Evaluating tools to support a new practical classification of diabetes: excellent control may represent misdiagnosis and omission from disease registers is associated with worse control.

To conduct a service evaluation of usability and utility on-line clinical audit tools developed as part of a UK Classification of Diabetes project to improve the categorisation and ultimately management of diabetes

Characteristics and costs of individuals experiencing severe hypoglycaemia requiring emergency ambulance assistance in the community

Background and aims: Hypoglycaemia causes considerable a burden to individuals the healthcare providers. The aim of this study was to examine clinical characteristics of individuals requiring emergency medical assistance by ambulance services for an episode of severe hypoglycaemia and to estimate provider costs of hypoglycaemia. Materials and methods: Routinely collected information was retrieved for all episodes of severe hypoglycaemia attended to by the emergency ambulance services for a population of 367,051 people, including 75,603 people with diabetes, in Nottinghamshire and Derbyshire, UK, between 01/11/10 to 28/02/11. A total of 90,435 emergency calls were received in the study period, of which 523 (0.6%) were recorded as severe hypoglycaemia. The time to response, on-site treatment and hospitalisation were recorded along with standard clinical and blood glucose (BG) measures. Ambulance services costs were calculated. Results: The mean (SD) [proportion <= 3.2 mmol/L] pre and post-treatment BG levels were 1.9 (0.9) mmol/L [92%] and 6.5 (3.1) mmol/L [3%] respectively, 74% were under insulin treatment, 28% had nocturnal hypoglycaemia, and 153 (32%) individuals were transported to hospital. Lower pre-treatment BG (p<0.01) and Glasgow Coma Scale scores (p=0.05) were observed in insulin treated individuals in comparison to non-insulin treated individuals. No significant differences in individual characteristics were observed for other clinical measurements: post-treatment blood glucose (p=0.39), systolic blood pressure (p=0.28), diastolic blood pressure (p=0.64) and heart rate (p=0.93). Non insulin treatment was an independent predictor of transportation to hospital (p<0.01). Median time from allocation of call to departure of scene by ambulance services was 39 and 59 minutes for those transported and not transported to hospital respectively, translating to costs of £92 and £139 respectively. The median time from allocation to handing over patients to emergency staff was 75 minutes, equating to a cost of £176. Conclusion: The majority of cases of severe hypoglycaemia are successfully treated at the scene by the emergency ambulance services. Insulin treated and non insulin treated individuals do not differ by clinical characteristics, however non insulin treated individuals were more likely to be transported to hospital. Further studies are needed into the effect of prehospital ambulance care by treatment type on subsequent outcomes

Estimating the economic burden of cardiovascular events in patients receiving lipid-modifying therapy in the UK.

OBJECTIVES: To characterise the costs to the UK National Health Service of cardiovascular (CV) events among individuals receiving lipid-modifying therapy. DESIGN: Retrospective cohort study using Clinical Practice Research Datalink records from 2006 to 2012 to identify individuals with their first and second CV-related hospitalisations (first event and second event cohorts). Within-person differences were used to estimate CV-related outcomes. SETTING: Patients in the UK who had their first CV event between January 2006 and March 2012. PARTICIPANTS: Patients ≥18 years who had a CV event and received at least 2 lipid-modifying therapy prescriptions within 180 days beforehand. PRIMARY AND SECONDARY OUTCOME MEASURES: Direct medical costs (2014 £) were estimated in 3 periods: baseline (pre-event), acute (6 months afterwards) and long-term (subsequent 30 months). Primary outcomes included incremental costs, resource usage and total costs per period. RESULTS: There were 24 093 patients in the first event cohort of whom 5274 were included in the second event cohort. The mean incremental acute CV event costs for the first event and second event cohorts were: coronary artery bypass graft/percutaneous transluminal coronary angioplasty (CABG/PTCA) £5635 and £5823, myocardial infarction £4275 and £4301, ischaemic stroke £3512 and £4572, heart failure £2444 and £3461, unstable angina £2179 and £2489 and transient ischaemic attack £1537 and £1814. The mean incremental long-term costs were: heart failure £848 and £2829, myocardial infarction £922 and £1385, ischaemic stroke £973 and £682, transient ischaemic attack £705 and £1692, unstable angina £328 and £677, and CABG/PTCA £-368 and £599. Hospitalisation accounted for 95% of acute and 61% of long-term incremental costs. Higher comorbidity was associated with higher long-term costs. CONCLUSIONS: Revascularisation and myocardial infarction were associated with the highest incremental costs following a CV event. On the basis of real-world data, the economic burden of CV events in the UK is substantial, particularly among those with greater comorbidity burden

Educational weight loss interventions in obese and overweight adults with type 2 diabetes : a systematic review and meta‐analysis of randomized controlled trials

Aim The worldwide prevalence of type 2 diabetes mellitus is increasing, with most individuals with the disease being overweight or obese. Weight loss can reduce disease‐related morbidity and mortality and weight losses of 10–15 kg have been shown to reverse type 2 diabetes. This review aimed to determine the effectiveness of community‐based educational interventions for weight loss in type 2 diabetes. Methods This is a systematic review and meta‐analysis of randomized controlled trials (RCT) in obese or overweight adults, aged 18–75 years, with a diagnosis of type 2 diabetes. Primary outcomes were weight and/or BMI. CINAHL, MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to June 2019. Trials were classified into specified a priori comparisons according to intervention type. A pooled standardized mean difference (SMD) (from baseline to follow‐up) and 95% confidence intervals (95% CI) between trial groups (difference‐in‐difference) were estimated through random‐effects meta‐analyses using the inverse variance method. Heterogeneity was quantified using I2 and publication bias was explored visually using funnel plots. Results Some 7383 records were screened; 228 full‐text articles were assessed and 49 RCTs (n = 12 461 participants) were included in this review, with 44 being suitable for inclusion into the meta‐analysis. Pooled estimates of education combined with low‐calorie, low‐carbohydrate meal replacements (SMD = –2.48, 95% CI –3.59, –1.49, I2 = 98%) or diets (SMD = –1.25, 95% CI –2.11, –0.39, I2 = 95%) or low‐fat meal replacements (SMD = –1.15, 95%CI –2.05, –1.09, I2 = 85%) appeared most effective. Conclusion Low‐calorie, low‐carbohydrate meal replacements or diets combined with education appear the most promising interventions to achieve the largest weight and BMI reductions in people with type 2 diabetes

Aspirin for primary prevention of cardiovascular and all-cause mortality events in diabetes:Updated meta-analysis of randomized controlled trials

AIMS: To evaluate the benefits and harms of aspirin for the primary prevention of cardiovascular disease and all-cause mortality events in people with diabetes by conducting a systematic review and meta-analysis. METHODS: Randomized controlled trials of aspirin compared with placebo (or no treatment) in people with diabetes with no history of cardiovascular disease were identified from MEDLINE, EMBASE, Web of Science, the Cochrane Library and a manual search of bibliographies to November 2015. Study-specific relative risks with 95% CIs were aggregated using random effects models. RESULTS: A total of 10 randomized trials were included in the review. There was a significant reduction in risk of major adverse cardiovascular events: relative risk of 0.90 (95% CI 0.81-0.99) in groups taking aspirin compared with placebo or no treatment. Limited subgroup analyses suggested that the effect of aspirin on major adverse cardiovascular events differed by baseline cardiovascular disease risk, medication compliance and sex (P for interaction for all > 0.05).There was no significant reduction in the risk of myocardial infarction, coronary heart disease, stroke, cardiovascular mortality or all-cause mortality. Aspirin significantly reduced the risk of myocardial infarction for a treatment duration of ≤ 5 years. There were differences in the effect of aspirin by dosage and treatment duration on overall stroke outcomes (P for interaction for all < 0.05). There was an increase in risk of major or gastrointestinal bleeding events, but estimates were imprecise and not significant. CONCLUSIONS: The emerging data do not clearly support guidelines that encourage the use of aspirin for the primary prevention of cardiovascular disease in adults with diabetes who are at increased cardiovascular disease risk

Beyond peer observation of teaching

OBJECTIVE To summarize the evidence on effectiveness of translational diabetes prevention programs, based on promoting lifestyle change to prevent type 2 diabetes in real-world settings and to examine whether adherence to international guideline recommendations is associated with effectiveness. RESEARCH DESIGN AND METHODS Bibliographic databases were searched up to July 2012. Included studies had a follow-up of ≥12 months and outcomes comparing change in body composition, glycemic control, or progression to diabetes. Lifestyle interventions aimed to translate evidence from previous efficacy trials of diabetes prevention into real-world intervention programs. Data were combined using random-effects meta-analysis and meta-regression considering the relationship between intervention effectiveness and adherence to guidelines. RESULTS Twenty-five studies met the inclusion criteria. The primary meta-analysis included 22 studies (24 study groups) with outcome data for weight loss at 12 months. The pooled result of the direct pairwise meta-analysis shows that lifestyle interventions resulted in a mean weight loss of 2.12 kg (95% CI -2.61 to -1.63; I(2) = 91.4%). Adherence to guidelines was significantly associated with a greater weight loss (an increase of 0.3 kg per point increase on a 12-point guideline-adherence scale). CONCLUSIONS Evidence suggests that pragmatic diabetes prevention programs are effective. Effectiveness varies substantially between programs but can be improved by maximizing guideline adherence. However, more research is needed to establish optimal strategies for maximizing both cost-effectiveness and longer-term maintenance of weight loss and diabetes prevention effects

Dietary Recommendations for the Prevention of Type 2 diabetes: What Are They Based on?

Introduction. Type 2 diabetes is increasing in all populations and all age groups across the world. Areas undergoing rapid westernisation and rapid nutrition transition are seeing the greatest increases in prevalence suggesting that environmental factors are important. Studies from around the world have shown that dietary modification for the prevention of T2DM can be successful; however which dietary factors are important remains to be fully elucidated. The WHO, ADA, and Diabetes UK have developed guidelines for the prevention of T2DM even though the WHO states that data from lifestyle modification programmes does not allow for the disentanglement of dietary factors. Aim of Review. The aim of this focused review is to evaluate the current dietary recommendations for the prevention of T2DM. In addition we aim to explore the available evidence from both observation studies and clinical trials to determine whether these recommendations are appropriate