• Experience in the use of self-expandable metal stents for the management of variceal haemorrhage

      Pick, Harry; Ososanya, A; Kayani, J; Austin, Andrew; Salmon, Claire; Taylor, Nick; Lawson, Adam (2015-06)
      Introduction Self-Expandable Metal Stents (SEMS) have been reported in small case series to be effective in controlling bleeding from oesophageal varices. A NICE technology appraisal published in 2008 (updated 2011) approved their use, providing arrangements were in place to audit practice. We describe our experience of SEMS in patients presenting with variceal haemorrhage. Method The Royal Derby Hospital has 24/7 provision of emergency endoscopy by a consultant gastroenterologist and TIPSS insertion available within normal working hours. A SEMS (SX- ELLA Danis) was inserted in 15 patients (M:F 12:3, mean age 56, range 29-73) presenting with variceal haemorhage between 2009 and 2014. All stents were inserted under endoscopic guidance. Portal hypertension was due to alcohol induced cirrhosis (n = 14) and Budd Chiari (n = 1). The median Child Pugh score was 11 (B=2/ C =13) and MELD 21 (range 12-35). All patients had band ligation therapy prior to SEMS insertion, with 6 patients having two attempts at endoscopic treatment and 8 patients having a Sengstaken-Blakemore Tube (SBT). The indication for SEMS insertion was ongoing variceal haemorrhage (n = 4), bleeding from band ligation ulceration (n = 7), a combination of the above (n = 2) or complication of SBT insertion (n = 2). SEMS was used as a bridge to TIPSS in 3 patients (though unsuccessful in 2), but TIPSS was felt to be contraindicated in 11 patients due to the severity of hepatic decompensation and in 1 patient due to portal vein thrombosis. Results SEMS insertion was successful and immediate haemostasis achieved in all 15 patients. One patient developed aspiration pneumonia, but patients were subsequently nursed at 45degree and received a prokinetic, without further incidence of aspiration. Stent migration into the stomach was observed in 3 patients, with partial slip across the gastro-oesophageal junction seen in a further 2 patients. The SEMS were removed from 9 patients after a median of 11 days (range 1-18) without complication. The remaining 6 patients died prior to removal. No patients had evidence of ongoing bleeding while SEMS in situ, but 33% had rebleeding within 30 days of removal. A median of 7 units of blood were transfused pre-SEMS insertion and 2 units post. Patient survival was 40% at 30 days and 27% at 1 year. Amongst survivors at 1 year the median Child Pugh/ MELD score at SEMS insertion was 8.5/ 14 compared to 11/ 24 in those who died. Conclusion Our experience shows that SEMS can be safely inserted and effectively achieve haemostasis in patients with refractory haemorrhage from oesophageal varices and in those with bleeding from band ligation induced ulceration. Patient survival was poor, however, due to the severity of hepatic decompensation in the study population.
    • External validity and clinical usefulness of a risk prediction model for 30 day unplanned hospitalization in patients receiving outpatient parenteral antimicrobial therapy.

      Durojaiye, OC
      OBJECTIVES: Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat a variety of infections. However, hospital readmissions remain relatively common. We examined the external validity and clinical usefulness of a previously derived risk prediction model for 30 day unplanned hospitalization in patients receiving OPAT. METHODS: A retrospective cohort study was conducted at two large teaching hospitals in the UK. The design comprised quasi-external temporal validation on patients from the same OPAT setting as the model development, and broader external validation on patients from a different setting. The model predictors were age, prior hospitalizations in the preceding 12 months, Charlson comorbidity score, concurrent IV antimicrobial therapy, type of infection and mode of OPAT treatment. Discriminative ability, calibration and clinical usefulness were assessed. RESULTS: Data from 2578 OPAT patients were analysed. The rates of 30 day unplanned hospitalization were 11.5% (123/1073), 12.9% (140/1087) and 25.4% (106/418) in the model derivation, temporal validation and broader external validation cohorts, respectively. The discriminative ability of the prediction model was adequate on temporal validation (c-statistic 0.75; 95% CI: 0.71-0.79) and acceptable on broader validation (c-statistic 0.67; 95% CI: 0.61-0.73). In both external cohorts, the model displayed excellent calibration between observed and predicted probabilities. Decision curve analysis showed increased net benefit across a range of meaningful risk thresholds. CONCLUSIONS: A simple risk prediction model for unplanned readmission in OPAT patients demonstrated reproducible predictive performance, broad clinical transportability and clinical usefulness. This model may help improve OPAT outcomes through better identification of high-risk patients and provision of tailored care.
    • Extreme QT prolongation in elderly women after non-ST elevation myocardial infarct

      Chatterjee, Debjit (2017-09)
      This is a brief report of three cases of non-ST elevation myocardial infarction presenting with giant T wave inversion and prolonged QT interval. Searching the medical literature revealed a handful of similar cases. There were quite a few common characteristics among these cases suggesting an uncommon but distinctive presentation.
    • Factors Associated With Change in Skin Autofluorescence, a Measure of Advanced Glycation End Products, in Persons Receiving Dialysis.

      Selby, Nicholas; Taal, Maarten (2020-02)
      Introduction: An increase over time in skin autofluorescence (SAF), a measure of accumulation of advanced glycation end products (AGE), predicts higher mortality on hemodialysis (HD). However, evidence is lacking regarding factors that contribute to changes in SAF over time in populations on dialysis. We investigated the rate of change in SAF over 1 year and the factors associated with these changes. Methods: We enrolled 109 patients on HD and 28 on peritoneal dialysis in a prospective study. SAF was measured at baseline, 3, 6, 9, and 12 months. Rate of change in SAF was calculated using the SLOPE function in Microsoft Excel (Microsoft, Redmond, WA). Participants were then grouped into those with stable SAF or increasing SAF. Dietary AGE intake and nutritional assessments were performed at baseline, 6, and 12 months. Results: The mean SAF trend observed was an increase of 0.30 ± 0.63 arbitrary units (AU) per year, but this varied from a decrease of 0.15 ± 0.44 to an increase of 0.76 ± 0.42 AU per year in stable and increasing SAF groups, respectively. Increasing SAF was more common in participants who developed malnutrition during the observation period, whereas those who became well-nourished were more likely to have stable SAF (8 [80%] vs. 14 [42%]; P = 0.02). Development/prevalence of malnutrition over 1 year, HD as first dialysis modality, and current smoking were independent predictors of increasing SAF. Conclusion: SAF increases over time in most persons on dialysis. Independent determinants of increasing SAF were development/prevalence of malnutrition, HD as first dialysis modality, and current smoking. Strategies to reduce/prevent the ise in SAF, including prevention/correction of malnutrition, should be investigated in prospective studies.
    • Feasibility and effectiveness of pre-emptive rehabilitation in persons approaching dialysis (PREHAB).

      Willingham, Fiona; Speelman, I; Hamilton, J; Von Fragstein, Gillian; Shaw, Susan; Taal, Maarten (2019-01)
      INTRODUCTION: End-stage kidney disease (ESKD) is characterised by several complications, leading to reduced functional ability and quality of life during transition to dialysis. This study aimed to establish the feasibility and effectiveness of a patient-centred programme of exercise, nutritional intervention and multidisciplinary education for persons approaching dialysis. METHODS: Patients with eGFR <15 ml/min/1.73 m2 and anticipated to start dialysis within 6-12 months were invited to participate. The 10-week pre-dialysis intervention included a weekly 1-hour gym-based exercise circuit and an education programme. Feasibility and acceptability were assessed through recruitment and retention rates, adherence to the intervention, and from patient feedback following the intervention. Physical function, nutritional status, and anxiety and depression, were assessed at baseline, after intervention, and as dialysis commenced. RESULTS: Thirty patients agreed to participate, with 22 completing the pre-dialysis intervention. Thirteen (59%) participants achieved 100% attendance at the exercise and education sessions, with only two participants attending less than 8/10 sessions. The intervention also led to improved physical function, demonstrated by significant increase in both incremental shuttle walk distance (330 vs. 385 m, p = 0.006) and quadriceps one repetition maximum (p = 0.007), and a trend towards increased sit-to-stand repetitions (20-23, p = 0.11). There was a trend for improved patient perception of activity (Duke Activity Status Index score 31.55 vs. 33.75, p = 0.09). Hand grip strength (29.1 vs. 29.8 kg), body mass index (30.4 vs. 30.5 kg/m2 ) and nutritional status assessed by subjective global assessment (73% well-nourished) were maintained. CONCLUSION: This study demonstrated the feasibility and effectiveness of a patient-centred exercise and education programme in those approaching dialysis. Further research is therefore required to evaluate the impact of this programme on clinical outcomes.
    • A Feasibility Study of Non-Invasive Continuous Estimation of Brachial Pressure Derived From Arterial and Venous Lines During Dialysis

      Horner, Daniela; Lucas, Bethany; White, Kelly; Muggleton, Andy; Selby, Nicholas; Taal, Maarten (2020-11)
      Objective: Intradialytic haemodynamic instability is a significant clinical problem, leading to end-organ ischaemia and contributing to morbidity and mortality in haemodialysis patients. Non-invasive continuous blood pressure monitoring is not currently part of routine practice but may aid detection and prevention of significant falls in blood pressure during dialysis. Brachial blood pressure is currently recorded intermittently during haemodialysis via a sphygmomanometer. Current methods of continuous non-invasive blood pressure monitoring tend to restrict movement, can be sensitive to external disturbances and patient movement, and can be uncomfortable for the wearer. Additionally, poor patient blood circulation can lead to unreliable measurements. In this feasibility study we performed an initial validation of a novel method and associated technology to continuously estimate blood pressure using pressure sensors in the extra-corporeal dialysis circuit, which does not require any direct contact with the person receiving dialysis treatment. Method: The paper describes the development of the measurement system and subsequent in vivo patient feasibility study with concurrent measurement validation by Finapres Nova physiological measurement device. Real-time physiological data is collected over the entire period of (typically 4-hour) dialysis treatment. Results: We identify a quasi-linear mathematical function to describe the relationship between arterial line pressure and brachial artery BP, which is confirmed in a patient study. The results from this observational study suggest that it is feasible to derive a continuous measurement of brachial pressure from continuous measurements of arterial and venous line pressures via an empirically based and updated mathematical model. Conclusion: The methodology presented requires no interfacing to proprietary dialysis machine systems, no sensors to be attached to the patient directly, and is robust to patient movement during treatment and also to the effects of the cyclical pressure waveforms induced by the hemodialysis peristaltic blood pump. This represents a key enabling factor to the development of a practical continuous blood pressure monitoring device for dialysis patients.
    • Flash forward: a review of flash glucose monitoring

      Wilmot, Emma (2018-01)
      The FreeStyle Libre flash glucose monitor became available on prescription (subject to local health authority approval) in all four nations of the UK from November 2017, a watershed moment in the history of diabetes care. Calibration free, the FreeStyle Libre is a disc worn on the arm for 14 days which is designed largely to replace the recommended 4-10 painful finger-stick blood glucose tests required each day for the self-management of diabetes. This review discusses clinical data from randomized and observational studies, considers device accuracy metrics and deliberates its popularity and the potential challenges that this new device brings to diabetes care in the UK. In randomized trials, FreeStyle Libre use is associated with a reduction in hypoglycaemia and, in observational studies, improvements in HbA1c levels. User satisfaction is high and adverse events are low. Accuracy of the FreeStyle Libre is comparable to currently available real-time continuous glucose monitors in adults, children and during pregnancy; the cost of the FreeStyle Libre is lower. Glucose data can be visualized in multiple devices and platforms, and summarized in an ambulatory glucose profile to aid pattern recognition and insulin dose adjustment. There is a need for appropriate education, of both users and healthcare professionals, to harness the full benefits. Further randomized studies to assess the long-termimpact on HbA1c , particularly in those with high baseline HbA1c and in specific age groups, such as adolescents and young adults, are warranted. The potential impact on complications, is yet to be realized.
    • Foot insensitivity is associated with renal function decline in patients with type 2 diabetes: a cohort study.

      Piya, Milan (2016-11)
      BACKGROUND: Identifying patients with diabetes at increased risk of chronic kidney disease (CKD) is essential to prevent/slow the progression to end-stage renal disease (ESRD). CKD and diabetic peripheral neuropathy (DPN) share common mechanisms. Hence, we aimed to examine the relationship between foot insensitivity and CKD in patients with Type 2 diabetes. METHODS: A prospective observational cohort study in adults with Type 2 diabetes. Patients with ESRD were excluded. Foot insensitivity was assessed using the 10-g monofilament test. Renal function was assessed using estimated glomerular filtration rate (eGFR) based on the MDRD equation. Albuminuria was defined as the presence of urinary albumin/creatinine ratio (ACR) >3.4 mg/mmol. RESULTS: Two hundred and twenty eight patients were recruited and followed-up for 2.5 years. One hundred and ninety patients (83.4%) had eGFR ≥ 60 ml/min/1.73 m(2). Seventy six (33.3%) patients had foot insensitivity (i.e. abnormal monofilament test). Patients with foot insensitivity had lower eGFR and higher prevalence of albuminuria compared to patients with normal monofilament test. After adjustment for age, gender, ethnicity, diabetes duration, HbA1c, body mass index, insulin treatment, number of anti-hypertensives, history of peripheral vascular disease, and baseline eGFR (R(2) 0.87), baseline foot insensitivity was associated with study-end eGFR (B = -3.551, p = 0.036). CONCLUSIONS: Patients with Type 2 diabetes and foot insensitivity are at increased risk of eGFR decline. Identifying these patients offers an opportunity to intensify metabolic and blood pressure control to prevent/retard the development of CKD. Future studies of larger sample size and longer follow up from multiple centres are needed to assess the diagnostic performance of our findings in predicting CKD development, and to compare the performance of the monofilament test with albuminuria
    • Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning).

      Jefferies, Helen; McIntyre, Christopher (2011-06)
      BACKGROUND AND OBJECTIVES: Recurrent hemodialysis (HD)-induced ischemic cardiac injury (myocardial stunning) is common and associated with high ultrafiltration (UF) requirements, intradialytic hypotension, long-term loss of systolic function, increased likelihood of cardiovascular events, and death. More frequent HD regimens are associated with lower UF requirements and improved hemodynamic tolerability, improved cardiovascular outcomes, and reduced mortality compared with conventional thrice-weekly HD. This study investigated the hypothesis that modification of UF volume and rate with more frequent HD therapies would abrogate dialysis-induced myocardial stunning. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: A cross-sectional study of 46 patients established on hemodialysis >3 months compared four groups receiving the current range of quotidian therapies: conventional thrice-weekly HD (CHD3); more-frequent HD five to six times/week in a center (CSD) and at home (HSD); and home nocturnal HD (HN). Serial echocardiography quantitatively assessed regional systolic function to identify intradialytic left ventricular regional wall motion abnormalities (RWMAs). Cardiac troponin T (cTnT), N-terminal prohormone brain natriuretic peptide (NT-proBNP), and inflammatory markers were quantified. RESULTS: More frequent HD regimens were associated with lower UF volumes and rates compared with CHD3. Intradialytic fall in systolic BP was reduced in CSD and HSD groups and abolished in HN group. Mean RWMAs per patient reduced with increasing dialysis intensity (CHD3 > CSD > HSD > HN). Home-based groups demonstrated lower high-sensitivity C-reative protein levels, with trends to lower cTnT and NT-proBNP levels in the more frequent groups. CONCLUSIONS: Frequent HD regimes are associated with less dialysis-induced myocardial stunning compared with conventional HD. This may contribute to improved outcomes associated with frequent HD therapies.
    • Gangrenous digital infarcts in a severe case of cutaneous polyarteritis nodosa

      Mahmood-Rao, Hamzah; Ding, Tina; Gandhi, Nirav (2017-05)
      Cutaneous polyarteritis nodosa (CPAN) is a rare diagnosis which is distinct from polyarteritis nodosa (PAN). PAN is a medium-vessel vasculitis which can affect multiple organs and classically produces microaneurysms in the vasculature. CPAN is limited to the skin mainly affecting small vessels. There is an absence of microaneurysms in CPAN and it does not affect internal organs. However, the histopathological findings on the skin are similar to PAN. CPAN rarely progresses to PAN but relapses more often. We will illustrate a challenging case of a patient with CPAN who developed gangrenous infarcts despite initial immunosuppressive treatment with high-dose steroids and azathioprine. His treatment had to be escalated to intravenous cyclophosphamide which induced disease remission
    • Gastric band erosion, infection and migration causing jejunal obstruction.

      Salar, Omer; Waraich, Naseem; Singh, Rajeev; Awan, Altaf (2013-01)
      Complications of laparoscopic adjustable gastric bands (LAGB) are well documented and may include migration, erosion, slippage, infection, pouch dilatation and, rarely, gastric perforation. We describe a rare case involving three such complications simultaneously, namely, gastric erosion, infection and migration through the pylorus-causing proximal jejunal obstruction. As LAGB is now the commonest performed bariatric procedure for the treatment of morbid obesity, we encourage the practising surgeon to be vigilant of these rare but potentially life-threatening complications.
    • General practitioners’ perspectives on campaigns to promote rapid help-seeking behaviour at the onset of rheumatoid arthritis

      Deighton, Chris (2014-03)
      Objective: To explore general practitioners’ (GPs’) perspectives on public health campaigns to encourage people with the early symptoms of rheumatoid arthritis (RA) to seek medical help rapidly. Design: Nineteen GPs participated in four semistructured focus groups. Focus groups were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results: GPs recognised the need for the early treatment of RA and identified that facilitating appropriate access to care was important. However, not all held the view that a delay in help seeking was a clinically significant issue. Furthermore, many were concerned that the early symptoms of RA were often non-specific, and that current knowledge about the nature of symptoms at disease onset was inadequate to inform the content of a help-seeking campaign. They argued that a campaign might not be able to specifically target those who need to present urgently. Poorly designed campaigns were suggested to have a negative impact on GPs’ workloads, and would "clog up" the referral pathway for genuine cases of RA. Conclusions: GPs were supportive of strategies to improve access to Rheumatological care and increase public awareness of RA symptoms. However, they have identified important issues that need to be considered in developing a public health campaign that forms part of an overall strategy to reduce time to treatment for patients with new onset RA. This study highlights the value of gaining GPs’ perspectives before launching health promotion campaigns.
    • Gentamicin-associated acute kidney injury

      Selby, Nicholas; Fluck, Richard; Kolhe, Nitin; Shaw, Susan; Woodier, Nicholas (2009-12)
      BACKGROUND: The incidence of gentamicin-associated acute kidney injury (AKI) as defined by the RIFLE criteria is unknown. AIM AND DESIGN: We performed a retrospective observational study to examine this and the predictive value of RIFLE stage on patient outcome in this setting. METHODS: We included all patients who were treated with gentamicin at our centre over a 1-month period. Data on 228 patients across all specialities were collected by manual searching of hospital notes and electronic pathology reporting systems. Information collected included baseline and peak serum creatinine results, gentamicin dose and serum levels, the presence of additional renal insults and the Stoke co-morbidity index. RESULTS: AKI occurred in 51 (24.4%) patients; 37 (17.7%) 'Risk', 9 (4.3%) 'Injury', 5 (2.4%) 'Failure'. Independent predictors of gentamicin associated AKI were number of gentamicin levels >2 mg/l (OR 1.845, 95% CI 1.22 to 2.79) and higher baseline serum creatinine (OR 1.014, 95% CI 1.001-1.028). There was a greatly increased risk of in-hospital mortality in the AKI group as compared to those without AKI (45.1% vs. 19.1%, OR 3.48, 95% CI 1.8-6.9, P = 0.0004). Risk of in hospital mortality increased with each RIFLE stage (P < 0.0001). CONCLUSION: This study shows that gentamicin-associated AKI remains a common and potentially serious clinical problem. There is a strong correlation between RIFLE class and in-hospital mortality.
    • Glucagon-like peptide 1 infusions overcome anabolic resistance to feeding in older human muscle.

      Williams, John P; Idris, Iskandar (2020-08)
      BACKGROUND: Despite its known insulin-independent effects, glucagon-like peptide-1 (GLP-1) role in muscle protein turnover has not been explored under fed-state conditions or in the context of older age, when declines in insulin sensitivity and protein anabolism, as well as losses of muscle mass and function, occur. METHODS: Eight older-aged men (71 ± 1 year, mean ± SEM) were studied in a crossover trial. Baseline measures were taken over 3 hr, prior to a 3 hr postprandial insulin (~30 mIU ml-1 ) and glucose (7-7.5 mM) clamp, alongside I.V. infusions of octreotide and Vamin 14 (±infusions of GLP-1). Four muscle biopsies were taken, and muscle protein turnover was quantified via incorporation of 13 C6 phenylalanine and arteriovenous balance kinetics, using mass spectrometry. Leg macro- and microvascular flow was assessed via ultrasound and anabolic signalling by immunoblotting. GLP-1 and insulin were measured by ELISA. RESULTS: GLP-1 augmented muscle protein synthesis (MPS; fasted: 0.058 ± 0.004% hr-1 vs. postprandial: 0.102 ± 0.005% hr-1 , p < 0.01), in comparison with non-GLP-1 trials. Muscle protein breakdown (MPB) was reduced throughout clamp period, while net protein balance across the leg became positive in both groups. Total femoral leg blood flow was unchanged by the clamp; however, muscle microvascular blood flow (MBF) was significantly elevated in both groups, and to a significantly greater extent in the GLP-1 group (MBF: 5 ± 2 vs. 1.9 ± 1 fold change +GLP-1 and -GLP-1, respectively, p < 0.01). Activation of the Akt-mTOR signalling was similar across both trials. CONCLUSION: GLP-1 infusion markedly enhanced postprandial microvascular perfusion and further stimulated muscle protein metabolism, primarily through increased MPS, during a postprandial insulin hyperaminoacidaemic clamp.
    • Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA)

      Wilmot, Emma (2020-12)
      Physical exercise is an important component in the management of type 1 diabetes across the lifespan. Yet, acute exercise increases the risk of dysglycaemia, and the direction of glycaemic excursions depends, to some extent, on the intensity and duration of the type of exercise. Understandably, fear of hypoglycaemia is one of the strongest barriers to incorporating exercise into daily life. Risk of hypoglycaemia during and after exercise can be lowered when insulin-dose adjustments are made and/or additional carbohydrates are consumed. Glycaemic management during exercise has been made easier with continuous glucose monitoring (CGM) and intermittently scanned continuous glucose monitoring (isCGM) systems; however, because of the complexity of CGM and isCGM systems, both individuals with type 1 diabetes and their healthcare professionals may struggle with the interpretation of given information to maximise the technological potential for effective use around exercise (ie, before, during and after). This position statement highlights the recent advancements in CGM and isCGM technology, with a focus on the evidence base for their efficacy to sense glucose around exercise and adaptations in the use of these emerging tools, and updates the guidance for exercise in adults, children and adolescents with type 1 diabetes.
    • Glycaemic measures for 8914 adult FreeStyle Libre users during routine care, segmented by age group and observed changes during the COVID-19 pandemic.

      Wilmot, Emma
      AIM: To evaluate the impact of the stay-at-home policy on different glucose metrics for time in range (%TIR 3.9-10 mmol/L), time below range (%TBR < 3.9 mmol/L) and time above range (%TAR > 10 mmol/L) for UK adult FreeStyle Libre (FSL) users within four defined age groups and on observed changes during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Data were extracted from 8914 LibreView de-identified user accounts for adult users aged 18 years or older with 5 or more days of sensor readings in each month from January to June 2020. Age-group categories were based on self-reported age on LibreView accounts (18-25, 26-49, 50-64 and ≥65 years). RESULTS: In January, prior to the COVID-19 pandemic, the 65 years or older age group had the highest %TIR (57.9%), while the 18-25 years age group had the lowest (51.2%) (P < .001). Within each age group, TIR increased during the analysed months, by 1.7% (26-49 years) to 3.1% (≥65 years) (P < .001 in all cases). %TBR was significantly reduced only in the 26-49 years age group, whereas %TAR was reduced by 1.5% (26-49 years) to 3.0% (≥65 years) (P < .001 in both cases). The proportion of adults achieving both of the more than 70% TIR and less than 4% TBR targets increased from 11.7% to 15.9% for those aged 65 years or older (P < .001) and from 6.0% to 9.1% for those aged 18-25 years (P < .05). Mean daily glucose-sensor scan rates were at least 12 per day and remained stable across the analysis period. CONCLUSIONS: Our data show the baseline glucose metrics for FSL users in the UK across different age groups under usual care. During lockdown in the UK, the proportion of adults achieving TIR consensus targets increased among FSL users.
    • Glycaemic variability: The under-recognized therapeutic target in type 1 diabetes care.

      Wilmot, Emma (2019-07)
      Type 1 diabetes mellitus (T1DM) remains one of the most challenging long-term conditions to manage. Despite robust evidence to demonstrate that near normoglycaemia minimizes (but does not completely eliminate) the risk of complications, its achievement has proved almost impossible to attain in a real-world setting. HbA1c to date has been used as the gold standard marker of glucose control and has been shown to reflect directly the risk of diabetes complications. However, it has been recognized that HbA1c is a crude marker of glucose control. Continuous glucose monitoring (CGM) provides the ability to measure and observe inter- and intraday glycaemic variability (GV), a more meaningful measure of glycaemic control, more relevant to daily living for those with T1DM. This paper reviews the relationship between GV and hypoglycaemia, and micro- and macrovascular complications. It also explores the impact of CGM, insulin pumps, closed-loop technologies, and newer insulins and adjunctive therapies on GV. Looking to the future, there is an argument that GV should become a key determinant of therapeutic success. Further studies are required to investigate the pathological and psychological benefits of reducing GV.
    • A guideline for the use of variable rate intravenous insulin infusion in medical inpatients.

      Hayat, Haleema (2015-06)
      The present paper summarizes the key recommendations in a recent publication produced by the Joint British Diabetes Societies for Inpatient Care on the use of variable rate i.v. insulin infusion in 'medical' inpatients. The full guideline is available at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_VRIII.pdf and is designed to be a practical guide that can used by any healthcare professional who manages medical inpatients with hyperglycaemia. Its main aim is to allow variable rate i.v. insulin infusion to be used safely, effectively and efficiently for this specific group of inpatients.