Diabetes and dementia in older people: a Best Clinical Practice Statement by a multidisciplinary National Expert Working Group.

Both dementia and diabetes mellitus are long-term disabling conditions and each may be a co-morbidity of the other. Type 2 diabetes is associated with a 1.5- to 2-fold higher risk of dementia. Diabetes also may occur for the first time in many individuals with mental ill health, including cognitive impairment and dementia, and this may complicate management and lead to difficulties in self-care. Case finding is often poor for cognitive impairment in medical settings and for diabetes in mental health settings and this needs to be addressed in the development of care pathways for both conditions. Many other deficiencies in quality care (both for dementia and diabetes) currently exist, but we hope that this Best Clinical Practice Statement will provide a platform for further work in this area. We have outlined the key steps in an integrated care pathway for both elements of this clinical relationship, produced guidance on identifying each condition, dealt with the potentially hazardous issue of hypoglycaemia, and have outlined important competencies required of healthcare workers in both medical/diabetes and mental health settings to enhance clinical care.

Excess mortality during hospital stays among patients with recorded diabetes compared with those without diabetes.

AIM: To assess the additional mortality during hospital admissions among patients with recorded diabetes and identify the extent of variation in English provider trusts. METHODS: Inpatient admissions to all English hospitals between April 2010 and March 2012 were extracted from Hospital Episode Statistics. Binary logistic regression was used to standardize for age, sex, deprivation, method and reason for admission, co-morbidities and type of trust. Trust level standardized mortality ratios for inpatients with recorded diabetes were compared with those without recorded diabetes and with published measures of hospital mortality. RESULTS: Of the 10 169 003 hospital admissions analysed, 11.2% had recorded diabetes, but 21.5% of inpatient deaths occurred in this group. After adjustment for case mix, hospital admissions in patients with recorded diabetes had a 6.4% greater risk of dying (2052 more deaths over 2 years) than would be expected compared with similar patients without recorded diabetes. The additional risk of death was significantly greater in smaller trusts. The highest additional risk of death was found in hospital admissions of younger female patients admitted electively. At provider trust level, 37.4% of variation in adjusted mortality in patients with recorded diabetes was explained by the mortality in those without recorded diabetes. CONCLUSION: A diagnosis of diabetes has an adverse impact on hospital mortality that cannot be explained by usual case-mix adjustments, and the additional risk of dying is greatest among hospital admissions that would normally have a low risk of death. This implies that diabetes may override the usual risk factors for hospital mortality.

Development and evaluation of a standardized registry for diabetes in pregnancy using data from the Northern, North West and East Anglia regional audits.

OBJECTIVES: To develop and evaluate a standardized data set for measuring pregnancy outcomes in women with Type 1 and Type 2 diabetes and to compare recent outcomes with those of the 2002-2003 Confidential Enquiry into Maternal and Child Health. METHODS: Existing regional, national and international data sets were compared for content, consistency and validity to develop a standardized data set for diabetes in pregnancy of 46 key clinical items. The data set was tested retrospectively using data from 2007-2008 pregnancies included in three regional audits (Northern, North West and East Anglia). Obstetric and neonatal outcomes of pregnancies resulting in a stillbirth or live birth were compared with those from the same regions during 2002-2003. RESULTS: Details of 1381 pregnancies, 812 (58.9%) in women with Type 1 diabetes and 556 (40.3%) in women with Type 2 diabetes, were available to test the proposed standardized data set. Of the 46 data items proposed, only 16 (34.8%), predominantly the delivery and neonatal items, achieved ≥ 85% completeness. Ethnic group data were available for 746 (54.0%) pregnancies and BMI for 627 (46.5%) pregnancies. Glycaemic control data were most complete-available for 1217 pregnancies (88.1%), during the first trimester. Only 239 women (19.9%) had adequate pregnancy preparation, defined as pre-conception folic acid and first trimester HbA(1c) ≤ 7% (≤ 53 mmol/mol). Serious adverse outcome rates (major malformation and perinatal mortality) were 55/1000 and had not improved since 2002-2003. CONCLUSIONS: A standardized data set for diabetes in pregnancy may improve consistency of data collection and allow for more meaningful evaluation of pregnancy outcomes in women with pregestational diabetes.

The role of the biochemistry department in the diagnosis of pituitary apoplexy.

A 47-year-old man presented with severe clinical hypoglycaemia. He had long-standing insulin-dependent diabetes with previously good glycaemic control. Intense headaches and vomiting initiated hospitalization. A brain computed tomography (CT) scan was normal, and a lumbar puncture showed elevated cerebrospinal fluid (CSF) protein [0.67 g/L; normal range (NR) 0.15-0.45 g/L], suggesting resolving viral meningitis. Routine thyroid function tests were abnormal (free thyroxine 10.6 pmol/L, NR 9-22.5 pmol/L; thyroid-stimulating hormone 0.16 mU/L, NR 0.35-5 mU/L). In the absence of evident thyroid therapy, the laboratory policy required an urgent cortisol assay to be added; this was very abnormal (42 nmol/L), suggesting hypopituitarism. Later analysis showed that concentrations of gonadotrophins and adrenocorticotrophin were low. An urgent pituitary magnetic resonance imaging scan revealed an unsuspected pituitary tumour with recent haemorrhage (pituitary apoplexy). The patient was given intravenous hydrocortisone and then stabilized on oral hydrocortisone, thyroxine and mesterolone. He made a full recovery and the hypoglycaemia resolved. The normal brain CT scan was falsely reassuring and the CSF protein was not due to viral meningitis but to haemorrhage into the pituitary tumour. If laboratory policy had not required the urgent cortisol assay be added, the diagnosis of hypopituitarism would have been delayed or even missed altogether. This could have led to the death of the patient.

Surgical management of pancreatic pseudocysts.

Pancreatic pseudocyst is a complication of pancreatitis or pancreatic trauma. A review of the experience with surgical treatment of pseudocyst of the pancreas at the University of Iowa was carried out. Pancreatitis associated with alcoholism accounted for a smaller percentage of the pseudocysts than is usually reported and reflects the nature of the population. Internal drainage of the pseudocyst obviates the development of pancreatic fistula which is often associated with external drainage; however, the mortality for each method of drainage was comparable.

Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care.

The Mini-Cog was shown to be a brief, acceptable and practical cognitive screen for older people with diabetes when administered by a primary care nurse. It could be integrated easily into the annual diabetes review and help to identify those who may benefit from extra help with their management.

A review of the job satisfaction and current practice of consultant diabetologists in England--barriers and successes.

AIMS: The project aimed to describe the perceptions of consultant diabetologists about their work, explore models of care, identify problem areas, consider potential solutions, and outline strategic issues for retention and recruitment. METHODS: The study was based on semistructured qualitative interviews with 92 consultant diabetologists, recruited via a purposive sample. Interviews were recorded, transcribed and anonymized, and analysed by the project team, assisted by QSR Nvivo software. RESULTS: The consultant diabetologist role encompasses a diversity of skills/expertise, with differing emphases between individuals. Integration with general medicine is seen by some as crucial to maintaining proficiency in diabetes, and by others as hindering fulfilment of other roles. Successful team working across organizational boundaries is recognized as essential to effective services, but often impeded by the continuous reorganization and competitive culture of the National Health Service. Significant differences between consultant diabetologist perspectives of primary care colleagues and of primary care trusts emerged. Some consultants have adopted innovative working approaches, adapting national guidance to local environments, but there is general resistance to adopting centrally imposed solutions. Training programmes are not sufficiently explicit about the core skills/attributes required of consultant diabetologists. CONCLUSIONS: The skills of specialist teams are not fully exploited. Competing calls on time could be addressed by encouraging multifaceted consultant teams, allowing individuals to concentrate in specific areas. Clear definition of core skills required by consultant diabetologists underpins training programme development. Collaboration in cross-boundary services reflecting local needs is impeded by competition between sectors. Protected time is necessary for cultivating multidisciplinary teams, cross-boundary partnerships and effective, relevant education programmes. Specialist training must reflect the changing role of consultant diabetologists, and include role-specific programmes.

Near patient blood ketone measurements and their utility in predicting diabetic ketoacidosis.

AIM: To assess the utility of near patient blood ketone measurements in predicting diabetic ketoacidosis (DKA) among a group of hyperglycaemic unwell patients presenting to a hospital emergency department. METHODS: Near patient blood beta-hydroxybutyrate (beta-OHB) testing has recently been introduced as a new tool in our hospital Accident and Emergency department (A&E) for patients with a finger-prick glucose of > 11 mmol/l. We reviewed the records of the first 50 patients to have a beta-OHB measurement to establish if they developed DKA or received treatment with intravenous insulin within 48 h of presentation. We then compared the diagnostic power of beta-OHB measurements with other clinical, physiological and biochemical markers of DKA. RESULTS: Nine patients had DKA, eight had a compensated metabolic acidosis secondary to raised serum ketones, and 33 had no evidence of DKA during the following 48 h. The median (range) beta-OHB levels in each group were 6.0 (3.1-6.0) mmol/l, 3.4 (1.2-5.7) mmol/l, and 0.1 (0.0-1.2) mmol/l, respectively. A beta-OHB level of > or = 3.0 mmol/l had a sensitivity of 100% and specificity of 88% for DKA. All those with beta-OHB level > 3.0 mmol/l required treatment with intravenous insulin. CONCLUSION: Measuring beta-OHB when a hyperglycaemic patient is identified could offer a simple method of identifying at an early stage those patients at highest risk of DKA (beta-OHB > 3.0 mmol/l), and redirecting the search for a diagnosis in others (beta-OHB < 1.0 mmol/l).

Diabetes Outward Bound Mountain Course, Eskdale, Cumbria.

Following a successful first British Diabetic Association/Outward Bound Mountain Course in 1981, biannual courses were established for insulin-treated diabetic patients. These mentally and physically demanding courses are intended to encourage young diabetic patients to take active exercise whilst learning how to manage their diabetes under varied conditions. Careful medical supervision and expert instruction with minute attention to safety and constant alertness for hypoglycaemia is essential. This paper details the experience gained during the first three courses.

Facial and sublingual temperature changes following intravenous glucose injection in diabetics.

Facial and sublingual temperatures were measured in 61 diabetics undergoing intravenous glucose tolerance tests. Within 2 minutes of starting glucose injection, 58 patients felt warm in the face and trunk, 56 showed a rise in cheek temperature and 23 had visible facial reddening. The most important determinant of cheek temperature rise was initial cheek temperature. Cheek temperature rise was a unimodally distributed variable and was significantly larger in patients with fasting plasma glucose greater than or equal to 6.1 mmol/l than in those with lower glucose (despite similar initial cheek temperatures). Initial cheek temperature correlated with ambient temperature in men with fasting glucose greater than or equal to 6.1 mmol/l but not in those with fasting glucose less than or equal to 6.0 mmol/l nor in women. Initial tongue temperature was also related to ambient temperature in men but not in women and fell following the glucose injection. Although the glucose flush differs from the the chlorpropamide-alcohol flush in its unimodal distribution and relatively small temperature rise, some of the factors which influence reaction could well be considered with benefit in analysis of the chlorpropamide-alcohol flush, in particular the initial cheek (and ambient) temperatures, sex and fasting plasma glucose concentration.

Hyperglycaemia is one correlate of deterioration in vibration sense during the 5 years after diagnosis of type 2 (non-insulin-dependent) diabetes.

Seventy-one Type 2 (non-insulin-dependent) diabetic patients showed only a slight deterioration in mean vibration sensory threshold (measured biothesiometrically) on the feet during the 5 years from diagnosis. However, multiple linear regression analysis of the wide range of individual changes in this threshold showed as significant independent associated factors the initial sensory threshold (p less than 0.001), age, gender, and both the mean fasting blood glucose and failure to become thinner under treatment (p less than 0.05 for all). The relationship with fasting glucose was stronger if the pre-treatment value was included in calculation of the mean (p less than 0.001). Mean fasting blood glucose under treatment accounted for only a small fraction of the total variance of the deterioration of the vibration sensory threshold, but represented one-twelfth of that attributable to identified factors, and one-third of the variance ascribable to factors subject to therapy. Interim values revealed the persistent effect of hyperglycaemia over the 5 years. An increase of 1 mmol/l in mean fasting blood glucose has an equivalent effect on the sensory threshold to an extra 5 years of age.

Street drug use among young patients with Type 1 diabetes in the UK.

BACKGROUND: Diabetic ketoacidosis (DKA) and poor glycaemic control in young adults with Type 1 diabetes may be associated with street drug use. There are few studies in the UK looking at the prevalence of drug use in young adults with diabetes. METHODS: One hundred and fifty-eight young adults, aged sixteen to thirty years, with Type 1 diabetes attending an urban diabetes clinic were sent an anonymous confidential postal questionnaire to determine the prevalence of street drug use. RESULTS: We received 85 completed responses. Twenty-nine percent of respondents admitted to using street drugs. Of those, 68 percent habitually took street drugs more than once a month. Seventy-two percent of users were unaware of the adverse effects on diabetes. INTERPRETATION: Self-reported street drug usage in young adults with Type 1 diabetes is common and may contribute to poor glycaemic control and serious complications of diabetes.