, compared with the pump users (80% vs 45.45%; χ ² = 10.34; p = 0.001).

CONCLUSION

A lower impact of COVID-19 lockdown on glycemic control was observed in patients with T1DM treated using insulin pumps compared to patients with T1DM who administered their insulin using insulin pens. Telemedicine and online consultations have brought significant improvements in diseases management. Stress, emotions, and anxiety were among the main reasons that led to increases in blood sugar levels, suggesting that the psychological impact may have long-term complications.

Questionnaire-Based Assessment of the Masticatory Function and Facial Nerve Recovery Post Pterional Approach in Brain Tumors Surgery

Background: The pterional approach for craniotomy, one of the most used surgical intervention in neurosurgery, results in a series of postoperative changes that, if they persist, affect the patient’s life, social reintegration, and his/her physical and mental recovery. The aim of the present study was to develop and validate a questionnaire for indicating directly affected masticatory muscles groups and facial nerve branches, in patients undergoing the pterional approach in neurosurgery, so that the recovery therapy can be monitored and personalized. Methods: A self-reporting questionnaire consisting of 18 items (12 for postoperative masticatory status and 6 for facial nerve branches involvement), validated on fifteen patients, following three steps: items development, scale development, and scale evaluation, was prospectively applied twice, at a one-year interval (T0 and T1), with thirty-two patients suffering from vascular or tumoral pathology and surgically treated through a pterional approach. Results: No statistically significant correlation could be found between postoperative outcomes and age or gender. Facial nerve branch involvement could not be correlated with any of the assessed variables. Pathology and time elapsed from surgery were statistically significantly correlated to preauricular pain on the non-operated side (p = 0.008 and p = 0.034, respectively). Time elapsed from surgery was statistically significantly correlated to the ability to chew hard food, pain while yawning, and preauricular pain during back and forward jaw movements and gradual mouth opening. Conclusions: We created and validated a valuable patient-centered questionnaire that can be employed as a tool for postoperative assessment of directly affected masticatory muscles and groups of facial nerve branches.