Intensive glucose control and the clinical paradox of transient progression of diabetic retinopathy: Prioritising the relevance of eye screening intervals.

The paradoxical early worsening of diabetic retinopathy with optimisation of glycaemic control is well recognised. Patients with type 2 diabetes mellitus with R0M0 grading at eye screening with enhanced glycaemic control and progression of diabetic retinopathy may get missed with just biennial monitoring as per the changes to national diabetes eye screening programme guidelines. However, from the perspective of patients with type 1 diabetes mellitus being offered newer hybrid closed-loop systems for insulin delivery, very recent guidance allows for this recommendation of a 24-month screening interval to be adjusted. There is an override option within the screening software to enable an additional 12-month screen following the initiation of the closed-loop system. More frequent screening during pregnancy when glycaemic control is tightened, was established several years ago. Interestingly, no such guidance is currently available for patients being treated with GLP-1RA for T2DM, or in patients following bariatric surgery despite the well-recognised impact that has been observed. With newer incretin mimetic treatments in the horizon, this warrants a review and needs a re-appraisal.

General internal medicine: acquiring clinical acumen from bedside to front door with opportunities for undergraduate and postgraduate training.

A general physician's training and experience enables them to manage a variety of acute and chronic medical conditions with multi-system pathology, while specialising in one specific area of medicine. In every illness there are other problems outside the specialty, requiring the wider expertise of the generalist as patients have multiple comorbidities and the multitude of disease pathology presenting are quite complex requiring a multi-faceted approach. The horizons of general internal medicine have broadened with a wide landscape of acute illnesses that are now being admitted under general medicine which is the path of least resistance. As we strive relentlessly while working on the ward at the bedside and in acute portals, we ought to remind ourselves of what are the attractions of general internal medicine and lead by example for the undergraduates and postgraduate doctors in training who see us as role models for doing clinical medicine, teaching, training and research.

Existing and emerging GLP-1 receptor agonist therapy: Ramifications for diabetic retinopathy screening.

GLP-1 receptor agonist treatment revolutionised the management of type 2 diabetes mellitus with significant enhancement of cardiovascular risk reduction. They have been instrumental in effectively managing the glycaemic control of this at-risk patient group. This class of drugs are associated with rapid improvement in glucose levels and consequently, transient early worsening of pre-existing diabetic retinopathy (DR) which is well-recognised, but this paradox is less commonly perceived in routine clinical practice. The recent shortage of supply has resulted in an enforced hiatus to prescribing all existing GLP-1 receptor agonists, which is expected to last all through 2024. This becomes even more pertinent as their DR could have progressed due to worsening HbA1c as a result of the unforeseen interruption to GLP-1 receptor agonist treatment. Therefore, when these medications are recommenced in a few months' time, all prescribers need to be aware of these patients' most up-to-date DR status and liaise with their affiliated screening service.

Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint.

Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium-glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.

Combination therapy of oxidised regenerated cellulose/collagen/silver dressings with negative pressure wound therapy for coverage of exposed critical structures in complex lower-extremity wounds.

Complex wounds with exposed critical structures such as tendon and bone are a conundrum in wound management, especially in the setting where the patient is not a suitable candidate for flap surgery. While the individual use of negative pressure wound therapy (NPWT) and oxidised regenerated cellulose (ORC)/collagen/silver (PROMOGRAN PRISMA) dressing has been described in the literature, there are little data on the efficacy of their combined use. In this study, we describe a novel technique of combining the use of NPWT and ORC/collagen/silver dressings to manage complex wound beds as an alternative management option for patients not suitable for reconstructive flap surgery. This technique was performed in a series of 37 patients with complex lower-extremity wounds that were not healing with conventional NPWT alone. All patients had open wounds with exposed critical structures that were difficult to manage, such as exposed tendon, bone, deep crevices, and joint. Successful coverage of exposed critical structures was achieved in 89% of patients, and coverage was achieved within 28 days of combination therapy in 82% of these patients, without any complications. The novel technique of combining ORC/collagen/silver dressing and NPWT provides a useful option in the armamentarium of a reconstructive surgeon dealing with difficult complex lower-extremity wounds.

Lesson of the month 2: Autoimmune sequelae of anti-GAD antibodies - thinking outside the box.

A 52 year-old female with no significant medical problems presented with left-sided weakness, unsteady gait and speech disturbance. It was thought that she had neuro-inflammation and she remained clinically stable. Several years later, she was diagnosed with latent autoimmune diabetes of adulthood. Her neurological symptoms deteriorated and she was admitted into hospital. The cerebrospinal fluid was normal, as were an array of blood tests. Imaging tests, including magnetic resonance imaging, computerised tomography and positron emission tomography scans were normal. However, her anti-glutamic acid decarboxylase antibody serum level, which had been taken in the diabetes outpatient clinic, returned at 2,000,000 IU/mL (normal range 0-10). This led to the diagnosis of glutamic acid decarboxylase (GAD) positive cerebellar ataxia. She was treated with plasma exchange and intravenous immunoglobulins and over next 12 weeks her symptoms improved. Our case highlights the need for appropriate treatment of patients with GAD positive cerebellar ataxia to achieve good outcomes.

Hyperthyroidism and Graves' disease: Is an ultrasound examination needed?

AIM: The aim of our study was to assess the limitation of clinical examination in determining the morphology of thyroid gland in patients with hyperthyroidism and its implications. METHODS: A retrospective analysis of consecutive patients with hyperthyroidism seen in a tertiary endocrine clinic were analyzed. Sub-analysis was performed on patients with proven Graves' disease. RESULTS: Of the 133 patients included in this study with hyperthyroidism, 60 (45%) patients had significant nodularity on ultrasound (US). However, only 67% of these were identified on clinical examination. In patients with confirmed Graves' disease (n = 73), the discordance between US and clinical examination was very similar (18 of 30 patients, 60%). CONCLUSION: US should form an essential part of the evaluation of hyperthyroidism as the morphology of thyroid gland could be variable and nodules in these glands would also need to be appropriately investigated. This would also significantly influence decision-making and appropriate immediate and follow-up management plan.

Splenic abscess as a potential initial manifestation of quiescent infective endocarditis in a patient with bronchopneumonia.

A 78-year-old woman presented to the acute medical unit with a productive cough, dyspnoea and decreased appetite of 4 days duration. Initial assessment supported a diagnosis of right-sided community-acquired pneumonia and she was started on antibiotics. In view of the clinical finding of splenomegaly, she had an ultrasound and, subsequently, a CT of the abdomen, which revealed a large splenic abscess. Pending cultures from a sample obtained from percutaneous drainage of the abscess, she was started on intravenous meropenem. The initial echocardiogram did not suggest any evidence of endocarditis. The pus drained from the abscess on cultures was subsequently positive for Staphylococcus aureus. An MRI of the spine excluded discitis as a source of infection. Owing to a high index of clinical suspicion a repeat echocardiogram was undertaken after 1-week, which confirmed acute endocarditis. The patient was treated with intravenous antibiotics for 6 weeks with improvement in clinical, radiological and biochemical parameters.

Challenges of emerging adulthood-transition from paediatric to adult diabetes.

Diabetes mellitus is a complex condition with far reaching physical, psychological and psychosocial effects. These outcomes can be significant when considering the care of a youth transferring from paediatric through to adult diabetes services. The art of mastering a smooth care transfer is crucial if not pivotal to optimising overall diabetic control. Quite often the nature of consultation varies between the two service providers and the objectives and outcomes will mirror this. The purpose of this review is to analyse the particular challenges and barriers one might expect to encounter when transferring these services over to an adult care provider. Particular emphasis is paid towards the psychological aspects of this delicate period, which needs to be recognised and appreciated appropriately in order to understand the particular plights a young diabetic child will be challenged with. We explore the approaches that can be positively adopted in order to improve the experience for child, parents and also the multi- disciplinary team concerned with the overall delivery of this care. Finally we will close with reflection on the potential areas for future development that will ultimately aim to improve long-term outcomes and experiences of the young adolescent confronted with diabetes as well as the burden of disease and burden of cost of disease.

The impact of improved glycaemic control with GLP-1 receptor agonist therapy on diabetic retinopathy.

Rapid improvement in glycaemic control with GLP-1 receptor agonist (RA) therapy has been reported to be associated with significant progression of diabetic retinopathy. This deterioration is transient, and continuing GLP-1 RA treatment is associated with reversal of this phenomenon. Pre-existent maculopathy, higher grade of retinopathy and longer duration of diabetes may be risk factors for persistent deterioration.

Diabetic cardiomyopathy: Pathophysiology, diagnostic evaluation and management.

Diabetes affects every organ in the body and cardiovascular disease accounts for two-thirds of the mortality in the diabetic population. Diabetes-related heart disease occurs in the form of coronary artery disease (CAD), cardiac autonomic neuropathy or diabetic cardiomyopathy (DbCM). The prevalence of cardiac failure is high in the diabetic population and DbCM is a common but underestimated cause of heart failure in diabetes. The pathogenesis of diabetic cardiomyopathy is yet to be clearly defined. Hyperglycemia, dyslipidemia and inflammation are thought to play key roles in the generation of reactive oxygen or nitrogen species which are in turn implicated. The myocardial interstitium undergoes alterations resulting in abnormal contractile function noted in DbCM. In the early stages of the disease diastolic dysfunction is the only abnormality, but systolic dysfunction supervenes in the later stages with impaired left ventricular ejection fraction. Transmitral Doppler echocardiography is usually used to assess diastolic dysfunction, but tissue Doppler Imaging and Cardiac Magnetic Resonance Imaging are being increasingly used recently for early detection of DbCM. The management of DbCM involves improvement in lifestyle, control of glucose and lipid abnormalities, and treatment of hypertension and CAD, if present. The role of vasoactive drugs and antioxidants is being explored. This review discusses the pathophysiology, diagnostic evaluation and management options of DbCM.