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

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

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

Psychometric validation of the Self-Care Inventory-Revised (SCI-R) in UK adults with type 2 diabetes using data from the AT.LANTUS follow-on study.

Background: Achieving optimal outcomes in type 2 diabetes (T2DM) involves several demanding self-care&nbsp;behaviours, e.g. managing diet, activity, medications, monitoring glucose levels, footcare. The Self-Care Inventory-Revised (SCI-R) is valid for use in people with T2DM in the US. Our aim was to determine its suitability for use&nbsp;in the UK.Methods: 353 people with T2DM participated in the AT.LANTUS Follow-on study, completing measures of diabetes&nbsp;self-care (SCI-R), generic and diabetes-specific well-being (W- BQ28), and diabetes treatment satisfaction (DTSQ).&nbsp;Statistical analyses were conducted to explore structure, reliability, and validity of the SCI-R.Results: Principal components analysis indicated a 13-item scale (items loading &gt;0.39) with satisfactory internal&nbsp;consistency reliability (&alpha; = 0.77), although neither this model nor any alternatives were confirmed in the&nbsp;confirmatory factor analysis. Acceptability was high (&gt;95% completion for all but one item); ceiling effects were&nbsp;demonstrated for six items. As expected, convergent validity (correlations between self-care behaviours) was found&nbsp;for few items. Divergent validity was supported by expected low correlations between SCI-R total and well-being&nbsp;(rs = 0.02-0.21) and treatment satisfaction (rs = 0.29). Known-groups validity was partially supported with significant&nbsp;differences in SCI-R total by HbA1c (&le;7.5% (58 mmol/mol): 72 &plusmn; 11, &gt;7.5% (58 mmol/mol): 68 &plusmn; 14, p &lt; 0.05) and&nbsp;diabetes duration (&le;16 years: 67 &plusmn; 13, &gt;16 years: 71 &plusmn; 12, p &lt; 0.001) but not by presence/absence of complications&nbsp;or by insulin treatment algorithm.Conclusions: The SCI-R is a brief, valid and reliable measure of self-care in people with T2DM in the UK. However,&nbsp;ceiling effects raise concerns about its potential for responsiveness in clinical trials. Individual items may be more&nbsp;useful clinically than the total score.</div

Are you handling genital oedema confidently?

Men, women or children can suffer from oedema (swelling) of the genitalia. When differential diagnosis has excluded acute trauma or pathology and swelling remains, the condition may be diagnosed as genital lymphoedema, a chronic condition that increases the relative risk of cellulitis. Diagnosis of genital oedema is often delayed due to problems with patient and health professional behaviour, in terms of embarrassment, lack of confidence or lack of knowledge. Awareness of this condition and knowledge on how to manage it will go a long way in helping both patients and clinicians overcome the challenges of addressing genital oedema. This article describes the authors' experiences in managing genital oedema. It also briefly discusses a new international project that seeks to identify the knowledge and training that health professionals need to manage this condition more confidently

New therapies for obesity

Obesity is a chronic disease associated with serious complications and increased mortality. Weight loss through lifestyle changes results in modest weight loss long-term possibly due to compensatory biological adaptations (increased appetite and reduced energy expenditure) promoting weight gain. Bariatric surgery was until recently the only intervention that consistently resulted in ≥ 15% weight loss and maintenance. Our better understanding of the endocrine regulation of appetite has led to the development of new medications over the last decade for treatment of obesity with main target the reduction of appetite. The efficacy of semaglutide 2.4 mg/week - the latest glucagon like peptide-1 (GLP-1) receptor analogue - on weight loss for people with obesity suggests that we are entering a new era in obesity pharmacotherapy where ≥15% weight loss is feasible. Moreover, the weight loss achieved with the dual agonist tirzepatide (GLP-1/glucose-dependent insulinotropic polypeptide) for people with type 2 diabetes and most recently also obesity, indicate that combining the GLP-1 with other gut hormones may lead to additional weight loss compared to GLP-1 receptor analogues alone and in the future, multi-agonist molecules may offer the potential to bridge further the efficacy gap between bariatric surgery and the currently available pharmacotherapies. This article provides a review of the currently available interventions for weight loss and weight maintenance with a focus on pharmacological therapies for obesity approved over the last decade, as well as the emerging development of new obesity pharmacotherapies.</p

Significance of sedimentary organic matter input for shale gas generation potential of Mississippian Mudstones, Widmerpool Gulf, UK

Carboniferous mudstones in central and northern England are shale gas prospects but the controls on the amount and composition of organic matter are not well understood, even though these parameters define the volumes of gas generated in fine-grained sediments. Organic matter in samples from basinal late Mississippian (Arnsbergian) mudstones in the Widmerpool Gulf was characterised by using semi-quantitative (n = 58) and quantitative palynofacies (n = 16) analyses, sporomorph counts and bulk rock geochemistry (total organic carbon, δ13C of bulk organic matter, Rock-Eval Pyrolysis). The results of this study suggest that most organic matter at this location was delivered to the sediment-water interface as aggregates of a granular translucent type of amorphous organic matter (AOMGr, mean 66.7±19.3%) via hemipelagic suspension settling. AOMGr represents fragments of algal material with subordinate inclusions of small plant fragments and pyrite framboids held together by microbial colonies. AOMBr (brown granular amorphous organic matter) is the second most abundant group (mean 15.6±8.5%) comprising similar microbial colonies that grew on suspended land plant-derived fragments in the water column. Palynofacies components representing clearly terrestrial organic matter are much less abundant and include gelified organic matter (G, mean 9.6±12.6%), black phytoclasts (PhBl mean 2.7±4.7%), brown phytoclasts (PhBr, mean 3.3±3.6%) and sporomorphs (mean 1.4±1.3%). Sediment delivery processes influence the balance between terrestrial organic matter and AOMGr. During low sea-level times, turbidity currents and debris flows delivered terrestrial organic matter (representing 12 to 40% of the palynofacies). Kerogen composition varies between Type II and III. In contrast, thin-bedded carbonate-bearing mudstones deposited during rising and high sea-level contain up to 95% AOMGr and these high abundances correspond to higher total organic carbon. Carbonate and AOMGr were generated by high bioproductivity in the water column. Type II (oil- and gas-prone) kerogens are dominant in these mudstones and therefore these intervals represent the best potential targets for thermogenic shale gas

Non-exercise equations to estimate fitness in white European and South Asian men

Cardiorespiratory fitness is a strong, independent predictor of health, whether it is measured in an exercise test or estimated in an equation. The purpose of this study was to develop and validate equations to estimate fitness in middle-aged white European and South Asian men.Multiple linear regression models (n=168, including 83 white European and 85 South Asian men) were created using variables that are thought to be important in predicting fitness (VO2 max, mL⋅kg⋅min): age (years); BMI (kg·m); resting heart rate (beats⋅min); smoking status (0=never smoked, 1=ex or current smoker); physical activity expressed as quintiles (0=quintile 1, 1=quintile 2, 2=quintile 3, 3=quintile 4, 4=quintile 5), categories of moderate- to vigorous-intensity physical activity (0=&lt;75 min⋅wk, 1=75-150 min⋅wk, 2=&gt;150-225 min⋅wk, 3=&gt;225-300 min⋅wk, 4=&gt;300 min⋅wk), or minutes of moderate- to vigorous-intensity physical activity (min⋅wk); and, ethnicity (0=South Asian, 1=white). The leave-one-out-cross-validation procedure was used to assess the generalizability and the bootstrap and jackknife resampling techniques were used to estimate the variance and bias of the models.Around 70% of the variance in fitness was explained in models with an ethnicity variable, such as: VO2 max = 77.409 - (age*0.374) - (BMI*0.906) - (ex or current smoker*1.976) + (physical activity quintile coefficient) - (resting heart rate*0.066) + (white ethnicity*8.032), where physical activity quintile 1 is 1, 2 is 1.127, 3 is 1.869, 4 is 3.793, and 5 is 3.029. Only around 50% of the variance was explained in models without an ethnicity variable. All models with an ethnicity variable were generalizable and had low variance and bias.These data demonstrate the importance of incorporating ethnicity in non-exercise equations to estimate cardiorespiratory fitness in multi-ethnic populations

Statins and risk of thromboembolism:A meta-regression to disentangle the efficacy-to-effectiveness gap using observational and trial evidence

Background and aims Meta-analyses of randomised controlled trials (RCTs) and observational studies indicate a lower risk of venous thromboembolism (VTE) associated with statin treatment. We aimed to compare the effect of statin therapy in these two settings and to identify and quantify potential factors to explain statin efficacy and effectiveness. Methods and results We electronically searched on December 11th, 2018, articles reporting on first VTE events in RCTs (statin vs placebo) and in observational studies (participants exposed vs non-exposed to statin). We performed Knapp-Hartung random-effect meta-analyses to calculate pooled relative risks (RRs) of VTE events associated with statin treatment, separately for RCTs and observational studies; and estimated the ratio of the relative risk (RRR) comparing RCTs and observational studies using meta-regressions, progressively adjusted for study-level characteristics. Twenty-one RCTs (115,107 participants; 959 events) and 8 observational studies (2,898,096 participants; 19,671 events) were included. Pooled RRs for RCTs and observational studies were 0.82 (95% confidence interval (CI): 0.67–1.00; I2 19.2%) and 0.60 (95% CI: 0.42–0.86; I2 86.3%), respectively. In meta-regressions, the unadjusted RRR indicated a nonsignificant 23% smaller benefit in RCTs (RRR 0.77; 95% CI: 0.52–1.13); accounting for age, sex, geographical region, and duration of follow-up, there was a sensible change of the RRR which resulted 0.30 (95% CI: 0.13–0.68). Conclusion Differences in the characteristics between patients included in RCTs and those in observational studies may account for the differential effect of statins in preventing VTE in the two settings

Prospective relationships between body weight and physical activity: an observational analysis from the NAVIGATOR study

Objectives: While bidirectional relationships exist between body weight and physical activity, direction of causality remains uncertain and previous studies have been limited by self-reported activity or weight and small sample size. We investigated the prospective relationships between weight and physical activity. Design: Observational analysis of data from the Nateglinide And Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) study, a double-blinded randomised clinical trial of nateglinide and valsartan, respectively. Setting Multinational study of 9306 participants. Participants: Participants with biochemically confirmed impaired glucose tolerance had annual measurements of both weight and step count using research grade pedometers, worn for 7 days consecutively. Along with randomisation to valsartan or placebo plus nateglinide or placebo, participants took part in a lifestyle modification programme. Outcome measures: Longitudinal regression using weight as response value and physical activity as predictor value was conducted, adjusted for baseline covariates. Analysis was then repeated with physical activity as response value and weight as predictor value. Only participants with a response value preceded by at least three annual response values were included. Results: Adequate data were available for 2811 (30%) of NAVIGATOR participants. Previous weight (χ2=16.8; p&lt;0.0001), but not change in weight (χ2=0.1; p=0.71) was inversely associated with subsequent step count, indicating lower subsequent levels of physical activity in heavier individuals. Change in step count (χ2=5.9; p=0.02) but not previous step count (χ2=0.9; p=0.34) was inversely associated with subsequent weight. However, in the context of trajectories already established for weight (χ2 for previous weight measurements 747.3; p&lt;0.0001) and physical activity (χ2 for previous step count 432.6; p&lt;0.0001), these effects were of limited clinical importance. Conclusions: While a prospective bidirectional relationship was observed between weight and physical activity, the magnitude of any effect was very small in the context of natural trajectories already established for these variables