Bilateral extensive leg pyomyositis presenting with diabetic ketoacidosis

Pyomyositis is a rare and serious acute purulent bacterial infection of the skeletal muscle. Diabetes is the most important predisposing factor and, if left untreated, the infection has significant complications. We report the case of an adult male who presented acutely with a history of abdominal pain, nausea and vomiting and bilateral thigh pain. His abdominal examination was unremarkable, but a fluctuant swelling was identified in both thighs. Biochemical investigations revealed raised inflammatory markers and diagnostic chemistry of diabetic ketoacidosis. Pyomyositis was treated with intravenous antibiotics and surgical abscess drainage. MRI is the definitive investigation of choice to diagnose pyomyositis. Differential diagnoses include cellulitis, septic arthritis and deep vein thrombosis.

ABCD debate at the annual ABCD virtual meeting 18 December 2020

Speakers: For the Motion: Dr Stephen Wheatcroft, Consultant Cardiologist and Professor of Cardiometabolic Medicine, University of Leeds, West Yorkshire Against the Motion: Professor John Wilding. Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, Liverpool

Hyperglycaemia in COVID-19: improving recognition and management in a single centre

Background: Hyperglycaemia is a recognised complication of COVID-19 disease and is associated with increased morbidity and mortality. Effects are noted in individuals with and without diabetes and potentiated by the use of recognised COVID-19 treatments such as corticosteroids. Early glycaemic control in the inpatient with COVID-19 disease impacts significantly on outcomes. Methods: A three-phase improvement project evaluated the recognition and management of hyperglycaemia in 120 adult inpatients with COVID-19 disease over a 4-month period. A local guideline and a separate acute care ‘bundle’ were implemented to improve performance. The main outcomes of the project were evaluated in a repeated cross- sectional design; assessing the performance of regular capillary blood glucose monitoring and appropriate treatment of hyperglycaemia where indicated. Results: Prior to intervention, 78.6% of patients had appropriate capillary blood glucose monitoring and no patients were deemed to receive appropriate treatment. Following interventions, 83–100% of patients had appropriate monitoring and 75–100% received appropriate treatment. Conclusions: In this setting, implementation of a guideline and a care bundle contributed towards improved recognition and management of hyperglycaemia in patients with COVID-19 disease. Future study could assess the impact of interventions on a larger scale whilst investigating variation in the subtype of diabetes, patient sex and other demographics on outcomes such as length of stay, morbidity and mortality.

Integrated diabetes care: The Association of British Clinical Diabetologists (ABCD) national survey report

Executive Summary A national survey on integrated diabetes services was carried out by the Association of British Clinical Diabetologists (ABCD) during the COVID-19 pandemic and has provided some very useful insights into the current state of integration to deliver a joined-up diabetes service in the UK. This survey was carried out during the second half of 2020 and explored three main areas: (1) current state of clinical integration between primary and secondary (specialist) diabetes services; (2) the state of IT integration among the diabetes IT systems and hospital-based electronic patient records (EPR) and between hospital and primary care; (3) to ascertain the membership of their views on a ‘one-stop service’ for collecting annual review data for diabetes and the potential barriers to achieve this. The results presented are a summary of the survey, while the full unedited survey report, especially on the qualitative aspects, is available to ABCD members. The survey was mailed to 518 individuals, of which 431 (83.2%) were consultants and 53 (10.2%) were specialist registrars. Of the 83 replies received, 98% were from consultants and the responses represented a total of 73 hospital diabetes services. The findings of this survey revealed that full integration of clinical services among primary care and specialist diabetes teams is uncommon, although there are good examples of clinical integration in different formats. In a number of areas, primary care and specialist diabetes services continue to work in silos despite a universal recognition that integrated services are desirable and are likely to improve quality of care. Clinical leadership, resources and buy-in from those who commission services were deemed important factors to help improve the development of integrated care systems. In hospitals with dedicated diabetes IT systems the information flow from these diabetes systems to the EPR was not universal, raising concerns that vital information about an individual’s diabetes may not be available to other hospital clinical specialities at the time of delivery of care, posing a significant clinical risk. IT integration among primary and specialist diabetes teams in England was only available in certain areas and was mostly based around the use of SystmOne. The survey also identified a diversity of opinions regarding the current arrangements of the Quality Outcome Framework (QOF), where GPs are incentivised to collect data for annual review of routine diabetes care. Many were of the opinion that annual review processes should be performed by clinical teams who are tasked to deliver diabetes care to the individual, while others felt that the status quo should continue with primary care GPs being responsible. A one-stop service for eye screening for diabetes and other annual measurements nearer to people’s homes was identified as an improvement, but several logistic barriers were identified. We recognise the limitations of any survey which expresses opinions of participants. However, we believe the present survey represents a significant proportion of diabetes units in the UK and provides insights into the current state of integrated services in diabetes. There are significant learnings for diabetes communities, and the information can be used to improve and galvanise delivery of integrated diabetes care in the UK.