Association of British Clinical Diabetologists, Diabetes Technology Network UK and Association of Children's Diabetes Clinicians Survey of UK Healthcare Professional Attitudes Towards Open-Source Automated Insulin Delivery Systems.

INTRODUCTION: Automated insulin delivery (AID) systems can enable improved glycaemic outcomes with reduced mental burden. Open-source AID (OS-AID) systems overcome some of the developmental and access barriers enabling a wider use of these systems. Limited data are available on healthcare professional (HCP) opinions and current practice regarding these systems. The aim of this survey was to gain insight into HCP perceptions and practices around OS-AID. METHODS: This survey was developed collaboratively with OS-AID users and distributed to adult and children's teams, using an online survey tool. Results were received between February and April 2019. Responses were assessed using simple descriptive statistics with analyses stratified by respondent characteristics. RESULTS: 317 responses were obtained from a range of HCPs in both adult and paediatric services. Key results include: HCP perception of OS-AID as "risky in the wrong hands" (43%); 91% felt uncomfortable initiating discussions around OS-AID because of lack of regulation (67%) and/or their own lack of knowledge (63%). Half of HCPs (47%) reported that they would choose OS-AID if they themselves had type 1 diabetes. CONCLUSIONS: HCPs are generally supportive of OS-AID users but many feel uncomfortable with the technicalities of the systems given the lack of approval. Knowledge around the use of these systems was limited. Re-assessment of HCP perceptions should be performed in the future given the evolving landscape of diabetes technology, recent consensus statements and emerging ethical and legal perspectives.

Open-source automated insulin delivery systems are an increasingly encountered diabetes technology. These involve a small glucose sensor and an insulin delivery device called an insulin pump. These two devices interact to allow adjustment of insulin delivery to maintain glucose levels in a desirable range. The computer codes which drive these systems are developed by people with diabetes or their families rather than by device companies; as such, they have not been through formal approval processes and therefore there is limited formal evidence concerning whether they are safe or beneficial to use. Users report high satisfaction with these devices and improvements in their diabetes management. This survey was performed to assess the opinions of UK healthcare professionals and their usual practice. Key results include: UK healthcare professionals would not routinely recommend the use of these devices and there was concern about the medicolegal implications of use. However, UK healthcare professionals were generally supportive of those who chose to use the devices. Interestingly, almost half of the healthcare professionals would use the systems if they had diabetes.

Size-dependent growth of individual Atlantic salmon Salmo salar alevins from hatch to first feeding.

Variation in egg size, hatch timing and size at hatch, and their influence on individual growth rates of Atlantic salmon Salmo salar alevins up to first feeding were examined in pure strain and hybrid crosses of fish from Scotland and Canada. At the intra-female, intra-cross type and inter-cross type levels, specific growth rates prior to first feed were strongly size dependent, with smaller and later hatching alevins growing significantly faster. The magnitude of this size-dependent growth was greatest in the hybrid crosses. This resulted in a 40% reduction in the coefficient of variation (c.v.) in alevin size from post-hatch to first feeding at the intra-female level, and a reduction of both intra- and inter-cross differences in alevin sizes in the same period.

A microsatellite linkage map for Atlantic salmon (Salmo salar).

A linkage map of the Atlantic salmon is described here consisting of 15 linkage groups containing 50 microsatellite loci with a 14 additional unlinked markers (including three allozymes). The map shows the largest sex-specific recombination rate differences so far found in any vertebrate species (3.92:1 female:male). Homologies with previous linkage mapping studies of Atlantic salmon and rainbow trout are described. An in silico search of the Genbank database carried out using the microsatellites used in the mapping process identified significant matches between the flanking regions of the microsatellite SS11 and the calcium-binding mitochondrial carrier protein, 'Aralar1'.

A tale of two sisters.

Hereditary haemochromatosis is the most common inherited disorder in white populations, whereas non-alcoholic steatohepatitis (NASH) is becoming the most common reason for referral for investigation of abnormal liver function tests (LFTs). This report describes two sisters, from similar environments, who were referred to the clinic after being found to be C282Y homozygotes and to have abnormal LFTs. One sister had developed features of haemochromatosis and the other had developed NASH. These cases illustrate the potential non-penetrance of HFE gene mutations and the need to investigate abnormal LFTs fully, even when there is a positive genetic test at the outset.

Minimal change nephropathy in the west of Scotland: a review of sixty-four patients.

Sixty-four patients with a histological diagnosis of minimal change nephropathy have been followed for a median of 110 months. Patients transferred from paediatric units (11%) had a worse prognosis in that all became frequent relapsers. Patients who relapsed within three months or who went on to become frequent relapsers had a higher 24 hour urine protein excretion at presentation than patients who did not relapse. After fifteen months of remission relapse was rare; 97% of those who relapsed did so within 36 months. Patients who have been off steroids and proteinuria free for 36 months might therefore be considered cured.

Glomerular basement membrane thinning in adults: clinicopathological correlations of a new diagnostic approach.

We have studied glomerular basal laminar thickness in biopsy material, using a simple technique involving 16 selected measurements per case. Twenty-nine biopsied cases of adult glomerular haematuria were examined together with 'diseased' controls represented by a variety of glomerulopathies including minimal-change disease and IgA nephropathy. 'Normal' control populations were provided by 13 patients with acute-onset renal failure of non-glomerular origin and nine patients undergoing nephrectomy. Analysis of groups determined by the presence or absence of haematuria, the degree of proteinuria and presence or absence of a diagnostically characteristic immunofluorescence pattern showed that the nine patients with haematuria and proteinuria of less than 200 mg/24 h represented a distinct subpopulation with a mean membrane thickness of 225 nm compared to the control mean of 343 nm (P less than 0.0001). All members of this subpopulation had mean values below an arbitrary cut-off value of 270 nm. Within other specific disease categories, sporadic cases had mean membrane thicknesses below this critical value, indicative of an overlap of pathologies. On short-term follow-up there is no evidence that the 'pure' thin-membrane population are subject to any deterioration in renal function. It is of further interest that eight of nine thin-membrane 'syndrome' cases were O Rh positive. This finding may provide a starting point for investigation of a specific genetic defect.

Immunoalkaline phosphatase technique applied to paraffin wax embedded tissues in diagnostic renal pathology.

An indirect immunoalkaline phosphatase (IAP) technique was used to evaluate the glomerular deposition of immunoglobulins, C3, C1q and fibrinogen. In 80 renal biopsy specimens the results obtained using this technique were compared with those obtained by direct immunofluorescence to see if it could be used as a viable alternative. The IAP technique was straightforward to perform, it yielded quick results, and was highly reproducible, provided that a standardised short fixation period of two and a half hours was used. For the detection of immunoglobulin deposits, the IAP results correlated well with those of immunofluorescence. Despite poorer performance in identifying complement components and fibrinogen it could, within certain limits, provide an adequate diagnostic alternative to immunofluorescence. Each technique gave false negative results, those of immunofluorescence being related to its failure to identify mesangial deposition of IgA in two cases where its distribution seemed to be focal, and those of IAP to a failure to detect linear deposition of IgG in all three cases of anti-glomerular basement membrane disease.

Progressive IgA nephropathy: the role of hypertension.

A retrospective study of 67 patients with IgA nephropathy carried out at the Glasgow Royal Infirmary revealed an overall 10-year actuarial renal survival of 77.4%. At the time of presentation, 27 patients (40.3%) were hypertensive and 40 (59.7%) were normotensive. As expected, the survival was worse in the hypertensive group. However, when the effect of control of blood pressure was assessed, a significantly worse survival was found in those whose hypertension was inadequately controlled, compared to those whose hypertension was well controlled, in whom survival was not significantly different from that of the normotensive group. The differences in survival could not be explained by increased patient age nor by longer duration of disease. Good control of hypertension may prevent progression to end-stage renal failure in IgA nephropathy.

Polyarteritis presenting with thrombocytosis and central retinal vein thrombosis.

We report a case of polyarteritis in a 54 year old woman who presented with marked thrombocytosis and acute blindness in one eye secondary to central retinal vein thrombosis. She also developed bilateral pulmonary infiltrates and renal failure. The diagnosis was confirmed by histological changes in the renal biopsy. Treatment with immunosuppressives, plasma exchange and antiplatelet drugs led to rapid clinical improvement and recovery of renal function and prevented further thromboembolic episodes. Plasma exchange and antiplatelet drugs should be considered in polyarteritis group of systemic vasculitis especially in the presence of thromboembolic complications or thrombocytosis.

The natural history of membranous nephropathy in the West of Scotland.

Membranous nephropathy was diagnosed in 54 patients between January 1975 and June 1983 in the Royal Infirmary, Glasgow. It was the commonest cause of the nephrotic syndrome and, with IgA nephropathy, the commonest primary glomerular disease. A cause was found in 10 patients. The last seven patients diagnosed were enrolled in the MRC trial. The natural history of the remaining 37 patients with idiopathic membranous nephropathy was studied. After an average observation period of 64 months, 50 per cent had stable renal function with or without proteinuria and 50 per cent had progressive renal failure or had died of other causes (five patients). Of the factors examined only heavy proteinuria and hypertension were significantly more common in patients who developed progressive renal failure. No patient who entered remission relapsed. Vascular complications were an important cause of morbidity and mortality. Incidence of events of arterial occlusion was significantly higher in these patients compared with patients with IgA nephropathy. Treatment of patients with membranous nephropathy should, therefore, be judged not only by its efficacy in preventing progressive renal failure, but also by its effect on vascular disease and by its toxicity.

Polyarteritis nodosa and monocytic leukaemia.

A 67 year old man presented with a polyarteritis nodosa-like syndrome with renal, pulmonary joint and neurological involvement during the 'preleukaemic' stage of monocytic leukaemia. The association between these two conditions is discussed.

Clostridium difficile-associated colitis in uremic patients.

Five uremic patients managed in a renal unit developed Clostridium difficile-associated colitis. Four cases occurred in a cluster at about the same time. All patients had previously received or were on antibiotic therapy at the onset of diarrhea and one patient was also on oral steroid therapy. Cefotaxime, a third generation cephalosporin was involved in all five cases. All patients had severe diseases with explosive diarrhea and systemic toxicity. The diagnosis was confirmed in all cases by culture of C. difficile and demonstration of high titers of C. difficile cytotoxin in the stool. Histology from rectal biopsy in one patient showed classical pseudomembranous colitis. Response to treatment with vancomycin was generally good though one patient had two relapses. Uremic patients have impaired immune response and intestinal motility and are predisposed to C. difficile infection. Cross-infection can occur and the isolation of affected patients seems prudent.

Polyarteritis group of systemic vasculitis--new diagnostic criteria.

We have used new diagnostic criteria to define patients with the polyarteritis nodosa (PAN) group of vasculitis. These were the combination of a necrotising glomerulitis without diffuse deposits of immunoglobulins or complement components in a patient presenting with systemic disease and multi-organ involvement. Twenty-two patients who fulfilled these criteria presented to our unit between 1975 and 1982. The diagnosis of PAN was confirmed by traditional histological criteria in eight. We anticipate that the use of these criteria will lead to earlier diagnosis and thereby improve the management of this potentially lethal disorder.

Phenylbutazone-induced systemic vasculitis with crescentic glomerulonephritis.

Two patients had phenylbutazone-induced systemic vasculitis syndrome. Both presented with acute oliguric renal failure, and renal biopsies showed severe crescentic glomerulonephritis with marked interstitial inflammatory cell infiltration. Withdrawal of phenylbutazone and treatment with immunosuppressives and plasma exchange led to recovery of renal function in one case.

Collagenous colitis: possible response to sulfasalazine and local steroid therapy.

A patient with rheumatoid arthritis and collagenous colitis apparently responding to sulfasalazine and prednisolone enemas is reported. It is suggested that this form of therapy should be considered in patients with this rare disorder not only as a short-term measure but also, in the case of sulfasalazine, as long-term treatment in patients with chronic symptoms.