While it may seem a distant memory, I hope you all had a fruitful and productive 2017 and an equally a good start to 2018. 2017 was an interesting year for ABCD and for diabetes, with several key new developments, some of which are summarised below.
FreeStyle Libre became available on the NHS on 1 November 2017. There are a variety of opinions about the use of this novel technology to help people with diabetes. Concerns have been expressed about how this locally commissioned technology will be implemented. ABCD, in collaboration with Diabetes UK, published its position on the use of this technology. Since then the regional medicine optimisation agencies have produced further local guidance with a view to supporting localities to review the technology and its introduction and implementation for our patients. The ABCD Type 1 Collaborative is keeping a close eye on further developments. Although a postcode lottery may be inevitable in the short term, the ambition is to ensure equality of access to this innovative technology. As of mid-January, 49 CCGs have given the ‘green light’ for the use of this technology based on RMOC recommendations. Manchester guidelines also include the use of FSL in women with type 2 diabetes who are pregnant.
I am delighted to announce the change in name of the Insulin Pump Network to the Diabetes Technology Network. The change in name recognises the wider role and remit of the network in the use of other technologies as they emerge, including and beyond insulin pumps. If you are interested in joining the Diabetes Technology Network please visit https://abcd.care/application-join-insulin-pump-network.
Make sure you don’t miss out on this Spring’s exciting ABCD and Network events. We are working with the Caledonian Endocrine Society to develop a balanced programme of diabetes and endocrine topics. As usual, the DTN meeting will take place the day prior to the ABCD Spring meeting.
I am delighted to announce that ABCD has decided to honour its first chairman, who sadly passed away last year, by hosting the inaugural “John Wales Memorial Lecture” at its Spring meeting starting in May 2018. This lecture will take place just after our annual AGM and prior to our event dinner on Wednesday 23 May 2018. The first lecture will be given by Dr Peter Winocour, who was one of the founding members of ABCD and also previous chair of the ABCD and currently chairs the JSC for Diabetes and Endocrinology at the RCP London. The lecture is planned to be hosted annually.
The first formal meeting of the ABCD Type 1 Collaborative is scheduled to take place this year at the Excel Centre in London on Wednesday 14 March during the DUK professional annual meeting. Already, 200 people have registered to join the Collaborative, with 70 members defining themselves as clinical leads for their organisations. The Collaborative has a number of pages hosted by the ABCD website at https://abcd.care/type1collaborative. Further development is planned to support members of the Collaborative. If you are interested in joining the Collaborative please visit https://abcd.care/T1Collaborative.
After canvassing the membership, interest from four excellent candidates was expressed and an election was held. I am delighted to announce that Dr Andy Macklin was successfully elected and will be shadowing Tony Robinson, our current treasurer, for the next few months before taking over in the Spring. Our sincere thanks go to Dr Tony Robinson for all his hard work, dedication and pragmatism, following a very successful 4 years in post.
ABCD will shortly be publishing some very important position statements to help its members, including: ‘The Use of Biosimilar Insulin in Diabetes’, ‘Use of SGLT2 Inhibitors in the Management of Type 1 Diabetes’ and ‘The Cardiovascular Benefits of GLP Analogues’. The position statements will be published and available free of charge via our website at https://abcd.care/position-papers.
These guidelines on the management of lipids in people with diabetes and chronic kidney disease and on the management of hypertension are available online on the ABCD website at https://abcd.care/position-papers
As members of ABCD will be aware, our website has long been a valuable resource for diabetes and endocrinology news, events and resources for diabetologists. To further develop this important tool, work is already in progress on redevelopment of the members’ website (https://abcd.care) to become the central website for all ABCD web and member content. The newly developed site will allow members to access all ABCD resources and information in one place, through one log in, and provide a new flexible way to search ABCD resources, making information easier to find. The new site will also be mobile and tablet friendly to ensure information can be accessed from any device. Over the next few months we will be migrating content from the current website and working on the new design. We will be ensuring that all information is still accessible during this transition and will keep you up to date as the development progresses. We look forward to sharing our new site with you soon.
I was shocked to the core when told by a young adult person with type 1 diabetes who was recovering from an episode of diabetic ketoacidosis in hospital: “I have gained three stones in weight, as I have been reliably informed that the insulin I take contains several fat molecules which get deposited in my body”. I was dumb founded, but quickly recovered to dispel the myth. I wonder what else our patients with type 1 diabetes get told by ‘experts’.
The above quote marginally beat the one I heard during my recent trip to India. “Going out for a walk in the open air is good for diabetes as fresh air contains insulin”. Well, I thought for a moment, could that be one way to motivate our patients with type 2 diabetes to be physically active? Given the multiple benefits of increased levels of physical activity, you would try anything! I can see someone writing a book about myths surrounding diabetes.
Diabetes UK is developing an ambitious roadmap outlining a strategy for improvement for diabetes inpatient care. At the moment too many people with diabetes are not getting the care they need when they stay in hospital. One in six beds in hospital is occupied by someone living with diabetes, so there has never been a more important time to improve inpatient care. The roadmap will lay out the challenges facing inpatient teams and the solutions that have been uncovered through extensive work with diabetes inpatient teams across England. It will also set out calls to action for diabetes teams, commissioners, trust management and Diabetes UK. The roadmap will be released in Spring 2018. Find out more at https://www.diabetes.org.uk/professionals/resources/improving-inpatient-care-programme. You can also read a blog about Diabetes UK’s plans from David Jones, Assistant Director for Improvement, Support and Innovation at https://blogs.diabetes.org.uk/?p=9757.
How you can help
You can help shape the future of inpatient care by sharing your successes and challenges. Share your experiences of delivering diabetes inpatient care by emailing us at this address inpatientcare@diabetes.org.uk.
How Diabetes UK can help
Access good practice by visiting the Diabetes UK Shared practice library at https://www.diabetes.org.uk/professionals/resources/shared-practice/inpatient-and-hospital-care
That's it for now. Goodbye until next time.
The Joint British Diabetes Societies (JBDS) inpatient group has announced the next round of this prestigious national award. The theme for this year is the best digital initiative. Please see details on ABCD website at https://abcd.care/2017-rowan-hillson-inpatient-safety-award or contact u.dashora@nhs.net.
To mark World Diabetes Day, the International Diabetes Federation (IDF) published new estimates on the global prevalence of diabetes, indicating that one in 11 adults are currently living with diabetes, 10 million more than in 2015. The new estimate is included in the eighth edition of the IDF Diabetes Atlas. The report also states that diabetes prevalence is set to rise to almost 700 million by 2045; one in two adults with diabetes remain undiagnosed; and 12% of global health expenditure is spent on diabetes. http://www.diabetesatlas.org/
The European Medicines Agency (EMA) will be relocating to Amsterdam. The agency now has just over 16 months to move and be operational by 30 March 2019. EMA Executive Director Guido Rasi said “Amsterdam ticks many of our boxes … It offers excellent connectivity and a building that can be shaped according to our needs … Our internal surveys have shown that a large majority of EMA staff would be willing to move with the agency to Amsterdam.” However, he also sounded a warning that he expects EMA activities to be impacted as a result of the move.
Dr Patrick Vallance has been appointed as the Government’s Chief Scientific Advisor. Dr Vallance is currently President of Research & Development (R&D) at GSK. He will take up the new role in April 2018.
Professor Steve Powis has been appointed as NHS England National Medical Director, replacing Sir Bruce Keogh. Professor Powis is the current medical director of the Royal Free Foundation Trust.
Ian Dalton CBE has been appointed as the new chief executive of NHS Improvement on a permanent basis. He replaces Jim Mackey who has held the post for the past two years. He has an extensive track record in NHS management, having served as Chief Operating Officer and Deputy Chief Executive at NHS England and CEO of NHS North of England, the North East Strategic Health Authority and two acute trusts, most recently acting as Chief Executive for Imperial College Healthcare NHS Trust.
The Care Quality Commission (CQC) published the State of Care report, its annual analysis of the quality of health and social care in England. The report highlighted that, although quality of care in England is mostly good, there are warnings of increasing numbers of people waiting over four hours in A&E, more operations cancelled and people waiting longer for treatment. It suggests that care is often better in places where providers are working together with all areas of the healthcare service and more should be done to encourage integration. http://www.cqc.org.uk/publications/major-report/state-care
The Government has published its response to the Accelerated Access Review (AAR). One of its key announcements is the creation of an Accelerated Access Pathway (AAP), which is intended to speed up patient access to ‘breakthrough’ medicines and technologies. From April 2018, the AAP will attempt to provide a shorter route to market for around five products each year by allowing early price negotiation, collection of real-world evidence and potential for more flexible commercial deals. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/664685/AAR_Response.pdf
Other announcements included:
The DH published its Pharmaceutical Price Regulation Scheme (PPRS) data from the second quarter, showing that the pharmaceutical industry paid a total of £190m to the DH during the first two quarters of 2017. The latest data indicate a 4.5% growth in the measured spend – the amount the medicines in the scheme cost – compared with last year. So far, under the 2014 PPRS, the industry has contributed over £1.9bn in payments to underwrite the growth in branded medicines covered by the scheme. http://www.abpi.org.uk/media-centre/news/2017/october/industry-pays-190-million-to-pprs-scheme-in-first-two-quarters-of-2017
NHS England has approved the merger of 18 clinical commissioning groups (CCGs) into six by April 2018. The following CCGs will be merged:
Other mergers will include a new Berkshire West CCG out of the merger of Newbury & District CCG, North & West Reading CCG, South Reading CCG and Wokingham CCG; and a new East Berkshire CCG will be created by the merger of Bracknell & Ascot CCG, Slough CCG, Windsor, Ascot & Maidenhead CCG. By April 2018 the number of CCGs will drop to at least 195, with many other CCGs considering similar moves.
The Welsh Health Secretary, Vaughan Gething AM, has announced plans to deliver 19 new integrated health and care centres across Wales by 2021. The pipeline of facilities is intended to improve access to a range of integrated health and social care services closer to people’s homes. A key theme is integration, and health boards will work with a range of delivery partners to bring together a range of public services into community hubs. Funding of up to £68 million has been identified for the centres. Construction will be subject to the agreement of successful business cases from the local health boards, and the expectation is that all schemes will be delivered by 2021. http://gov.wales/newsroom/health-and-social-services/2017/care-centres/?lang=en
New guidelines on diabetes management in renal disease are now available online:
http://www.diabetologists-abcd.org.uk/Position_Papers/ABCDRA_BP_guidelines_2017.pdf
Frankel A et al. Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association. BJD 2016;16:69–77.
http://bjd-abcd.com/index.php/bjd/article/view/134
| Authors | Type of study | Main results |
| Davies et al | In vitro study on breast cancer cell lines |
Metformin inhibits the development and increases the sensitisation of treatment resistant breast cancer in vitro in cells possibly by an indirect histone deacetylase inhibitor (HDACi) activity. It reduces the expression of multiple classic protein markers of multidrug resistance in vitro. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0187191 |
| Lean et al | Open-label clusterrandomised trial in 49 primary care centres in patients with type 2 diabetes with BMI 27–45 kg/m2 |
Withdrawal of antidiabetic and antihypertensive drugs and replacement of diet by approximately 840 kcal/day formula diet for 3–5 months followed by stepped food reintroduction over 2–8 weeks and structured support for long-term weight loss maintenance programme achieves weight loss of 15 kg or more in 24% of the participants in the intervention group. Diabetes remission was achieved in 46% of the participants in the intervention group vs 4% in the control group. Remission varied with weight loss in the whole study population. 86% of the participants who lost 15 kg or more achieved remission of their diabetes. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext |
| Nasr et al | Animal experiment |
Autoimmune diabetes can be reversed in non-obese diabetic (NOD) mice by inducing programme death ligand 1 (PD-1) on haematopoietic stem and progenitor cells which in turn is known to inhibit T cells involved in beta cell destruction. http://stm.sciencemag.org/content/9/416/eaam7543 |
| Wan et al | Prospective (4 years) populationbased cohort study |
Psoriasis is associated with a higher incidence of diabetes (3.44% vs. 2.44%), the hazard ratio being 1.21 (95% CI 1.01 to 1.44), 1.01 (95% CI 0.81 to 1.26) and 1.64 (95% CI 1.23 to 2.18) in the groups with psoriasis affecting 2%, 3–10% and >10% of body surface area, respectively, compared with those with no psoriasis (p=0.004 for trend). http://www.jaad.org/article/S0190-9622(17)32616-6/fulltext |
| Svane et al | Nationwide cohort study |
Young people with diabetes (<50 years of age) have a seven times higher risk of sudden death compared with those without diabetes. The all-cause mortality for people with diabetes was 235 per 100,000 personyears compared with 51 in people without diabetes (mortality ratio (MR) of 5, 95% CI 4 to 5, p<0.001). The commonest cause of death was heart disease (34%) with a MR of 8. 17% suffered sudden cardiac death and the MR ratio between persons with and without DM was 7 (95% CI 6 to 9, p<0.001). The commonest causes of sudden cardiac death in autopsies were coronary artery disease (47%) and sudden arrhythmic death syndrome (26%). http://circ.ahajournals.org/content/136/Suppl_1/A20507 |
| Duerrschmid et al | Animal and human research |
Asprosin, a recently discovered hormone, acts on orexigenic AgRP neurons via a cAMP-dependent pathway and results in inhibition of proopiomelanocortin (POMC)-positive neurons in a GABA-dependent manner which leads to stimulation of appetite and can result in obesity. Deficiency of this hormone can cause a syndrome characterised by low appetite and extreme leanness. Obese humans and mice have higher levels of asprosin. Monoclonal antibody to asprosin can reduce appetite and body weight. https://www.nature.com/articles/nm.4432 |
| Balsevich et al | Animal research | Stress responsive protein FKBP51 can regulate AKT-AS160 signalling that is involved in glucose uptake and can result in diabetes. This can be a potential therapeutic target in future. https://www.nature.com/articles/s41467-017-01783-y |
| Cummings et al | Animal research | Branched chain amino acids (BCAA; leucine, isoleucine and valine) are elevated in obese insulin-resistant humans and rodents. Reducing dietary BCAA promotes weight loss, reduces adiposity and improves blood glucose control in diet-induced obese mice with pre-existing metabolic syndrome. Interestingly, mice that were on high calorie, high sugar diets with reduced levels of BCAA lost weight and fat mass rapidly. This effect seems to be mediated by increased expenditure and was accompanied by induction of energy balance regulating hormone FGF21. http://onlinelibrary.wiley.com/doi/10.1113/JP275075/abstract |
| Tianwei et al | Multicohort study | Self-reported workplace bullying (9%) and violence (12%) at baseline is associated with a higher incidence of diabetes in the subsequent years with a hazard ratio of 1.46 (95% CI 1.23 to 1.74) and 1.26 (95% CI 1.02 to 1.56). The results are similar for men and women, and are consistent across cohorts. https://link.springer.com/article/10.1007/s00125-017-4480-3 |
| Mancini et al | Large prospective cohort study (>64,000 women) |
Antioxidant-rich diet can reduce the risk of developing diabetes. In a multivariate model, compared with women in the lowest quintile, women in the third, fourth and fifth quintiles for total antioxidant capacity had HRs of 0.74 (95% CI 0.63 to 0.86), 0.70 (95% CI 0.59 to 0.83) and 0.73 (95% CI 0.60 to 0.89), respectively. The inverse association between total antioxidant capacity and risk of type 2 diabetes was linear up to values of 15 mmol/day, after which the effect reaches a plateau. https://link.springer.com/article/10.1007/s00125-017-4489-7 |
| Keating et al | Review of epigenetics in diabetic complications |
The role of chromatin-dependent mechanisms in diabetic complications with a special focus on diabetic nephropathy. https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4490-1.pdf |
| Jia et al | Review of cardiac complications of diabetes |
Diabetes affects the heart by various ways including hyperglycaemia, insulin resistance, diastolic dysfunction, systolic dysfunction and clinical heart failure even in the absence of hypertension, dyslipidaemia and coronary artery disease. Possible mechanisms such as cardiac lipotoxicity, cardiac insulin resistance, mitochondrial dysfunction, oxidative stress, impaired calcium handling, oxidative stress, inflammation, endoplasmic reticulum stress, cell death and dysregulation of coronary endothelial cells are discussed in this review. https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4390-4.pdf |
| Hammes et al | Review of diabetic retinopathy |
In this review the author highlights the mechanisms of diabetic retinopathy including not only the effect on microvasculature but also on all cells that communicate with the vasculature. Newer mechanisms and potential treatments are considered. https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4435-8.pdf |
| Loh et al | RCT | Pioglitazone reduces cold-induced glucose uptake by brown adipose tissue in cultured human fat cells, raising questions about the clinical utility of browning induced by pioglitazone. https://link.springer.com/content/pdf/10.1007%2Fs00125-017-4479-9.pdf |
| Zinman et al | RCT | Day to day fasting glucose variability is associated with a higher risk of severe hypoglycaemia (HR 4.11), cardiovascular events (HR 1.36) and all-cause mortality (HR 1.58) before adjustments, but not with cardiovascular events after adjusting for baseline characteristics. https://link.springer.com/article/10.1007/s00125-017-4423-z |
| Pieber et al | RCT | Severe hypoglycaemia is associated with a higher risk of all-cause mortality (HR 2.51) 15, 30, 60, 90, 180 and 365 days after the event, even after adjustment for many baseline characteristics, but it is not certain whether there is any direct causal effect. https://link.springer.com/article/10.1007/s00125-017-4422-0 |
| Hope et al | Clinical cohort study |
Low random C-peptide level is associated with higher glucose variability (SD of glucose 4.2 vs 3.0 mmol/L), sustained hypoglycaemia (94% vs 41%), higher mean rate of hypoglycaemia (5.5 vs 2.1 per person per week), longer mean duration of hypoglycaemia (630 vs 223 min per person per week) and higher frequency of hypoglycaemia <3 mmol/L (1.8 vs 0.4 episodes per person per week) in patients with insulin-treated type 2 diabetes and represents a practical, stable and inexpensive biomarker for assessment of hypoglycaemia risk. https://link.springer.com/article/10.1007/s00125-017-4449-2 |
| Wan et al | 5-year prospective cohort study |
A primary care-based multidisciplinary risk assessment and management programme can reduce the cumulative incidence of all events (DM-related complications and all-cause mortality) (23.2% vs. 43.6%). There were significantly greater reductions in cardiovascular disease, microvascular complications, mortality, specialist attendance, emergency attendance and hospitalisations (56.6%, 11.9%, 66.1%, 35.0%, 41.2% and 58.5%, respectively) in the intervention group. http://care.diabetesjournals.org/content/41/1/49 |
| Ahmann et al | RCT (Sustain 3) | Semaglutide once weekly led to lower HbA1c (16.8 vs. 10 mmol/mol, p<0.0001), greater weight loss (5.6 kg vs. 1.9 kg, p<0.0001), with more patients achieving an HbA1c of <53 mmol/mol (67% vs. 40%) and fewer injection site reactions (1.2% vs. 22%) but produced more gastrointestinal side effects (41.8% vs. 33.3%) compared with exenatide ER once weekly. http://care.diabetesjournals.org/content/early/2017/12/14/dc17-0417 |
| Brouwer et al | Pooled RCTs (SPRINT and ACCORD-BP) |
Intensive BP lowering (<120 vs. <140) may have favourable effect for people with or without diabetes (HR 0.82, p<0.001) http://care.diabetesjournals.org/content/early/2017/11/30/dc17-1722 |
| Pareek et al | Prospective population-based cohort study on 4,867 men for 39 years |
The 1 hour glucose value of ≥8.6 mmol/L after an OGTT has stronger predictive value for developing type 2 diabetes, vascular complications and mortality compared with the 2 hour value of ≥7.8 mmol/L. http://care.diabetesjournals.org/content/41/1/171 |
We started the year at the Diabetes UK professional conference where data were presented on a national survey we undertook looking at perceptions of the specialty and career choice. Whilst sobering, it was not entirely unexpected. The next step was to build on this, and we were able to organise a national taster day together with eager members from the Society for Endocrinology. Held in Birmingham, over 70 final year medical students, foundation year and core medical doctors got a taste of our specialty. Feedback was excellent and overwhelmingly positive.
Not just satisfied with a national taster day, we were (and are) also happy to get involved in supporting regional taster days across the UK, with one already occurring in the North East and another planned for the South West. It is important that we promote our specialty as an excellent career option for juniors to avoid recruitment issues in the future, and are happy to support colleagues who are interested in organising further events.
In addition to recruitment, we were also looking at current training. Adnan Agha, one of the committee members, assessed burnout amongst registrars in our specialty and found a large proportion felt some effects of this. He also looked at regional variations in training across the country, the results of which are published in this month’s journal. It is important that current trainees are supported and something we at YDEF work towards.
Besides continuing to run our regular highly regarded courses, we have a few other plans for 2018.
First is a new course aimed at recently starting registrars in our specialty. The ABC of D&E course is scheduled to be held in the summer and will cover all the basics of our specialty to ensure new registrars have a good platform to develop their knowledge and skills. Please highlight this to your colleagues and recently recruited registrars. More details to be announced very shortly.
We are also due to launch our new and updated website in the coming few months. Our newest committee member Clare Whicher is leading on this with a few enthusiastic registrars, and has been developing a more user-friendly, simpler website so that members can have better access to our resources as well as new features such as a forum to exchange ideas and generate discussion.
In addition, there are ongoing plans for a potential obesity course and further taster days in our specialty, ensuring a busy year ahead!
YDEF Annual Day
13th March 2018
Our main event this year is being led by Sophie Harris and centres around the NHS England transformation funds with a variety of workshops on service development and a chance for attendees to present their work.
YDEF NI
23rd March 2018
In addition to YDEF Day, we have YDEF NI which offers an opportunity for local trainees to benefit from another exciting and varied programme from retinopathy to inpatient care and national audit work.
NEYD
23rd-25th May 2018
Another highly regarded course from YDEF. Together with our Danish and Dutch colleagues, this research meeting allows attendees to present their research in a relaxed environment and gain considerable presentation skills and experience. Over 3 days the best 10 candidates from each of the UK, Netherlands and Denmark present their work with more experienced researchers on hand to guide and support. This year our NEYD meeting will be held in the Netherlands.
Applications are open for abstract submission, including any submitted to recent conferences.
Dr Amar Puttanna
Email: amarputtanna@doctors.org.uk