Non-insulin therapies in addition to insulin in Type 1 DM treatment.

INTRODUCTION: Complications of Type 1 diabetes (T1DM) remain prevalent due to suboptimal glycaemic control despite advances in analogue insulin, its delivery and technological advances in glucose monitoring. Intensive insulin therapy is associated with hypoglycaemia and weight gain. Non-insulin-dependent glucose lowering strategies may provide a strategy in improving glycaemic control without hypoglycaemia and weight gain. SOURCES OF DATA: Research papers and reviews about adjunctive treatment with insulin in T1DM in the published literature. AREAS OF AGREEMENT: Non-insulin-dependent strategies may be beneficial inT1DM particularly when there is insulin resistance, but the evidence for benefit at the current time is limited. Although there have been trials with various drugs as adjunctive therapy to insulin in T1DM currently in the UK, there is only one sodium glucose transport protein 2 (SGLT2) inhibitor with a marketing authorization for use in this indication. AREAS OF CONTROVERSY: Potential for harm with SGLT2 inhibitors in T1DM is a potential issue, particularly euglycaemic diabetic ketoacidosis. Clinical trials confirm that there is a risk albeit small, but emerging safety data have led to questions as to whether the risk of euglycaemic diabetic ketoacidosis is higher with the use of SGLT2 inhibitors in clinical practice. GROWING POINTS: Patient education is paramount-the work being done in T1DM to ensure safe use of SGLT2 inhibitors may help improve safety in the prescribing of SGLT2 inhibitors in Type 2 diabetes. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need for larger clinical trials with SGLT2 inhibitors in T1DM and real world studies to clarify safety.

Predicting admission at triage: are nurses better than a simple objective score?

AIM: We compared two methods of predicting hospital admission from ED triage: probabilities estimated by triage nurses and probabilities calculated by the Glasgow Admission Prediction Score (GAPS). METHODS: In this single-centre prospective study, triage nurses estimated the probability of admission using a 100 mm visual analogue scale (VAS), and GAPS was generated automatically from triage data. We compared calibration using rank sum tests, discrimination using area under receiver operating characteristic curves (AUC) and accuracy with McNemar's test. RESULTS: Of 1829 attendances, 745 (40.7%) were admitted, not significantly different from GAPS' prediction of 750 (41.0%, p=0.678). In contrast, the nurses' mean VAS predicted 865 admissions (47.3%), overestimating by 6.6% (p<0.0001). GAPS discriminated between admission and discharge as well as nurses, its AUC 0.876 compared with 0.875 for VAS (p=0.93). As a binary predictor, its accuracy was 80.6%, again comparable with VAS (79.0%), p=0.18. In the minority of attendances, when nurses felt at least 95% certain of the outcome, VAS' accuracy was excellent, at 92.4%. However, in the remaining majority, GAPS significantly outperformed VAS on calibration (+1.2% vs +9.2%, p<0.0001), discrimination (AUC 0.810 vs 0.759, p=0.001) and accuracy (75.1% vs 68.9%, p=0.0009). When we used GAPS, but 'over-ruled' it when clinical certainty was ≥95%, this significantly outperformed either method, with AUC 0.891 (0.877-0.907) and accuracy 82.5% (80.7%-84.2%). CONCLUSIONS: GAPS, a simple clinical score, is a better predictor of admission than triage nurses, unless the nurse is sure about the outcome, in which case their clinical judgement should be respected.

Deficits in Trabecular Bone Microarchitecture in Young Women With Type 1 Diabetes Mellitus.

The pathophysiological mechanism of increased fractures in young adults with type 1 diabetes mellitus (T1DM) is unclear. We conducted a case-control study of trabecular bone microarchitecture and vertebral marrow adiposity in young women with T1DM. Thirty women with T1DM with a median age (range) age of 22.0 years (16.9, 36.1) attending one outpatient clinic with a median age at diagnosis of 9.7 years (0.46, 14.8) were compared with 28 age-matched healthy women who acted as controls. Measurements included MRI-based assessment of proximal tibial bone volume/total volume (appBV/TV), trabecular separation (appTb.Sp), vertebral bone marrow adiposity (BMA), and abdominal adipose tissue and biochemical markers of GH/IGF-1 axis (IGF-1, IGFBP3, ALS) and bone turnover. Median appBV/TV in cases and controls was 0.3 (0.22, 0.37) and 0.33 (0.26, 0.4), respectively (p = 0.018) and median appTb.Sp in T1DM was 2.59 (2.24, 3.38) and 2.32 (2.03, 2.97), respectively (p = 0.012). The median appBV/TV was 0.28 (0.22, 0.33) in those cases with retinopathy (n = 15) compared with 0.33 (0.25, 0.37) in those without retinopathy (p = 0.02). Although median visceral adipose tissue in cases was higher than in controls at 5733 mm(3) (2030, 11,144) and 3460 mm(3) (1808, 6832), respectively (p = 0.012), there was no difference in median BMA, which was 31.1% (9.9, 59.9) and 26.3% (8.5, 49.8) in cases and controls, respectively (p = 0.2). Serum IGF-1 and ALS were also lower in cases, and the latter showed an inverse association to appTbSp (r = -0.30, p = 0.04). Detailed MRI studies in young women with childhood-onset T1DM have shown clear deficits in trabecular microarchitecture of the tibia. Underlying pathophysiological mechanisms may include a microvasculopathy.

A simple tool to predict admission at the time of triage.

AIM: To create and validate a simple clinical score to estimate the probability of admission at the time of triage. METHODS: This was a multicentre, retrospective, cross-sectional study of triage records for all unscheduled adult attendances in North Glasgow over 2 years. Clinical variables that had significant associations with admission on logistic regression were entered into a mixed-effects multiple logistic model. This provided weightings for the score, which was then simplified and tested on a separate validation group by receiving operator characteristic (ROC) analysis and goodness-of-fit tests. RESULTS: 215 231 presentations were used for model derivation and 107 615 for validation. Variables in the final model showing clinically and statistically significant associations with admission were: triage category, age, National Early Warning Score (NEWS), arrival by ambulance, referral source and admission within the last year. The resulting 6-variable score showed excellent admission/discharge discrimination (area under ROC curve 0.8774, 95% CI 0.8752 to 0.8796). Higher scores also predicted early returns for those who were discharged: the odds of subsequent admission within 28 days doubled for every 7-point increase (log odds=+0.0933 per point, p<0.0001). CONCLUSIONS: This simple, 6-variable score accurately estimates the probability of admission purely from triage information. Most patients could accurately be assigned to 'admission likely', 'admission unlikely', 'admission very unlikely' etc., by setting appropriate cut-offs. This could have uses in patient streaming, bed management and decision support. It also has the potential to control for demographics when comparing performance over time or between departments.

Differences in level of confidence in diabetes care between different groups of trainees: the TOPDOC diabetes study.

BACKGROUND: There is an increasing prevalence of diabetes. Doctors in training, irrespective of specialty, will have patients with diabetes under their care. The aim of this further evaluation of the TOPDOC Diabetes Study data was to identify if there was any variation in confidence in managing diabetes depending on the geographical location of trainees and career aspirations. METHODS: An online national survey using a pre-validated questionnaire was administered to trainee doctors. A 4-point confidence rating scale was used to rate confidence in managing aspects of diabetes care and a 6-point scale used to quantify how often trainees would contribute to the management of patients with diabetes. Responses were grouped depending on which UK country trainees were based and their intended career choice. RESULTS: Trainees in Northern Ireland reported being less confident in IGT diagnosis, use of IV insulin and peri-operative management and were less likely to adjust oral treatment, contact specialist, educate lifestyle, and optimise treatment. Trainees in Scotland were less likely to contact a specialist, but more likely to educate on lifestyle, change insulin, and offer follow-up advice. In Northern Ireland, Undergraduate (UG) and Postgraduate (PG) training in diagnosis was felt less adequate, PG training in emergencies less adequate, and reporting of need for further training higher. Trainees in Wales felt UG training to be inadequate. In Scotland more trainees felt UG training in diagnosis and optimising treatment was inadequate. Physicians were more likely to report confidence in managing patients with diabetes and to engage in different aspects of diabetes care. Aspiring physicians were less likely to feel the need for more training in diabetes care; however a clear majority still felt they needed more training in all aspects of care. CONCLUSIONS: Doctors in training have poor confidence levels dealing with diabetes related care issues. Although there is variability between different groups of trainees according to geographical location and career aspirations, this is a UK wide issue. There should be a UK wide standardised approach to improving training for junior doctors in diabetes care with local training guided by specific needs.

Prevalence and causes of prescribing errors: the PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) study.

OBJECTIVES: Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing. METHOD: A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors' self-efficacy were established. RESULTS: 4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p<0.001), surgical (p = <0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p<0.001), a greater number of prescribed medicines (p<0.001) and the months December and June (p<0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen. CONCLUSIONS: Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.

Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors.

BACKGROUND: Prescribing errors are a major source of morbidity and mortality and represent a significant patient safety concern. Evidence suggests that trainee doctors are responsible for most prescribing errors. Understanding the factors that influence prescribing behavior may lead to effective interventions to reduce errors. Existing investigations of prescribing errors have been based on Human Error Theory but not on other relevant behavioral theories. The aim of this study was to apply a broad theory-based approach using the Theoretical Domains Framework (TDF) to investigate prescribing in the hospital context among a sample of trainee doctors. METHOD: Semistructured interviews, based on 12 theoretical domains, were conducted with 22 trainee doctors to explore views, opinions, and experiences of prescribing and prescribing errors. Content analysis was conducted, followed by applying relevance criteria and a novel stage of critical appraisal, to identify which theoretical domains could be targeted in interventions to improve prescribing. RESULTS: Seven theoretical domains met the criteria of relevance: "social professional role and identity," "environmental context and resources," "social influences," "knowledge," "skills," "memory, attention, and decision making," and "behavioral regulation." From critical appraisal of the interview data, "beliefs about consequences" and "beliefs about capabilities" were also identified as potentially important domains. Interrelationships between domains were evident. Additionally, the data supported theoretical elaboration of the domain behavioral regulation. CONCLUSIONS: In this investigation of hospital-based prescribing, participants' attributions about causes of errors were used to identify domains that could be targeted in interventions to improve prescribing. In a departure from previous TDF practice, critical appraisal was used to identify additional domains that should also be targeted, despite participants' perceptions that they were not relevant to prescribing errors. These were beliefs about consequences and beliefs about capabilities. Specifically, in the light of the documented high error rate, beliefs that prescribing errors were not likely to have consequences for patients and that trainee doctors are capable of prescribing without error should also be targeted in an intervention. This study is the first to suggest critical appraisal for domain identification and to use interview data to propose theoretical elaborations and interrelationships between domains.

Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: the Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study.

BACKGROUND: As the incidence and prevalence of diabetes increases across the world, resource pressures require doctors without specialist training to provide care for people with diabetes. In the UK, national standards have been set to ensure quality diabetes care from diagnosis to the management of complications. In a multi-centre pilot study, we have demonstrated a lack of confidence among UK trainee doctors in managing diabetes. Suboptimal confidence was identified in a number of areas, including the management of diabetes emergencies. A national survey would clarify whether the results of our pilot study are representative and reproducible. METHODS/DESIGN: Target cohort: All postgraduate trainee doctors in the UK. DOMAINS STUDIED: The self reported online survey questionnaire has 5 domains: (1) confidence levels in the diagnosis and management of diabetes, (2) working with diabetes specialists, (3) perceived adequacy of training in diabetes (4) current practice in optimising glycaemic control and (5) perceived barriers to seeking euglycaemia.Assessment tools: Self-reported confidence is assessed using the 'Confidence Rating' (CR) scale for trainee doctors developed by the Royal College of Physicians. This scale has four points--('not confident' (CR1), 'satisfactory but lacking confidence' (CR2), 'confident in some cases (CR3) and 'fully confident in most cases' (CR4).Frequency of aspects of day-to-day practice is assessed using a six-point scale. Respondents have a choice of 'always' (100%), 'almost always' (80-99%), 'often' (50-79%), 'not very often' (20-49%) and 'rarely' (5-19%) or never (less than 5%). DISCUSSION: It is anticipated that the results of this national study will clarify confidence levels and current practice among trainee doctors in the provision of care for people with diabetes. The responses will inform efforts to enhance postgraduate training in diabetes, potentially improving the quality of care for people with diabetes.

A combined diabetes renal clinic improves risk factor management and progression of renal disease in a district general hospital.

AIMS: Aggressive management of vascular risk factors reduces the rate of progression to end-stage renal failure in patients with diabetic nephropathy. The aim of our audit was to clarify whether improvements in patient care could be demonstrated within a short time period after establishing a combined diabetes renal clinic in a district general hospital. METHODS: A retrospective analysis of weight, glycaemic control, blood pressure control, rate of decline in renal function and appropriate use of medications for vascular risk management for patients in a district general hospital was performed before and after attendance at a combined diabetes renal clinic. RESULTS: Data were complete for 45 patients. There was no significant change in weight from 14 months before attending the combined clinic, referral to the clinic and after 14 months of mean follow-up. An improvement in mean systolic blood pressure was achieved at the combined diabetes renal clinic (from 147 to 134 mmHg with an average fall of 16.5 mmHg, P < 0.01). The mean glycated haemoglobin (HbA1c) improved from 8.6% to 8% (P = 0.002). The rate of decline in estimated glomerular filtration rate of 1.16 mL min(-1) per month prior to referral improved to 0.21 mL min(-1) per month on attending the combined clinic (P = 0.002). CONCLUSIONS: Vascular risk factor management was improved and decline in renal function slowed in patients with diabetic nephropathy within a short period of establishing a combined diabetes renal clinic in a district general hospital.

Therapeutic strategies in the treatment of diabetic nephropathy - a translational medicine approach.

Type 2 Diabetes (T2D) is an important cause of renal dysfunction and the most common cause of end-stage renal disease (ESRD). Diabetic nephropathy is also associated with an increased risk of vascular disease and patient mortality. Aggressive management of hypertension to reduce microalbuminuria, together with tight glycaemic control are important therapeutic strategies for renal and vascular disease prevention in T2D. The main pathophysiological mechanisms associated with diabetic nephropathy result from activation of the renin-angiotensin-aldosterone system (RAAS), protein kinase C pathway, pro-inflammatory cytokines and various growth factors. Angiotensin II and transforming growth factor-beta (TGF-beta) are two important molecular mediators. The production of advanced glycation end-products (AGEs) and increased oxidative stress further exacerbates renal injury. These molecular changes within the renal tissue result in mesangial expansion, increased extracellular matrix deposition and an alteration in podocyte structure and function. Therapeutic targeting of these molecular pathways is an important area of translational research in diabetes. The elucidation of new genetic associations and proteomic biomarkers of diabetic kidney disease will also assist in the identification and treatment of high-risk patients. This review article will discuss both the molecular and clinical aspects of diabetic nephropathy, providing a bench-to-bedside research perspective to potential new therapeutic strategies.

Training tomorrow's doctors in diabetes: self-reported confidence levels, practice and perceived training needs of post-graduate trainee doctors in the UK. A multi-centre survey.

OBJECTIVE: To assess the confidence, practices and perceived training needs in diabetes care of post-graduate trainee doctors in the UK. METHODS: An anonymised postal questionnaire using a validated 'Confidence Rating' (CR) scale was applied to aspects of diabetes care and administered to junior doctors from three UK hospitals. The frequency of aspects of day-to-day practice was assessed using a five-point scale with narrative description in combination with numeric values. Respondents had a choice of 'always' (100%), 'almost always' (80-99%), 'often' (50-79%), 'not very often' (20-49%) and 'rarely' (less than 20%). Yes/No questions were used to assess perception of further training requirements. Additional 'free-text' comments were also sought. RESULTS: 82 doctors completed the survey. The mean number of years since medical qualification was 3 years and 4 months, (range: 4 months to 14 years and 1 month). Only 11 of the respondents had undergone specific diabetes training since qualification.4(5%) reported 'not confident' (CR1), 30 (37%) 'satisfactory but lacked confidence' (CR2), 25 (30%) felt 'confident in some cases' (CR3) and 23 (28%) doctors felt fully confident (CR4) in diagnosing diabetes. 12 (15%) doctors would always, 24 (29%) almost always, 20 (24%) often, 22 (27%) not very often and 4 (5%) rarely take the initiative to optimise gcaemic control. 5 (6%) reported training in diagnosis of diabetes was adequate while 59 (72%) would welcome more training. Reported confidence was better in managing diabetes emergencies, with 4 (5%) not confident in managing hypoglycaemia, 10 (12%) lacking confidence, 22 (27%) confident in some cases and 45 (55%) fully confident in almost all cases. Managing diabetic ketoacidosis, 5 (6%) doctors did not feel confident, 16 (20%) lacked confidence, 20 (24%) confident in some cases, and 40 (50%) felt fully confident in almost all cases. CONCLUSION: There is a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies, amongst postgraduate trainee doctors with a perceived need for more training. This may have considerable significance and further research is required to identify the causes of deficiencies identified in this study.

Non-European Union doctors in the National Health Service: why, when and how do they come to the United Kingdom of Great Britain and Northern Ireland?

BACKGROUND: As many as 30% of doctors working for the National Health System (NHS) of the United Kingdom of Great Britain and Northern Ireland (UK) have obtained their primary qualifications from a country outside the European Union. However, factors driving this migration of doctors to the UK merit continuing exploration. Our objective was to obtain training and employment profile of UK doctors who obtained their primary medical qualification outside the European Union (non-European doctors) and to assess self-reported reasons for their migration. METHODS: We conducted an online survey of non-European doctors using a pre-validated questionnaire. RESULTS: One thousand six hundred and nineteen doctors of 26 different nationalities completed the survey. Of the respondents, 90.1% were from India and over three-quarters migrated to the UK mainly for 'training'. Other reasons cited were 'better pay' (7.2%), 'better work environment' (7.1%) and 'having family and friends in the UK' (2.8%). Many of the respondents have been in the UK for more than a year (88.8%), with 31.3% having spent more than 3 years gaining experience of working in the NHS. Most respondents believe they will be affected by recent changes to UK immigration policy (86.6%), few report that they would be unaffected (3.7%) and the rest are unsure (9.8%). CONCLUSION: The primary reason for many non-European doctors to migrate to the UK is for training within the NHS. Secondary reasons like better pay, better work environment and having friends and family in the UK also play a role in attracting these doctors, predominantly from the Indian subcontinent and other British Commonwealth countries.