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December 2016

Lowest glucose variability and hypoglycemia are observed with the combination of a GLP-1 receptor agonist and basal insulin (VARIATION Study)
Harpreet S. Bajaj et al. Diabetes Care. DOI: http://dx.doi.org/10.2337/dc16-1582

This study compared glucose variability (GV) using continuous glucose monitoring (CGM) in patients with well-controlled type 2 diabetes using four common insulin regimens: basal insulin + oral drugs, basal insulin + glucagon-like peptide 1 receptor agonist, premixed insulin, and basal-bolus insulin. A total of 160 patients with comparable baseline characteristics were enrolled in the study. It was found that the lowest GV and lowest hypoglycemia were observed in patients using the combination of basal insulin with a GLP-1 RA. The authors suggest that the observed benefits in GV and hypoglycemia may contribute to the cardiovascular outcome reduction seen with GLP-1 RA therapy and should be investigated further.


Diabetes Delivery Plan for Wales 2016-2020
Welsh Government

In this refreshed 22-page diabetes delivery plan, the Welsh Government states their “commitment to giving all people in Wales with diabetes the best possible care and support“. The plan sets out how the health service and its partners will deliver that commitment. It goes on to say that “Much progress has already been made under the first phase of the plan … Yet there is still more to do and all stakeholders must continue to work together and build on the success to date and continue the improvement seen in recent years“. This is explored in detail under the sections:

Preventing type 2 diabetes.
Detecting diabetes.
Supporting children and young people with diabetes.
Delivering fast and effective diabetes care.
Delivering person-centred diabetes care.
Researching diabetes.
Performance managing the Diabetes Delivery Plan.


Outcomes and inequalities in diabetes from 2004/2005 to 2011/2012: English longitudinal study
Robert Fleetcroft et al. BJGP. DOI: 10.3399/bjgp16X688381

In this whole-population longitudinal study of 32,482 neighbourhoods in England between 2004/2005 and 2011/2012, inequality between neighbourhoods of great and little deprivation were measured annually for: glycated haemoglobin control in people with diabetes; emergency hospitalisation for diabetes; and mortality from diabetes. It found that diabetes-related mortality improved in all social groups, but decreased at a faster rate in neighbourhoods of greater deprivation. Although mortality declined faster, emergency hospitalisation grew faster in more deprived neighbourhoods. The authors posit that the unequal growth in emergency hospitalisation for diabetes is likely to be partly due to increased diabetes prevalence and patients living longer, but may also be due to overuse of glycaemic control medication.


Challenges in diagnosis and management of diabetes in the young
Ranjit Unnikrishnan et al. Clinical Diabetes and Endocrinology. DOI: 10.1186/s40842-016-0036-6

This is a comprehensive and wide-ranging consideration of diabetes in the young. The diagnosis and management of diabetes in youth presents several unique challenges, and all are covered in this open-access paper. Diagnosis, pathology and the subsequent challenges for management are discussed.


New insulin delivery recommendations
Anders H. Frid et al. Mayo Clinic Proceedings. DOI: http://dx.doi.org/10.1016/j.mayocp.2016.06.010

Another huge open-access resource that provides new, evidence-based recommendations, that build into a practical, and comprehensive set of guidelines for patients and professionals worldwide. The authors say that if followed, they should ensure safe and efficacious delivery of diabetic therapies into the subcutaneous space. To assist with implementation of these new recommendations, the paper provides 6 sets of golden rules in the Appendix. These are meant as a clear and simple road map for nurses, educators, and patients. The assertion is that if the rules are followed, nearly all of the new recommendations will be implemented. The recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. The recommendations are organised around the themes of anatomy, physiology, pathology, psychology, and technology.


Tackling variation in diabetes care
All-Party Parliamentary Group for Diabetes

Your Journal Watch this month will certainly provide much to read over the festive season. Following on from the papers above, this All-Party Parliamentary Group for Diabetes report titled ‘Levelling Up: Tackling Variation in Diabetes Care’, is the result of a year-long inquiry into the causes and solutions to the variation in diabetes care. The easily assimilated report sums up the evidence collected from healthcare professionals, academics, commissioners and people with diabetes, making recommendations for how we can secure a better diabetes care for everyone.

Introduction: https://diabetes-appg.co.uk/2016/11/23/tackling-variation-in-diabetes-care/
Report download (24-page PDF):  https://diabetesappg.files.wordpress.com/2016/11/appg-for-diabetes-report.pdf


Severe hypoglycemia rates are not associated with HbA1c
Aveni Haynes et al. Pediatric Diabetes. DOI: 10.1111/pedi.12477

This paper examined the association between HbA1c and severe hypoglycemia rates in patients with type 1 diabetes receiving usual care. It analysed data from: the US Type 1 Diabetes Exchange (T1DX), German/Austrian Diabetes Patienten Verlaufsdokumenation (DPV), and Western Australian Children Diabetes Database (WACDD) diabetes registries. The analysis did not observe an inverse relationship between mean HbA1c and risk of severe hypoglycemia. The authors recommend further investigations in other large, longitudinal cohorts to further characterise the contemporary relationship between glycemic control and risk of severe hypoglycemia rates in pediatric patients with type 1 diabetes.


The course of diabetes in children, adolescents and young adults: does the autoimmunity status matter?
Rasa Verkauskiene et al. BMC Endocrine Disorders. DOI: 10.1186/s12902-016-0145-3

This study examined markers of beta-cell autoimmunity in a cohort of young (0 – 25 years) patients with type 1 diabetes and compared the presentation and course of the disease according to the presence of pancreatic antibodies. The findings were that antibody-negative pediatric and young adult patients with type 1 diabetes had higher incidence of family history of diabetes, higher frequency of retinopathy, less frequent ketosis at presentation, but they had a similar age at onset, HbA1c, incidence of nephropathy and neuropathy when compared to antibody-positive patients.


Combined diabetes-renal multifactorial intervention in patients with advanced diabetic nephropathy
Leon Fogelfeld et al. Journal of Diabetes and Its Complications. DOI: http://dx.doi.org/10.1016/j.jdiacomp.2016.11.019

This study evaluated the efficacy of a multifactorial-multidisciplinary approach in delaying the progression of chronic kidney disease (CKD) stages 3 – 4 to end stage renal disease (ESRD). The 2-year proof-of-concept trial was conducted in an outpatient clinic of a large public hospital system, and the intervention was led by a team of endocrinologists, nephrologists, nurse practitioners, and registered dietitians. They integrated intensive diabetes-renal care with behavioral/dietary and pharmacological interventions. The findings were that the intervention delayed ESRD, improved HbA1C and albumin/creatinine ratio. The authors conclude that multifactorial-multidisciplinary care may serve as a CKD 3 – 4 treatment paradigm.


Fibrinogen: a marker in predicting diabetic foot ulcer severity
X. H. Li et al. Journal of Diabetes Research. DOI: http://dx.doi.org/10.1155/2016/2358321

This retrospective study examined whether fibrinogen levels were a valuable biomarker for assessing disease severity and monitoring disease progression in patients with diabetic foot ulcer (DFU). 152 hospitalised patients with DFU were enrolled in the study group between January 2015 and January 2016. 52 age- and gender-matched people with diabetes, but no DFU, were included as the control group. The investigators found that fibrinogen values correlated with C-reactive protein levels, neutrophil, and WBC count. [C-reactive protein (CRP) is a blood test marker for inflammation in the body]. The authors conclude that fibrinogen levels might be a valuable tool for assessing the disease severity and monitoring the disease progression in patients with DFU.

InDependent Diabetes Trust