Summary
Fulminant type 1 diabetes mellitus (FT1DM) is characterised by extremely rapid destruction of pancreatic beta cells. An association between FT1DM and pregnancy has been reported and can lead to unfavourable pregnancy outcomes without timely treatment. We report a case of FT1DM in a pregnancy with gestational diabetes mellitus (GDM), the first of its kind in the English literature to date. A 27-year-old woman with insulin-requiring GDM presented with rapidly deteriorating glycaemic control in her third trimester of pregnancy despite good concordance to treatment. The investigation identified the hallmarks of FT1DM: hyperglycaemia with acute metabolic decompensation and non-immune-mediated beta-cell failure. She received prompt treatment with intravenous insulin therapy and was transitioned to subcutaneous insulin once biochemical improvement had been achieved, albeit with higher insulin requirements than before. She had a good pregnancy outcome and delivered a healthy male infant 5 weeks later through induction of labour. Due to persistent beta-cell dysfunction, she remained on basal-bolus insulin postpartum. This case highlights the importance of early recognition and treatment of FT1DM in pregnancy to prevent adverse maternal and fetal prognoses.
Learning points
Fulminant type 1 diabetes mellitus (FT1DM) is a subtype of type 1 diabetes characterised by extremely rapid beta-cell destruction, leading to abrupt-onset hyperglycaemia with ketosis or ketoacidosis.
The pathognomonic characteristics of FT1DM include the development of diabetic ketosis or ketoacidosis typically within 7 days after the onset of symptoms of hyperglycaemia, a near-normal level of glycated haemoglobin despite elevated plasma glucose levels and the absence of islet cell autoantibodies.
The pathophysiology of FT1DM is unclear but the association with genetic predisposition, viral infection and pregnancy has been reported.
Due to its predilection for pregnancy, clinicians should have a high index of suspicion for FT1DM in pregnant women with rapidly progressing hyperglycaemic ketoacidosis.
As diabetic ketoacidosis in pregnancy is associated with adverse maternal and fetal outcomes, immediate initiation of treatment in pregnant women with suspected FT1DM is extremely vital to prevent morbidity and mortality, even if investigations are still underway.
Patients with FT1DM require lifelong insulin therapy due to the complete loss of beta-cell function.
Methods:We planned to complete an audit cycle. Review of guidelines and legislations relevant to medical documentation was conducted to establish a gold standard, which resulted in creation of a questionnaire as audit tool. The answers to the questions were among Yes/No/Not applicable. Ninety case notes were audited against the questionnaire by an auditor and areas of deficiencies were identified. To address those deficiencies using the above-mentioned standards, a Medical Assessment Proforma was constructed and implemented for a prospective trial of 3 months. As a secondary measure and to facilitate clinical handover among all disciplines, a section for ISBAR handover was added to the front page of the proforma. The staff got educated regarding the new proforma. At the end of the trial period, using the original audit tool, another audit was conducted on 90 patients to assess thoroughness of documentation on the new proforma. The results were analysed using a Chi-squared test; the significant level was taken as P < 0.05.OutcomesThe implementation of the admission proforma led to statistically significant improvement in details of the clerking in the following areas: None of the items were more accurately documented prior to implementation of the proforma. There was a 100% compliance with documenting ISBAR handover section on the front cover of the proforma which is expected to improve structured clinical handover.
Conclusion:Utilizing a standard medical admission proforma significantly improved overall documentation on admission to the acute medical unit. This is expected to enhance the quality of patient care, decrease medico-legal risks to medical patients, generate more accurate funding for medical units and decrease the risk arising from coding errors.
Methods:Centre-based haemodialysis patients from three geographically different kidney units in Queensland, Australia, underwent a single, crosssectional assessment of total daily pill burden from phosphate binders between May 2015 and August 2015. The total number of phosphate binder pills per week comprised of calcium carbonate, aluminium hydroxide, sevelamer hydrochloride, lanthanum and cinacalcet. The urea reduction ratio, serum albumin, serum calcium, serum phosphate and serum parathyroid hormone (PTH) were averaged across this period.
Results:Of the 138 patients in this study, 62 (44.9%) patients were from the Royal Brisbane and Women's Hospital (RBWH), 40 (29.0%) patients were from Redcliffe Satellite Unit and 36 (26.1%) patients were from the Northlakes Satellite Unit. Eighty-two (59.4%) were male and the mean age was 66 (standard deviation 15) years. Between hospital comparisons of baseline co-morbidities revealed significant difference in hypertension (P = 0.014) only. Sevelamer hydrochloride was most commonly used at RBWH at 41%, followed by calcium carbonate (32%) and aluminium hydroxide (22%). In contrast, both Northlakes and Redcliffe had similar phosphate binder use with calcium carbonate being most popular (36% and 58% respectively), followed...
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