Successful Implementation of Continuous Glucose Monitoring in an Internal Medicine Residency Community Continuity Clinic in Patients with Diabetes Mellitus | Chapter 5 | Disease and Health Research: New Insights Vol. 8

Diabetes mellitus (DM) is the leading cause of blindness, non-traumatic amputation, and end-stage renal disease in the US. Continuous Glucose Monitoring (CGM) is an advancement in diabetes technology that continuously and automatically tracks blood glucose throughout the day and night. Continuous glucose monitoring (CGM) devices help people to manage diabetes with fewer fingerstick checks. Learning how to use a CGM takes time, but it can help more easily manage a diabetic patient's health. Using a CGM device can make it easier to manage diabetes. Several studies show that people with Type 1 and Type 2 diabetes who use a CGM have fewer episodes of low blood sugar and a lower A1C. When combined with proper education, follow-up, and support, CGM has proven effective at improving the management of insulin-dependent diabetics. Our study aims to implement CGM in a resident-run internal medicine clinic, not specialized in endocrinology, to improve the quality of care for diabetic patients using 3-4 insulin injections daily. This was a retrospective observational cohort study that lasted one and a half years. Despite the bias related to individual patients' adherence to diet, exercise, and other lifestyle interventions, the study aimed to evaluate the improvement of glucose control with CGM in a clinic run primarily by internal medicine residents under the supervision of an endocrine specialist. The role of the endocrinologist was mostly prominent in educating the residents initially on how to manage the patients using CGM. After that, the Internal Medicine residents worked autonomously in calling the patients, obtaining their CGM information, and adjusting based on it patient’s treatment of diabetes mellitus.

Methods: Twenty-five patients at the Internal Medicine Residency Clinic with Type 1 or Type 2 DM on at least 3-4 insulin injections were provided with a CGM Dexcom 6 device and assigned to a resident who assesses their glucose management and subsequently adjusts their treatment regimens on a biweekly basis after consultation with board Certified Endocrinologist. Data were collected from the Dexcom Clarity database and the clinic EHR to assess changes in the following endpoints before and after implementation of CGM: average Hba1c/glucose management indicator (GMI), blood glucose, the incidence of low blood glucose (55-70 mg/dL), the incidence of very low blood glucose (<54 mg/dL), percent time in range (70-180 mg/dL), and satisfaction measures on quality of life questionnaire.

Results: Average Hba1c/GMI was reduced to 7.04% from 11.21%, average blood glucose decreased to 158 mg/dL from 286 mg/dL, and incidence of low blood glucose < 70 mg/dl was reduced to 11 minutes per day from 1 hour and 14 min per day, the incidence of very low blood glucose less than 54 mg/dl was reduced to 3 minutes per day from 29 minutes per day, and time in range increased to 74% per day from 18%. A questionnaire given to patients after they started CGM also showed an improvement in their quality of life compared to self-monitoring blood glucose. Furthermore, 16% of the patients in this study eventually discontinued their insulin and controlled it with only perioral medications and an injectable once a week.

Conclusion: This study shows that CGM devices can be successfully utilized in a resident-run clinic to improve the management of diabetic patients administering insulin multiple times a day.

 

Author (s) Details

Andrey Manov
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Sukhjinder Chauhan
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

Gundip Dhillon
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Athena Dhaliwal
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Sabrina Antonio
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Yema Jalal
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Ashrita Donepudi
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Jonathan Nazha
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

Melissa Banal
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Joseph House
Internal Medicine Residency Program, Sunrise Health Consortium GME, Las Vegas, Nevada, USA, Transitional Year Residency Program, Sunrise Health GME Consortium, Las Vegas, Nevada, USA and Mountain View Hospital, Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Please see the book here:- https://doi.org/10.9734/bpi/dhrni/v8/2651

 

Ceramide Synthase Isoforms and Insulin Resistance: A Molecular Perspective | Chapter 12 | Achievements and Challenges of Medicine and Medical Science Vol. 2

The review analyzes the literature data that forms the basis for the "ceramide-centric" view of insulin resistance pathogenesis and obesity-associated diabetes mellitus type 2. The results of recent independent studies have shown that normal sphingolipid metabolism is one of the most important conditions for maintaining glucose homeostasis in the body. The lipid analysis of adipose tissue, skeletal muscles and liver in rodents with experimental obesity, as well as biopsic specimens of diabetics, indicate the high pathogenicity of specific ceramide family members. Analysis of the clinical material and the results of model experiments showed that increased expression of the isoenzyme CerS-6 positively correlated with the degree of resistance to insulin. The degree of pathogenicity is determined by the length of the acyl chain included in de novo synthesized ceramide with the involvement of one of the six ceramide synthase isoenzymes. Selective inhibition of the ceramide synthase-6 isoenzyme to reduce the tissue level of the most pathogenic C16:0-ceramide may be a promising approach for correcting insulin resistance. The creation of a specific inhibitor of CerS-6 will allow selectively to reduce the tissue content of C16:0-ceramide, which, apparently, may contribute to the development of a new direction of pathogenetically grounded pharmacological correction of obesity-associated insulin resistance.

 

Author (s) Details

Kuzmenko Dmitry Ivanovich
Department of Biochemistry and Molecular Biology, Clinical Laboratory Diagnostics of the Siberian State Medical University, SSMU, 634055, Tomsk, Moskovsky trakt, 2, Building 2. Russia.

 

Klimentyeva Tatyana Konstantinovna
Department of Biochemistry and Molecular Biology, Clinical Laboratory Diagnostics of the Siberian State Medical University, SSMU, 634055, Tomsk, Moskovsky trakt, 2, Building 2. Russia.

 

Please see the book here:- https://doi.org/10.9734/bpi/acmms/v2/2795

 

Review of Genetic, Immunological and Clinical Differences in Type 1 Diabetes: A Comparison of Young and Adult Patients | Chapter 7 | Medical Science: Trends and Innovations Vol. 8

The goal of this review article is to describe the differences in genetic, immunological, and clinical presentations of type 1 diabetes mellitus (T1DM) in children and adults. This can add to the knowledge of clinicians treating patients with DM and improve their management skills. T1DM has traditionally been associated with younger populations with onset below the age of 30.  Recent epidemiological data have shown that more than half of all new cases of T1DM occur in adults. Key genetic, immune, and metabolic differences exist between adult- and childhood–adolescent-onset T1DM, many of which are not well understood. A substantial risk of misclassification of diabetes mellitus type can result. Notably, some adults with T1DM may not require insulin at diagnosis, their clinical disease can masquerade as type 2 diabetes mellitus (T2DM), and the consequent misclassification may result in inappropriate treatment. Here, the epidemiology and immunogenetic and metabolic characteristics of adult-onset T1DM was highlighted and summarized. In adult-onset, as compared with childhood-adolescent onset T1DM, HLA-associated risk is lower, with more protective genotypes and lower genetic risk scores. Multiple diabetes-associated autoantibodies are decreased, though Glutamic-acid decarboxylase antibody (GAD65) remains dominant although at lower titers than in children-adolescents with T1DM. After diagnosis, adult patients with T1DM progress more slowly, their serum C-peptide is higher, with ketoacidosis being less frequent. Tools to distinguish types of diabetes are discussed, including body phenotype, clinical course, genetic predisposition, autoantibodies, comorbidities, and C-peptide level. By providing this perspective, the aim is to improve the management of adults presenting with T1DM. Misdiagnosis in adult-onset T1DM is common due to overlapping features with T2DM, leading to inappropriate treatment. This mini-review integrates findings from recent studies to identify distinctions between T1DM in children and adolescents and adult-onset T1DM in genetic predispositions, autoimmunity, and clinical symptoms. Recognizing these differences is critical for timely diagnosis and personalized treatment strategies, ultimately improving patient outcomes.

 

Author (s) Details

 

A. Manov
Internal Medicine and Transitional Year Residency Program, Mountain View Hospital, Las Vegas, USA.

 

S. Shehnaz
Mountain View Hospital, Las Vegas, USA.

 

Y. Badi
Nevada Sunrise Health GME Consortium, Las Vegas, Nevada, USA.

 

Please see the book here:- https://doi.org/10.9734/bpi/msti/v8/4506

Adult–onset Type 1 Diabetes Mellitus Patients Treated Successfully with Insulin and Continuous Glucose Monitoring (CGM): Autoimmunity and CGM in Focus | Chapter 8 | Achievements and Challenges of Medicine and Medical Science Vol. 12

Type 1 Diabetes Mellitus (DM) in adults is currently more common than in children, as traditionally thought. The new data show that up to 40% of Type 1 DM in adults above the age of 30 is misdiagnosed as type 2 DM. The reason for this is that Type 1 DM in adults has a slightly different clinical presentation, usually is not as acute as in children, and can have a short period in which insulin is not needed, generally less than 6- months compared to Latent autoimmune diabetes in adults (LADA). The other reason is that the physicians think that if DM is diagnosed above 40, the patients have DM type 2. This was the traditional way of thinking in the past. Also, 61% of patients with Type 1 DM are overweight and/or obese, which further makes the clinical diagnosis more difficult.

In our case series we are describing two patients misdiagnosed for 14- years one of them and for 4- years the other one as having DM type 2.

They were, from the beginning of their Disease treated with Insulin and other oral antidiabetic medications as well as injectable GLP1-RAG and had very brittle DM, admissions in the hospital for DKA’s, and inferior control of their disease.

Both of them had DKA as the initial presentation of their DM.

We saw those two patients in the clinic and proved that they have adult-onset type 1 DM by checking their GAD-65, IA-2, and Zn- T8 antibodies, which were very positive and showing that their C-peptide was undetectable while their plasma glucose was between 80-180 mg/dl. We treated them with a Basal bolus Insulin regimen and stopped other oral or injectable antidiabetic medications. We switched them from self-monitoring their blood Glucose (SMBG) four times a day to Continuous Glucose monitoring (CGM) with the devices Dexcom G6 and Dexcom G7. The patients were sharing their CGM data with our Internal Medicine Residency clinic. The Internal medicine Residents, part of the CGM team under the supervision of a Certified Endocrinologist who was a part of the clinic, were adjusting their Insulin bi-weekly and seeing the patients every two months. The control of their adult-onset DM type 1 improved significantly after the right diagnosis had been given and CGM introduced.

 

Author (s) Details

 

A. Manov
Department of Internal Medicine, Mountain View Hospital, Sunrise Health Graduate Medical Education Consortium, Las Vegas, Nevada, USA.

 

S. Chauhan
Department of Internal Medicine, Mountain View Hospital, Sunrise Health Graduate Medical Education Consortium, Las Vegas, Nevada, USA.

 

G.Dhillon
Department of Internal Medicine, Mountain View Hospital, Sunrise Health Graduate Medical Education Consortium, Las Vegas, Nevada, USA.

 

A. Donepudi
Department of Internal Medicine, Mountain View Hospital, Sunrise Health Graduate Medical Education Consortium, Las Vegas, Nevada, USA.

 

Please see the book here:- https://doi.org/10.9734/bpi/acmms/v12/3912