Can the introduction of a 12-lead ECG help reduce mortality in those presenting with foot ulceration to multidisciplinary diabetic foot clinics? An observational evaluation of a real-world implementation pilot in England.

AIMS/HYPOTHESIS: The risk of dying within 2 years of presentation with diabetic foot ulceration is over six times the risk of amputation, with CVD the major contributor. Using an observational evaluation of a real-world implementation pilot, we aimed to assess whether for those presenting with diabetic foot ulceration in England, introducing a 12-lead ECG into routine care followed by appropriate clinical action was associated with reduced mortality. METHODS: Between July 2014 and December 2017, ten multidisciplinary diabetic foot services in England participated in a pilot project introducing 12-lead ECGs for new attendees with foot ulceration. Inception coincided with launch of the National Diabetes Footcare Audit (NDFA), whereby all diabetic footcare services in England were invited to enter data on new attendees with foot ulceration. Poisson regression models assessed the mortality RR at 2 and 5 years following first assessment of those receiving care in a participating pilot unit vs those receiving care in any other unit in England, adjusting for age, sex, ethnicity, deprivation, type and duration of diabetes, ulcer severity, and morbidity in the year prior to first assessment. RESULTS: Of the 3110 people recorded in the NDFA at a participating unit during the pilot, 33% (1015) were recorded as having received an ECG. A further 25,195 people recorded in the NDFA had attended another English footcare service. Unadjusted mortality in the pilot units was 16.3% (165) at 2 years and 37.4% (380) at 5 years for those who received an ECG, and 20.5% (430) and 45.2% (950), respectively, for those who did not receive an ECG. For people included in the NDFA at other units, unadjusted mortality was 20.1% (5075) and 42.6% (10,745), respectively. In the fully adjusted model, mortality was not significantly lower for those attending participating units at 2 (RR 0.93 [95% CI 0.85, 1.01]) or 5 years (RR 0.95 [95% CI 0.90, 1.01]). At participating units, mortality in those who received an ECG vs those who did not was lower at 5 years (RR 0.86 [95% CI 0.76, 0.97]), but not at 2 years (RR 0.87 [95% CI 0.72, 1.04]). Comparing just those that received an ECG with attendees at all other centres in England, mortality was lower at 5 years (RR 0.87 [95% CI 0.78, 0.96]), but not at 2 years (RR 0.86 [95% CI 0.74, 1.01]). CONCLUSIONS/INTERPRETATION: The evaluation confirms the high mortality seen in those presenting with diabetic foot ulceration. Overall mortality at the participating units was not significantly reduced at 2 or 5 years, with confidence intervals just crossing parity. Implementation of the 12-lead ECG into the routine care pathway proved challenging for clinical teams-overall a third of attendees had one, although some units delivered the intervention to over 60% of attendees-and the evaluation was therefore underpowered. Nonetheless, the signals of potential mortality benefit among those who had an ECG suggest that units in a position to operationalise implementation may wish to consider this. DATA AVAILABILITY: Data from the National Diabetes Audit can be requested through the National Health Service Digital Data Access Request Service process at: https://digital.nhs.uk/services/data-access-request-service-dars/dars-products-and-services/data-set-catalogue/national-diabetes-audit-nda.

Empowering podiatrists to perform pulse checks for opportunistic atrial fibrillation detection during annual diabetes foot checks.

Objective: To determine whether training podiatrists to provide opportunistic screening for atrial fibrillation (AF) during the local diabetes foot check was feasible and whether it detects previously unknown AF. Method: During the initiative, 45 podiatrists from across North Durham, Darlington and Durham Dales Easington and Sedgefield Clinical Commissioning Groups were trained to recognise heart irregularities when taking pulse readings of feet of patients with diabetes during their annual foot screening reviews. Results: Over the course of the 3-month pilot, 5000 patients with diabetes had their feet pulse-tested. The project uncovered that for every 500 patients who had their feet checked, one new case of AF could be identified. Conclusion: A report following the Podiatry and Atrial Fibrillation Case Finding scheme revealed that the National Health Service in the United Kingdom North East and North Cumbria area could benefit from potential cost savings in excess of £500 000. In 2013, the National Diabetes Information Service, Yorkshire and Humber Public Health Observatory estimated 231 777 people in the North East, North Cumbria, Hambleton and Richmondshire area with diabetes. Therefore 463 patients could be found with AF, preventing 23 strokes and saving £539 742 or in excess of £0.5 M.

Perceptions of Adolescent Patients of the "Lived Experience" of Type 1 Diabetes.

The care and management of adolescents with type 1 diabetes presents numerous challenges that are inherent to the fears, attitudes, and perceptions of their illness. This qualitative study aimed to explore the "lived experience" of individuals with type 1 diabetes. In-depth interviews were conducted with 20 patients diagnosed with type 1 diabetes in their adolescent years to elicit their views, perceptions, and concerns regarding living with diabetes. All interviews were conducted and analyzed using the principles of grounded theory. Five categories defining the patients' lived experience were elicited: Barriers, Develop Skills, Manage Emotion, Social World, and Health Care Professionals. The problems experienced by adolescents with type 1 diabetes are multifactorial. Existentially, type 1 diabetes affects their daily activities and impinges on their academic achievement and personal aspirations. They have great difficulty coping with their health status and highlight a lack of empathy from health care professionals (HCPs). Their major fear is of hypoglycemia, resulting in their subsequent focus of preventing hypoglycemic episodes. Indeed, regardless of consequence, blood glucose levels are often deliberately kept above recommended levels, which serves to decrease the effectiveness of their health care management. This study shows that the quality of care provided for adolescent patients with type 1 diabetes is failing to meet their expectations and falls short of the essential standards commensurate with current health care policy. Improvements in long-term care management for these patients require changes in both patients' and professionals' understanding of the disease and of the ways it is managed.

Long-term management of type 2 diabetes with glucagon-like peptide-1 receptor agonists.

Continuously reducing excess blood glucose is a primary goal for the management of type 2 diabetes (T2D). Most patients with T2D require glucose-lowering medications to achieve and maintain adequate glycemic control; however, treatment failure may occur, limiting treatment options. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are an emerging therapeutic class that can be prescribed for patients instead of basal insulin after the failure of oral therapies. Recent studies have focused on the durability and tolerability of long-term GLP-1RA therapy. This review summarizes the key efficacy and safety findings from prospective phase 3 clinical studies of at least 76 weeks' duration for the GLP-1RAs currently approved in the United States and the European Union (albiglutide, dulaglutide, exenatide twice daily [BID], exenatide once weekly [QW], liraglutide, and lixisenatide). Currently, most of the long-term data are from uncontrolled extension studies, and continuous patient benefit has been observed for up to 3 years with multiple GLP-1RAs. Four-year comparative data demonstrated a longer time to treatment failure for exenatide BID than for sulfonylurea, and 3-year comparative extension data demonstrated greater glycated hemoglobin (HbA1c) reductions and weight loss with exenatide QW than with insulin glargine. Currently, the longest extension study for a GLP-1RA is the DURATION-1 study of exenatide QW, with >7 years of clinical data available. Data from DURATION-1 demonstrated that continuous HbA1c reductions and weight loss were observed for the patients continuing on the treatment, with no unexpected adverse events. Taken together, these data support GLP-1RAs as a long-term noninsulin treatment option after the failure of oral therapies.

Severe recurrent hypoglycaemia following discontinuation of olanzapine.

Severe hypoglycaemia is a diagnostic challenge.1 It is often explained by mismatch between insulin doses, food ingestion and exercise. Recurrent hypoglycaemia can indicate underlying medical problems. Drug related events usually concern insulin or sulphonylureas. However, withdrawal of drugs which can cause insulin resistance can be causative if insulin or sulphonylureas continue.2We report the case of an insulin-treated patient who presented with severe recurrent hypoglycaemia. After exclusion of secondary causes of hypoglycaemia it was established that at the time of diagnosis of diabetes he had been taking olanzapine. This had subsequently been discontinued. Olanzapine is recognised to cause diabetes and diabetic ketoacidosis. Our patient was able to discontinue insulin therapy.

Accidents in patients with insulin-treated diabetes: increased risk of low-impact falls but not motor vehicle crashes--a prospective register-based study.

BACKGROUND: Patients with diabetes mellitus may be at increased risk of accidents, mainly because of hypoglycemia. A variety of approaches have been adopted in an attempt to quantify this risk, but there has not been, to date, a systematic study using a national trauma register. In this study, we report findings from the Scottish Trauma Audit Group database. METHODS: The database includes all patients admitted to hospital for 3 or more days, or who died in hospital as a result of their accident. The study includes 11,244 cases aged 15 years or over entered into the database between July 1996 and June 1998. This included 151 patients with insulin-treated diabetes. Using detailed prescribing information from one representative region, we have calculated the rates of different types of accidents for patients treated with insulin and compared this with the control population. We have analyzed information on the mechanism and severity of injury, outcome, and length of hospital stay. RESULTS: Overall, the rate of accidents for insulin-treated patients was estimated at 291.2 per 100,000 population per year compared with 148.4 for the control population (p < 0.001; relative risk, 1.97; 95% confidence interval, 1.68-2.32). Insulin-treated patients were, on average, older (p < 0.005), more likely to be women (p < 0.02), and had longer stay in hospital (p < 0.001). The major excess of injuries related to low falls (< 2 m), which accounted for 62.3% of the injuries in the insulin-treated group compared with 47.1% in the remainder (p < 0.01). Low falls in the insulin-treated group (n = 94) were examined in detail: compared with the control population, there was no difference in age and sex, Injury Severity Score, Revised Trauma Score (a measure of the severity of physiologic disturbance), or calculated probability of survival (TRISS). Length of inpatient stay was higher in the insulin-treated low-fall patients (10 vs. 7 days, p < 0.01). Of the 151 catalogued injuries, the vast majority were fractures at peripheral sites. Only 23 insulin-treated individuals were admitted after a motor vehicle crash during the study period. This represents a slight but not significant increase above the rate for the background population. CONCLUSION: This study confirms that patients taking insulin are at increased risk of accidents. Among the different types of injury, only low-impact falls were significantly increased. This is most likely related to an increased tendency for insulin-treated patients to fall during a hypoglycemic episode. However, patients with diabetes may also be at higher risk of sustaining a fracture after a fall. The number of car crashes involving drivers with insulin-dependent diabetes is small, and the rate is not significantly greater than that of the background population. Further study of the causes and consequences of falls in diabetic patients is warranted.