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Long-term improvements in glycemia and user-reported outcomes associated with open-source automated insulin delivery systems in adults with type 1 Diabetes in the United Kingdom : a real-world observational studyObjective: To evaluate real-world outcomes in adults with type 1 diabetes initiating open-source automated insulin delivery systems (OS-AID). Methods: Adults with type 1 diabetes who commenced OS-AID, between May 2016 and April 2021, across 12 centers in the United Kingdom were included. Anonymized clinical data, collected during routine clinical care between December 2019 and November 2023, were submitted to a secure web-based tool within the National Health Service network. Outcomes included change in hemoglobin A1c (HbA1c), sensor glucometrics, diabetes distress score, Gold score (hypoglycemia awareness), user opinion of OS-AID, and event rates (hospital admissions, paramedic callouts, severe hypoglycemia, and adverse events) between baseline and follow-up. Results: In total, 81 OS-AID users were included (51.9% male; 90.1% White British; mean age 41.4 years; median diabetes duration 25 years [IQR 17-32]). Over a mean follow-up of 1.7 years, HbA1c reduced by 0.8% (9 mmol/mol) (7.3 ± 1.1% vs. 6.5 ± 0.7%; P < 0.001), and the percentage of individuals achieving HbA1c ≤ 7.0% (53 mmol/mol) increased from 48.6% to 75.7% (P < 0.001). Diabetes-related distress score reduced by 0.9 (95% confidence interval [CI] -0.3, -1.5; P = 0.006), and Gold score reduced by 0.7 (95% CI -0.1, -1.3; P = 0.022). The percentage of individuals with impaired hypoglycemia awareness (Gold score ≥4) reduced (27.8% at baseline vs. 8.3% at follow-up; P = 0.039). Of those asked, all participants stated that OS-AID had a positive impact on quality of life. The number of hospital admissions was low. Conclusions: The use of OS-AID is associated with long-term improvements in HbA1c, hypoglycemia awareness, and diabetes-related distress in type 1 diabetes. These benefits were achieved without increased rates of hospital admissions, diabetic ketoacidosis, or severe hypoglycemia.
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Time below range and its influence on hypoglycemia awareness and severe hypoglycemia : insights from the Association of British Clinical Diabetologists studyObjective: This study aimed to explore the relationship between time below range (TBR), impaired awareness of hypoglycemia (IAH), and severe hypoglycemia (SH). Research design and methods: This cross-sectional study analyzed data from individuals with diabetes using continuous glucose monitors (CGMs) in the Association of British Clinical Diabetologists audit. Hypoglycemia awareness was assessed via the Gold score (≥4 denoting IAH), and SH was defined as hypoglycemia requiring third-party assistance. Logistic regression was used to determine the association between TBR percentage (<70 mg/dL; 3.9 mmol/L) at first follow-up and follow-up Gold score and SH incidence. The Youden J index identified optimal TBR percentage cutoffs for detecting IAH and SH. Results: The study included 15,777 participants, with follow-up TBR and SH data available for 5,029. The median TBR percentage was 4% (interquartile range 2-6.6%), with 42% meeting the recommended TBR of ≤4%. Adjusted for age, sex, and BMI, TBR was significantly associated with SH (P < 0.001) and IAH (P = 0.005). Optimal TBR cutoffs for identifying IAH and SH were 3.35% and 3.95%, yielding negative predictive value (NPV) values of 85% and 97%, respectively. Conclusions: Our findings support the international consensus recommending a TBR of <4% in type 1 diabetes, with high NPV values suggesting the utility of TBR in screening for SH.
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Predictors of diabetes-related distress before and after FreeStyle Libre-1 use: Lessons from the Association of British Clinical Diabetologists nationwide study.Aim: To identify the baseline demographic and clinical characteristics associated with diabetes-related distress (DRD) and factors associated with improvement in DRD after initiating use of the FreeStyle Libre (FSL) in people living with type 1 diabetes (T1D). Methods: The study was performed using baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes who initiated use of the FSL in the United Kingdom. DRD was assessed using the two-item diabetes-related distress scale (DDS; defined as the average of the two-item score ≥3). People living with T1D were categorized into two groups: those with high DRD, defined as an average DDS score ≥3 and those with lower DRD, defined as a DDS score <3. We used a gradient-boosting machine-learning (GBM) model to identify the relative influence (RI) of baseline variables on average DDS score. Results: The study population consisted of 9159 patients, 96.6% of whom had T1D. The median (interquartile range [IQR]) age was 45.1 (32-56) years, 50.1% were women, the median (IQR) baseline body mass index was 26.1 (23.2-29.6) kg/m2 and the median (IQR) duration of diabetes was 20 (11-32) years. The two components of the DDS were significantly correlated (r2 = 0.73; P < 0.0001). Higher DRD was prevalent in 53% (4879/9159) of people living with T1D at baseline. In the GBM model, the top baseline variables associated with average DDS score were baseline glycated haemoglobin (HbA1c; RI = 51.1), baseline Gold score (RI = 23.3), gender (RI = 7.05) and fear of hypoglycaemia (RI = 4.96). Follow-up data were available for 3312 participants. The top factors associated with improvement in DDS score following use of the FSL were change in Gold score (RI = 28.2) and change in baseline HbA1c (RI = 19.3). Conclusions: In this large UK cohort of people living with T1D, diabetes distress was prevalent and associated with higher HbA1c, impaired awareness of hypoglycaemia and female gender. Improvement in glycaemic control and hypoglycaemia unawareness with the use of the FSL was associated with improvement in DRD in people living with T1D.
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Level of adherence to vitamin D supplementation guidelines in an antenatal centre in Birmingham, UK, and its effect on biochemical and obstetrical outcomes: a single-centre cross-sectional study.Objectives: A third of pregnant women in the UK are vitamin D deficient, which may confer deleterious consequences, including an increased risk of pre-eclampsia, gestational diabetes mellitus and intrauterine growth restriction. This study aims to determine the proportion of women that met National Institute for Health and Care Excellence (NICE) standards for vitamin D supplementation in pregnancy and compare biochemical and obstetrical outcomes according to supplementation status. Design and setting: This is a single-centre cross-sectional study in an antenatal centre in Birmingham, UK. Participants received a questionnaire regarding their experiences with vitamin D supplementation during their pregnancy with their general practitioner. Serum 25-hydroxyvitamin D and bone profile results were obtained during the same appointment and obstetrical outcomes were collected retrospectively once participants had delivered. Results: 41.8% of participants (n=61) received written and/or verbal advice about supplementation, (NICE standards=100%). 72.6% (n=106) had one or more risk factors for vitamin D deficiency, of which 38.7% (n=41, NICE standards=100%) were asked about supplementation. Among those asked, 85.4% (n=41, NICE standards=100%) received the correct dosage. Compared with the supplementation group, the non-supplementation group had offspring that were 1.40 cm (95% CI 0.01 to 2.80, p=0.04) longer at birth; which was significant after adjusting for confounding factors. No significant differences in any biochemical parameters were observed between supplementation categories (p>0.05). Conclusions: Adherence to NICE standards was suboptimal. This may be attributed to insufficient training for general practitioners on the importance of supplementation, causing them to underestimate the consequences of gestational vitamin D deficiency. Recommendations include implementing a mandatory screening tool to identify 'at-risk' women and providing more clinician training to ensure that supplementation during pregnancy is standard of care.
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Hypertension is the major predictor of poor outcomes among inpatients with COVID-19 infection in the UK: a retrospective cohort study.Objective: To assess the impact of diabetes, hypertension and cardiovascular diseases on inpatient mortality from COVID-19, and its relationship to ethnicity and social deprivation. Design: Retrospective, single-centre observational study SETTING: Birmingham, UK. Participants: 907 hospitalised patients with laboratory-confirmed COVID-19 from a multi-ethnic community, admitted between 1 March 2020 and 31 May 2020. Main outcome measures: The primary analysis was an evaluation of cardiovascular conditions and diabetes in relation to ethnicity and social deprivation, with the end-point of inpatient death or death within 30 days of discharge. A multivariable logistic regression model was used to calculate HRs while adjusting for confounders. Results: 361/907 (39.8%) died in hospital or within 30 days of discharge. The presence of diabetes and hypertension together appears to confer the greatest mortality risk (OR 2.75; 95% CI 1.80 to 4.21; p<0.001) compared with either condition alone. Age >65 years (OR 3.32; 95% CI 2.15 to 5.11), male sex (OR 2.04; 95% CI 1.47 to 2.82), hypertension (OR 1.69; 95% CI 1.10 to 2.61) and cerebrovascular disease (OR 1.87; 95% CI 1.31 to 2.68) were independently associated with increased risk of death. The mortality risk did not differ between the quintiles of deprivation. High-sensitivity troponin I was the best predictor of mortality among biomarkers (OR 4.43; 95% CI 3.10 to 7.10). Angiotensin-receptor blockers (OR 0.57; 95% CI 0.33 to 0.96) and ACE inhibitors (OR 0.65; 95% CI 0.43 to 0.97) were not associated with adverse outcome. The Charlson Index of Comorbidity scores were significantly higher in non-survivors. Conclusions: The combined prevalence of hypertension and diabetes appears to confer the greatest risk, where diabetes may have a modulating effect. Hypertension and cerebrovascular disease had a significant impact on inpatient mortality. Social deprivation and ethnicity did not have any effect once the patient was in hospital.
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Endoscopic duodenal-jejunal bypass liner treatment of moderate obstructive sleep apnoea - a pilot studyWe aimed to assess the extent to which people with type 2 diabetes or pre-diabetes, obesity (BMI 30-45 kg/m2) and moderate obstructive sleep apnoea (OSA) requiring continuous positive airway pressure ventilation (CPAP) were able to discontinue CPAP following EndoBarrier-related weight loss. We assessed sleep and metabolic parameters before, during and after EndoBarrier in 12 participants with moderate OSA requiring CPAP (75% female, 8/12 [66%] type 2 diabetes, 4/12 [34%] prediabetes, mean ± SD age 52.6 ± 9.7 years, BMI 37.4 ± 3.5 kg/m2, median duration of OSA while on CPAP 9.0 [7.0-15.0] months). With EndoBarrier in-situ, mean ± SD Apnoea Hypopnoea Index (AHI) fell by 9.1 ± 5.0 events/h from 18.9 ± 3.8 to 9.7 ± 3.0 events/h (p < .001) with an associated reduction in symptoms of daytime sleepiness (mean Epworth Sleepiness Score) such that all the 12 participants no longer required CPAP according to National Institute for Health and Care Excellence criteria. After EndoBarrier removal, 10/12 (83%) patients attended follow-up and at 12 months after removal, AHI remained below 15 in 5/10 (50%) patients but in other five the AHI rose above 15 such that restarting CPAP was recommended as justified by their symptoms. Rather than restart CPAP, two patients lost the regained weight and their AHI dropped below 15 again. Thus, 7/10 (70%) of patients were able to remain off CPAP 12 or more months after EndoBarrier removal. These results demonstrate major benefit of EndoBarrier in moderate OSA, allowing all patients to discontinue CPAP during treatment, and with maintenance of improvement at follow-up in 70%. They confirm previously demonstrated metabolic improvements in diabetes and obesity.
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Cardioprotective Effects of Pioglitazone in Type 2 Diabetes.Antidiabetic medications that improve glycemic control as well as cardiovascular outcomes will be the mainstay of treatment for type 2 diabetes moving forward. This article reviews the beneficial effects of the thiazolidinedione pioglitazone of ameliorating hyperglycemia and improving cardiovascular risk factors. While the newer sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide 1 receptor agonist drug classes have confirmed cardiovascular benefits, pioglitazone also has been shown to reduce major adverse cardiovascular events, in both people with type 2 diabetes and nondiabetic subjects with insulin resistance. Adverse effects associated with pioglitazone can be mitigated by its use at a lower dose and in combination with antidiabetic agents from other drug classes.
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Atypical presentation of stroke in a person with autoimmune polyendocrine syndromeA 62-year-old man with type 1 diabetes mellitus presented to hospital with new onset anterograde amnesia in the absence of any other focal neurology or visual deficit. Computed tomography of his head revealed an established fronto-parietal infarct – however, it failed to detect the culprit acute infarct in the left temporal and occipital lobe, which was subsequently revealed by diffusion-weighted magnetic resonance imaging. This posterior cerebral artery stroke is thought to have been caused by thrombotic emboli. This case highlights an atypical stroke presentation in the context of multiple endocrine comorbidities, including type 1 diabetes mellitus, coeliac disease and previously treated hyperthyroidism. This raises the possibility of an autoimmune polyendocrine syndrome. The patient was managed by the stroke and diabetes teams and is currently receiving cognitive rehabilitation in the community. Learning points from this case hinge around recognition of atypical stroke presentations, the limitations of computed tomography in patients with stroke and the contributions that endocrine comorbidities may add to the risk of stroke.
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Association of British Clinical Diabetologists and Renal Association guidelines on the detection and management of diabetes post solid organ transplantation.Post-transplant diabetes mellitus (PTDM) is common after solid organ transplantation (SOT) and associated with increased morbidity and mortality for allograft recipients. Despite the significant burden of disease, there is a paucity of literature with regards to detection, prevention and management. Evidence from the general population with diabetes may not be translatable to the unique context of SOT. In light of emerging clinical evidence and novel anti-diabetic agents, there is an urgent need for updated guidance and recommendations in this high-risk cohort. The Association of British Clinical Diabetologists (ABCD) and Renal Association (RA) Diabetic Kidney Disease Clinical Speciality Group has undertaken a systematic review and critical appraisal of the available evidence. Areas of focus are; (1) epidemiology, (2) pathogenesis, (3) detection, (4) management, (5) modification of immunosuppression, (6) prevention, and (7) PTDM in the non-renal setting. Evidence-graded recommendations are provided for the detection, management and prevention of PTDM, with suggested areas for future research and potential audit standards. The guidelines are endorsed by Diabetes UK, the British Transplantation Society and the Royal College of Physicians of London. The full guidelines are available freely online for the diabetes, renal and transplantation community using the link below. The aim of this review article is to introduce an abridged version of this new clinical guideline ( https://abcd.care/sites/abcd.care/files/site_uploads/Resources/Position-Papers/ABCD-RA%20PTDM%20v14.pdf).
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Burnout among diabetes specialist registrars across the United Kingdom in the post-pandemic eraIntroduction: Burnout syndrome is a condition resulting from chronic work-related stress exposure and can be identified by the presence of one or more of the three classic dimensions of burnout, i.e., emotional exhaustion, depersonalization, and lack of personal accomplishment, which negatively impact physician health and productivity. Objective: This study aimed to identify burnout among Diabetes and Endocrinology Specialty Training Registrars (DStRs) across the United Kingdom. Design/setting: It was a Cross-sectional observational study after ethical approval ERSC_2022_1166, utilizing the gold standard Maslach Burnout Inventory to measure burnout syndrome, and to determine self-reported stressors and compare them with the results of our previous survey in 2018. Participants: Over 430 DStRs across the United Kingdom were invited electronically through their deanery representatives and specialty training bodies. Results: Using Google Forms™ to gather data, we were able to collect 104 completed surveys. Results revealed that 62.5% (n = 65) of participants have burnout (5% increase from the previous survey in 2018), 38.6% (n = 40) have high emotional exhaustion, and 44.2% (n = 46) feel a lack of personal accomplishment. "General Internal Medicine specific workload" was the most common self-reported stressor reported by 87.5% (n = 91) of participants, whereas bullying/harassment and discrimination at work were reported by 35.6% (n = 37) and 30.77% (n = 32) of participants, respectively. Using multivariable logistic regression model, personal stress (OR, 4.00; 95% CI, 1.48-10.86; p = 0.006) had significant, while Bullying/harassment (OR, 3.75; 95% CI, 0.93-15.12; p = 0.063) had marginal impact on the presence of burnout. Conclusion: Diabetes and Endocrinology Specialty Training Registrars frequently experience burnout syndrome, which has increased over the last 4 years. However, organizational changes can help identify, prevent, and treat physician burnout.
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Real-world outcomes of Omnipod DASH system use in people with type 1 diabetes : evidence from the Association of British Clinical Diabetologists (ABCD) studyAims: To evaluate real-world outcomes in people with Type 1 Diabetes (PwT1D) initiated on Omnipod DASH® Insulin Management System. Methods: Anonymized clinical data were submitted to a secure web-based tool within the National Health Service network. Hemoglobin A1c (HbA1c), sensor-derived glucometrics, total daily dose of insulin (TDD), and patient-reported outcome changes between baseline and follow-up were assessed. Individuals were classified to "new-to-pump" (switched from multiple daily injections) and "established-on-pump" (switched from a tethered insulin pump) groups. Results: 276 individuals from 11 centers [66.7 % female; 92 % White British; median age 41 years (IQR 20-50); diabetes duration 20 years (IQR 11-31); 49.3 % within "new-to-pump" group] were included. Baseline HbA1c was 8.0 ± 1.3 % (64 ± 14 mmol/mol). At follow-up [3 years (IQR 1.5-3.2)], HbA1c reduced by 0.3 % [(3 mmol/mol); p = 0.002] across the total population, 0.4 % [(5 mmol/mol); p = 0.001] in those "new-to-pump" and remained unchanged in those "established-on-pump". TDD decreased in the "new-to-pump" cohort (baseline:44.9 ± 21.0units vs follow-up:38.1 ± 15.4units, p = 0.002). Of those asked, 141/143 (98.6 %) stated Omnipod DASH had a positive impact on quality of life. Conclusions: Omnipod DASH was associated with improvements in HbA1c in PwT1D "new-to-pump" and maintained previous HbA1c levels in those "established-on-pump". User satisfaction in all groups and TDD reduction in those "new-to-pump" were reported.
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A UK nationwide study of people with type 1 diabetes admitted to hospital with COVID-19 infection.Aims/hypothesis: The aim of this work was to describe the clinical characteristics of adults with type 1 diabetes admitted to hospital and the risk factors associated with severe coronavirus disease-2019 (COVID-19) in the UK. Methods: A retrospective cohort study was performed using data collected through a nationwide audit of people admitted to hospital with diabetes and COVID-19, conducted by the Association of British Clinical Diabetologists from March to October 2020. Prespecified demographic, clinical, medication and laboratory data were collected from the electronic and paper medical record systems of the participating hospitals by local clinicians. The primary outcome of the study, severe COVID-19, was defined as death in hospital and/or admission to the adult intensive care unit (AICU). Logistic regression models were used to generate age-adjusted ORs. Results: Forty UK centres submitted data. The final dataset included 196 adults who were admitted to hospital and had both type 1 diabetes and COVID-19 on admission (male sex 55%, white 70%, with mean [SD] age 62 [19] years, BMI 28.3 [7.3] kg/m2 and last recorded HbA1c 76 [31] mmol/mol [9.1 (5.0)%]). The prevalence of pre-existing microvascular disease and macrovascular disease was 56% and 39%, respectively. The prevalence of diabetic ketoacidosis on admission was 29%. A total of 68 patients (35%) died or were admitted to AICU. The proportions of people that died were 7%, 38% and 38% of those aged <55, 55-74 and ≥75 years, respectively. BMI, serum creatinine levels and having one or more microvascular complications were positively associated with the primary outcome after adjusting for age. Conclusions/interpretation: In people with type 1 diabetes and COVID-19 who were admitted to hospital in the UK, higher BMI, poorer renal function and presence of microvascular complications were associated with greater risk of death and/or admission to AICU. Risk of severe COVID-19 is reassuringly very low in people with type 1 diabetes who are under 55 years of age without microvascular or macrovascular disease. IN PEOPLE WITH TYPE 1 DIABETES AND COVID-19 ADMITTED TO HOSPITAL IN THE UK, BMI AND ONE OR MORE MICROVASCULAR COMPLICATIONS HAD A POSITIVE ASSOCIATION AND LOW SERUM CREATINE LEVELS HAD A NEGATIVE ASSOCIATION WITH DEATH/ADMISSION TO INTENSIVE CARE UNIT AFTER ADJUSTING FOR AGE.
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Effect of intermittently scanned continuous glucose monitoring in people with diabetes with a psychosocial indication for initiationAim: To understand the effect of intermittently scanned continuous glucose monitoring (isCGM) in people with diabetes with a 'psychosocial' indication for access. Methods: The study utilized baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes in the UK. Diabetes-related distress (DRD) was assessed using the two-item diabetes-related distress scale (DDS). Participants were categorized into two groups: high DRD (DDS score ≥ 3) and lower DRD (DDS score < 3). The t-test was used to assess the difference in the pre- and post-isCGM continuous variables. Results: The study consisted of 17 036 people with diabetes, with 1314 (7%) using isCGM for 'psychosocial' reasons. Follow-up data were available for 327 participants, 322 (99%) of whom had type 1 diabetes with a median diabetes duration of 15 years; 75% (n = 241) had high levels of DRD. With the initiation of isCGM, after a mean follow-up period of 6.9 months, there was a significant reduction in DDS score; 4 at baseline versus 2.5 at follow-up (P < .001). The prevalence of high DRD reduced from 76% to 38% at follow-up (50% reduction in DRD, P < .001). There was also a significant reduction in HbA1c (78.5 mmol/mol [9.3%] at baseline vs. 66.5 mmol/mol [8.2%] at follow-up; P < .001). This group also experienced an 87% reduction in hospital admissions because of hyperglycaemia/diabetic ketoacidosis (P < .001). Conclusion: People with diabetes who had isCGM initiated for a psychosocial indication had high levels of DRD and HbA1c, which improved with the use of isCGM.
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Clinical features of type 1 diabetes in older adults and the impact of intermittently scanned continuous glucose monitoring : an Association of British Clinical Diabetologists (ABCD) studyAims: To evaluate the clinical features and impact of flash glucose monitoring in older adults with type 1 diabetes (T1D) across age groups defined as young-old, middle-old, and old-old. Materials and methods: Clinicians were invited to submit anonymized intermittently scanned continuous glucose monitoring (isCGM) user data to a secure web-based tool within the National Health Service secure network. We collected baseline data before isCGM initiation, such as demographics, glycated haemoglobin (HbA1c) values from the previous 12 months, Gold scores and Diabetes Distress Scale (DDS2) scores. For analysis, people with diabetes were classified as young-old (65-75 years), middle-old (>75-85 years) and old-old (>85 years). We compared baseline clinical characteristics across the age categories using a t test. All the analyses were performed in R 4.1.2. Results: The study involved 1171 people with diabetes in the young-old group, 374 in the middle-old group, and 47 in the old-old group. There were no significant differences in baseline HbA1c and DDS2 scores among the young-old, middle-old, and old-old age groups. However, Gold score increased with age (3.20 [±1.91] in the young-old vs. 3.46 [±1.94] in the middle-old vs. 4.05 [±2.28] in the old-old group; p < 0.0001). This study showed reduced uptake of insulin pumps (p = 0.005) and structured education (Dose Adjustment For Normal Eating [DAFNE] course; p = 0.007) in the middle-old and old-old populations compared to the young-old population with T1D. With median isCGM use of 7 months, there was a significant improvement in HbA1c in the young-old (p < 0.001) and old-old groups, but not in the middle-old group. Diabetes-related distress score (measured by the DDS2) improved in all three age groups (p < 0.001) and Gold score improved (p < 0.001) in the young-old and old-old populations but not in the middle-old population. There was also a significant improvement in resource utilization across the three age categories following the use of is CGM. Conclusion: This study demonstrated significant differences in hypoglycaemia awareness and insulin pump use across the older age groups of adults with T1D. The implementation of isCGM demonstrated significant improvements in HbA1c, diabetes-related distress, hypoglycaemia unawareness, and resource utilization in older adults with T1D.
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Oral abstractsAim:SGLT2i have recognised benefits in slowing the pro-gression of renal disease and reducing microalbuminuria. Previous analyses from the ABCD audits demonstrated significant changes in urinary albumin creatinine ratios (uACR). This analysis aims to compare this effect across the class. Methods: Datasets were extracted from the ABCD audit. Those with relevant data at baseline and at least one follow- up were included. Absolute and relative change uACR were assessed stratified by drug (Empa- , Dapa- and Canagliflozin) and baseline uACR (normo- , micro- and macroalbuminuria) using Wilcoxon Sign- Rank (within group) and Dunn’s Test (Bonferroni corrected, between groups).Results: 7,104 datasets were included (Empagliflozin = 4,049; Dapagliflozin = 2,239; Canagliflozin = 816) with baseline mean±SD age 61.1±10.2 years, HbA1c 74.5±16.2mmol/mol, weight 97.0±21.3kg, BMI 33.6± 6.6kg/m2, eGFR 80.5±15.3mL/min/1.73m2and median (IQR) diabetes duration 8.8years (5- 13.2) with follow- up over 1.8 years (1.0- 2.8). These were similar across all three drugs.Stratified by baseline uACR, those with microalbuminu-ria (3≤uACR < 30mcg/mmol) had uACR reductions of 1.7mcg/mmol (95% CI 1.5- 1.9, p < 0.001) and those with macroalbuminuria (uACR≥30mcg/mmol) had 31.6mcg/mmol reductions (95% CI 27.1- 35.4, p < 0.001). No change was noted in the normoalbuminuric group. Differences between groups were significant (p < 0.0001). Relative reductions in uACR were greatest in the macroalbuminu-ria group (55%, 95% CI 49- 61%, p < 0.001). Dapagliflozin appeared to be marginally inferior to Canagliflozin and Empagliflozin (p < 0.001 for both), particularly in the macroalbuminuric individuals with an attenuated fall in uACR of 16.3mcg/mmol (95% CI 4.8- 29), significantly less than the average for this group.Conclusion: SGLT2i are associated with reductions in uACR at follow- up. These reductions are greatest in those with macroalbuminuria at baseline. Dapagliflozin ap-peared to be slightly inferior in those with baseline mac-roalbuminuria. Reasons for this are unclear and may be due to confounding factors.Acknowledgement: ABCD SGLT2 audit contributorsA42 (P219)
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Association of statin and/or renin-angiotensin-aldosterone system modulating therapy with mortality in adults with diabetes admitted to hospital with COVID-19: A retrospective multicentre European study.Background & aims: To assess the impact of pre-admission renin-angiotensin-aldosterone system inhibitor (RAASi) and statin use on mortality following COVID-19 hospitalization in adults with pre-existing diabetes. Methods: Retrospective cohort study of adults with diabetes admitted to ninety-nine participating hospitals in the United Kingdom, France and Spain during the first wave of the COVID-19 pandemic. Logistic regression models adjusted for demographic factors and comorbidity were used to describe associations with mortality in hospital or within 28 days of admission and individual or combined RAASi and statin therapy prescription followed by a country level meta-analysis. Results: Complete data were available for 3474 (42.6%) individuals. Prescribing patterns varied by country: 25-50% neither RAASi nor statin therapy, 14-36% both RAASi and statin therapy, 9-24% RAASi therapy alone, 12-36% statin alone. Overall, 20-37% of patients died within 28 days. Meta-analysis found no evidence of an association between mortality and prescription of RAASi therapy (OR 1.09, CI 0.78-1.52 (I2 22.2%)), statin (OR 0.97, CI 0.59-1.61 (I2 72.9%)) or both (OR 1.14, CI 0.67-1.92 (I2 78.3%)) compared to those prescribed neither drug class. Conclusions: This large multicentre, multinational study found no evidence of an association between mortality from COVID-19 infection in people with diabetes and use of either RAASi, statin or combination therapy. This provides reassurance that clinicians should not change their RAASi and statin therapy prescribing practice in people with diabetes during the COVID-19 pandemic.
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Association Between SGLT2 Inhibitor Treatment and Diabetic Ketoacidosis and Mortality in People With Type 2 Diabetes Admitted to Hospital With COVID-19.Objective: To determine the association between prescription of SGLT2 inhibitors (SGLT2is) and diabetic ketoacidosis (DKA) incidence or mortality in people with type 2 diabetes (T2D) hospitalized with COVID-19. Research design and methods: This was a retrospective cohort study based on secondary analysis of data from a large nationwide audit from a network of 40 centers in the U.K. with data collection up to December 2020. The study was originally designed to describe risk factors associated with adverse outcomes among people with diabetes who were admitted to hospital with COVID-19. The primary outcome for this analysis was DKA on or during hospital admission. The secondary outcome was mortality. Crude, age-sex adjusted, and multivariable logistic regression models were used to generate odds ratios (ORs) and 95% CIs for people prescribed SGLT2i compared with those not prescribed SGLT2i. Results: The original national audit included 3,067 people with T2D who were admitted to hospital with COVID-19, of whom 230 (7.5%) were prescribed SGLT2is prior to hospital admission. The mean age of the overall cohort was 72 years, 62.3% were men, and 34.9% were prescribed insulin. Overall, 2.8% of the total population had DKA and 35.6% of people in the study died. The adjusted odds of DKA were not significantly different between those prescribed SGLT2is and those not (OR 0.56; 95% CI 0.16-1.97). The adjusted odds of mortality associated with SGLT2is were similar in the total study population (OR 1.13; 95% CI 0.78-1.63), in the subgroup prescribed insulin (OR 1.02; 95% CI 0.59-1.77), and in the subgroup that developed DKA (OR 0.21; 95% CI 0.01-8.76). Conclusions: We demonstrate a low risk of DKA and high mortality rate in people with T2D admitted to hospital with COVID-19 and limited power, but no evidence, of increased risk of DKA or in-hospital mortality associated with prescription of SGLT2is.
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EndoBarrier treatment for longstanding type 2 diabetes and obesity: outcomes one year after EndoBarrier in 90 consecutively treated patientsAims: EndoBarrier is a 60cm duodenal–jejunal bypass liner endoscopically implanted for up to one year and designed to mimic the by-pass part of Roux-en-Y bariatric surgery. We aimed to assess the safety and efficacy of EndoBarrier in patients with suboptimally-controlled diabesity. Methods: Between July 2013 and November 2017 we implanted 90 EndoBarriers in a single centre with all removed by November 2018. Outcomes were monitored in a registry. Results: All 90 patients have completed one-year post EndoBarrier removal and, of these, 71/90 (79%) – age 51.3 ± 8.6 years, 46% male, 52% White ethnicity, diabetes duration 13.0 (7.0–17.0) years, 59% insulin-treated, BMI 41.1 ± 6.5kg/m2) – attended follow-up and 19/90 (21%) did not attend follow-up. During EndoBarrier implantation, mean ± SD HbA1c fell by 19.5 ± 18.4mmol/mol from 78.1 ± 18.9 to 58.6 ± 13.6mmol/mol (p < 0.001), weight by 15.9 ± 8.6kg from 118.4 ± 27.0 to 102.4 ± 27.7kg (p < 0.001), systolic BP from 139.0 ± 15.0mmHg to 126.6 ± 17.6mmHg (p < 0.001), cholesterol from 4.8 ± 1.2 to 4.0 ± 1.0mmol/L (p < 0.001), and serum alanine-aminotransferase (marker of liver fat) from 31.0 ± 16.5 to 19.8 ± 11.5U/L (p < 0.001). Median (IQR) total daily insulin dose reduced from 98 (53–163) to 30 (0–63) units (p < 0.001). Eleven of 42 (26.2%) insulin treated patients discontinued insulin. One year post-EndoBarrier 32/71 (45%) demonstrated fully-sustained improvement, 25/71 (35%) partially-sustained improvement and 14/71 (20%) reverted to baseline. Of those deteriorating, 10/14 (71%) had depression and/or bereavement. Thirteen of 90 (14%) patients required early EndoBarrier removal: five for gastrointestinal haemorrhage, two for liver abscess, one for non-hepatic intra-abdominal abscess, and five for gastrointestinal symptoms. All made a full recovery. Conclusion: Our data demonstrate EndoBarrier as highly effective in patients with refractory diabesity, with maintenance of significant improvement one year after removal in 80% of cases. As it requires only an endoscopic procedure, EndoBarrier treatment is relatively simple and non-invasive and it deserves further investigation.