Changes to care delivery at nine international pediatric diabetes clinics in response to the COVID-19 global pandemic

BACKGROUND

Pediatric diabetes clinics around the world rapidly adapted care in response to COVID-19. We explored provider perceptions of care delivery adaptations and challenges for providers and patients across nine international pediatric diabetes clinics.

METHODS

Providers in a quality improvement collaborative completed a questionnaire about clinic adaptations, including roles, care delivery methods, and provider and patient concerns and challenges. We employed a rapid analysis to identify main themes.

RESULTS

Providers described adaptations within multiple domains of care delivery, including provider roles and workload, clinical encounter and team meeting format, care delivery platforms, self-management technology education, and patient-provider data sharing. Providers reported concerns about potential negative impacts on patients from COVID-19 and the clinical adaptations it required, including fears related to telemedicine efficacy, blood glucose and insulin pump/pen data sharing, and delayed care-seeking. Particular concern was expressed about already vulnerable patients. Simultaneously, providers reported 'silver linings' of adaptations that they perceived as having potential to inform care and self-management recommendations going forward, including time-saving clinic processes, telemedicine, lifestyle changes compelled by COVID-19, and improvements to family and clinic staff literacy around data sharing.

CONCLUSIONS

Providers across diverse clinical settings reported care delivery adaptations in response to COVID-19-particularly telemedicine processes-created challenges and opportunities to improve care quality and patient health. To develop quality care during COVID-19, providers emphasized the importance of generating evidence about which in-person or telemedicine processes were most beneficial for specific care scenarios, and incorporating the unique care needs of the most vulnerable patients.

MON-057 MODY Diagnosis: Missed Opportunity to Avert Insulin Therapy. A Case Series

BACKGROUND Prevalence of MODY is 1.2% in pediatric diabetes population. SEARCH study reported most of these patients were misdiagnosed as T1DM or T2DM up to 36% and 51% respectively (1). GCK (MODY 2) and HNF1A/HNF4A (MODY3) are the most common forms of MODY. Despite improvement in testing strategy (panel testing instead of step-wise approach) and cost, MODY testing remains underutilized. These conditions do not require insulin therapy, and MODY 2 patients may even be discharged from clinic after diagnosis. We present 4 cases and valuable lessons learned.

MODY 2 Case 1. 4 yo M referred for hyperglycemia in the 300s during surgery. A1c 6.4%. FBG at home 150s, asymptomatic. MGM and MGM’s siblings have diabetes. Diabetes autoantibodies (DAA) negative. C-peptide 5.4 (NL 0.78 - 5.19 ng/ml). MODY panel (GeneDx) showed heterozygous mutation in GCK gene (c.70 C>T). Patient remains off insulin, family reassured and advised to undergo genetic testing.

MODY 2 Case 2. 8 yo M diagnosed at local ED with “T1DM” after presenting with polyuria, polydipsia, and random BG 237. A1c 6.7%, C-peptide 1.9, started on basal-bolus insulin. MODY panel (sent a year later when patient was found to have low insulin requirement, negative DAA) showed pathogenic variant in GCK gene. Weaned from insulin, A1c unchanged (6.3–7%). Mother found to have same mutation. MODY 3 Case 1. 16 yo F referred by PCP who started her on insulin a year prior after an incidental finding of hyperglycemia. A1c was 7.5% at diagnosis. Mom, MGM have diabetes, unknown type (MGM thin by report). DAA neg, C-Peptide 1.74. MODY Panel showed HNF1A heterozygous gene mutation for RI31Q. She was switched to Glyburide, blood glucose 90s. MODY 3 Case 2. 10 yo M referred from the ED for “T1DM” (weight loss, fatigue, A1c 7.6%) started on basal-bolus insulin, but lost to follow up for a year. Brother has MODY 3. DAA neg, C-Peptide 3.1. Targeted gene sequencing showed HNF1A gene mutation. He was switched to Glyburide, A1c improved to 6.7%. However, patient became noncompliant as teenager, A1c now 9.3%.

CONCLUSION MODY remains underdiagnosed. A high index of suspicion should be maintained in nonobese, DAA-negative patients diagnosed with DM before 25yo. Although DAA and genetic testing can be costly, diagnosis can dramatically alter diabetes management as illustrated in all 4 cases, and overall cost of management may be lower in the end. Patients with MODY 2 do not develop vascular complications associated with diabetes, nor require pharmacotherapy. MODY 3 patients may be safely switched to sulfonylurea monotherapy, though degree of diabetes control depends on compliance with medication. Testing gives relatives previously misdiagnosed the opportunity to improve their own quality of life. More education for health care providers is warranted for prompt diagnosis and appropriate management of this condition.

Reference:1. Pihoker, et al. JCEM 2013; 98:4055–62

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

A step towards decentralized wastewater management in the Lower Jordan Rift Valley

In order to address serious concerns over public health, water scarcity and groundwater pollution in Jordan, the expansion of decentralized wastewater treatment and reuse (DWWT&R) systems to small communities is one of the goals defined by the Jordan government in the "Water Strategy 2009-2022". This paper evaluates the general potential of decentralized wastewater system solutions to be applied in a selected area of the Lower Jordan Rift Valley in Jordan. For the study area, the connection degree to sewer systems was calculated as 67% (5% in the rural sector and 75% in the urban sector). The annual wastewater production available for DWWT&R in the rural sector of the investigation area was calculated to be nearly 3.8 million m(3) at the end of 2007. The future need of wastewater treatment and reuse facilities of the rural sector was estimated to be increasing by 0.11 million m(3) year(-1), with an overall potential of new treatment capacity of nearly 15,500 population equivalents (pe) year(-1). The overall potential for implementing DWWT&R systems in the urban sector was estimated as nearly 25 million m(3) of wastewater in 2007. The future need of wastewater treatment and reuse facilities required for the urban sector was estimated to be increasing at a rate of 0.12 million pe year(-1). Together with the decision makers and the stakeholders, a potential map with three regions has been defined: Region 1 with existing central wastewater infrastructure, Region 2 with already planned central infrastructure and Region 3 with the highest potential for implementing DWWT&R systems.

Aspects of design, structure, performance and operation of reed beds--eight years' experience in northeastern New South Wales, Australia

Reed beds (horizontal subsurface flow constructed wetlands) have been employed as secondary treatment devices in on-site and decentralised wastewater management systems in the northeast of the Australian state of New South Wales (NSW) for over a decade. This paper summarises some of the practical and research findings that have come to light in that time. Experience with various aspects of reed bed structure is discussed. A study of the evaporative performance of four small beds planted with Phragmites australis yielded an annual crop factor of 2.6. A total of 28 studies on reed beds treating a variety of commonly encountered wastewater streams yielded the following mean pollutant removal efficiencies: total suspended solids (TSS) 83%, biochemical oxygen demand (BOD) 81%, total nitrogen (TN) 57%, total phosphorus (TP) 35% and faecal coliforms (FC) 1.9 logs. The reed bed is becoming the preferred on-site technology for removing TN and BOD and polishing TSS from primary settled domestic wastewater. Sizing beds for a residence time of approximately five days has become standard practice. A study of six reed beds found six different species of earthworm present, mainly Perionyx excavatus (Indian Blue). A mesocosm experiment subsequently showed that the worms were translocating clogging material from the substrate interstices to the surface of the bed thereby indicating a possible method for prolonging reed bed life.

On-site domestic wastewater treatment by reed bed in the moist subtropics

This paper summarises the results of studies on four subsurface flow wetlands (reed beds) located in the moist sub-tropical north eastern corner of the Australian state of New South Wales. The reed beds, which are subjected to a variety of effluent types, all have a gravel substrate planted with Phragmites australis. All four units were found to maintain satisfactory treatment performance year round. Mean removal efficiencies ranged from 56% to 90% (SS), 70% to 93% (BOD), 38% to 66% (TN), 87% to 99.8% (Faecal coliforms), and 42% to 70% (TP--with one seasonal result of 0% for the eight year old unit) for the four reed beds. After eight years in operation the oldest reed bed was showing signs of phosphorus saturation with outlet TP concentrations exceeding inlet concentrations on some occasions. The youngest reed bed studied appeared to be operating efficiently after five months. A summer water balance on one of the reed beds revealed an average crop factor of 1.6 and a moisture loss to atmosphere of 40% of influent flow. Treatment performance (particularly for TN and SS) was found to be negatively correlated with rainfall during one study. The paper discusses the implications of the above results for on-site system designers and regulators and identifies areas for further investigation.