Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial.

OBJECTIVE: To determine whether routine blood glucose assessment of patients admitted to hospital from emergency departments (EDs) results in higher rates of new diagnoses of diabetes and documentation of follow-up plans. DESIGN, SETTING: Cluster randomised trial in 18 New South Wales public district and tertiary hospitals, 31 May 2011 - 31 December 2012; outcomes follow-up to 31 March 2016. PARTICIPANTS: Patients aged 18 years or more admitted to hospital from EDs. INTERVENTION: Routine blood glucose assessment at control and intervention hospitals; automatic requests for glycated haemoglobin (HbA1c ) assessment and notification of diabetes services about patients at intervention hospitals with blood glucose levels of 14 mmol/L or more. MAIN OUTCOME MEASURE: New diagnoses of diabetes and documented follow-up plans for patients with admission blood glucose levels of 14 mmol/L or more. RESULTS: Blood glucose was measured in 133 837 patients admitted to hospital from an ED. The numbers of new diabetes diagnoses with documented follow-up plans for patients with blood glucose levels of 14 mmol/L or more were similar in intervention (83/506 patients, 16%) and control hospitals (73/278, 26%; adjusted odds ratio [aOR], 0.83; 95% CI 0.42-1.7; P = 0.61), as were new diabetes diagnoses with or without plans (intervention, 157/506, 31%; control, 86/278, 31%; aOR, 1.51; 95% CI, 0.83-2.80; P = 0.18). 30-day re-admission (31% v 22%; aOR, 1.34; 95% CI, 0.86-2.09; P = 0.21) and post-hospital mortality rates (24% v 22%; aOR, 1.07; 95% CI, 0.74-1.55; P = 0.72) were also similar for patients in intervention and control hospitals. CONCLUSION: Glucose and HbA1c screening of patients admitted to hospital from EDs does not alone increase detection of previously unidentified diabetes. Adequate resourcing and effective management pathways for patients with newly detected hyperglycaemia and diabetes are needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12611001007921.

Access to a youth-specific service for young adults with type 1 diabetes mellitus is associated with decreased hospital length of stay for diabetic ketoacidosis.

BACKGROUND: Management of type 1 diabetes mellitus in youth with diabetes (YWD) is complex, and glycaemic control often deteriorates during this challenging period. We hypothesise that attendance at a youth-specific diabetes clinic reduces hospital admission rates and length of stay (LOS) for diabetic ketoacidosis (DKA). AIMS: To assess the impact of a youth-specific diabetes service for YWD on DKA admissions in two adjacent local health districts. METHODS: A retrospective cohort analysis of admissions for DKA in YWD aged 15-25 years, presenting to four hospitals in Western Sydney in 2011 was performed. Number of admissions, LOS and DKA severity were assessed. Cost was analysed as a function of LOS. Groups were divided by attendance at a youth-specific diabetes service and no record of attendance. RESULTS: There were 55 DKA admissions from 39 patients (median age 20.0 years); the majority of admissions (82%) was YWD not supported by a youth-specific diabetes service. Median LOS was significantly longer in the unsupported group (3.0 vs 1.5 days, P = 0.028). Median pH at presentation in the unsupported group was significantly lower, 7.11 versus 7.23 (P = 0.05). The admission rate was four times greater for those not supported by youth-specific diabetes services, 5.5% compared with 1.6% (P = 0.001). The estimated cost saved by youth-specific services was over $250,000 pa. CONCLUSIONS: Lack of access to supported care for YWD during transition from paediatric to adult care has an adverse impact on subsequent DKA admission rates and LOS.

Favourable effects of fenofibrate on lipids and cardiovascular disease in women with type 2 diabetes: results from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

AIMS/HYPOTHESIS: In the double-blind placebo-controlled Fenofibrate Intervention and Event Lowering in Diabetes trial (n = 9,795), fenofibrate reduced major cardiovascular events in type 2 diabetes. Sex-related differences in fenofibrate response could be clinically relevant and were pre-specified analyses. METHODS: Women (n = 3,657) and men (n = 6,138) with type 2 diabetes not using statins were assigned fenofibrate (200 mg/day) or placebo for 5 years. Effects on lipoproteins and total cardiovascular events were evaluated by sex. RESULTS: Baseline total, LDL-, HDL- and non-HDL cholesterol and apolipoproteins A-I and B differed between sexes, and these and triacylglycerol levels improved with fenofibrate in both sexes (all p < 0.001). Fenofibrate reduced total, LDL- and non-HDL cholesterol and apolipoprotein B more in women (all p < 0.001), independent of menopausal status and statin uptake. Adjusted for covariates, fenofibrate reduced total cardiovascular outcomes (cardiovascular death, fatal and non-fatal stroke and carotid and coronary revascularisation) by 30% in women (95% CI 8%, 46%; p = 0.008) and 13% in men (95% CI -1%, 24%; p = 0.07) with no treatment-by-sex interaction (p > 0.1). In patients with high triacylglycerol levels and low HDL-cholesterol, fenofibrate reduced total cardiovascular outcomes by 30% (95% CI -7%, 54%) in women and 24% (95% CI 2%, 42%) in men, with no treatment-by-sex interaction (p > 0.1). CONCLUSIONS/INTERPRETATION: Fenofibrate improved the lipoprotein profile more in women than men. Cardiovascular event reductions with fenofibrate were consistently similar in women and men, both overall and among those with low HDL-cholesterol and high triacylglycerol levels. These data provide reassurance about fenofibrate efficacy in women and men. Both sexes with type 2 diabetes should be considered for fenofibrate therapy for cardioprotection.

Preconception care and contraceptive use among Australian women with diabetes mellitus

Background and objective: Effective contraception is important for pregnancy planning and reducing adverse pregnancy outcomes in women with diabetes mellitus (DM). The aim of this study was to explore preconception care practices and contraception use among women with DM. Methods: The study used a cross-sectional structured questionnaire to survey women with DM aged 16­49 years in Nepean Blue Mountains Local Health District (NBMLHD), a Western Sydney tertiary referral centre. Results: A total of 107 of 215 (49.7%) women completed the questionnaire. While 80.4% were aware of DM-related pregnancy risks, preconception advice was reported by only 46.8% of the 47 previously or currently pregnant women. Most women had used condoms (87.2%) and/or the combined oral contraceptive pill (74.4%). Many did not know if intrauterine contraception (61.7%) or contraceptive implants (43.7%) were safe in DM. Discussion: Despite being aware of the risks of DM in pregnancy, less than half of the women had sought preconception care, and many had poor knowledge of the most reliable contraceptive methods.

Riedel's Thyroiditis with Intense FDG Uptake Demonstrated on FDG PET/CT.

A 39 year old female presented with rapidly enlarging goitre, minimal obstructive symptoms and no constitutional symptoms. Clinical examination revealed diffusely enlarged, firm, non-tender thyroid gland. Biochemical investigations showed subclinical hypothyroidism, positive thyroid antibodies and unremarkable inflammatory markers. Ultrasound examination and CT scan of the neck were suspicious of Riedels thyroiditis. The patient was referred for a FDG PET scan to evaluate for systemic fibro-inflammatory process or lymphoma. Subsequent core biopsy of the thyroid gland demonstrated a chronic inflammatory process with fibrosis consistent with Riedels thyroiditis. A FDG PET/CT study showed diffuse FDG uptake in the thyroid gland and no abnormal retroperitoneal FDG uptake elsewhere to suggest active retroperitoneal fibrosis. The goitre reduced in size with thyroid hormone replacement and steroids, however the patient was lost to follow up.

Hyperglycemia: still an important predictor of adverse outcomes following AMI in the reperfusion era.

Hyperglycemia in patients admitted to hospital with myocardial infarction has been associated with adverse outcomes. However, with the improvements in survival seen in the reperfusion era, the glycometabolic state of patients presenting with acute myocardial infarction (AMI) is often given a low priority. The aim of this study was to determine if hyperglycemia remains a significant predictor of cardiac mortality and morbidity in the reperfusion era. We conducted a retrospective review of 158 patients presenting with AMI to our institution, where reperfusion therapy is routinely administered. The glucose level on admission and other risk factors were correlated against adverse cardiac outcomes. From multi-variate logistic regression analysis, admission glucose level was a consistent predictor of mortality and morbidity for all AMI patients as well as those who were reperfused. The odds ratios (OR) of in-hospital and 6-month mortality for each 1 mmol/l increment of glucose level were 1.14 (P = 0.002) and 1.18 (P < 0.001) respectively. For patients who underwent reperfusion therapy, the OR of in-hospital and 6-month mortality for each 1 mmol/l increment of glucose level were 1.27 (P = 0.001) and 1.36 (P = 0.001), respectively. We conclude that in the reperfusion era, hyperglycemia is still associated with adverse cardiac outcomes, although it is unclear whether treatment of hyperglycemia will lead to improved outcomes.

Utility of the estimated glucose disposal rate as a marker of microvascular complications in young adults with type 1 diabetes.

In 61 young adults with type 1 diabetes mellitus, the estimated glucose disposal rate (eGDR), a validated marker for insulin resistance, correlated positively with the prevalence of microvascular complications. In the absence of an established vascular risk calculator specific to diabetes, the eGDR may present a useful clinical tool in the assessment of complication risk in type 1 diabetes.

Interrater and intrarater reliability of photoplethysmography for measuring toe blood pressure and toe-brachial index in people with diabetes mellitus.

BACKGROUND: A reliable tool to measure arterial flow to the feet in people with diabetes is required given that they are particularly prone to peripheral arterial disease. Traditionally, the ankle brachial index (ABI) has been used to measure arterial circulation, but its application is limited due to calcification of larger arteries. More recently, toe pressure and the toe brachial index (TBI) has been suggested as superior to ABI measurements because they assess smaller digital arteries less prone to arterial calcification. However, reliability studies for the clinical use of photoplethysmography (PPG) in people with diabetes are lacking. METHODS: Sixty people with diabetes mellitus (35 males and 25 females, mean age 59.6 yrs) consented to take part in the study. The majority (92%) had type 2 diabetes and 8% had type 1 diabetes. Forty-three percent were diagnosed as having peripheral neuropathy when tested using a biothesiometer and 15% were current smokers (10 - 40/day). A podiatrist and a diabetes educator measured toe and brachial blood pressure independently and in a random order using PPG. These measurements were repeated again seven days later, and subsequently analysed with intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM). RESULTS: The intrarater reliability of measuring toe pressures was excellent (ICC3,1 =0.78-0.79, SEM 8 mmHg) and interrater reliability was also excellent (ICC2,2 = 0.93, SEM 4 mmHg). The intrarater reliability for measuring brachial pressures was generally poor (ICC3,1 = 0.40 - 0.42, SEM 19 mmHg) and interrater reliability was fair-good (ICC2,2. 0.65, SEM 14 mmHg). The TBI intrarater reliability was fair-good (ICC3,1 = 0.51-0.72, SEM 0.08), whilst the interrater reliability of TBI was excellent (ICC2,2 = 0.85, SEM 0.07). CONCLUSIONS: Based on these results, interrater and intrarater reliability of PPG is excellent for measuring toe blood pressure, good for TBI and only fair for brachial pressures in people with diabetes mellitus.