Influencing Factors Associated with Delayed Initiation of Insulin Among Patients with Type 2 Diabetes Mellitus at The Diabetes Clinic of a Tertiary Hospital in Ethiopia

Background Guidelines recommend the initiation of insulin in patients with type 2 diabetes mellitus who failed on maximum dose of oral medications. However, time to initiation is inconsistent due to different barriers resulting in delay and thus leads to failure to achieve glycemic control which in turn may lead to different complications. The aim of this study was to explore factors influencing the delayed initiation of insulin among patients with type 2 diabetes being managed at the Diabetes Clinic of Tikur Anbessa Specialized Hospital. Methods A qualitative descriptive study design was employed. Data was collected using in-depth interviews with 27 participants, including patients and healthcare providers. Audio-recorded data was transcribed and then thematically analyzed. Results Different factors influencing the delayed initiation of insulin in patients with type 2 diabetes mellitus were revealed. Patient factors included beliefs about the necessity of insulin and concerns related to starting insulin. Physician factors included perceived patient’s situation and lack of clinical competency. Health institution factors included inadequate laboratory set up and absence of contextual guidelines for diabetes management including insulin initiation. Conclusions The study findings indicated different influencing factors some of which were similar to those reported from other settings while there were others which somehow were unique to study setting. These are indicative of the need to implement interventions such as strengthening the patients’ diabetes health education program that is considerate of the religious, cultural, and social aspects of the society.

Serum PCSK9 Correlates with PTX3 and Apolipoproteins B, A1, and C3 Concentrations in Patients with Type 2 Diabetes

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is involved in the regulation of LDL metabolism. There is evidence that circulating PCSK9 is a cardiovascular risk factor. In this study, we determined factors associated with circulating PCSK9 in a group of patients with type 2 diabetes mellitus (DM2). Material included 116 consecutive patients with DM2 from outpatient diabetes clinic. Circulating PCSK9, PTX3, apolipoprotein (apo) B100, apo B48, and apo C3 levels were determined by ELISA, apo A1 by immunoturbidimetry. The mean (sd) age of patients was 59.1 (11.1) years, the mean (sd) values of serum PCSK9 were 255.4 (106.97) ng/ml. Circulating PCSK9 correlated negatively with age ( r = − 0.21 , p < 0.05 ) and HbA1c ( r = − 0.21 , p < 0.05 ) and positively with BMI ( r = 0.21 , p < 0.05 ), total cholesterol ( r = 0.59 ), LDL-cholesterol ( r = 0.50 ), triglyceride ( r = 0.35 ), apo B100 ( r = 0.43 ), apo A1 ( r = 0.43 ) ( p < 0.001 for all), apo C3 ( r = 0.29 , p < 0.01 ), and apo B48 ( r = 0.25 , p < 0.01 ) concentration and FLI ( r = 0.26 , p < 0.01 ). Strong correlation between PTX3 and PCSK9 levels was observed ( r = 0.47 , p < 0.001 ). Multiple stepwise backward regression analysis with PCSK9 as dependent variable revealed that PTX3, apo B100, apo A1, apo B48, and BMI were significantly positive and the presence of NAFLD and HbA1c negatively associated with PCSK9 concentrations. These variables together explain 57% of PCSK9 variability; the strongest relationship was observed between PCSK9 and PTX3 and apo B100. Our results indicate that circulating PCSK9 is significantly associated with inflammation marker PTX3 as well as atherogenic lipids and apolipoproteins C3, B100, and B48, which might be of value in understanding interactions between development of atherosclerosis and inflammatory state in DM2 patients.

Structural Factors and Quality of Diabetes Health Services in Hail, Saudi Arabia: A Cross-Sectional Study

The chronic disease burden in Saudi Arabia has created adverse health, social and economic consequences that require urgent attention from health and political authorities. Diabetes has become an epidemic in Saudi Arabia. Data on personal and structural factors associated with diabetes in the Hail region are scarce. Such data are imperative to develop effective strategies to control the epidemic in the region. A cross-sectional study of diabetes patients attending diabetes health care facilities in Hail was conducted using a sample of 392 patients. An interviewer-administered questionnaire was used. A slightly higher proportion of female participants (54.1%) were included in the sample. Most of the participants were from rural areas (73.9%), and 70.9% of the participants were from the middle-age (30–50 years) category. A close proximity to the diabetes clinic (OR = 1.98; 95% CI: 1.08–3.44), good transport facilities (OR = 1.67; 95% CI: 1.11–2.78) and feeling contented with supportive services (OR = 2.03; 95% CI: 1.12–4.04) were associated with patients’ satisfaction with the overall quality of the diabetes clinic services. The presence of good-quality health care professionals working in these treatment centers also seemed to contribute to patients’ satisfaction with the services they received. These structural factors associated with patients’ satisfaction with the services they received from diabetes clinics must be considered in diabetes control programs in the region. The minimization of structural barriers will eventually assist the national strategic plan, Vision 2030, which aims to improve the quality of life of the Saudi people by 2030.

Type 1 diabetes management and hospitalisation in the over 25’s at an Australian outer urban diabetes clinic

AimsTo describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged >25 years attending a public outpatient diabetes service. MethodsRetrospective cohort study of people with T1D aged >25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines. ResultsAmong the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m2), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of <53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy. ConclusionsA high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a “wait for acute event” rather than “complication prevention” model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required.

Incidental finding of lipaemia retinalis on diabetic retinal screening

Summary A 37-year-old female of South Asian origin was referred to our diabetes clinic for evaluation of an unusual finding during her retinal screening. Her retinal blood vessels appeared white in contrast to the normal pink-red colour. She had type I hyperlipidaemia, confirmed by genotype, and was recently diagnosed with diabetes, secondary to pancreatic insufficiency, for which she had suboptimal control and multiple hospitalisations with recurrent pancreatitis. On examination, she had multiple naevi on her skin; the rest of the examination was unremarkable. The patient did not report any visual disturbances and had intact visual acuity. Investigations showed raised total cholesterol (12.5 mmol/L) and triglycerides (57.7 mmol/L). Following evaluation, the patient was diagnosed with lipaemia retinalis, secondary to type I hyperlipidaemia. The patient was managed conservatively to reduce the cholesterol and triglyceride burdens. However, therapies with orlistat, statin, fibrates and cholestyramine failed. Only a prudent diet, omega-3 fish oil, medium-chain triglycerides oil and glycaemic control optimised with insulin showed some improvements in her lipid profile. Unfortunately, this led her to becoming fat-soluble vitamin deficient; hence, she was treated with appropriate supplementation. She was also recently started on treatment with volanesorsen. Following this, her lipid parameters improved and lipaemia retinalis resolved. Learning points Lipaemia retinalis is an uncommon incidental finding of type I hyperlipidaemia that may not affect vision. Management of associated dyslipidaemia is challenging with minimal response to conventional treatment. Increased awareness of lipaemia retinalis and specialist management is needed as part of regular patient monitoring and personalised management.

Diabetic Retinopathy Screening Programme: Attendance, Barriers and Enablers amongst Young People with Diabetes Mellitus Aged 12–26 Years

The study aim is to investigate characteristics, barriers and enablers for attendance at the Diabetic Eye Screening Programme Northern Ireland (DESPNI) among people with diabetes aged 12–26 years. A mixed-methods approach with retrospective analysis and prospective, questionnaire-based data collection was completed. Data were analysed using ordinal logistic regression. A questionnaire collected information on barriers and enablers to attending DESPNI. Age, diabetes duration, attendance at diabetes clinic and lower HbA1c values were significantly associated with better attendance. Those aged 12–15 were more likely to attend screening than 16–26 years, odds ratio (OR) 4.01. Subjects diagnosed less than 5 years were more likely to attend than those with longer diabetes duration (OR = 2.52, p =< 0.001). Subjects who attended diabetes clinics were more likely to attend screening (OR = 1.89, p =< 0.001) and have a lower HbA1c (OR = 1.46, p =< 0.001). Questionnaires revealed major barriers to attendance which included inconvenient appointment times, lack of access and poor communication. While many subjects were aware of the impact of diabetes on the eye, many had little understanding of screening. This study provides pivotal information on potential barriers and enablers for young people attending eye screening. We suggest modest changes such as convenient appointment times, clearer communication and one-stop clinics could improve attendance.

Adjusting health care: practicing care for socially vulnerable type 2 diabetes patients

Background Type 2 diabetes cluster in lower social groups and people with type 2 diabetes from lower social groups experience more complications, benefit less from health services and live shorter lives than people with type 2 diabetes from higher social groups. Different logics govern diabetes care and potentially influence the possibility of socially vulnerable type 2 diabetes patients to access and benefit from health services. In order to understand which practice and underlying logic enable socially vulnerable type 2 diabetes patients to access and benefit from diabetes care we aim to describe what professionals at a specialized diabetes clinic do to adjust services to patient’s needs and make the tasks involved in diabetes care doable for socially vulnerable patients and how this work is embedded in an organizational and moral context. Methods Ethnographic fieldwork combining participant observation and interviews was carried out between February 2017 and March 2018 in a specialized diabetes clinic located in a socially deprived area in the capital region of Denmark. Sixteen patients (9 male, 7 female, aged 35-73 years) and 12 professionals (7 doctors, 4 nurses, 1 secretary) participated in the study. We used Annemarie Mol’s concept of “the logic of care” to guide our analysis. Results Our analysis shows that the logic of care and the care practices in this clinic are characterized by a needs-based approach to treatment involving adjustment of services (permeability, timing, and content) and seeing the patient as a person with many needs. Throughout our description of selected care practices, we both characterize how health professionals practice this particular logic of care and the organizational and normative conditions that this logic is entangled with. Conclusions Practicing diabetes care based on patients’ needs involves individualization, something often described as an element of patient centred care. Our study shows that this ideal of individualization and adjustment of treatment is possible in practice. Organizational flexibility and an organizational culture that values patient needs enable needs-based care. In order for socially vulnerable type 2 diabetes patients to benefit from health services it is necessary to create conditions under which professionals can attend to these patients’ multiple and complex needs. Adjusting care to these needs demand a variety of professional efforts some of which are hardly predictable or standardisable.