Comparative evaluation of quality of diabetes care within a population using discrete HbA1c thresholds versus longitudinal trends within a defined time period.

BACKGROUND: HbA1c is a quality measurement for a population's diabetes care. Currently, discrete values are used to judge the care quality. However, an improved trend may have been achieved without reaching a discrete threshold. We aimed to compare the quality of glycaemic care using discrete thresholds versus longitudinal trends of a patient's HbA1c. METHODS: We derived a study population of 4062 with two consecutive HbA1c's within 1-6 months. We used current discrete thresholds and then used these to define the longitudinal thresholds (the change in HbA1c between the first and second measurement). RESULTS: We found that even with discrete thresholds, overall care was improving with 61% (Excellent care), 13% (Good care), 13% (Average care) and 13% (Poor care) turning into 68%, 12%, 11% and 9%, respectively (χ² 3335, p<0.0001). Using longitudinal trends shows a greater improvement of care with the original values achieving 74%, 7%, 9%, 7% and 4%, respectively (χ² 4111.3, p<0.0001). There was an additional 28% (Good care), 15% (Average care) and 12% (Poor and Very poor care) who with longitudinal trends improved to an excellent category without being identified as such. CONCLUSION: Our study highlights the need to consider longitudinal trends when measuring quality of diabetes care.

Hypertriglyceridaemia-induced pancreatitis.

Hypertriglyceridaemia is the third most common cause of acute pancreatitis but is relatively rare and therefore requires a high level of clinical suspicion to be diagnosed. We discuss the case of a 46-year-old man who initially presented to the accident and emergency department with suspected first presentation of diabetic ketoacidosis (DKA) and a normal amylase but who did not respond to DKA treatment. Further history revealed significant cardiovascular risk factors, examination showed an evidence of hyperlipidaemia and investigations revealed acute pancreatitis secondary to hypertriglyceridaemia. We discuss the causes of hypertriglyceridaemia, the difficulty in differentiating primary versus secondary hypertriglyceridaemia, possible pathogenesis and current evidence-based treatments.

Severe and disabling diabetic autonomic neuropathy: a case report.

We report a case of a woman with several and severe disabling manifestations of autonomic neuropathy in whom reasonable quality of life was established by combining continuous insulin infusion, jejunal feeding, colostomy and bladder self-catheterisation. We discuss the prevalence rates, pathophysiology, management and prognosis of this disabling condition.