BJD

Hello to the readers of BJD. This is my first newsletter about the ABCD News since taking over from Rob Gregory. I have some big boots to fill and of course I am a bit nervous whilst writing this.

The national programme to deal with unwarranted variations in diabetes care is on the move. The national clinical leads for diabetes have been appointed as a job share. Both Dr Gerry Rayman and Dr Partha Kar will be familiar to you all. While there are concerns that this initiative may turn out to be just nothing more than a peer review of specialist diabetes services ‘on the cheap’, ABCD is very supportive of this National Initiative and has committed to work closely with the National Leads and the Director Professor Tim Briggs, who is leading this programme. I urge you all to read the recent King's Fund write-up about this (see link). The programme for diabetes started on 1 July 2017 and has been fast-tracked forward.
https://www.kingsfund.org.uk/publications/tackling-variations-clinical-care
www.kingsfund.org.uk

In the current squeeze on funding in the NHS, all of us are finding that the funding for study leave is getting harder to come by, which makes it more difficult for SpRs to attend international meetings to present their research. ABCD has decided to support young academics to attend and present their research at these meetings (such as ADA and EASD), and will give up to five grants of £1,000 each year. The support will be based on the quality of original research being presented, as decided by the Chair of the Academic Subcommittee.

Medical Care is a web-based initiative by the RCP which replaces the old document "Doctors working for patients", which had served its time gaining dust on the shelves and never really put to any real use (well that's my view). The diabetes and endocrine aspect of Medical Care goes live this month on the RCP website. This document has been produced by ABCD and SfE and describes comprehensively the services provided by our specialty, and the workforce needed to deliver a good quality specialist service and a structure for developing physicians. Of particular interest to commissioners, medical directors and hospital managers are the detailed layout of diabetes and endocrine care provision and the complexity of specialist services. It includes recommendations for optimum time required for new and follow-up appointments and also the number of consultant colleagues needed to deliver diabetes and endocrine services as recommended by this RCP document. Thank you to all of you who contributed to this. The link should be live soon and will be mailed to you.
http://www.rcpmedicalcare.org.uk/designing-services/specialties/diabetes
www.rcpmedicalcare.org.uk

Recently launched by NHS England to help commission local services in the specialty, this document will be useful for those who wish to commission the whole pathway and help reduce the variations associated with diabetes care. A valiant effort from NHS England! The exemplars are very informative; of course, the most comprehensive and oldest existing model of integrated model of supporting primary care does not get a mention. I wonder why? Reminds me of a cliché – it is not enough just to do 'good work', you must shout loud about what you are doing to those who care! It is time we learnt to share good practice.
https://www.england.nhs.uk/rightcare/2017/06/23/nhs-rightcare-pathway-diabetes/

This year’s ADA meeting had some big trials presented as usual, but a few things really grabbed my attention other than the mega trials.

I thought I could. Of course I don't mean if you can or cannot speak English, but this is all about using the right language while communicating with your patients. Sometimes we underestimate the impact of what comes out of our lips on patients’ morale and motivation. Using the right words during a consultation CAN motivate your patient! I thought this was another form of ‘motivational interview’ but – no – this is a bit different. Can we take a leaf out of this approach by Yanks and do this in the UK? Why not? Dr Partha Kar believes we can, and has taken it on himself and pulled together all the relevant societies and organisations. ABCD thinks that this is worth supporting. The first meeting is next month. You will hear more about this rather simple initiative which will cost you nothing, but will make a difference to those patients we serve.

Surely it cannot be right? We can hardly treat them right, never mind over-treat. I found this session at the ADA meeting absolutely fascinating, during which speakers challenged our health behaviours about escalating but never de-escalating treatment when needed and hence doing more harm than good to our patients. Somewhere we have lost the plot and have become so frightened of litigation in medicine that we have forgotten our first duty: do no harm to my patients. Have a think? A real soul searcher.

Have you ever wondered? How do I interpret the continuous glucose monitoring (CGM) data with tons of stats coming out of the computer? What do I do when things don't seem right? Or do I leave it to those wonderful angels called DSNs. Well I used to until I heard a pump expert talk about CGM recently. I will let you guess who it might be! Don't worry – help is on its way. The international diabetes community has agreed to an international CGM data standardisation process which will make it easier not only to interpret the data but will also help us to provide consistent solutions wherever needed. CGM is here to stay! It can help a proportion of patients transform their life. I am reminded of a young lady with hypoglycaemia unawareness who used to call the ambulance twice weekly but, with CGM, has had no paramedic call in 9 months. Imagine the savings to the NHS.

The much publicised event sponsored by ABCD – the live telecast from four centres was a big success. The morning session, during which we shared the recent news from the ADA, was followed by a joint venture between commissioners and clinicians. The feedback has been great. Can we do it for a third time again next year? Well, why not? I was speechless when one budding SpR (lone ranger) who was there asked me why there were no SpRs at the meeting. I had no answer for him, but it made me think! Why not?

NHS England has announced that its National Diabetes Prevention Programme (NDPP) has been expanded to make an additional 50,000 places available to people who are at high risk of developing diabetes. Latest figures show that 18,000 people joined the programme last year; the ambition is for the NDPP to eventually cover the whole of England, with as many as 80,000 people on the programme by 2018–19. Funding for next year has also been agreed for the 27 existing sites, as well as for 13 new areas.

NICE updates type 2 diabetes management guideline to include SGLT-2 inhibitors

NICE has published the updated guideline on the management of type 2 diabetes (NG28). The guideline focuses on patient education and the management of blood glucose levels, cardiovascular risk and long-term complications. It has been updated to include information on sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and it states that treatment with SGLT-2 inhibitors may be appropriate for some adults with type 2 diabetes if metformin is contraindicated or not tolerated.

NHS England Digital and Transformation Fund opened for applications on 17 July

NHS England has developed the Innovation and Technology Payment (ITP) 2018/19. The aim of the ITP is to help deliver on the commitment detailed within the Five Year Forward View – creating the conditions and cultural change necessary for proven innovations to be adopted faster and more systematically through the NHS, and to deliver examples into practice for demonstrable patient and population benefit. The application process opened on 17 July 2017. Successful innovation or technology themes will be identified through a competitive process and NHS England will then identify ways of supporting adoption of these across the NHS – for example, through introducing a reimbursement for usage or centrally procuring items.
https://www.england.nhs.uk/ourwork/innovation/innovation-and-technology-payment-201819/#.WUlxpfoNf0w.twitter

Report calls for the use of scientific evidence to be strengthened to benefit patients

The Academy of Medical Sciences has published a report which looks at how scientific evidence can be improved to help patients judge the potential benefits and risks of medicines. The report found that, while two-thirds of the public trust the experiences of friends and family when making decisions about medicines, only one-third trust medical research. It contains a number of recommendations to improve the use of scientific evidence, including: involving patients and carers in research; developing best practice guidelines for academia-industry relationships; and improving the content of patient information leaflets.

2017/18 Diabetes Treatment and Care Transformation Fund Allocations Per STP have been published. Each NHS England regional body was provided a proportion of the excess left from the Transformation Fund for inequalities funding and this is targeted at areas which had submitted unsuccessful bids or no bids.

ABCD, in partnership with Diabetes UK, have announced the Type 1 Diabetes Clinical Collaborative UK (T1DCC-UK) to ensure that everyone with type 1 diabetes has access to a suitably-trained multidisciplinary specialist team for expert assessment, care and support for self-management. The committee is made up of individual healthcare professionals from all the disciplines from the four nations who are passionate about raising the standards of care for people with type 1 diabetes and is chaired by Dr Rob Gregory, immediate past chair of ABCD, with Professor Stephanie Amiel and Professor Simon Heller as non-executive co-chairs.
https://abcd.care/type1collaborative

Data from the first National Diabetes Transition Audit have been published. This, the first report, has been developed from the linked data sets (NDA and NPDA) and presents the key findings and recommendations on care processes and treatment target achievement rates from 2003/04 to 2014/15 in age groups of 12–24 years in England and Wales. The audit measures against the National Service Framework and NICE Clinical Guidelines and Quality Standards.
http://www.digital.nhs.uk/catalogue/PUB30008

Public Health Wales publishes the National Prescribing Indicators for 2017–18

Public Health Wales has published the National Prescribing Indicators (NPIs) for 2017–18, which are used to highlight therapeutic priorities and compare the way in which different prescribers use particular medicines. There are 14 primary care and three secondary care NPIs.
http://www.awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202017-2018.pdf

Brexit Health Alliance to ensure the NHS is not disadvantaged by the negotiations

A Brexit Health Alliance has been established to help ensure the NHS and the life sciences industry are not disadvantaged by the Brexit negotiations. Members include the NHS Confederation, the Association of the British Pharmaceutical Industry (ABPI) and National Voices. The alliance will be co-chaired by the Chair of Guy’s and St Thomas’ Foundation Trust, Sir Hugh Taylor, and the Chief Executive of NHS Confederation, Niall Dickson.

£2m to be made available to Scottish Health Boards to fund adult insulin pumps and glucose monitors

The Scottish Government has announced that £2m will be made available to NHS Health Boards in 2017–18 to fund adult insulin pumps and continuous glucose monitoring devices. This is part of a larger £10m funding package which will be spread out over the course of the Parliament. The funding to each Board has been allocated on the basis of the local prevalence of type 1 diabetes, the current levels of provision and equity of access.

Guidelines on managing lipids and high blood pressure (including RAAS blockade) are now on the ABCD website and the Renal Association website for professionals to use. The summary guidelines were published in the British Journal of Diabetes in June.
https://abcd.care/
https://renal.org/

Hertfordshire Diabetes Conference finalist in BMJ awards (Andrew Solomon)

A highly successful project known as the 'Hertfordshire Diabetes Conference' was a finalist in the Education category of this year's 2017 BMJ Awards. Dr Andrew Solomon, together with Dr Ana Pokrajac, Consultant at West Hertfordshire Hospitals NHS Trust, initiated a series of annual conferences, starting in 2014, that have aimed to bring together 250 local diabetes professionals. Each year the conferences have grown and are oversubscribed. The next conference will be October of this year.

Interesting recent research

In a comparison of people with impaired glucose tolerance who developed diabetes compared to those who did not in the Finnish Diabetes Prevention Study over 15 years, the authors show that higher indolepropionic acid seems to be protective and is associated with better insulin secretion and sensitivity. The researchers suggest that indolepropionic acid, a gut microbial-produced metabolite, might be helping in beta cell preservation.
https://www.nature.com/articles/srep46337

In a paper published in Diabetologia the authors show that obesity in people with type 2 diabetes is associated with lower cortical thickness (p=0.003), white matter integrity (p=0.02), slower psychomotor sped performance (p=0.03) compared with people with type 2 diabetes who were normal weight.
http://link.springer.com/article/10.1007/s00125-017-4266-7

In a general practice-based study published in the Journal of the Endocrine Society the researchers from the UK showed that the incidence of type 1 and type 2 diabetes per 100,000 persons per year increased from 38.2 to 52.1 and 6.4 to 33.2 between 2009 and 2013. Obese individuals had a markedly higher incidence rate of type 2 diabetes (odds ratio 3.75) compared with people with normal BMI.
https://academic.oup.com/jes/article-lookup/doi/10.1210/js.2017-00044

ID1 protein causes diabetes and obesity by preventing brown fat thermogenesis

Research published in Diabetes reports a novel mechanism connected with obesity. Brown adipose tissue (BAT) helps energy loss by a mechanism involving peroxisome proliferator activated receptor γ coactivator 1α (PGC1α) which, in turn, is regulated by other molecular mechanisms. A transcription factor called inhibitor of differentiation 1 (ID1) plays an important role in cellular proliferation and differentiation. The researchers found that overexpression of ID1 may be responsible for reduced thermogenesis from brown fat. This could be a therapeutic target in future.
http://diabetes.diabetesjournals.org/content/early/2017/03/02/db16-1079

Researchers report a new type of immature beta cells in the pancreas which are present throughout life and develop from non-beta precursors in a special environment at the islet periphery. These cells express insulin but cannot sense glucose and handle calcium influx. This research opens the prospects of converting immature beta cells formed from alpha cells into properly functioning beta cells.
http://www.cell.com/cell-metabolism/abstract/S1550-4131(17)30169-9

In a paper presented at the European Congress on Obesity, the researchers showed that physical inactivity of as little as 14 days can affect metabolism adversely. Following a period of reduction in activity from 161 min to 36 min daily and an increase in sedentary time by 129 min, whole body lean mass reduced by 0.36 kg, leg mass reduced by 0.21 kg, central body fat increased and cardiorespiratory fitness levels declined.
https://www.eurekalert.org/pub_releases/2017-05/eaft-j2w051517.php

Beta 1 but not beta 2 receptors may be responsible for the heart rate-related problems in people with diabetes

In a study published in Experimental Physiology researchers show that beta 1 but not beta 2 receptors in the heart are responsible for diabetes-related changes in heart rate regulation. In an experiment with two devices implanted in rats, the drugs with beta 1 adrenoreceptor block were more effective than non-specific beta blockers.
http://onlinelibrary.wiley.com/doi/10.1113/EP086293/abstract

In a study comparing cardiovascular association of central obesity (waist to hip ratio) and general obesity (BMI), the authors found that both measures were associated with a higher risk of CHD (OR 1.48, 48% higher risk for each 1 SD higher) and type 2 diabetes (OR 1.82 and 1.98 per 1SD higher), but central obesity had a greater association with stroke risk (OR 1.32 for each 1 SD higher). Both measures were associated with higher left ventricular hypertrophy, glycaemic traits, interleukin-6 and circulating lipids.
http://circ.ahajournals.org/content/early/2017/05/04/CIRCULATIONAHA.116.026560

In experiments on mice, researchers report that oestrogen receptor α (ERα) has two separate activation functions, AF1 and AF2. Selective ERα-AF1 activation by tamoxifen confers metabolic protection against food intake, adiposity, insulin resistance and steatosis. ERα-AF2 is required for other metabolic functions of 17β-estradiol. Both ERα-AFs are implicated in breast cancer cell proliferation. The research has the therapeutic potential of selective ER modulation.
http://ajp.amjpathol.org/article/S0002-9440(17)30219-5/fulltext

In research announced recently, investigators from the University of Texas reported curing type 1 diabetes in mice up to one year by transferring a gene into non-beta pancreatic cells using a gene transfer technology called cellular networking integration and processing through a virus. The cells start producing insulin in response to glucose and therefore hypoglycaemia is not an issue. Human clinical trials may begin within the next 3 years.
http://www.eurekaselect.com/138066

Scientists report an inverse association of glioma and pre-diagnostic blood glucose levels (p=0.002). Excess glucose consumption by the preclinical tumour might explain this inverse relationship.
http://www.nature.com/articles/s41598-017-01553-2

Parkinson’s disease is characterised by neuronal death which is associated with intracellular aggregates of the neuronal protein α-synuclein known as Lewy bodies. Similar misfolded α-synuclein is also found in enteric nerves before it appears in the brain. In a recent publication, authors report their discovery that enteroendocrine cells (EECs), which are part of the gut epithelium, also possess neuron-like properties and connect to enteric nerves. The researchers report that these EECs also contain α-synuclein and directly connect to nerves containing α-synuclein, forming a pathway for toxins like folded α-synuclein to travel from the gut to the brain.
https://insight.jci.org/articles/view/92295

In a study which compared the benefits of resistance and aerobic exercise on metabolic syndrome, the authors from Texas reported that resistance exercise can reduce the risk of metabolic syndrome by 17% after adjusting for potential confounders and aerobic exercise. Moreover, less than 1 hour of weekly resistance exercise was associated with 29% lower risk of development of metabolic syndrome compared with no resistance exercise. Additional resistance exercise did not provide any further benefits. Participants who met both recommended resistance and aerobic exercise guidelines had a 25% lower risk of developing the metabolic syndrome.
http://www.mayoclinicproceedings.org/article/S0025-6196(17)30167-2/abstract

In a large national claims database study, authors studied records of 2,322 new cases of PD and matched them with controls. The results showed that statin use was significantly associated with PD risk, the risk being highest with lipophilic statins (OR 1.58) and in the initial period after starting statins (<1 year: OR 1.82; 1–2.5 years: OR 1.75; and >2.5 years: OR 1.37).
http://onlinelibrary.wiley.com/doi/10.1002/mds.27006/full

Pancreatic islets G-protein coupled receptor C5C (GPRC5C) may be a novel therapeutic target in diabetes

In a paper published in the Endocrine Journal, the authors examined the role of the orphan GPRC5C on the pancreatic islets from humans and mice. mRNA expression and protein levels were reduced in the islets from donors with type 2 diabetes. GPRC5C expression was correlated with the expression of genes controlling apoptosis, cell survival and proliferation. Down-regulation of GPRC5C was associated with lower insulin secretion. Agents activating these receptors may therefore be a novel form of treatment and prevention of diabetes by improving β-cell mass.
https://www.jstage.jst.go.jp/article/endocrj/64/3/64_EJ16-0338/_article

In a study comparing the effect of an isocaloric calorie restricted (-500 calories) vegetarian diet and conventional diet on thigh adipose tissue distribution in people with type 2 diabetes, the researchers showed greater reduction in total leg area, subfascial fat and intramuscular fat with the vegetarian diet. Changes in fat correlated to changes in HbA1c, fasting plasma glucose and β-cell insulin sensitivity after adjusting for changes in BMI.
http://www.tandfonline.com/doi/full/10.1080/07315724.2017.1302367

In a recent publication in NEJM, CANVAS results were reported. From 10,142 patients with type 2 diabetes and high cardiovascular risk, patients were randomly assigned to placebo or canagliflozin for 188 weeks. The rate of primary outcome (death from cardiovascular causes, non-fatal myocardial infarction or non-fatal stroke) was lower in the canagliflozin group than in the placebo group (26.9 vs. 31.5 participants per 1,000 patient-years; hazard ratio (HR) 0.86, p<0.001). There was a possible benefit with respect to progression of albuminuria (HR 0.73) and the composite outcome of a sustained 40% reduction in estimated glomerular filtration rate, the need for renal replacement therapy or death from renal causes in the canagliflozin group. There was an increase in the risk of amputations (6.3 vs. 3.4 participants per 1,000 patient-years; HR 1.97), mainly at the level of the toe or metatarsal in the canagliflozin group.
http://www.nejm.org/doi/full/10.1056/NEJMoa1611925

In a meta-analysis of 20 studies including 250,016 patients with diabetes, the study investigators found a significantly reduced risk of all-cause mortality in overweight patients (HR 0.82, p>0.001) compared with people with normal weight. The benefit was, however, observed only in the elderly patients (HR 0.69) but not in the younger patients. The benefit also appeared to reduce with longer follow-up duration.
http://onlinelibrary.wiley.com/doi/10.1111/jdi.12677/full

In a retrospective study using a population-based database, the researchers analysed the records of 148,739 patients with diabetes. Over 27,000 patients were taking aspirin. The intake of aspirin in these patients reduced the risk of breast cancer by 18% (HR 0.82) after adjusting for confounders. Statistically, a cumulative dose of aspirin exceeding 88,900 mg was seen to reduce the cancer risk by 40% (HR 0.53), however lower doses did not reduce the risk.
http://online.liebertpub.com/doi/10.1089/jwh.2016.6040

In a retrospective cohort study from the Clinical Practice Research Datalink over the period from 1991 to 2013 in the UK, type 2 diabetes prevalence seems to have increased from 1.32% to 4.54% and mean HbA1c has reduced from 71 mmol/mol (8.6%) to 58 mmol/mol (7.5%). The increase in prevalence may in part be due to improved survival.
http://onlinelibrary.wiley.com/doi/10.1111/dme.13332/full

Two hour post-load glucose is a better prognostic predictor than fasting plasma glucose or HbA1c

In a study comparing the prognostic value of various tests to detect dysglycaemia in 4,004 patients with coronary artery disease, the researchers report a higher predictive value of 2-hour post glucose (2 h-PG) >7.8 mmol/L but not fasting plasma glucose or HbA1c with the primary end points including cardiovascular mortality, non-fatal myocardial infarction, stroke or hospitalisation for heart failure. During follow-up, fasting plasma glucose did not predict new diabetes but HbA1c 5.7–6.6% and 2 h-PG 7.8-11 mmol/L were both significant independent predictors.
http://care.diabetesjournals.org/content/early/2017/06/20/dc17-0245

Auto-injected exenatide once-weekly suspension versus sitagliptin or placebo is more effective

In a randomised controlled trial, once-weekly exenatide suspension for auto-injection in people with type 2 diabetes who were not well controlled on metformin alone showed a greater reduction in HbA1c than sitagliptin or placebo (−1.13% vs. 0.75%, p=0.02; −0.40%, p=0.001), with a greater proportion of patients on exenatide achieving HbA1c <7.0% compared to sitagliptin or placebo (43% vs. 32% and 24.6%; both p<0.05). Body weight decreased with both active treatments (−1.12 and −1.19 kg) but not with placebo (+0.15 kg). The side effects were gastrointestinal events and injection site reactions.
http://onlinelibrary.wiley.com/doi/10.1111/dom.12908/full

YDEF NEWS

Keeping one eye on the future

Earlier this year at Diabetes UK we presented the findings from our survey on perceptions of medical students and undifferentiated trainees of our specialty. Sadly, there were very few who were interested in a career in the specialty, with most stating the medical component as the main reason. The positive aspects were that many found our specialty interesting and were inspired by those working in it.

We at YDEF are keen to promote and highlight our speciality for what it is – an excellent choice for future trainees. With this in mind, we set about planning a National Taster Day to kick start interest in our specialty and encourage prospective trainees. Together with ABCD, the Society for Endocrinology and with support from enthusiastic colleagues, we are delighted to run our first National Taster Day on 30 September in Birmingham. Full of interesting cases and patients, we hope this will be one of many recruitment drives to our specialty and hope our members and colleagues will support this and continue to promote our specialty amongst junior colleagues. If you are interested in running a local taster day, please get in touch if you require help.

Not just looking at future specialty members but our current ones, we are also working on the first National Diabetes and Endocrinology Burnout Survey – something no other medical specialty has assessed. Burnout is getting more awareness these days amidst the ever increasing pressures on our NHS. Recent data suggest that there is an increase in levels of burnout amongst trainees and there needs to be some input into how best to manage and address this. We have been collecting data on current registrars in the specialty and hope to bring you the results of our survey very soon.

Our dedication to our specialty is paramount and only by highlighting the challenges faced will we truly improve perceptions and current trainee support.

Upcoming YDEF courses

‘Keep Your Career Sweet’, a National Diabetes and Endocrine Taster day, 30 September 2017

Queen Elizabeth Hospital Conference Centre, Birmingham

New for this year is our drive to seeing the uptake to our specialty improve and cultivating the interest in our wonderful specialty. Together with the Society for Endocrinology and ABCD, we have organised a taster day for medical students, foundation years and core medical trainees with eminent speakers from our specialty. A must for anyone interested in diabetes and endocrinology.

YDEF Retinopathy, 27th-28th November 2017

Bimingham Heartlands Hospital

Our popular retinopathy course returns and is led by Professor Paul Dodson, who was a key figure in setting up retinal screening services across the UK. The course is aimed at educating trainees on how to grade retinal screening photographs, with break-out sessions throughout the course to support lectures on this important complication of diabetes.

YDEF Wales, 8th-9th December 2017

Cardiff

This off-shoot of YDEF day returns for its sixth outing for our Welsh colleagues, as well as trainees all over the country, and retains its high educational content in the field of clinical diabetes and research. The event features a set of workshops on soft skills with a great opportunity for collaboration and networking and remains a highlight in the YDEF calendar.

YDEF is dedicated to all diabetes and endocrine trainees and is open for new members to register on our website. Take advantage of our regular newsletters and up-to-date advertising of a wide variety of courses and meetings to complement your training.

As always, we are continuously looking to develop and propagate our specialty so do not hesitate to contact us if you have any suggestions or questions!

www.youngdiabetologists.org.uk @youngdiab on twitter