Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD).

Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.

Discovery and insights from DSX mission's high-power VLF wave transmission experiments in the radiation belts.

Space weather phenomena can threaten space technologies. A hazard among these is the population of relativistic electrons in the Van Allen radiation belts. To reduce the threat, artificial processes can be introduced by transmitting very-low-frequency (VLF) waves into the belts. The resulting wave-particle interactions may deplete these harmful electrons. However, when transmitting VLF waves in space plasma, the antenna, plasma, and waves interact in a manner that is not well-understood. We conducted a series of VLF transmission experiments in the radiation belts and measured the power and radiation impedance under various frequencies and conditions. The results demonstrate the critical role played by the plasma-antenna-wave interaction around high-voltage space antennae and open the possibility to transmit high power in space. The physical insight obtained in this study can provide guidance to future high-power space-borne VLF transmitter developments, laboratory whistler-mode wave injection experiments, and the interpretation of various astrophysical and optical phenomena.

Metabolic phenotypes explain the relationship between dysglycaemia and frailty in older people with type 2 diabetes.

BACKGROUND: Dysglycaemia (hyperglycaemia and hypoglycaemia) increase the risk of frailty in older people with diabetes, which appears contradictory. However, the characteristics of patients included in these studies are different and may reflect different metabolic phenotypes of frailty that may explain this apparent contradiction. AIMS: To review the characteristics of frail patients included in clinical studies that reported an association between dysglycaemia and frailty in order to explore whether there is any metabolic differences in the profile of these patients. METHODS: A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Key words around older people, type 2 diabetes mellitus, frailty, hyperglycaemia and low glycaemia were used in the literature search. RESULTS: Only 8 studies met the inclusion criteria. Four studies investigated the risk of frailty associated with low glycaemia. Two studies showed that hypoglycaemia increased the risk of frailty by 44% (HR 1.60, 95% CI 1.14 to 2.42) and predicted greater level of dependency (p < 0.001), respectively. The other two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.0% was associated with increased risk of disability (3.45, 1.02 to 11.6), respectively. Compared with non-frail patients, those with frailty tended to have lower body weight or body mass index (BMI), have features of malnutrition such as low serum albumin or low total cholesterol and suffer from more comorbidities including dementia. Four studies explored the association of high glycaemia with frailty. Higher HbA1c predicted frailty (OR 1.43, 95% CI 1.045 to 1.97) and positively correlated with Edmonton frail score (r = 0.44, p < 0.001), respectively in two studies. The other two studies found that subjects with HbA1c ≥ 6.5% had the greatest prevalence of frailty (70.3%) and subjects with higher HbA1c at baseline to have a higher frailty level throughout later life, respectively. Compared with non-frail patients, those with frailty tended to have higher body weight, waist circumference and BMI. They also have less physical activity, higher cholesterol level and have more comorbidities. CONCLUSIONS: Dysglycaemia increases the risk of frailty but the characteristics of patients in these studies suggest different metabolic phenotypes of frailty. Therefore, these metabolic differences in frailty should be taken into consideration in the management of older people with diabetes.

Intracranial pressure directly predicts headache morbidity in idiopathic intracranial hypertension.

OBJECTIVE: Headache is the predominant disabler in idiopathic intracranial hypertension (IIH). The aim was to characterise headache and investigate the association with intracranial pressure. METHODS: IIH:WT was a randomised controlled parallel group multicentre trial in the United Kingdom investigating weight management methods in IIH. Participants with active IIH (evidenced by papilloedema) and a body mass index (BMI) ≥35 kg/m2 were recruited. At baseline, 12 months and 24 months headache characteristics and quality of life outcome measures were collected and lumbar puncture measurements were performed. RESULTS: Sixty-six women with active IIH were included with a mean age of 32.0 years (SD ± 7.8), and mean body mass index of 43.9 ± 7.0 kg/m2. The headache phenotype was migraine-like in 90%. Headache severity correlated with ICP at baseline (r = 0.285; p = 0.024); change in headache severity and monthly headache days correlated with change in ICP at 12 months (r = 0.454, p = 0.001 and r = 0.419, p = 0.002 respectively). Cutaneous allodynia was significantly correlated with ICP at 12 months. (r = 0.479, p < 0.001). Boot strap analysis noted a positive association between ICP at 12 and 24 months and enabled prediction of both change in headache severity and monthly headache days. ICP was associated with significant improvements in quality of life (SF-36). CONCLUSIONS: We demonstrate a positive relationship between ICP and headache and cutaneous allodynia, which has not been previously reported in IIH. Those with the greatest reduction in ICP over 12 months had the greatest reduction in headache frequency and severity; this was associated with improvement of quality of life measures. TRIAL REGISTRATION: This work provides Class IIa evidence of the association of raised intracranial pressure and headache. ClinicalTrials.gov number, NCT02124486 .

Low glycaemic state increases risk of frailty and functional decline in older people with type 2 diabetes mellitus - Evidence from a systematic review.

AIMS: To explore risk of frailty and functional decline associated with low glycaemia in older people with type 2 diabetes. METHODS: Systematic review. RESULTS: 11 studies included. Six studies investigated risk of frailty or physical decline with hypoglycaemia. Hypoglycaemia increased risk of incident frailty (HR 1.60, 95% CI 1.14 to 2.42) in one study and risk of fractures in four studies (2.24, 1.56 to 3.21, 1.24, 1.13 to 1.37, 1.94, 1.67 to 2.24 and 1.71, 1.35 to 2.16 respectively). In sixth study, hypoglycaemia associated with dependency (P < 0.001). Five studies explored association of low blood glucose/HbA1c with frailty. One study showed that mean blood glucose decreased with increasing frailty (p = 0.003). Two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.9% increased risk of frailty (HR, 1.41 95% CI 1.12 to 1.78) respectively. Last two studies showed that HbA1c < 6.5% associated with risk of any fracture (HR 1.08, 95% CI 1.06 to 1.11) and HbA1c < 6.0% associated with increased risk of care need (3.45, 1.02 to 11.6) respectively. CONCLUSIONS: Low glycaemia increases risk of frailty and functional decline in older people with type 2 diabetes. Management should minimise incidence of low glycaemia in these patients.

Solid waste management in western Canadian First Nations.

This research examined solid waste management on First Nations communities in western Canada to provide information and insight into programs, practices, policies, and activities, as well as to help bridge an identified gap related to these in the literature. Utilizing a qualitative case study approach, we examined twelve First Nations communities in Canada's western provinces, which relative to other communities, had 'advanced' solid waste management systems in place. Interviews conducted in each of the communities yielded information on six themes grounded in the data, including solid waste facilities and infrastructure, solid waste programs, local capacity, provincial stewardship programs, regulation and enforcement, and funding/finance. Our analysis show that majority of the communities examined are advancing their waste management systems and now have infrastructure/facilities, such as transfer stations and recycling depots, and have implemented recycling programs, which they previously did not have. As well, we learned that implementing such programs has reduced practices, such as open dumping, which the literature highlights as a common way of managing waste in First Nations communities. Most of the communities attributed the success of their programs to regular residential curbside pickups, ability to transport waste out of the community, and community involvement and interest in programs. Despite these improvements, inadequate funding hampers the efforts of communities to sustain and/or expand their programs and maintain facilities. Additionally, most communities face challenges partnering with provincial stewardship programs, and some communities are not clear whether they even qualify to participate in these programs.

Characteristics of patients with diabetes hospitalised for COVID-19 infection-a brief case series report.

OBJECTIVES: Diabetes has been shown to be a risk factor for corona virus disease-2019 (COVID-19) infection. The characteristics of patients with diabetes vulnerable to this infection are less specified. We aim to present the characteristics of patients with diabetes admitted to hospital with COVID-19. DESIGN: A retrospective case series. SETTING: A single clinical centre in the UK. METHODS: We have retrospectively collected the demographics, medical characteristics and outcome of all patients with diabetes admitted to hospital over two-week period with COVID-19 infection. All cases were diagnosed by a reverse transcription polymerase chain reaction (RT-PCR) of pharyngeal and nasal swabs. RESULTS: A total of 71 COVID-19 patients were admitted during the study period of whom 16 (22.5%) patients had diabetes and were included in this case series. There was no significant difference between patients with compared to those without diabetes regarding age, gender or clinical presentation. However, comorbidities were more common in patients with diabetes specially hypertension {75% v 36.4%, a difference of 38.6%, 95% confidence interval (CI) 6.5-58.3} and chronic kidney disease (37.5 v 5.5, a difference of 32% (1.6-51.6). Patients with diabetes were significantly more obese than those without diabetes (56.2% v 21.8% a difference of 34.4%, 95% CI 7.7-61.1). About one third (31.3%) of patients with diabetes were frail. Mean {standard deviation (SD)} duration of diabetes was 10 (2.8) years and mean (SD) HbA1c was 60.3 (15.6) mmol/mol. The use of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAIDs) was common (37.5%, 25% and 18.8% respectively). There was no significant difference in the outcomes between patients with compared to those without diabetes. CONCLUSION: Patients with diabetes hospitalised for COVID-19 were significantly more obese and had high prevalence of comorbidities than those without diabetes. Other features of patients with diabetes and COVID-19 infection included long duration of diabetes, less tight glycaemic control and common use of ACE inhibitors, ARBs and NSAIDs.

New hypoglycaemic therapy in frail older people with diabetes mellitus-phenotypic status likely to be more important than functional status.

Frail older people are largely excluded from clinical trials and therefore glycaemic targets and optimum hypoglycaemic therapy in this group has not been fully investigated. Guidelines generally recommend tight glycaemic control in functionally fit individuals and relaxed targets in frail ones mainly due to the fear of hypoglycaemia. The newly introduced sodium glucose cotransporter-2 inhibitors and the glucagon like peptide-1 receptor agonists have shown benefit that is independent of glycaemic control and a minimal risk of hypoglycaemia. However, guidelines still express caution about its use in frail older people due to fear of other side effects such as weight loss, hypotension and falls. Some frail older people will miss out on the benefits of this new therapy if frailty is considered as a one entity with a blanket application of guidelines. We propose that frailty should be viewed as two distinct metabolically different phenotypes, the sarcopenic-obese, in which new therapy will improve their metabolic profile and should be liberally used if no contraindications, and the anorexic-malnourished phenotype in which the new therapy should be cautiously considered. In other words, glycaemic targets should be driven by individual's overall function but the use of new therapy should be driven by frailty phenotype.

Joint British Diabetes Societies for Inpatient Care (JBDS-IP) Clinical Guideline Inpatient care of the frail older adult with diabetes: an Executive Summary.

We present an Executive Summary of a guideline produced by a Joint British Diabetes Societies for Inpatient Care Writing Group for managing frail older inpatients with diabetes. This represents a multidisciplinary stakeholder consensus document providing more than 100 recommendations in eight areas: functional assessment and detection of frailty; preventative care: assessing risk factors and avoiding hospital admissions; general inpatient management principles; managing therapy choices for the frail older inpatient with diabetes; managing associated comorbidities and concerns; pre-operative assessment and care; discharge planning and principles of follow-up; and end of life care. The document is intended to guide effective clinical decision-making in an inpatient setting and is supported by four appendices: Appendix 1, STOPPFRAIL criteria; Appendix 2, Acute care toolkit 3-Royal College of Physicians; Appendix 3, a description of physical performance and frailty measures for routine NHS application; and Appendix 4, Inpatient Frailty Care Pathway-template. This document is expected to enhance clinical outcomes and overall health status for this vulnerable inpatient population of older people with diabetes. The full version of the guideline, including the appendices, can be found at https://abcd.care/sites/abcd.care/files/resources/Inpatient_Care_of_the_Frail_Older_Adult.pdf.

European Headache Federation recommendations for neurologists managing giant cell arteritis.

BACKGROUND AND AIM: Giant cell arteritis (GCA) remains a medical emergency because of the risk of sudden irreversible sight loss and rarely stroke along with other complications. Because headache is one of the cardinal symptoms of cranial GCA, neurologists need to be up to date with the advances in investigation and management of this condition. The aim of this document by the European Headache Federation (EHF) is to provide an evidence-based and expert-based recommendations on GCA. METHODS: The working group identified relevant questions, performed systematic literature review and assessed the quality of available evidence, and wrote recommendations. Where there was not a high level of evidence, the multidisciplinary (neurology, ophthalmology and rheumatology) group recommended best practice based on their clinical experience. RESULTS: Across Europe, fast track pathways and the utility of advanced imaging techniques are helping to reduce diagnostic delay and uncertainty, with improved clinical outcomes for patients. GCA is treated with high dose glucocorticoids (GC) as a first line agent however long-term GC toxicity is one of the key concerns for clinicians and patients. The first phase 2 and phase 3 randomised controlled trials of Tocilizumab, an IL-6 receptor antagonist, have been published. It is now been approved as the first ever licensed drug to be used in GCA. CONCLUSION: The present article will outline recent advances made in the diagnosis and management of GCA.

The Use of Posturography in Investigating the Risk of Falling in Frail or Prefrail Older People with Diabetes.

BACKGROUND: In older people, diabetes is associated with an increased risk of falls and frailty. The value of using posturography for evaluating the risk of falling is unclear. In theory, a time-scale analysis should increase the metrological properties of the posturography assessment. OBJECTIVES: This study aimed to determine which posturographic parameters can be used to identify fall-risk patients in a frail diabetic older population and to assess their interest in comparison to usual clinical trials for gait and balance. DESIGN: This is a prospective observational cohort. SETTINGS: frail or pre-frail diabetic patients, in Bordeaux, France. PARTICIPANTS: 84 patients were included in the study (mean age 80.09 years, 64.5% of men).Criteria for inclusion were: age over 70 years, diabetes mellitus for over 2 years, and at least one of the Fried's frailty criteria. MEASUREMENTS: Gait and balance assessments were undertaken at baseline: Static posturography, the timed up and go test, short physical performance battery, and (gait) walking speed. Raw data from posturography were used for wavelet analysis. Data on self reported new falls were collected prospectively during 6 months. RESULTS: The posturography parameter most useful was area of 90% confidence ellipse of statokinesigram (COP90area): area under the ROC curve AUC = 0.617 (95% CI, 0.445-0.789) and OR=1.003 (95%CI 1.000-1.005) p =0.05. The optimum clinical test was the time to walk over 4m AUC=0.735 (95%CI, 0.587-0.882) and OR=1.42 (95%CI 1.08-1.87) p= 0.013. CONCLUSION: Posturography has limited utility for assessment of falls risk in frail older people with diabetes. Gait and balance clinical assessments such as walking speed continue to retain their value.

Triad of impairment in older people with diabetes-reciprocal relations and clinical implications.

Frailty is emerging as a new category complication of diabetes in older people. Clinically, frailty is still not well defined and mostly viewed as a decline in solely the physical domain. However, frailty is a multidimensional syndrome and the newly introduced concept of "triad of impairment" (physical, cognitive and emotional) may be a more representative of the broad nature of frailty. The components of the triad of impairment (TOI) commonly coexist and demonstrate a reciprocal relation. Diabetes in old age appears to increase the risk of the triad of impairment, which may eventually progress to disability. Therefore, older people with diabetes should be regularly assessed for the presence of these three key components. Adequate nutrition and regular resistance exercise training have been shown to have a positive impact on the long-term outcome in this population. However, the role of good glycaemic control and the use of current hypoglycaemic medications in reducing the incidence of this triad are less clear. Future research is needed to develop novel hypoglycaemic medications that not only focus on glycaemic control and cardiovascular safety but also on reducing the risk of the triad of impairment.

A new era for giant cell arteritis.

The landscape of the investigation and management of giant cell arteritis (GCA) is advancing. In this review we will outline the recent advances by searching the current English literature for relevant articles using key words of giant cell arteritis, temporal arteritis, Horton's disease, investigation, and treatment. Delay in diagnosis, diagnostic uncertainty and glucocorticoid (GC) morbidity are among the highest concerns of clinicians and patients in this disease area. The positive news is that fast track pathways, imaging techniques and new therapies are emerging for routine management of GCA. Future directions for intervention in the treatment paradigm will be discussed.

Clinical guidelines for type 1 diabetes mellitus with an emphasis on older adults: an Executive Summary.

We present a summary of a guideline produced by an international group of experts for managing type 1 diabetes in adults with an emphasis on the special needs of older people with this condition. The rationale for delivering high-quality diabetes care for adults with type 1 diabetes, why it is important to include older people in our considerations, and the key underpinning principles of the guideline are included. The structure of the recommendations given is described and consists of 'general' recommendations followed by 'specific' recommendations according to three categories depending on the characteristics of adults addressed, such as functional level or self-management ability. Recommendations are provided in the areas of: clinical diagnosis, establishing management plans and glucose regulation, diabetes self-management education, nutritional therapy, physical activity, exercise and lifestyle modification, insulin treatments and regimens, use of technology in diabetes management, hypoglycaemia, managing cardiovascular risk, management of microvascular risk, and inpatient management of type 1 diabetes and ketoacidosis.

Glycaemic control and hypoglycaemia risk with insulin glargine 300 U/mL versus glargine 100 U/mL: A patient-level meta-analysis examining older and younger adults with type 2 diabetes.

AIM: Older people with type 2 diabetes (T2DM) are at an increased risk of hypoglycaemia and its consequences. However, efficacy and safety data for basal insulin therapy are limited in these individuals. This patient-level meta-analysis assessed the treatment effects of insulin glargine 300 U/mL (Gla-300) versus glargine 100 U/mL (Gla-100) in people with T2DM ≥ 65 years old. METHODS: Data were pooled for patients randomised to receive Gla-300 or Gla-100 in the Phase 3a, treat-to-target EDITION 1, 2 and 3 trials. Glycaemic efficacy, hypoglycaemia, changes in body weight and insulin dosage and adverse events were examined over 6 months' treatment with Gla-300 versus Gla-100 for participants aged ≥ 65 and < 65 years. RESULTS: Of 2496 participants randomised, 662 were ≥ 65 years (Gla-300, n = 329; Gla-100, n = 333). Glycaemic control was comparable for Gla-300 and Gla-100 in participants ≥ 65 years (LS mean [95% CI] difference in HbA1c change from baseline to month 6: 0.00 [-0.14 to 0.15] %; 0.00 [-1.53 to 1.64] mmol/mol) and < 65 years (0.00 [-0.09 to 0.08] %; 0.00 [-0.98 to 0.87] mmol/mol). Fewer participants receiving Gla-300 versus Gla-100 experienced nocturnal confirmed (≤ 3.9 mmol/L [≤ 70 mg/dL]) or severe hypoglycaemia (relative risk: ≥ 65 years: 0.70 [0.57 to 0.85]; < 65 years: 0.77 [0.68 to 0.87]). Annualised rates of nocturnal confirmed or severe hypoglycaemia were lower with Gla-300 than Gla-100 for both age groups. CONCLUSION: Gla-300 was associated with a reduced risk of nocturnal hypoglycaemia versus Gla-100, accompanied by comparable glycaemic improvement, for people aged ≥ 65 and < 65 years with T2DM.

Cost-effectiveness analysis of the Neuropad device as a screening tool for early diabetic peripheral neuropathy.

OBJECTIVE: To carry out a cost-effectiveness analysis of the use of Neuropad as a screening test for diabetic neuropathy together with the standard care tool, the 10-g monofilament, in people with diabetes. RESEARCH DESIGN AND METHODS: A cost-effectiveness analysis using a Markov model was developed to assess the impact on costs and outcomes of using Neuropad as a test for diabetic neuropathy (1) as a complement to the standard test, the 10-g monofilament (Neuropad + monofilament vs. monofilament); and (2) as a substitute for the monofilament (Neuropad vs. monofilament); from the healthcare provider perspective. The time horizon was 3 years. Data on costs and health gains were extracted from the literature. The incremental cost-utility ratio was calculated. Deterministic and probabilistic sensitivity analyses were also performed. RESULTS: Compared with standard care, Neuropad, in combination with the 10-g monofilament tool, is the dominant strategy as it leads to higher health gains and lower costs. In practice, compared with using the monofilament alone, performing both tests would lead to a savings of £1049.26 per patient and 0.044 QALY gain. Results were found to be consistent across the sensitivity analyses. CONCLUSIONS: Using both screening tools (Neuropad + monofilament) is a cost-effective strategy and the dominant alternative, when compared against using the 10-g monofilament alone. The results would be of special relevance in the early detection of diabetic peripheral neuropathy and to ensure the efficient allocation of resources and, thus, the sustainability of healthcare systems.