With sustained growth of diabetes numbers, sustained patient engagement is essential. Using nationally available data, we have shown that the higher mortality associated with a diagnosis of T1DM/T2DM ...could produces loss of 6.4 million future life years in the current UK population. In the model, the ‘average’ person with T1DM (age 42.8 years) has a life expectancy from now of 32.6 years, compared to 40.2 years in the equivalent age non diabetes mellitus population, corresponding to lost life years (LLYs) of 7.6 years/average person. The ‘average’ person with T2DM (age 65.4 years) has a life expectancy from now of 18.6 years compared to the 20.3 years for the equivalent non diabetes mellitus population, corresponding to LLY of 1.7 years/average person. We estimate that for both T1DM and T2DM, one year with HbA1c >58 mmol/mol loses around 100 life days. Linking glycaemic control to mortality has the potential to focus minds on effective engagement with therapy and lifestyle recommendation adherence.
Abstract Aim The Clinical Guidelines provide an opportunity to summarise the interpretation of relevant clinical trial evidence for older people with diabetes. They are intended to support clinical ...decisions in older people with diabetes and the primary focus is enhancing high quality diabetes care by the use of best available evidence. Methods The principles used for developing the recommendations are drawn from the Scottish Intercollegiate Guidelines Network (SIGN) based in Edinburgh, Scotland. Using SIGN 50, the Guidelines developer's handbook, each reviewer evaluated relevant and appropriate studies which have attempted to answer key clinical questions identified by the Working Party. Searches were generally limited to English language citations over the previous 15 years but the wide experience and multinational nature of the Working party ensured that citations in Italian, French Spanish, and German were considered if relevant. All relevant published articles were identified from the following databases: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 13 key major peer-reviewed journals was undertaken by two reviewers and included the Lancet, Diabetes, Diabetologia, Diabetes Care, Diabetes and Metabolism, British Medical Journal, New England Journal of Medicine, and the Journal of the American Medical Association. Results Key evidenced-based recommendations were made in 18 clinical domains of interest and Good Clinical Practice points identified. A glucose-lowering algorithm has been provided for frail older patients with diabetes. Conclusion We have provided an up-to-date evidenced-based approach to practical clinical decision-making for older adults with type 2 diabetes of 70 years and over. We have included a user-friendly set of recommendations to aid clinical decision-making in primary, community-based and secondary care settings.
Nausea and vomiting are experienced by most women during pregnancy. The onset is usually related to Last Menstrual Period (LMP) the date of which is often unreliable. This study describes the time to ...onset of nausea and vomiting symptoms from date of ovulation and compares this to date of last menstrual period METHODS: Prospective cohort of women seeking to become pregnant, recruited from 12 May 2014 to 25 November 2016, in the United Kingdom. Daily diaries of nausea and vomiting were kept by 256 women who were trying to conceive. The main outcome measure is the number of days from last menstrual period (LMP) or luteinising hormone surge until onset of nausea or vomiting.
Almost all women (88%) had Human Chorionic Gonadotrophin rise within 8 to 10 days of ovulation; the equivalent interval from LMP was 20 to 30 days. Many (67%) women experience symptoms within 11 to 20 days of ovulation.
Onset of nausea and vomiting occurs earlier than previously reported and there is a narrow window for onset of symptoms. This indicates that its etiology is associated with a specific developmental stage at the foetal-maternal interface.
NCT01577147 . Date of registration 13 April 2012.
Diabetes mellitus is a highly prevalent metabolic condition in ageing societies associated with high levels of morbidity, multiple therapies, and functional deterioration that challenges even the ...best of health care systems to deliver high-quality, individualized care. Most international clinical guidelines have ignored the often-unique issues of frailty, functional limitation, changes in mental health, and increasing dependency that characterize many aged patients with diabetes. A collaborative Expert Group of the IAGG and EDWPOP and an International Task Force have explored the key issues that affect diabetes in older people using a robust method comprising a Delphi process and an evidence-based review of the literature. Eight domains of interest were initially agreed and discussed: hypoglycemia, therapy, care home diabetes, influence of comorbidities, glucose targets, family/carer perspectives, diabetes education, and patient safety. A set of “consensus” statements was produced in each domain of interest. These form a foundation for future policy development in this area and should influence the clinical behavior and approach of all health professionals engaged in delivering diabetes care to older people.
Hypoglycaemia, especially in older people, increases the risk of falls, fractures, cardiovascular events, admissions and death.2,3 What do we say therefore when we are reviewing a person with type 2 ...diabetes who is 75, has osteoarthritis, and is on sulphonulurea, metformin and basal insulin and has a HbA1c of 7.0% and does not report any significant hypoglycaemia? ...many of these guidelines usually do not take age or life expectancy into consideration. The IDF guideline Managing Older People with type 2 Diabetes published in 2013 was the first to recommend revising upward HbA1c targets for older people when they are functionally dependant due to either frailty or dementia or are in the last year of life.4 Like many other clinical datasets of people with diabetes the dataset being used in this study from Brazil did not record frailty or dementia so the IDF HbA1c recommendations could not be used.
ObjectiveThere are many uncertainties surrounding the aetiology, treatment and sequelae of hyperemesis gravidarum (HG). Prioritising research questions could reduce research waste, helping ...researchers and funders direct attention to those questions which most urgently need addressing. The HG priority setting partnership (PSP) was established to identify and rank the top 25 priority research questions important to both patients and clinicians.MethodsFollowing the James Lind Alliance (JLA) methodology, an HG PSP steering group was established. Stakeholders representing patients, carers and multidisciplinary professionals completed an online survey to gather uncertainties. Eligible uncertainties related to HG. Uncertainties on nausea and vomiting of pregnancy and those on complementary treatments were not eligible. Questions were verified against the evidence. Two rounds of prioritisation included an online ranking survey and a 1-hour consensus workshop.Results1009 participants (938 patients/carers, 118 professionals with overlap between categories) submitted 2899 questions. Questions originated from participants in 26 different countries, and people from 32 countries took part in the first prioritisation stage. 66 unique questions emerged, which were evidence checked according to the agreed protocol. 65 true uncertainties were narrowed via an online ranking survey to 26 unranked uncertainties. The consensus workshop was attended by 19 international patients and clinicians who reached consensus on the top 10 questions for international researchers to address. More patients than professionals took part in the surveys but were equally distributed during the consensus workshop. Participants from low-income and middle-income countries noted that the priorities may be different in their settings.ConclusionsBy following the JLA method, a prioritised list of uncertainties relevant to both HG patients and their clinicians has been identified which can inform the international HG research agenda, funders and policy-makers. While it is possible to conduct an international PSP, results from developed countries may not be as relevant in low-income and middle-income countries.
Background
Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin.
We recently examined patient ...experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK.
Methods
An online self‐reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1).
Results
Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months.
For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c <65 mmol/mol of whom 35% were concerned.
Regarding BG monitoring/insulin adjustment, only 25% of responders reported having sufficient information with 13% believing that the accuracy and precision of their BG metre was being independently checked. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and only 7% were aware of the International Standardisation Organisation (ISO) standards for BG metres. 77% did not recall discussing BG metre performance with a healthcare professional.
Conclusion
The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.
We conducted an online survey of experience of BG monitoring in people with T2DM. Perceptions of shorter vs longer term consequences of hyperglycaemia varied widely. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and 77% did not recall discussing BG metre performance with a healthcare professional ‐ this is clearly an area where changes in education and support would benefit many.
Prevalence of Diabetes in Care Home Residents
Alan J. Sinclair , MD, FRCP 1 ,
Roger Gadsby , MB 2 ,
Sue Penfold , MB 5 ,
Simon C.M. Croxson , MD, FRCP 3 and
Antony J. Bayer , MB 4
1 Diabetes Research ...Unit, Selly Oak Hospital, University of Birmingham, Bimingham
2 Red Roofs Surgery, Nuneaton
3 Department of Medicine for the Elderly, Bristol General Hospital, Bristol
4 Department of Geriatric Medicine, University of Wales College of Medicine, Llandough Hospital, Penarth
5 the Department of Primary Care Medicine, the Ladywood Project, U.K.
Abstract
OBJECTIVE —To determine the prevalence of known and undetected diabetes diagnosed either by an elevated fasting baseline sample or by
a 2-h post–glucose load sample in a group of residents of care homes in an urban-district setting.
RESEARCH DESIGN AND METHODS —We completed individual interviews with patients and caregivers in 30 care homes (both residential and nursing homes) in
two metropolitan districts of Birmingham, West Midlands, U.K. All care homes were under the supervision of primary care physicians
(general practitioners). We carried out 75-g oral glucose tolerance tests (OGTTs) in consenting residents without previous
known diabetes. Criteria for diagnosis of diabetes were obtained from the World Health Organization (1998) and the American
Diabetes Association (1997).
RESULTS —Of 636 residents available for study, 76 residents (12.0%) were known to have diabetes; of the 560 remaining residents, 286
either refused to participate or were deemed too ill or unavailable to undergo testing. Complete data on 274 OGTTs were obtained
(median age 83 years, range 45–101). A total of 46 subjects were diagnosed as having diabetes and 94 as having impaired glucose
tolerance. Allowing for subjects who refused or were unable to participate, the calculated total prevalence (which includes
known and newly detected diabetes) was 26.7% (95% CI 21.9–32.0). The calculated overall prevalence of impaired glucose tolerance
was 30.2% (25.2–35.6).
CONCLUSIONS —In a group of care home residents not known to have diabetes and able to undergo testing, a substantial proportion have undetected
diabetes based on a 2-h postglucose load. These residents warrant further study as they may be at higher cardiovascular risk
and require an intervention.
IGT, impaired glucose tolerance
OGTT, oral glucose tolerance test
Footnotes
Address correspondence and reprint requests to Prof. A.J. Sinclair, Professor of Medicine and Consultant Diabetologist, Diabetes
Research Unit, Centre for Health Services Studies (CHESS), University of Warwick, Coventry CV4 7AL, U.K. E-mail: a.j.sinclair{at}bham.ac.uk .
Received for publication 22 August 2000 and accepted in revised form 23 February 2001.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
Nausea and vomiting of pregnancy (NVP) is the most prevalent medical condition associated with pregnancy. The Royal College of Obstetricians and Gynaecologists published its first guidelines for ...management of NVP in 2016, although many current treatments are off label, with only one recently licensed treatment for NVP in the UK.
To identify the current practices for NVP management across the patient pathway, and estimate the economic burden to NHS services.
This was an observational, retrospective research study conducted in the Newcastle Gateshead Clinical Commissioning Group (CCG) health economy area in England.
Data were collected from GP practices, local hospital datasets, ambulance services (April 2013-March 2016), and the Hospital Episode Statistics dataset (2006-2016).
Eight GP practices participated in the study. In all, 15.2% of the total pregnant population presented with NVP. Treatment varied significantly between GP practices, and 33.6% of women re-presented to their GP. There was an annual increase in women admitted to hospital for NVP symptoms, with increasing length of stay per admission. Almost half (44.6%) of the calls to 999/111 from women experiencing NVP symptoms resulted in an ambulance dispatch. The annual cost of NVP to this health economy was estimated to be £199 804, which crudely extrapolates to £25 758 731 at UK level. Due to underestimations of costs, the impact to the UK NHS could be up to £62 373 961.
There is considerable variation in current management practices for NVP outside of recently published guidelines, and this may result in substantial resource use and avoidable financial impact to the NHS.
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