Endocrinology

Individualised glucocorticoid weaning can reduce the risk of cushingoid side effects and facilitate prompt restoration of adrenal function

David J Torpy · Wu Tzen Lim

The nationwide use of insulin began 100 years ago with experiments in an Adelaide laboratory

Sophie Templer

Despite the large national DFD burden, Australian regions implementing guideline-based care have demonstrated large reductions in their regional DFD burdens and costs

Peter A Lazzarini · Anita Raspovic · Jenny Prentice · Robert J Commons · Robert A Fitridge · James Charles · Jane Cheney · Nytasha Purcell · Stephen M Twigg

A 44-year-old man presented to the emergency department with one month of worsening breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, and pitting oedema to the thighs

Yi‐An Pan · David Roberts · Yi‐An Pan · David Roberts

We need inexpensive methods for distinguishing between people with hypertension who have primary aldosteronism and those who do not

John W Funder

Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants

Elisabeth Ng · Stella M Gwini · Michael Stowasser · Morag J Young · Peter J Fuller · Gurmeet R Singh · Jun Yang

Joshua M Inglis · Ganessan Kichenadasse · Arduino A Mangoni

Lack of clinician knowledge, poor access to services, negative attitudes, and lagging research have led to substandard menopause-related health care

Susan R Davis · Karen Magraith

Pregnancy can be seen as a stress test for cardiometabolic conditions, where the physiological demands of pregnancy can unmask women at risk for CVD

Simone Marschner · Anushriya Pant · Amanda Henry · Louise J Maple‐Brown · Lisa Moran · N Wah Cheung · Clara K Chow · Sarah Zaman

A 77-year-old man with a history of type 2 diabetes was admitted to hospital for acute hyperglycaemia

Manon Levy · Lucien Marchand

Health care professionals caring for men with prostate cancer starting ADT should ensure that their bone health is routinely assessed

Mariya F Hamid · Amy Hayden · Tania Moujaber · Sandra Turner · Howard Gurney · Mathis Grossmann · Peter Wong

A 71-year-old man with a history of 6 weeks of generalised decline presented for outpatient clinic assessment

Karen Bromley · Jessica Phillips · Ashley Irish

Continuous glucose monitoring (CGM) has transformed diabetes management

Rose Lin · Fran Brown · Elif I Ekinci

SGLT2 inhibitors show promise in improving metabolic and cardiovascular health in type 1 diabetes, yet ideal candidates for therapy require careful selection

Jennifer R Snaith · Jerry R Greenfield

To the Editor: We present a case of hypotensive shock after insulin pump delivery interruption during a diabetes technology trial, and offer a systematic insulin pump troubleshooting approach.1 A 61‐year‐old woman with long‐duration type 1 diabetes using an insulin pump, coronary artery disease and hypertension presented to an emergency department with hyperglycaemia, hypotension and presyncope. She had self‐identified insulin pump delivery interruption but felt too unwell to troubleshoot independently. Initial subcutaneous insulin bolus dose administration via the pump as directed by the hospital doctor was ineffective and diabetic ketoacidosis developed. In the context of cardiovascular comorbidities and antihypertensives, including transdermal glyceryl trinitrate, the patient deteriorated rapidly progressing to hypotensive shock requiring intensive care. Insulin delivery interruption was ultimately attributed to line blockage; earlier identification and prompt administration of insulin via an alternative route may have avoided the development of ketoacidosis. Therapeutic diabetes technology is evolving, with an increasing proportion of people with type 1 diabetes now using insulin pumps to replace lost pancreatic β‐cell function.2 Insulin pumps subcutaneously infuse rapid‐acting insulin alone, providing both background basal and bolus insulin doses. These insulin preparations have peak effect at 1–2 hours and duration of action of about 4 hours. Therefore, for people with type 1 diabetes, insulin pump delivery interruption typically causes relative insulin deficiency within 2 hours and absolute insulin deficiency within 4 hours with consequent risk of rapid development of hyperglycaemia, ketosis and ketoacidosis.3 Pump users are routinely instructed on how to troubleshoot insulin delivery problems, including proactive self‐management of pump‐related issues; however, management may revert to clinicians during acute illness. All clinicians should therefore be familiar with common complications during insulin pump therapy, and when to convert to an alternative route of insulin administration to prevent rapid metabolic deterioration.4 The treatment of hyperglycaemia and ketosis is time‐critical, and decisions regarding insulin pump continuation during hospital admissions should be individualised within the acute context.4,5 Once stabilised, patients should reconnect with their diabetes management team for ongoing education. We present a systematic approach to managing rising blood glucose and/or ketones during insulin pump use (Box). As the vignette illustrates, individuals with medical comorbid conditions are at risk of rapid, life‐threatening deterioration after insulin pump delivery interruption. Box – Clinical practice flowchart of steps to troubleshoot insulin pump delivery‐related problems SGLT‐2 = sodium glucose co‐transporter 2. The potential causes of insulin delivery interruption are presented systematically from the site of insulin delivery to the insulin pump. * Hyperglycaemia generally considered to be glucose level>14mmol/L. † Ketosis generally considered to be ketone level>0.6mmol/L. Clinicians should consider the flowchart to be a general guide; always adapt treatment approach to the clinical presentation and refer to local policies and procedures. Management of hyperglycaemia and ketosis is time‐critical; refer to the Royal Australian College of General Practitioners and Australian Diabetes Society joint clinical position statement for a primary care emergency management algorithm.4 Assess whether it is clinically appropriate for hospitalised patients to continue insulin pump therapy.5 Inset: Schematic diagram of the main components of insulin pump therapy; the insulin “infusion set” comprises the cannula (inserted subcutaneously), delivery line and insulin reservoir.

Anindita Chakrabarti · Richard J MacIsaac · Sybil A McAuley

The estimated prevalence of hereditary pancreatitis in South Australia is higher than in Europe, particularly among Indigenous young people

Denghao Wu · Tristan J Bampton · Hamish S Scott · Alex Brown · Karin Kassahn · Christopher Drogemuller · Sunita MC De Sousa · David Moore · Thuong Ha · John WC Chen · Sanjeev Khurana · David J Torpy · Toni Radford · Richard Couper · Lyle Palmer · P Toby Coates

A 55-year-old man was referred for management of resistant hypertension

Kay W Choy · Renata Libianto · Ian Simpson · Jun Yang

Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents

Jencia Wong · Glynis P Ross · Sophia Zoungas · Maria E Craig · Elizabeth A Davis · Kim C Donaghue · Louise J Maple‐Brown · Margaret J McGill · Jonathan E Shaw · Jane Speight · Natalie Wischer · Stephen Stranks

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1 The management of large numbers of COVID‐19 inpatients with diabetes has been challenging. People with diabetes are a vulnerable population who are at risk of adverse outcomes from COVID‐19, with a two‐ to threefold likelihood of death compared with people without diabetes.2 Hyperglycaemia is associated with higher risk;3 hence, good glucose management is desirable. Exacerbation of diabetes by dexamethasone therapy, used to treat patients with COVID‐19, and the development of steroid‐induced hyperglycaemia in non‐diabetic patients present further challenges. Traditional models of care relying on referrals from parent teams to an endocrinologist (or registrar), who then reviews the patient daily to chart insulin, are inefficient and impractical for this situation. We have developed a virtual inpatient diabetes management service (vIDMS) as a means for a small diabetes team to manage COVID‐19 inpatients with diabetes. The success of this model has revolved around an electronic medical record, electronic inpatient prescribing, a diabetes dashboard, and videoconferencing communications. The recording of all glucose measurements (including point of care) within the electronic medical record has enabled the systematic capture and display of hospital‐wide glucose data on a diabetes dashboard (Box). This also allows viewing and filtering by any variable in the electronic medical record, such as ward, age, biochemistry (including formal laboratory glucose and glycated haemoglobin), development of hypoglycaemia, prescribed medications (including corticosteroids), and COVID‐19 status. Therefore, COVID‐19 patients with diabetes or hyperglycaemia are easily identified. The vIDMS, comprising of a consultant, a registrar and a diabetes educator, reviewed patients with COVID‐19 and hyperglycaemia on a daily basis, using the dashboard and electronic medical record, by sharing a screen on a videoconferencing platform. Remote management was undertaken through the electronic medical record, including medication and insulin dose adjustments. Communication with ward staff and patients with COVID‐19 through the electronic medical record, or by telephone or video, was undertaken when needed, including for diabetes education. Entry into the COVID‐19 wards and usage of personal protective equipment was not required. In the 6 weeks to 5 September 2021, 112 COVID‐19 patients with diabetes were thus managed in Westmead Hospital (median age, 62 years; range, 23–91 years), with up to 40 patients reviewed per day. Necessitated by COVID‐19, the future of inpatient diabetes management is now here. With one‐quarter of patients in metropolitan hospitals having self‐reported diabetes4 but insufficient specialised diabetes staff to provide individual management, the vIDMS will become a significant part of the wider model of diabetes care for large hospitals.5 While initial and intermittent face‐to‐face contact remains valuable to build a relationship and discuss relevant issues, and careful review of medical records is necessary to understand perturbations in glucose levels (eg, fasting, missed medication), the vIDMS enables daily specialist care for large numbers of patients with diabetes by a small team. The health system needs to facilitate its wider application for the management of both COVID‐19 and non‐COVID‐19 patients with diabetes in hospital. Box – Diabetes dashboard showing hospital‐wide glucose data for patients with coronavirus disease 2019 (COVID‐19)

N Wah Cheung · Amanda Hor · Tien‐Ming Hng

GPs actively screening for primary aldosteronism could facilitate early treatment of this readily managed form of secondary hypertension

Renata Libianto · Grant M Russell · Michael Stowasser · Stella M Gwini · Peta Nuttall · Jimmy Shen · Morag J Young · Peter J Fuller · Jun Yang