Endocrinology and Diabetes

A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus (2024)

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Type of publication:
Journal article

Author(s):
White, Billy; Ng, S M; Agwu, J C; Barrett, T G; Birchmore, N; Kershaw, M; Drew, J; Kavvoura, F; Law, J; Moudiotis, C; Procter, E; Paul, P; Regan, F; Reilly, P; Sachdev, P; *Sakremath, R; Semple, C; Sharples, K; Skae, M; Timmis, A; Williams, E; Wright, N; Soni, A.

Citation:
BMC Medicine. 22(1):144, 2024 Apr 02.

Abstract:
BACKGROUND: Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS: Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION: Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS: This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

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Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance (2024)

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Type of publication:
Journal article

Author(s):
Lauri, Chiara; Noriega-Alvarez, Edel; *Chakravartty, Riddhika M; Gheysens, Olivier; Glaudemans, Andor W J M; Slart, Riemer H J A; Kwee, Thomas C; Lecouvet, Frederic; Panagiotidis, Emmanouil; Zhang-Yin, Jules; Martinez, Jose Luis Lazaro; Lipsky, Benjamin A; Uccioli, Luigi; Signore, Alberto.

Citation:
European Journal of Nuclear Medicine & Molecular Imaging. 2024 Mar 27.

Abstract:
PURPOSE: Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS: This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS: Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION: These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

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Hypoglycaemia in adrenal insufficiency (2023)

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Type of publication:Journal article

Author(s):*Lee, Shien Chen; Baranowski, Elizabeth S; *Sakremath, Rajesh; Saraff, Vrinda; Mohamed, Zainaba

Citation:Frontiers in Endocrinology. 2023. [epub ahead of print]

Abstract:Adrenal insufficiency encompasses a group of congenital and acquired disorders that lead to inadequate steroid production by the adrenal glands, mainly glucocorticoids, mineralocorticoids and androgens. These may be associated with other hormone deficiencies. Adrenal insufficiency may be primary, affecting the adrenal gland's ability to produce cortisol directly; secondary, affecting the pituitary gland's ability to produce adrenocorticotrophic hormone (ACTH); or tertiary, affecting corticotrophin-releasing hormone (CRH) production at the level of the hypothalamus. Congenital causes of adrenal insufficiency include the subtypes of Congenital Adrenal Hyperplasia, Adrenal Hypoplasia, genetic causes of Isolated ACTH deficiency or Combined Pituitary Hormone Deficiencies, usually caused by mutations in essential transcription factors. The most commonly inherited primary cause of adrenal insufficiency is Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency; with the classical form affecting 1 in 10,000 to 15,000 cases per year. Acquired causes of adrenal insufficiency can be subtyped into autoimmune (Addison's Disease), traumatic (including haemorrhage or infarction), infective (e.g. Tuberculosis), infiltrative (e.g. neuroblastoma) and iatrogenic. Iatrogenic acquired causes include the use of prolonged exogenous steroids and post-surgical causes, such as the excision of a hypothalamic-pituitary tumour or adrenalectomy. Clinical features of adrenal insufficiency vary with age and with aetiology. They are often non-specific and may sometimes become apparent only in times of illness. Features range from those related to hypoglycaemia such as drowsiness, collapse, jitteriness, hypothermia and seizures. Features may also include signs of hypotension such as significant electrolyte imbalances and shock. Recognition of hypoglycaemia as a symptom of adrenal insufficiency is important to prevent treatable causes of sudden deaths. Cortisol has a key role in glucose homeostasis, particularly in the counter-regulatory mechanisms to prevent hypoglycaemia in times of biological stress. Affected neonates particularly appear susceptible to the compromise of these counter-regulatory mechanisms but it is recognised that affected older children and adults remain at risk of hypoglycaemia. In this review, we summarise the pathogenesis of hypoglycaemia in the context of adrenal insufficiency. We further explore the clinical features of hypoglycaemia based on different age groups and the burden of the disease, focusing on hypoglycaemic-related events in the various aetiologies of adrenal insufficiency. Finally, we sum up strategies from published literature for improved recognition and early prevention of hypoglycaemia in adrenal insufficiency, such as the use of continuous glucose monitoring or modifying glucocorticoid replacement.

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The impact of community teaching sessions on onward referral to specialist diabetic foot services (2024)

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Type of publication:Journal article

Author(s):Al-Saadi, Nina; *Beard, Nichola; Al-Hashimi, Khalid; Suttenwood, Helen; Wall, Michael; *Jones, Steven; Merriman, *Catherine

Citation:Primary care diabetes. 18(1):79-83, 2024 Feb.

Abstract:INTRODUCTION: Prompt referral of patients with diabetic foot ulceration (DFU) to specialist services can lead to more timely assessment of these patients and subsequent improved rates of limb salvage and patient outcomes. In this study we wanted to determine the impact of education in the primary care setting on onward referrals to our specialist Diabetic Foot multi-disciplinary team (MDT) clinic. METHODS: As part of a Diabetic Foot Roadshow, four teaching sessions were delivered in primary care settings across Shropshire by our specialist team from 17th March to the 25th May 2022. Attendees included podiatrists, tissue viability nurses, district nurses and wound care practitioners. Hospital records were used to identify all onward referrals to our Diabetic Foot MDT clinic in the weeks before and after delivery of the roadshow education sessions. RESULTS: 184 referrals were made to the diabetic foot clinic from January to July 2022. There were 0.3 referrals per day in the months prior to the commencement of the education sessions, compared to 1.5 referrals per day following the commencement of the teaching sessions. This increase in referrals was statistically significant (p < 0.0001). CONCLUSION: Teaching sessions delivered to community specialist healthcare professionals significantly increase onward referral of patients to specialist services, facilitating more timely assessment and management of patients with DFUs.

Managing hypertension in type 2 diabetes – the basics (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(6)

Abstract:Brought to you by Diabetes & Primary Care, this interactive case study takes you through the basic considerations of managing hypertension in type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.

Fatty liver disease and type 2 diabetes (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(5)

Abstract:This interactive case study, presented by Diabetes & Primary Care, takes you through the necessary considerations in managing fatty liver disease in an individual with type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.

Steroid-induced hypoglycaemia (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(4)

Abstract:Brought to you by Diabetes & Primary Care, the three mini-case studies presented below take you through what it is necessary to consider in identifying and managing steroid-induced hyperglycaemia. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Hypoglycaemia and type 2 diabetes (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(4)

Abstract:Brought to you by Diabetes & Primary Care, the four mini-case studies presented below will help you to consider what constitutes hypoglycaemia, what its causes and risk factors are in type 2 diabetes, how to detect and manage it in primary care, and strategies for minimising the risk. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Making a diagnosis in type 2 diabetes (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(2)

Abstract:Brought to you by Diabetes & Primary Care, the three mini-case studies presented below take you through what it is necessary to consider in making an accurate diagnosis of type 2 diabetes. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Diabetic nephropathy and type 2 diabetes (2021)

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Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(1)

Abstract:This interactive case study, presented by Diabetes & Primary Care, takes you through the necessary considerations in managing diabetic nephropathy in an individual with type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.