Diabetic ketoacidosis in an adolescent and young adult population in the UK in 2014: a national survey comparison of management in paediatric and adult settings:Special Issue on Diabetes and Childhood

Aims: To assess the management of diabetic ketoacidosis in young people, which differs in the UK between paediatric and adult services, and to evaluate outcomes and extent to which national guidelines are used. Methods: A standardized questionnaire was sent to all paediatric and adult diabetes services in England, requesting details of all diabetic ketoacidosis admissions in young people aged > 14 years in paediatric services (‘paediatric’ patients), and in young adults up to the age of 22 years in adult services (‘adult’ patients). Results: A total of 64 adult patients aged ≤ 22 years (mean age 19.2 years) were reported, of whom seven were aged between 10 and 16 years. A total of 71 paediatric patients were reported [mean (range) age 14.9 (11–18) years]. We found that 85% of paediatric and 69% of adult patients were treated according to national guidelines, 99% of paediatric and 89% of adult patients were treated with 0.9% saline and fixed-rate insulin infusions and 16% of adult patients received an insulin bolus. Insulin treatment was initiated later in paediatric patients than in adult patients (100 vs 39 min; P < 0.001). In 23% of adult patients and 8.8% of paediatric patients, potassium levels were < 3.5 mmol/l (P < 0.005). The lowest mean potassium levels were 3.8 mmol/l in paediatric and 3.5 mmol/l in adult patients (P < 0.005). Hypoglycaemia occurred in 42.3% of paediatric and 36% of adult patients. Time to resolution was similar in paediatric and adult patients (16.0 vs 18.2 h), as was duration of hospital stay (2.35 vs 2.53 days). Conclusions: Young people were treated according to national guidelines, but the quality of monitoring was variable in both paediatric and adult settings. The incidence of hypoglycaemia and hypokalaemia was unacceptably high

Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA)

Purpose of Review: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. Recent Findings: Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. Summary: There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol

Predictors of outcomes in diabetic foot osteomyelitis treated initially with conservative (nonsurgical) medical management: A retrospective study

The optimal way to manage diabetic foot osteomyelitis remains uncertain, with debate in the literature as to whether it should be managed conservatively (ie, nonsurgically) or surgically. We aimed to identify clinical variables that influence outcomes of nonsurgical management in diabetic foot osteomyelitis. We conducted a retrospective study of consecutive patients with diabetes presenting to a tertiary center between 2007 and 2011 with foot osteomyelitis initially treated with nonsurgical management. Remission was defined as wound healing with no clinical or radiological signs of osteomyelitis at the initial or contiguous sites 12 months after clinical and/or radiological resolution. Nine demographic and clinical variables including osteomyelitis site and presence of foot pulses were analyzed. We identified 100 cases, of which 85 fulfilled the criteria for analysis. After a 12-month follow-up period, 54 (63.5%) had achieved remission with nonsurgical management alone with a median (interquartile range) duration of antibiotic treatment of 10.8 (10.1) weeks. Of these, 14 (26%) were admitted for intravenous antibiotics. The absence of pedal pulses in the affected foot (n = 34) was associated with a significantly longer duration of antibiotic therapy to achieve remission, 8.7 (7.1) versus 15.9 (13.3) weeks (P = .003). Osteomyelitis affecting the metatarsal was more likely to be amputated than other sites of the foot (P = .016). In line with previous data, we have shown that almost two thirds of patients presenting with osteomyelitis healed without undergoing surgical bone resection

Effective diabetes complication management is a step toward a carbon-efficient planet: an economic modeling study

Background The management of diabetes-related complications accounts for a large share of total carbon dioxide equivalent (CO2e) emissions. We assessed whether improving diabetes control in people with type 2 diabetes reduces CO2e emissions, compared with those with unchanging glycemic control. Methods Using the IQVIA Core Diabetes Model, we estimated the impact of maintaining glycated hemoglobin (HbA1c) at 7% (53 mmol/mol) or reducing it by 1% (11 mmol/mol) on total CO2e/patient and CO2e/life-year (LY). Two different cohorts were investigated: those on first-line medical therapy (cohort 1) and those on third-line therapy (cohort 2). CO2e was estimated using cost inputs converted to carbon inputs using the UK National Health Service’s carbon intensity factor. The model was run over a 50-year time horizon, discounting total costs and quality adjusted life years (QALYs) up to 5% and CO2e at 0%. Results Maintaining HbA1c at 7% (53 mmol/mol) reduced total CO2e/patient by 18% (1546 kgCO2e/patient) vs 13% (937 kgCO2e/patient) in cohorts 1 and 2, respectively, and led to a reduction in CO2e/LY gain of 15%–20%. Reducing HbA1c by 1% (11 mmol/mol) caused a 12% (cohort 1) and 9% (cohort 2) reduction in CO2e/patient with a CO2e/LY gain reduction of 11%–14%. Conclusions When comparing people with untreated diabetes, maintaining glycemic control at 7% (53 mmol/mol) on a single agent or improving HbA1c by 1% (11 mmol/mol) by the addition of more glucose-lowering treatment was associated with a reduction in carbon emissions

Factors determining the risk of diabetes foot amputations - a retrospective analysis of a tertiary diabetes foot care service

Aims: To identify which factors predict the need for minor or major amputation in patients attending a multidisciplinary diabetic foot clinic. Methods: A retrospective analysis of patients who attended over a 27 month period were included. Patients had to have attended ≥3 consecutive consultant led clinic appointments within 6 months. Data was collected on HbA1c, clinic attendance, blood pressure, peripheral arterial disease (PAD), and co-morbidities. Patients were followed up for 1 year. Results: 165 patients met the inclusion criteria. 121 were male. 33 patients had amputations. There was an association between poor glycaemic control at baseline and risk of amputation when adjusted for other factors, with those patients having HbA1c ≤58 at less risk of amputation with an odds of 0.14 (0.04 to 0.53) of amputation(p = 0.0036). Other statistically significant factors predictive of amputation were: missing clinic appointments (p = 0.0079); a high Charlson index (p = 0.03314); hypertension (p = 0.0216). No previous revascularisation was protective against amputation (p = 0.0035). However PAD was not seen to be statistically significant, although our results indicated a lower risk of amputation with no PAD. Overall, 34.9% (n = 58) of patients had good glycaemic control (HbA1c <58 mmol/mol) at baseline & 81.3% (n = 135) had improved their glycaemic control at their last follow up appointment. Conclusions: In this cohort poor glycaemic control, poor attendance, previous revascularisation & hypertension were associated with higher risk of amputation, with PAD showing a trend. Moreover, we demonstrated benefits in glycaemic control achieved by attending this DFC, which is likely to translate to longer term diabetes related health benefits

The endocrine management of intractable masturbation after epilepsy surgery: A case report and literature review

Intractable masturbation has been reported after epilepsy surgery and can be difficult to control, we present a case treated with cyproterone acetate and haloperidol to achieve an endocrine based resolution of symptoms

The Management of Hospital In-patients with Diabetes Mellitus

In the UK, the prevalence of diabetes in adults in the general population is currently reported as just over 6% in 2014-15 [1]. This rose from a prevalence of 5.5% in 2010. However, the most recent data from the 2016 United Kingdom National Diabetes In-patient Audit reported that the prevalence of diabetes amongst hospitalised in-patients was 17% [2]. This represented a rise of over 15% since the first National Diabetes In-patient Audit was carried out in 2010, and was the same rise in prevalence seen in the general population during that time. Thus diabetes is disproportionately over represented in the in-patient population. It has been recognised for many years that in-patients with diabetes experience ‘glucose-related’ harms. Any form of dysglycaemia is associated with increased harms – in terms of poor outcomes (however that is defined) and also increased mortality [3]. For many years it was well recognised that having long term high glucose concentrations was associated with an increased risk of developing the long term micro and macrovascular complications of diabetes. It was only with the publication of the two seminal trials, the Diabetes Control and Complications Trial in type 1 diabetes and the United Kingdom Prospective Diabetes Study in type 2 diabetes that showed conclusively that in an outpatient population tight glycaemic control was associated with a reduced risk of developing those complications [4,5]. However, to date whilst there are a great deal of data to show that high glucose concentrations are associated with harm in hospitalised in-patients with diabetes, there are almost no data to show that improving glucose concentrations is associated with benefit. However, most authorities agree that glucose concentrations between 6.0 and 10.0mmol/l (with an acceptable range of 4.0 to 12.0mmol/l) are likely to be most beneficial (or rather, least likely to be associated with harm). In the UK there is an organisation called the Joint British Diabetes Societies for Inpatient Care group (JBDS), of which I am a senior member. JBDS is a group of professionals interested in the care of in-patients with diabetes. This group, which is funded by Diabetes UK and the Association of British Clinical Diabetologists and is a collaboration between these two national organisations and the National Diabetes Inpatient Specialist Nurse Group, had as it’s ‘mission statement’ the focus on producing evidence based or, where this was not possible, consensus based, clinical guidelines for the management of diabetes in hospitalised in-patients. These guidelines were designed to be used by non-specialists, and written in a user friendly way to make them clinically useful. I have been involved in writing or contributing to most of the guidelines produced by the group, and have been the lead author on two of the most widely read / used documents – peri-operative care and diabetic ketoacidosis. Indeed, as a result of my involvement in these writing groups, I am now recognised as an international expert on these two subjects. I am regularly invited to speak on these subjects, but also invited to write about them as well. This thesis is a journey through various aspects of my involvement in in-patient care for patients with diabetes from the time I was first appointed as a consultant in Norwich in 2004 to the spring of 2017. In particular my hypothesis is that because of the work I and others have published, the management of in-patients with diabetes has improved the care of this vulnerable group

Defining and characterising diabetic ketoacidosis in adults

Aims: Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. Methods: Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines Results: The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. Conclusions: DKA should only be diagnosed when all three components are present – the ‘D’, the ‘K’ and the ‘A’. In addition, the definitions used to diagnose DKA should be standardised – in particular for clinical trials