Specialist Diabetes Care Research Articles

Renoprotective Effects of Additional SGLT2 inhibitor Therapy in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease Stages 3b-4: A Real World Report From A Japanese Specialized Diabetes Care Center.

BackgroundLarge randomized clinical trials of patients with type 2 diabetes mellitus (T2DM) and at high risk for cardiovascular disease revealed that sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduced renal events. However, the trials included small numbers of patients with moderate-to-severe chronic kidney disease (CKD). Therefore, the renoprotective effects of SGLT2 inhibitors remain unknown in T2DM patients complicated with impaired renal function. We examined if SGLT2 inhibitors conferred beneficial effects on kidney function in T2DM patients with CKD.MethodsWe retrospectively recruited T2DM patients who were newly treated with add-on of SGLT2 inhibitors and suffered from moderate-to-severe renal impairment with CKD stages 3b-4 (15 < estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2), at initiation of SGLT2 inhibitor therapy. We analyzed T2DM patients with moderate-to-severe renal impairment who continued to use SGLT2 inhibitors for at least 1 year. We investigated the effects of SGLT2 inhibitor therapy on 1-year changes in eGFR and urinary protein excretion before and after the treatment.ResultsWe analyzed 42 T2DM patients with median eGFR of 40.4 mL/min/1.73 m2. One-year SGLT2 inhibitor therapy lowered median hemoglobin A1c (HbA1c) levels from 7.6% to 7.5% (not significant). Body weight and blood pressure were significantly decreased, and hemoglobin was significantly increased. The median value of eGFR after 1 year of SGLT2 inhibitor therapy was 41.0 mL/min/1.73 m2, with no significant difference compared with baseline. The annual decline in eGFR improved significantly after SGLT2 inhibitor therapy (eGFR: (median), pre: -3.8, vs. post: 0.1 mL/min/1.73 m2 per year, P < 0.01). We also found a significant decrease in urinary protein excretion after SGLT2 inhibitor therapy (urinary protein-to-creatinine ratio: (median), pre: 0.36, vs. post: 0.23 g/g creatinine, n = 35, P < 0.01).ConclusionsThis study revealed the promising observations that add-on treatment with SGLT2 inhibitors exerted significant renoprotective effects, culminating in improvements in annual decline in eGFR and urinary protein excretion in T2DM patients with CKD stages 3b-4, but did not significantly reduce HbA1c. Further prospective clinical trials are warranted to fully elucidate the effects of SGLT2 inhibitors on glycemic control and renal function in T2DM patients with moderate-to-severe renal impairment.

Обновленные клинические рекомендации «Алгоритмы специализированной медицинской помощи больным сахарным диабетом», 9-й выпуск. На что обратить внимание

Обновленные клинические рекомендации «Алгоритмы специализированной медицинской помощи больным сахарным диабетом», 9-й выпуск. На что обратить внимание

Trends in Insulin Therapy—A1C and Age at the Time of Insulin Initiation in the Real-World Setting

Majority of T2DM patients will eventually require insulin; yet not much is known about the trends and type of insulin choice for initiation in different geographies. We analyzed databases at two specialized diabetes care centers in urban India and identified patients initiated on insulin. A total of 673 eligible patients [males (N= 342), females (N=331)]initiated on insulin during the period of Jan to Dec 2017, were analyzed. Among trends observed, there was a predominant usage of premix insulin for initiation as compared to basal insulin (4.96:1),indicating the physician preference. Results are presented in the Table. Patients in two groups, receiving basal insulin and premix insulin were further divided on the basis of age into sub-groups of less than 60 years and more than 60 years. In the premix insulin group, a statistically significant difference in the A1C levels at initiation was observed in between the age groups defined earlier [Mean A1C in &amp;lt; 60-year group was 9.5% vs. 9.2% in &amp;gt; 60-year group, p = 0.03.] High A1C at initiation reflects the physician-patient inertia in insulin initiation, despite several guidelines recommending early insulinization. Although our study has the limitation of being a two-center evaluation, the utilization pattern reflects a delay in insulin initiation and predominant premix insulin usage in the Indian population, in view of the high carbohydrate content of the Indian diet. Mean Age and A1C at Insulin Initiation in Different GroupsMean ± SD95% CIMin, MaxAge (years) at Premix Initiation (N=560)57 ± 1356-5817, 86Age (years) at Basal Initiation (N=113)57 ± 1454-5918, 82Mean Age at Initiation (N=673)57 ± 1356-5817, 86HbA1c (%) at Premix Initiation (N=560)9.4 ± 1.89.2-9.54.1, 16HbA1c (%) at Basal Initiation (N=113)9.8 ± 1.89.5-106.4, 15Mean A1C at Initiation (N=673)9.5 ± 1.89.3-9.64.1, 16 Disclosure R. Kovil: Speaker's Bureau; Self; Eli Lilly and Company, Novo Nordisk A/S, Sanofi, Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca, Janssen Pharmaceuticals, Inc., MSD Pharmaceuticals Pvt. Ltd. M.S. Chawla: Speaker's Bureau; Self; IPCA Laboratories, Eli Lilly and Company, Novo Nordisk A/S, MSD Pharmaceutical Pvt. Ltd., Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca. Speaker's Bureau; Spouse/Partner; Sanofi. P.M. Chawla: Speaker's Bureau; Self; Sanofi. Speaker's Bureau; Spouse/Partner; Eli Lilly and Company, IPCA LABORATORIES, Novo Nordisk A/S, MSD PHARMACEUTICALS PVT. LTD., Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca. M.C. Kothari: None. A.F. Shaikh: None.

Pancreatic exocrine dysfunction: common in type 3c diabetes, but don't forget types 1 and 2 diabetes mellitus

AbstractIt is well understood that the pancreas has two distinct roles: the endocrine and exocrine functions, that are functionally and anatomically closely related. As specialists in diabetes care, we are adept at managing pancreatic endocrine failure and its associated complications. However, there is frequent overlap and many patients with diabetes also suffer from exocrine insufficiency.Here we outline the different causes of exocrine failure, and in particular that associated with type 1 and type 2 diabetes and how this differs from diabetes that is caused by pancreatic exocrine disease: type 3c diabetes. Copyright © 2017 John Wiley &amp; Sons.

Standards of specialized diabetes care. Edited by Dedov II, Shestakova MV, Mayorov AY. 8th edition

Dear Colleagues!&#x0D; We are glad to present the8th Editionof Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation.&#x0D; The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2012, 2017), American Association of Clinical Endocrinologists (AACE, 2017), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EMPA-REG OUTCOME, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals.&#x0D; Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 415 million patients by the end of 2015. According to the current estimation by the International Diabetes Federation, 642 million patients will be suffering from DM by 2040. These observations resulted in the UN Resolution on Diabetes 61/225 passed on 20.12.2006, and in 2011 - UN Political Declaration, addressed to national health systems, calling for the establishment of multidisciplinary strategy in the prevention and control of non-communicable diseases, where special attention is drawn to the problem of diabetes as one of the leading causes of disability and mortality.&#x0D; Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4.35 million patients with DM in this country by the end of 2016 (3% of population) with 92% (4 million) Type 2 DM, 6% (255 th) Type 1 DM and 2% (75 th) other types of DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) confirmed that only 50% of Type 2 DM are diagnosed. So real prevalence of patients with DM in Russia is no less than 8-9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications.&#x0D; Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death.&#x0D; Current edition of the Standards emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of Type 2 DM and its vascular complications, added information about bariatric surgery as a method of treatment of DM with morbide obesity.&#x0D; This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of DM.&#x0D; On behalf of the Working Group

Stepwise strategies to successfully recruit diabetes patients in a large research study in Mexican population

AimsDescribe stepwise strategies (electronic chart review, patient preselection, call-center, personnel dedicated to recruitment) for the successful recruitment of >5000 type 2 diabetes patients in four months. MethodsTwenty-five family medicine clinics from Mexico City and the State of Mexico participated: 13 usual care, 6 specialized diabetes care and 6 chronic disease care. Appointments were scheduled from 11/3/2015 to 3/31/2016. Phone calls were generated automatically from an electronic database. A telephone questionnaire verified inclusion criteria, and scheduled an appointment, with a daily report of appointments, patient attendance, acceptance rate, and questionnaire completeness. Another recruitment log reviewed samples collected. Absolute number (percentage) of patients are reported. Means and standard deviations were estimated for continuous variables, χ2 test and independent “t” tests were used. OR and 95% CI were estimated. Results14,358 appointments were scheduled, 9146 (63.7%) attended their appointment: 5710 (62.4%) fulfilled inclusion criteria and 5244 agreed to participate (91.8% acceptance). Those accepting participation were more likely women, younger and with longer disease duration (p<0.05). The cost of the call-center service was $3,010,000.00 Mexican pesos (∼$31.70 USD per recruited patient). ConclusionsStepwise strategies recruit a high number of patients in a short time. Call centers offer a low cost per patient.

Integrated Diabetes Care, Brining Specialist Diabetes Care to Primary Care-Diabetes Local improvement Scheme SWBCCG

Integrated Diabetes Care, Brining Specialist Diabetes Care to Primary Care-Diabetes Local improvement Scheme SWBCCG

Telemedicine in response to challenges of modern diabetology

Due to the steadily increasing number of patients with diabetes all over the world, access to specialist diabetes care is becoming difficult, especially in rural areas. Approximately 30% of diabetic patients do not achieve the target blood glucose values, which is certainly an important problem of modern diabetology, because it translates into late vascular complications of diabetes, lower quality of life and premature death. In response to the raising demand for diabetes care, technological solutions increasing the accessibility to healthcare professionals with a concomitant reduction of costs of such care may be very useful. In a view of the above, the contribution of continuously developing widely understood information and communication technologies (ICT) to an improvement of blood glucose control in diabetic patients has been recently evaluated in research studies. Phone consultations, remote blood glucose levels monitoring and video consultations are the most commonly studied telemedical interventions. Each of them leads to an increased accessibility to specialist diabetes care. Besides clinical trials, in real patients’ life there are many mobile health applications (apps) available which may be helpful in daily life diabetes management however raise concerns about regulation and approval, privacy, accuracy and safety. Contrary to cardiology, telemedical solutions in diabetology are not popular for commercial use yet, which is why patients and their physicians still have to wait for standardisation and appropriate legal regulations for telemedical interventions in diabetes care. Although as evidenced by clinical trials, such interventions translate into improved blood glucose control, lower costs of diabetes care and even a reduction of hypoglycaemia risk.

Effect of low-dose spironolactone on resistant hypertension in type 2 diabetes mellitus: a randomized controlled trial in a sub-Saharan African population

BackgroundLow-dose spironolactone has been proven to be effective for resistant hypertension in the general population, but this has yet to be confirmed in type 2 diabetic (T2DM) patients. We assessed the efficacy of a low-dose spironolactone on resistant hypertension in a sub-Saharan African population of T2DM patients from Cameroon.MethodsThis was a four-week single blinded randomized controlled trial in 17 subjects presenting with resistant hypertension in specialized diabetes care units in Cameroon. They were randomly assigned to treatment with a daily 25 mg of spironolactone (n = 9) or to an alternative antihypertensive regimen (n = 8), on top of any ongoing regimen and prevailing lifestyle prescriptions. They were seen at the start of the treatment, then 2 and 4 weeks later. The primary outcome was change in office and self-measured blood pressure (BP) during follow-up, and secondary outcomes were changes in serum potassium, sodium, and creatinine levels.ResultsCompared with alternative treatment, low-dose spironolactone was associated with significant decrease in office systolic BP (−33 vs. −14 mmHg; p = 0.024), and in diastolic BP (−14 vs. −5 mmHg; p = 0.006). After 1 month of spironolactone, all the patients were controlled based on BP below 130/80 mmHg, with significant office BP reduction from 158 ± 17/86 ± 11 to 125 ± 11/72 ± 8, vs. 158 ± 8/94 ± 8 to 144 ± 17/89 ± 12 mmHg in the alternative treatment group. There was no significant variation in sodium and creatinine levels in both groups, but a mild increase of potassium levels in the spironolactone group.InterpretationAdd-on low-dose spironolactone was effective in reducing BP to optimal levels in T2DM Cameroonian patients despite mild increase in serum potassium.Trial registration ClinicalTrials.gov Identifier NCT02426099. Date of registration April 2015

Three-phase bone scintigraphy for diagnosis of Charcot neuropathic osteoarthropathy in the diabetic foot - does quantitative data improve diagnostic value?

To investigate whether inclusion of quantitative data on blood flow distribution compared with visual qualitative evaluation improve the reliability and diagnostic performance of 99m Tc-hydroxymethylene diphosphate three-phase bone scintigraphy (TPBS) in patients suspected for charcot neuropathic osteoarthropathy (CNO) of the foot. A retrospective cohort study of TPBS performed on 148 patients with suspected acute CNO referred from a single specialized diabetes care centre. The quantitative blood flow distribution was calculated based on the method described by Deutsch etal. All scintigraphies were re-evaluated by independent, blinded observers twice with and without quantitative data on blood flow distribution at ankle and focus level, respectively. The diagnostic validity of TPBS was determined by subsequent review of clinical data and radiological examinations. A total of 90 patients (61%) had confirmed diagnosis of CNO. The sensitivity, specificity and accuracy of three-phase bone scintigraphy without/with quantitative data were 89%/88%, 58%/62% and 77%/78%, respectively. The intra-observer agreement improved significantly by adding quantitative data in the evaluation (Kappa value 0·79/0·94). The interobserver agreement was not significantly improved. Adding quantitative data on blood flow distribution in the interpretation of TBPS improves intra-observer variation, whereas no difference in interobserver variation was observed. The sensitivity of TPBS in the diagnosis of CNO is high, but holds limited specificity. Diagnostic performance does not improve using quantitative data in the evaluation. This may be due to the reference intervals applied in the study or the absence of a proper gold standard diagnostic procedure for comparison.

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V. (7th edition)

We are glad to present the 7th Edition of Standards of Diabetes Care.These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation.The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2012, 2015), American Association of Clinical Endocrinologists (AACE, 2013), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014) and Russian Association of Endocrinologists (RAE, 2011, 2012).Current edition of the ?Standards? also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals.Latest data indicates that prevalence of DM increased during the last decade more than two-fold, reaching some 387 million patients by the end of 2014. According to the current estimation by the International Diabetes Federation, 592 million patients will be suffering from DM by 2035. These observations resulted in the UN Resolution 61/225 passed on 20.12.2006 that encouraged all Member States "to develop national policies for the prevention, treatment and care of diabetes".Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian State Diabetes Register, there are at least 4.1 million patients with DM in this country. However, the epidemiological survey conducted by the Federal Endocrinology Research Centre during 2002-2010 suggests that actual prevalence is 3 to 4 times greater than the officially recognized and, by this estimate, amounts to 9-10 million persons, comprising 7% of the national population.Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death.Current edition of the "Standards" emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of vascular complications.This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of diabetes mellitus.

Early Identification of Individuals with Poorly Controlled Diabetes Undergoing Elective Surgery: Improving A1c Testing in the Preoperative Period

To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (glycated hemoglobin [A1C] ≥8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care. An algorithm was developed to ensure A1C measurements were obtained as per the American Association of Clinical Endocrinologists/American Diabetes Association (AACE/ADA) guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and preoperative nurse practitioners to improve the glycemic control of patients with an A1C ≥8%. Before implementing the program, A1C testing was recorded in 854 out of 2,335 (37%) patients with diabetes seen in the preoperative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1,236 out of 1,334 (93%) patients with diabetes. After excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8%, and 175 were available for endocrine preoperative consultation. The program led to significant blood glucose level improvements on the day of surgery. A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multidisciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care, and glycemic control on the day of surgery. The impact of improved glycemic control on hospital and surgical outcomes needs further evaluation.

Tele-diabetology to Screen for Diabetes and Associated Complications in Rural India: The Chunampet Rural Diabetes Prevention Project Model.

Diabetes, with its acute and long-term complications, has become a major health hazard in developing countries. An estimated 62.4 million people in India have diabetes. With increasing urbanization and industrialization, we can expect huge numbers of people with diabetes in India in the future. Moreover, all diabetes efforts in India are currently focused in urban areas while 70% of India's population actually lives in rural areas. The current statistics demonstrates that urgent interventions are mandatory to curb the epidemic of diabetes and its complications at the grassroots level. This gap in providing diabetes care can be nullified by the use of tele-diabetology. This holds great potential to overcome barriers and improve quality and access to diabetes care to remote, underserved areas of developing counties. The Chunampet Rural Diabetes Prevention Project (CRDPP) has been developed and tested as a successful model for screening and delivering diabetes care to rural areas in developing countries. Using a tele-diabetology mobile van loaded with appropriate equipment, trained technicians, and satellite technology helped us to screen for diabetes and its complications and deliver diabetes care to remote villages in southern India. The Chunampet model can be applied in reaching out to remote areas where specialized diabetes care facilities may not be available.

Standards of specialized diabetes care. Edited by Dedov II, Shestakova MV (6th edition)

Dear Colleagues!. We are glad to present the 6th Edition of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011), International Diabetes Federation (IDF, 2011), American Diabetes Association (ADA, 2013), American Association of Clinical Endocrinologists (AACE, 2009), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2009) and Russian Association of Endocrinologists (RAE, 2011, 2012). Current edition of the ?Standards? also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM increased during the last decade more than two-fold, reaching some 371 million patients by 2013. According to the current estimation by the International Diabetes Federation, every tenth inhabitant of the planet will be suffering from DM by 2030. These observations resulted in the UN Resolution 61/225 passed on 20.12.2006 that encouraged all Member States ?to develop national policies for the prevention, treatment and care of diabetes?. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian State Diabetes Register, there are at least 3.799 million patients with DM in this country. However, the epidemiological survey conducted by the Federal Endocrinology Research Centre during 2002-2010 suggests that actual prevalence is 3 to 4 times greater than the officially recognized and, by this estimate, amounts to 9-10 million persons, comprising 7% of the national population. . Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. . Current edition of the ?Standards? emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of vascular complications and new RAE position statement on gestational diabetes, produced in collaboration with Russian Association of Obstetrics and Gynecology. . This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of diabetes mellitus.

Diabetes care provision: barriers, enablers and service needs of young adults with Type 1 diabetes from a region of social disadvantage

To determine the barriers to and enablers of engaging with specialist diabetes care and the service requirements of young adults with Type 1 diabetes mellitus from a low socio-economic, multicultural region. A cross-sectional survey targeted 357 young adults with Type 1 diabetes, aged 18-30 years. Participants completed questions about barriers/enablers to accessing diabetes care and service preferences, self-reported HbA(1c), plus measures of diabetes-related distress (Problem Areas in Diabetes), depression/anxiety (Hospital Anxiety and Depression Scale), and illness perceptions (Brief Illness Perceptions Questionnaire). Eighty-six (24%) responses were received [55 (64%) female; mean ± sd age 24 ± 4 years; diabetes duration 12 ± 7 years; HbA(1c) 68 ± 16 mmol/mol (8.4 ± 1.5%)]. Logistical barriers to attending diabetes care were reported; for example, time constraints (30%), transportation (26%) and cost (21%). However, 'a previous unsatisfactory diabetes health experience' was cited as a barrier by 27%. Enablers were largely matched to overcoming these barriers. Over 90% preferred a multidisciplinary team environment, close to home, with after-hours appointment times. Forty per cent reported severe diabetes-related distress, 19% reported moderate-to-severe depressive symptoms and 50% reported moderate-to-severe anxiety. Among these young adults with Type 1 diabetes, glycaemic control was suboptimal and emotional distress common. They had identifiable logistical barriers to accessing and maintaining contact with diabetes care services, which can be addressed with flexible service provision. A substantial minority were discouraged by previous unsatisfactory experiences, suggesting health providers need to improve their interactions with young adults. This research will inform the design of life-stage-appropriate diabetes services targeting optimal engagement, access, attendance and ultimately improved healthcare outcomes in this vulnerable population.

A clinical audit on diabetes care in patients with type 2 diabetes in Al-ain, United arab emirates.

Objectives:To implement a prospective interventional clinical audit to evaluate the current clinical practice and the effect of standard interventions on the management of type 2 diabetes (T2DM).Methods:254 patients with T2DM where recruited in a specialized diabetes care center in Al-Ain, UAE. The diabetes care components were audited before (baseline) and after (3 and 6 months) implementation of Institute of Clinical System Improvement (ICSI) guidelines. Data was compared against international guidelines to achieve target goals of normoglycemia, blood pressure (BP), and low density lipoprotein-cholesterol (LDL-C). We measured changes in mean scores of patient satisfaction level regarding diabetes care at similar intervals, by validated Patient Satisfaction Questionnaire (PSQ-18).Results:We observed a significant reduction in fasting blood glucose (FBG; mean± SD; 9.3 ± 0.03 vs 7.4 ± 0.3mmol/l; P=0.03), and HbA1c (8.7 ± 0.02 vs 8.1 ± 0.02 %; P=0.04) levels after 6 months compared with baseline. Patients who achieved target FBG and HbA1c levels improved significantly (45.7 vs 81.1%; P=0.03), and (40.1 vs 73.6%; P=0.04), respectively. The LDL-C levels improved, though this was not statistically significant. Patients achieving target of BP control improved significantly (SBP 142±7.6 and DBP 95±6.2 vs SBP 136±8.2 and DBP 87±5.8 mmHg;P=0.05).Conclusions:The results of this interventional audit were generally positive and emphasized the feasibility of improving the current clinical practice. Our individualized approach has helped us to achieve a better target in glycemic and BP control as well as patient satisfaction. Further research is needed to understand the long-term impact of our structured approach to improve the quality of T2DM care in the UAE.

Prevalence of diabetes in patients admitted to a cancer hospital

Cancer rates are increased in people with diabetes. There is also recent evidence that outcomes from cancer treatment are worse in those with diabetes. There is a need to assess the prevalence of diabetes in cancer patients in order to tailor resources and improve clinical outcomes. This study examined the prevalence of diabetes and hyperglycaemia and specific referrals amongst hospitalised patients in a specialist cancer hospital. In a cancer hospital 11% of in-patients had either identified diabetes or hyperglycaemia (random blood glucose &gt;11mmol/l.) Consecutive referrals to a diabetes consultant confirmed that over half of patients had gastro-intestinal tract primary cancers, over 20% had poor glycaemic control whilst on steroids, and 18% had poor glycaemic control during artificial nutrition. Referrals came from both medical and surgical teams. Thus diabetes and hyperglycaemia are common problems amongst in-patients with cancer, and these patients have complex diabetes requirement. Patients with cancer and diabetes need access to specialist diabetes care.

Women with pre-existing diabetes and their experiences of maternity care services

Aims and objectivesthe aims of the study were to explore the experience of maternity care services used by women whose pregnancy is complicated by pre-existing diabetes, to gain a deeper understanding of service use and to identify aspects of services that women with pre-existing diabetes would like improved. Backgroundfor women with pre-existing diabetes; pregnancy, birth and the transition to motherhood can be complex and even chaotic. The aim of specialist diabetes care given during pregnancy and delivered by a specialist team of health-care professionals is to optimise pregnancy outcome. However, how health-care professionals within maternity services provide care and support women with pre-existing diabetes during pregnancy and early motherhood has received limited attention. Designan exploratory study utilising a grounded theory approach was conducted. Data were collected via in-depth interviews with 20 respondents; one-to-one, dyad and group interviews were undertaken to fully explore issues. Analysis was undertaken by sub-groups of the research team with at least two members working on each of them. Findingsthree themes were identified from interviews: empathic care with care more focused on diabetes not pregnancy; feeling judged by health-care professionals (with nearly all respondents reporting negative encounters of consultation with the specialist team); and the notion of expertise (with respondents reporting feeling frustrated when it seemed health-care professionals did not value their expertise). Conclusionsthe study emphasised the importance of the health-care relationship for pregnant women with pre-existing diabetes. For outcomes to be optimised women need to be able to form open and trusting relationships with the health-care team. Relevance to clinical practicethis study highlights the need for the health-care team not only to provide physical care to optimise outcome but also supportive care to assist women with pregnancies complicated by diabetes to achieve the best possible physical and emotional health and well-being.

One-third of doctors completing specialist training in diabetes fail to secure a substantive consultant post: Young Diabetologists’ Forum survey 2010

Reports have highlighted a shortage of consultant diabetologist posts in the UK. The number of doctors completing specialist training in diabetes has increased in recent years, but little is known about their employment after they receive their certificate of completion of training. An online survey was sent to all doctors who completed specialist diabetes training from January 2008 to September 2010. Of the 95 eligible respondents, 69 (73%) completed the survey (61% men; median age 36 years). Forty-three (62%) respondents secured substantive NHS consultant posts, and of those who gave their job breakdown, 48/51 (94%) were contributing to specialist diabetes care. Five (7%) respondents held substantive academic positions, while 11 (16%) were locum consultants. Seven (9%) respondents worked abroad, with half of these attributing their emigration to lack of opportunities in the UK. When asked about alternative choices, 39% of respondents were likely to seek 'general physician' roles, which equalled the number who would consider emigrating. Overall, only two-thirds of doctors who complete specialist training in diabetes secure substantive NHS consultant positions, which suggests a failure in workforce planning and a lack of expansion of the number of consultant posts despite progression of the diabetes epidemic.

Commissioning specialist diabetes care

Commissioning specialist diabetes care