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Aim: People with coexisting severe mental illness (SMI) and type 2 diabetes have a shorter life expectancy and poorer diabetes outcomes than those without SMI. This is partly explained by the separate treatment of diabetes and SMI, which occurs in parallel silos in many healthcare systems. The Steno Diabetes Center Sjaelland and Region Zealand established the Fusion Clinic to offer combined psychiatric and diabetes care delivered by both diabetes and mental healthcare professionals. This study describes how the clinic was established and the initial diabetes outcomes., Methods: The Fusion Clinic was co-designed by people with diabetes and SMI and healthcare professionals to improve the care of adults with diabetes and SMI. The clinic approach utilised the F-ACT model. The 63 people referred to the Fusion Clinic between 01.02.2020 and 01.01.2022 who attended the clinic for more than 6 months were included in this study. Diabetes outcomes were recorded in the electronic medical records (Sundhedsplatformen EPIC)., Results: There was a high prevalence of diabetes complications at baseline. Furthermore, 70% had one or more additional concomitant diseases, as well as SMI and diabetes. Assessment of diabetes complications and measurements of HbA 1c and lipid profile improved after referral to the clinic. HbA 1c declined during the first 6 months of attendance at the clinic., Conclusions: This model of service delivery has the potential to improve the quality of care for people with SMI and type 2 diabetes., (© 2023 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Diabetic wound (DW) is considered as one of the serious complications associated with diabetes mellitus. Though some pharmacological approaches are available for managing DW, none of them has been reported to be very effective. Widely accepted options for its management include treatment of infection caused by various pathogens, wound debridement, reducing the period of the prolonged inflammatory phase, and supervision of the remodeling phase of wound healing. Satisfactory management of DW thus requires exploring new avenues for finding a potential therapeutic strategy. Literature shows that human beta defensins (HBDs) help in combating the insulin resistance by inhibiting the production of glucocorticoids, reducing chronic inflammation by acting through Toll-like receptor signaling pathway, and provoking cell migration, proliferation, angiogenesis, and stabilization of fibroblasts and keratinocytes, ultimately resulting in wound closure. In the present review, beneficial role of HBDs in the treatment of DW is discussed in detail., (© 2019 by the Wound Healing Society.)

Aim: Diabetes impairs the quality of life of people living with the condition and is a major public health concern. The aim of this paper is to create a state of the nation report of diabetes in the UK., Methods: Diabetes UK collates information about diabetes from diverse sources. This paper synthesizes these data to create a national report., Results: Some 7% of the UK population are now living with diabetes; approximately one million people have undiagnosed type 2 diabetes, 40 000 children have diabetes and more than 3000 children are diagnosed every year. Forty-nine per cent of people with type 1 diabetes were offered structured education, but only 7.6% attended; the corresponding figures for type 2 diabetes were 90% and 10.4%, respectively. Among people with diabetes, 28% reported having issues obtaining medication or equipment for self-management. Fifty-seven per cent of people with type 1 diabetes and 42% with type 2 diabetes do not receive all eight annual health checks. Around 40% of people with diabetes have diminished psychological well-being. One-third of people have a microvascular complication at the time of diagnosis of type 2 diabetes. Diabetes is responsible for 530 myocardial infarctions and 175 amputations every week. The National Health Service spends at least £10 billion a year on diabetes, equivalent to 10% of its budget; 80% is spent treating complications. One in six hospital inpatients has diabetes., Conclusion: Diabetes continues to place a significant burden on the individual with diabetes and wider UK society. This report will be updated annually to understand how diabetes is changing across the UK., (© 2020 Diabetes UK.)

Aim: To assess the health-related outcomes of hypoglycaemia for people with diabetes admitted to hospital; specifically, hospital length of stay and mortality., Methods: We conducted a systematic review and meta-analysis of studies relating to hypoglycaemia (< 4 mmol/l) for hospitalized adults (≥ 16 years) with diabetes reporting the primary outcomes of interest, hospital length of stay or mortality. Final papers for inclusion were reviewed in duplicate and the adjusted results of each were pooled, using a random effects model then undergoing further prespecified subgroup analysis., Results: In total, 15 studies were included in the meta-analysis. The pooled mean difference in length of stay for ward-based inpatients exposed to hypoglycaemia was 4.1 days longer [95% confidence interval (CI) 2.36 to 5.79; I² = 99%] compared with those without hypoglycaemia. This association remained robust across the pre-specified subgroup analyses. The pooled relative risk (RR) of in-hospital mortality was greater for those exposed to hypoglycaemia (RR 2.09, 95% CI 1.64 to 2.67; I² = 94%, n = 7 studies) but not in intensive care unit mortality (RR 0.75, 95% CI 0.49 to 1.16; I² =0%, n = 2 studies)., Conclusion: There is an association between inpatient hypoglycaemia and longer length of stay and greater in-hospital mortality. Studies examining this association were heterogenous in terms of both clinical populations and effect size, but the overall direction of the association was consistent. Therefore, glucose concentration should be considered a potential tool to aid the identification of inpatients at risk of poor health-related outcomes., (© 2019 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims: To investigate the acceptability of two questionnaires, the five item WHO Well-being Index (WHO-5) and the Beck Depression Inventory II (BDI-II), which differ in length and focus, by comparing three screening groups: (1) WHO-5, (2) BDI-II and (3) WHO-5 and BDI-II., Methods: A total of 699 individuals with diabetes were approached to participate in the study, of whom 95 completed the WHO-5, 254 completed the BDI-II and 350 completed both the WHO-5 and the BDI-II questionnaires. Five facets of acceptability were compared, including objective aspects (response rate and completion level) and subjective aspects (appreciation, agreeableness and accuracy of the screening questionnaire). Data were analysed using logistic regression analysis and (multivariate) analysis of covariance., Results: The overall response rate was 65% (453 out of 699). No differences between the three groups were found with respect to the response rate (WHO-5: 66%; BDI-II: 63%; WHO-5 and BDI-II: 66%; P ≥ 0.19) and completion level (WHO-5: 99.5%; BDI-II: 97.8%; WHO-5 and BDI-II: 98.7%; P=0.45). The three groups did differ significantly in their scores on two of the three subjective indicators (P<0.03), i.e. appreciation (P=0.002) and agreeableness (P=0.035), with those completing only the WHO-5 reporting greater appreciation and agreeableness., Conclusions: A brief well-being questionnaire, such as the WHO-5, results in greater appreciation of mood screening and appreciation of completing the questionnaire, but this does not result in a better response rate and higher questionnaire completion. Given these results, either or both questionnaires can be used to screen for depressive symptoms in people with diabetes in clinical practice., (© 2018 Diabetes UK.)

This paper is an abridged and modified version of guidelines produced by the Joint British Diabetes Societies for inpatient care on glycaemic management during the enteral feeding of people with stroke and diabetes. These were revised in 2017 and have been adapted specifically for Diabetic Medicine. The full version can be found at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Many people have both diabetes and an acute stroke, and a stanv dard approach to the management of people with stroke is the provision of adequate nutrition. Frequently, this involves a period of enteral feeding if there is impaired ability to swallow food safely. There is currently considerable variability in the management of people with diabetes fed enterally after a stroke, and the evidence base guiding diabetes management in this clinical situation is very weak, although poor glycaemic outcomes in people receiving enteral feeding after stroke may worsen recovery and cause harm. The aim of this document is to provide sensible clinical guidance in this area, written by a multidisciplinary team; this guideline had input from diabetes specialist nurses, diabetologists, dietitians, stroke physicians and pharmacists with expertise in this area, and from UK professional organizations. It is aimed at multidisciplinary teams managing people with stroke and diabetes who require enteral feeding. We recognize that there is limited clinical evidence in this area., (© 2018 Diabetes UK.)

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Care guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes., (© 2018 Diabetes UK.)

Glucocorticoids (steroids) are widely used across many medical specialities for their anti-inflammatory and immunosuppressive properties. However, one of their major side effects is the development of hyperglycaemia. It is well recognized that high glucose levels in people with diabetes in hospital are associated with harm and increased lengths of hospital stay. The use of glucocorticoid (steroid) treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control, and this may be termed 'steroid-induced hyperglycaemia', and will warrant temporary additional, and more active, glycaemic management. A rise in glucose may occur in people without a known diagnosis of diabetes, and this may be termed 'steroid-induced diabetes'. There is a lack of evidence to guide how people with hyperglycaemia should be managed, and much of the guidance given here is a consensus based on best practice collated from around the United Kingdom. Where evidence is available, this is referenced. These guidelines on the management of people with diabetes treated with steroids has been adapted specifically for Diabetic Medicine. The full version of the guidelines can be found on line at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group., (© 2018 Diabetes UK.)

Diabetes is highly and increasingly prevalent in the dialysis population and negatively impacts both quality and quantity of life. Nevertheless, the best approach to these patients is still debatable. The question of whether the management of diabetes should be different in dialysis patients does not have a clear yes or no answer but is divided into too many sub-issues that should be carefully considered. In this review, lifestyle, cardiovascular risk, and hyperglycemia management are explored, emphasizing the possible pros and cons of a similar approach to diabetes in dialysis patients compared to the general population., (© 2018 Wiley Periodicals, Inc.)

Aims: Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact., Methods: An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012., Results: Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8., Conclusions: Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system., (© 2017 Diabetes UK.)

Aims: To examine the appropriateness of medicine use and potentially high-risk prescribing before and after hospitalization for diabetes., Methods: A retrospective cohort study of patients hospitalized for diabetes was conducted using administrative data from the Australian Government Department of Veterans' Affairs for the period between 1 January 2012 and 31 December 2012. The appropriateness of medicine use and potentially high-risk prescribing, including hyper-polypharmacy and associated treatment conflicts, were examined for the 120-day periods before and after hospitalization., Results: A total of 876 patients were hospitalized for a diabetes-related complication. Of these, 25% were not dispensed an antidiabetic medicine 4 months before hospitalization and 25% had not had their HbA 1c levels measured in the preceding 6 months. The use of antidiabetic medicines increased to 85% after hospitalization, with a 25.6% relative increase (95% CI 10.9-42.1) in the proportion of those dispensed insulin. The prevalence of high-risk prescribing before hospital admission was high; 70% had > 10 medicines dispensed, a third had at least one treatment conflict and half were dispensed a potentially inappropriate medicine. The use of long-acting sulphonylureas and corticosteroids had relative decreases of 46.0% (95% CI 17.0-64.9) and 29.9% (95% CI 8.8-46.0), respectively. Few changes in other high-risk prescribing patterns were observed after discharge., Conclusions: This study has identified poor medication-related care and, in particular, high-risk-prescribing in people subsequently hospitalized for diabetes. While diabetes medicine use improved after hospitalization, there was little change in potentially inappropriate medicine use, which suggests that an opportunity to improve medication use in this older vulnerable population has been missed., (© 2016 Diabetes UK.)

Aims: To compare all-cause mortality in older people with or without diabetes and consider the associated risk of comorbidity and polypharmacy., Methods: A 10-year cohort study using data from the Health Innovation Network database (2003-2013) comparing mortality in people aged ≥ 70 years with diabetes (DM cohort) (n = 35 717) and without diabetes (No DM cohort) (n = 307 918)., Results: The mean age of the DM cohort was 78.1 ± 5.8 years vs. 79.0 ± 6.3 years in the No DM cohort. Mean diabetes duration was 8.2 ± 8.1 years, and 30% had diabetes for > 10 years. The DM cohort had a greater comorbidity load and people in this cohort were prescribed more therapies than the No DM cohort. The 5- and 10-year survival rates were lower in the DM cohort at 64% and 39%, respectively, compared with 72% and 50% in the No DM cohort. The excess mortality in the DM cohort was greatest in those aged < 75 years with longer duration diabetes, the relative hazard for mortality was higher in females. Although comorbidity and polypharmacy were associated with increased mortality risk in the DM cohort, this risk was lower compared with the No DM cohort. The hazard ratios (95% confidence interval) for comorbidities > 4 and medicines ≥ 7 were 1.29 (1.19 to 1.41) and 1.34 (1.25 to 1.43) in the DM cohort and 1.63 (1.57 to 1.70) and 1.48 (1.40 to 1.56) in the No DM cohort, respectively., Conclusions: There is significant excess mortality in older people with diabetes, which is unexplained by comorbidity or polypharmacy. This excess is greatest in the younger old with longer disease duration, suggesting that it may be related to the effect of diabetes exposure., (© 2016 Diabetes UK.)

Aims: Hypoglycaemia is a serious medical emergency. The need for emergency medical service care and the costs of hypoglycaemic emergencies are not completely known., Methods: This was a retrospective observational study using Public Company for Health Emergencies (EPES) data for hypoglycaemia in 2012. The EPES provides emergency medical services to the entire population of Andalusia, Spain (8.5 million people). Data on event type, onsite treatments, emergency room visits or hospitalization were collected. Medical costs were estimated using the public rates for healthcare services., Results: From a total of 1 137 738 emergency calls that requested medical assistance, 8683 had a primary diagnosis of hypoglycaemia (10.34 per 10 000 person-years). The incidence of severe hypoglycaemic episodes requiring emergency treatment in the estimated population with diabetes was 80 episodes per 10 000 person-years. A total of 7479 episodes (86%) required an emergency team to visit the patient's residence. The majority of cases (64%) were addressed in the residence, although 1784 (21%) cases were transferred to hospital. A total of 5564 events (65%) involved patients aged > 65 years. Overall mortality was 0.32% (28 cases). The total annual cost of attending a hypoglycaemic episode was €6 093 507, leading to an estimated mean direct cost per episode of €702 ± 565. Episodes that required hospital treatment accounted for 49% of the total costs., Conclusions: Hypoglycaemia is a common medical emergency that is associated with high emergency medical service utilization, resulting in a significant economic impact on the health system., (© 2015 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims: To assess the cost-effectiveness of dapagliflozin, a sodium-glucose co-transporter-2 (SGLT-2) inhibitor, compared with a sulfonylurea, when added to metformin for treatment of UK people with Type 2 diabetes mellitus inadequately controlled on metformin alone., Methods: Clinical inputs sourced from a head-to-head randomized controlled trial (RCT) informed the Cardiff diabetes decision model. Risk equations developed from the United Kingdom Prospective Diabetes Study (UKPDS) were used in conjunction with the clinical inputs to predict disease progression and the incidence of micro- and macrovascular complications over a lifetime horizon. Cost and utility data were generated to present the incremental cost-effectiveness ratio (ICER) for both treatment arms, and sensitivity and scenario analyses were conducted to assess the impact of uncertainty on the final model results., Results: The dapagliflozin treatment arm was associated with a mean incremental benefit of 0.467 quality-adjusted life years (QALYs) [95% confidence interval (CI): 0.420; 0.665], with an incremental cost of £1246 (95% CI: £613; £1637). This resulted in an ICER point estimate of £2671 per QALY gained. Incremental costs were shown to be insensitive to parameter variation, with only treatment-related weight change having a significant impact on the incremental QALYs. Probabilistic sensitivity analysis determined that dapagliflozin had a 100% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY., Conclusions: Dapagliflozin in combination with metformin was shown to be a cost-effective treatment option compared with sulfonylurea from a UK healthcare perspective for people with Type 2 diabetes mellitus who are inadequately controlled on metformin monotherapy., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Aims: This population-based study assesses the healthcare utilization of people with Type 2 diabetes by analysing routine data from Allgemeine Orts-Krankenkasse (AOK), the largest statutory health insurance provider in Germany., Methods: Anonymized billing data from all AOK-insured persons with at least one day of insurance during the evaluation year 2010 were analysed. Treatment and cost data from all areas of inpatient and outpatient care were available, as was information regarding patient age and sex. International Classification of Diseases (ICD-10) diagnosis and Anatomical Therapeutic Chemical (ATC) classification were used to identify 2.7 million insured persons with diabetes., Results: The age- and sex-standardized prevalence of Type 2 diabetes was 9.8%. Of those patients identified, 33.9% had at least one diabetes-related complication and 83.0% had a diagnosis of hypertension. Almost two-thirds (63.1%) received antihyperglycaemic medication. Metformin and sulfonylurea were prescribed most often; medications without proof of benefit in endpoint studies were prescribed much less frequently. People without diabetes were admitted to hospital only half as often as those with Type 2 diabetes. The projected total expenditure in Germany for all people with Type 2 diabetes amounted to approximately €33.3 billion in 2010., Conclusions: This study shows an increase in both the prevalence of diabetes and treatment costs. The majority of people with Type 2 diabetes were aged 70 years or older. One third of this group has diabetes-related complications. Antihyperglycaemic medications without proof of benefit in endpoint studies were prescribed much less frequently than drugs with proof of benefit., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Aims: To examine the short- and long-term cost-effectiveness of intensive multifactorial treatment compared with routine care among people with screen-detected Type 2 diabetes., Methods: Cost-utility analysis in ADDITION-UK, a cluster-randomized controlled trial of early intensive treatment in people with screen-detected diabetes in 69 UK general practices. Unit treatment costs and utility decrement data were taken from published literature. Accumulated costs and quality-adjusted life years (QALYs) were calculated using ADDITION-UK data from 1 to 5 years (short-term analysis, n = 1024); trial data were extrapolated to 30 years using the UKPDS outcomes model (version 1.3) (long-term analysis; n = 999). All costs were transformed to the UK 2009/10 price level., Results: Adjusted incremental costs to the NHS were £285, £935, £1190 and £1745 over a 1-, 5-, 10- and 30-year time horizon, respectively (discounted at 3.5%). Adjusted incremental QALYs were 0.0000, - 0.0040, 0.0140 and 0.0465 over the same time horizons. Point estimate incremental cost-effectiveness ratios (ICERs) suggested that the intervention was not cost-effective although the ratio improved over time: the ICER over 10 years was £82,250, falling to £37,500 over 30 years. The ICER fell below £30 000 only when the intervention cost was below £631 per patient: we estimated the cost at £981., Conclusion: Given conventional thresholds of cost-effectiveness, the intensive treatment delivered in ADDITION was not cost-effective compared with routine care for individuals with screen-detected diabetes in the UK. The intervention may be cost-effective if it can be delivered at reduced cost., (© 2015 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims: To evaluate the impact of an integrated model of care for patients with complex Type 2 diabetes mellitus on potentially preventable hospitalizations., Methods: A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. Study and hospital admissions data were linked for the period from 12 months before to 24 months after commencement of the trial. The primary outcome was the number of potentially preventable hospitalizations with diabetes-related principal diagnoses. Length of stay once hospitalized was also reported., Results: Of 327 adult participants, 206 were hospitalized and accounted for 667 admissions during the study period. Compared with the usual care group, patients in the integrated model of care group were nearly half as likely to be hospitalized for a potentially preventable diabetes-related principal diagnosis in the 24 months after study commencement (incidence rate ratio 0.53, 95% CI 0.29, 0.96; P = 0.04). The magnitude of the result remained similar after adjusting for age, sex, education and baseline HbA1c concentration (incidence rate ratio 0.54, 95% CI 0.29, 1.01; P = 0.05).When hospitalized, patients in the integrated care group had a similar length of stay compared with those in the usual care group (median difference -2 days, 95% CI -6.5, 2.3; P = 0.33)., Conclusions: Patients receiving the integrated model of care had a reduction in the number of hospitalizations when the principal diagnosis for admission was a diabetes-related complication. Integrated models of care for people with complex diabetes can reduce hospitalizations and help attempts to curtail increasing demand on finite health services., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Hyperglycaemic hyperosmolar state (HHS) is a medical emergency, which differs from diabetic ketoacidosis (DKA) and requires a different approach. The present article summarizes the recent guidance on HHS that has been produced by the Joint British Diabetes Societies for Inpatient Care, available in full at http://www.diabetologists-abcd.org.uk/JBDS/JBDS&#95;IP&#95;HHS&#95;Adults.pdf. HHS has a higher mortality rate than DKA and may be complicated by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis and there is some evidence that rapid changes in osmolality during treatment may be the precipitant of central pontine myelinolysis. Whilst DKA presents within hours of onset, HHS comes on over many days, and the dehydration and metabolic disturbances are more extreme. The key points in these HHS guidelines include: (1) monitoring of the response to treatment: (i) measure or calculate the serum osmolality regularly to monitor the response to treatment and (ii) aim to reduce osmolality by 3-8 mOsm/kg/h; (2) fluid and insulin administration: (i) use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, (ii) fluid replacement alone will cause a fall in blood glucose (BG) level, (iii) withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic), (iv) an initial rise in sodium level is expected and is not itself an indication for hypotonic fluids and (v) early use of insulin (before fluids) may be detrimental; and (3) delivery of care: (i) The diabetes specialist team should be involved as soon as possible and (ii) patients should be nursed in areas where staff are experienced in the management of HHS., (© 2015 The Author. Diabetic Medicine © 2015 Diabetes UK.)

Objectives: To evaluate the prevalence of metabolic syndrome (MetS) and its association with physical capacity, disability, and self-rated health in older adults at high risk of mobility disability, including those with and without diabetes mellitus., Design: Cross-sectional analysis., Setting: Lifestyle Interventions and Independence for Elders (LIFE) Study., Participants: Community-dwelling sedentary adults aged 70 to 89 at high risk of mobility disability (Short Physical Performance Battery (SPPB) score ≤9; mean 7.4 ± 1.6) (N = 1,535)., Measurements: Metabolic syndrome was defined according to the 2009 multiagency harmonized criteria; outcomes were physical capacity (400-m walk time, grip strength, SPPB score), disability (composite 19-item score), and self-rated health (5-point scale ranging from excellent to poor)., Results: The prevalence of MetS was 49.8% in the overall sample (83.2% of those with diabetes mellitus, 38.1% of those without). MetS was associated with stronger grip strength (mean difference (Δ) = 1.2 kg, P = .01) in the overall sample and in participants without diabetes mellitus and with poorer self-rated health (Δ = 0.1 kg, P < .001) in the overall sample only. No significant differences were found in 400-m walk time, SPPB score, or disability score between participants with and without MetS, in the overall sample or diabetes mellitus subgroups., Conclusion: Metabolic dysfunction is highly prevalent in older adults at risk of mobility disability, yet consistent associations were not observed between MetS and walking speed, lower extremity function, or self-reported disability after adjusting for known and potential confounders. Longitudinal studies are needed to investigate whether MetS accelerates declines in functional status in high-risk older adults and to inform clinical and public health interventions aimed at preventing or delaying disability in this group., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Aims: Accurate measurement of emergency diabetes admissions is essential for healthcare delivery and research. This study examines whether current approaches to identifying diabetes-related admissions may underestimate the true burden on hospital care., Methods: Data spanning the period 1 January 2006 to 31 December 2010 inclusive were extracted from Hospital Episode Statistics data for England. Emergency admissions citing diabetes (E10, E11, E13 or E14) in any diagnosis position in adults (≥ 17 years) were included. E10 and E11 were considered analogous to type 1 and type 2 diabetes mellitus respectively; E13 and E14 were grouped as 'other or unspecified' diabetes mellitus. For admissions citing diabetes multiple times, those with concordant citations were classified as appropriate; discordant citations were assigned to the 'other or unspecified' group. Frequencies of diabetes classifications and complications for each diagnosis position and frequencies of all International Classification of Diseases 10th revision codes for the primary diagnosis field were calculated., Results: In total, 2 443 046 admissions were identified. Diabetes was cited as the primary diagnosis in 6.2% and most commonly cited as the third diagnosis (23.1%). Type 2 diabetes mellitus was the most common (85.0%). The majority of diabetes citations were 'without complication' (2 188 965, 89.6%). The most common primary diagnosis was 'chest pain, unspecified' (R07.4, 99 678, 4.1%)., Conclusions: Reliance on the primary diagnosis field to identify emergency admissions in people with diabetes grossly underestimates the true burden placed on hospital care and leads to underestimates of effect sizes in studies utilizing admission rates as outcome measures. An alternative strategy to identify such admissions is required., (© 2014 The Authors. Diabetic Medicine © 2014 Diabetes UK.)

Aim: To determine if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with primary care diabetes management., Methods: We performed an observational study in the population in England during the period 2004-2009 (54 741 278 people registered with 8140 general practices). We used multivariable negative binomial regression to model the associations between indirectly standardized hospital admission rates for complications and primary healthcare quality, supply and access indicators, diabetes prevalence and population factors., Results: In multivariate regression models, increasing deprivation (incidence rate ratio: 1.0154; P < 0.001, 95% CI 1.0141-1.0166) and diabetes prevalence (incidence rate ratio: 1.0956; P < 0.001, 95% CI 1.0677-1.1241) were risk factors for admission, while most healthcare covariates, i.e. a larger practice population (incidence rate ratio 0.9999, P = 0.013, 95% CI 0.9999-0.9999), better patient-perceived urgent and non-urgent access to primary care (incidence rate ratio: 0.9989, P = 0.023; 95% CI 0.9979-0.9998 and incidence rate ratio: 0.9988; P = 0.003, 95% CI 0.9980-0.9996, respectively) and better HbA1c target achievement (incidence rate ratio: 0.9971; P < 0.001, 95% CI 0.9958-0.9984), were protective. Diabetes admissions decreased significantly during the period 2004-2009., Conclusions: After controlling for population factors, better scheduled primary care access and glycaemic control were associated with lower hospital admission rates across most complications. There is little rationale to restrict primary care-sensitive condition definitions to acute complications. They should be revised to improve the usefulness of hospital admission data as an outcome measure, and to facilitate international comparisons. The risk of emergency hospital admission should be monitored routinely., (© 2014 The Authors. Diabetic Medicine © 2014 Diabetes UK.)

Aims: We investigated the effects of diabetes and the presence of lung cavities on treatment outcomes in patients with pulmonary tuberculosis., Methods: We conducted a retrospective review of the clinical records of all consecutive patients admitted to the Kanagawa Cardiovascular and Respiratory Centre with the diagnosis of pulmonary tuberculosis. The study outcomes examined were time to sputum culture conversion and percentage of patients with sputum culture conversion by the time 2 months of treatment, and these outcomes were compared between patients with and without diabetes., Results: Of the 260 patients enrolled in the study, 69 were diagnosed as having diabetes mellitus, while the remaining 191 did not have diabetes. The percentage of patients with cavities was higher in the patients with diabetes (71.0%) than in those without (45.5%; P = 0.0003). The time to sputum culture conversion was significantly longer in the patients with diabetes than in those without (P = 0.0005), and the percentage of patients with a positive sputum culture at 2 months was higher in the patients with diabetes (43.5%) than in those without (18.8%; P = 0.0001). Multivariate analyses revealed that the presence/absence of lung cavities was a more important determinant of treatment outcomes than the presence/absence of diabetes., Conclusions: The presence of lung cavities was found to be a more important determinant of the treatment outcomes than that of diabetes per se in patients with pulmonary tuberculosis., (© 2014 The Authors. Diabetic Medicine © 2014 Diabetes UK.)

Aims: To assess pre-hospital patient delay and its associated variables in patients with diabetic foot problems., Methods: We classified 270 patients with diabetic foot problems retrospectively based on the distribution of pre-hospital delay. Clinical, demographic and socio-economic data were collected. Logistic regression analysis was performed to examine independent associations with patient delay., Results: The median pre-hospital delay time was 46.49 days. Patients reported short (≤ 1 week; 77 patients, 28.5%), moderate (> 1 week and ≤ 1 month; 106 patients, 39.3%) and long delays (> 1 month; 87 patients, 32.2%). In a univariate analysis, nine variables were associated with a longer delay (P < 0.05): (1) no previous ulcer; (2) no health insurance; (3) poor housing conditions; (4) low income level; (5) low educational level; (6) infrequent foot inspection; (7) few follow-up medical visits; (8) absence of diabetic foot education; (9) lack of knowledge of foot lesion warning signals. A multivariate analysis showed that absence of diabetic foot education (odds ratio 2.70, 95% CI 1.03-7.06, P = 0.043) and lack of knowledge of foot lesion warning signals (odds ratio 2.14, 95% CI 1.16-3.94, P = 0.015) were independent predictors of long patient delay. Long delay increased the risk of amputation (odds ratio 2.22, 95% CI 1.36-3.64, P = 0.002) and mortality (odds ratio 2.69, 95% CI 1.35-5.33, P = 0.005)., Conclusions: A number of factors were involved in pre-hospital delay among patients with diabetic foot problems and contributed to poor outcomes. We recommend developing a community intervention programme that targets at-risk communities to encourage earlier multidisciplinary team assessment to reduce disparities and improve foot outcomes in patients with diabetes., (© 2013 The Authors. Diabetic Medicine © 2013 Diabetes UK.)

Aims: To build a flexible and comprehensive long-term type 1 diabetes mellitus model incorporating the most up-to-date methodologies to allow a number of cost-effectiveness evaluations., Methods: This paper describes the conceptual modelling, model implementation and model validation of the Sheffield type 1 diabetes policy model (version 1.0), developed through funding by the U.K. National Institute for Health Research as part of the Dose Adjustment for Normal Eating research programme. The model is an individual patient-level simulation model of type 1 diabetes and it includes long-term microvascular (retinopathy, neuropathy and nephropathy) and macrovascular (myocardial infarction, stroke, revascularization and angina) diabetes-related complications and acute adverse events (severe hypoglycaemia and diabetic ketoacidosis). The occurrence of these diabetes-related complications in the model is linked to simulated individual patient-level risk factors, including HbA1c , age, duration of diabetes, lipids and blood pressure. Transition probabilities were modelled based on a combination of existing risk functions, published trials, epidemiological studies and individual-level data from the Dose Adjustment for Normal Eating research programme., Results: The model takes a lifetime perspective, estimating the impact of interventions on costs, clinical outcomes, survival and quality-adjusted life years. Validation of the model suggested that, for almost all diabetes-related complications predicted, event rates were within 10% of the normalized rates reported in the studies used to build the model., Conclusions: The model is highly flexible and has broad potential application to evaluate the Dose Adjustment for Normal Eating research programme, other structured diabetes education programmes and other interventions for type 1 diabetes., (© 2013 Crown copyright. Diabetic Medicine © 2013 Diabetes UK.)

Hyperbaric oxygen (HBO) therapy is an effective treatment for diabetic chronic wounds. HBO reduces inflammation and accelerates wound healing, by mechanisms that remain unclear. Here we examined a mechanism by which HBO may reduce neutrophil recruitment, through changes in endothelial and neutrophil adhesion molecule expression and function. Human umbilical vein endothelial cells and neutrophils were exposed to selected chronic wound conditions, comprising hypoxia in the presence of lipopolysaccharide and tumor necrosis factor-alpha, and then treated with HBO. We observed neutrophil adhesion to endothelial cells following treatment with chronic wound conditions, which was reversed by HBO treatment. This was partly explained by reduced expression of endothelial intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 by HBO. No changes in neutrophil adhesion molecule expression (CD18, CD11b, CD62L, CD31) were observed following HBO treatment. However, HBO decreased hydrogen peroxide generation by neutrophils, and induced nitrous oxide-related protein modifications. The transnitrosating agent S-nitroso-L-cysteine ethyl ester (600 μM) also reduced neutrophil adhesion to human umbilical vein endothelial cell monolayers, and the iNOS inhibitor 1400 W (10 μM) and HgCl2, which promotes the decomposition of S-nitrosothiols (1 mM), reversed the effect of HBO, suggesting that S-nitrosation may inhibit neutrophil-endothelial cell adhesion. This study indicates that HBO could reduce inflammation in wounds through reduced neutrophil recruitment, mediated by S-nitrosation., (© 2013 by the Wound Healing Society.)

Chronic wounds that fail to heal are a common complication of diabetes mellitus and the most common precipitating reason for nontraumatic lower limb amputation. Unfortunately, the bacterial species that cause these infections are becoming more resistant to antibiotics, making them increasingly difficult to treat. We assessed the feasibility of combating chronic bacterial infections with a topically delivered bacteriophage cocktail in two animal models of diabetes mellitus. Microbiological, planimetric, and histological parameters were compared in debrided infected wounds with or without topical bacteriophage treatment. We determined that bacteriophage treatment effectively decreased bacterial colony counts and improved wound healing, as indicated by smaller epithelial and dermal gaps, in Staphylococcus aureus and Pseudomonas aeruginosa infections but was not as effective against Acinetobacter baumannii. Although the improvements were more significant in the rodent model than in the porcine model, our results suggest that topically administered bacteriophage treatment may be effective in resolving chronic infections, especially when applied in conjunction with wound debridement. These findings have important implications for the feasibility of using topical antimicrobial therapies to safely treat chronic infections in diabetes mellitus patients., (© 2013 by the Wound Healing Society.)

Aims: We investigated use and efficacy of glucagon-like peptide-1 (GLP-1) receptor agonists in UK practice., Methods: People starting a GLP-1 receptor agonist (exenatide, liraglutide) or insulin (glargine, detemir, NPH) after a regimen of two or three oral glucose-lowering agents were identified from The Health Information Network observational primary care database (2007-2011). Mean change in HbA1c and body weight were compared at 1 year between cohorts, adjusting for baseline characteristics., Results: Baseline characteristics of GLP-1 receptor agonist (n = 1123) vs. insulin (n = 1842) users were HbA1c 78 vs. 84 mmol/mol (9.3 vs. 9.8%) and BMI 38.2 vs. 30.9 kg/m². The GLP-1 receptor agonist cohort was younger, had shorter diabetes duration and follow-up, less microvascular disease and heart failure, higher estimated glomerular filtration rate and more use of oral glucose-lowering agents. Lower HbA1c reduction on GLP-1 receptor agonist [7 vs. 13 mmol/mol (0.6 vs. 1.2%) (n = 366 vs. 892)] was not statistically significant [adjusted mean difference -1.4 (95% CI -4.1, 1.2) mmol/mol], except in the highest HbA1c quintile [>96 mmol/mol (>10.9%); adjusted mean difference -17.8 (-28.6, -7.0) mmol/mol]. GLP-1 receptor agonist users lost weight [-4.5 vs. +1.5 kg; adjusted mean difference 4.7 (3.7, 5.8) kg; n = 335 vs. 634]. A UK 6-month target reduction for GLP-1 receptor agonists of 11 mmol/mol (1.0%) HbA1c and 3% weight was reached by 24.9% of those continuing treatment., Conclusions: Those starting GLP-1 receptor agonists are heavier with better glycaemic control than those starting basal insulin. Subsequently, they have improved weight change, with similar HbA1c reduction unless baseline HbA1c is very high. The UK 6-month GLP-1 receptor agonist target is usually not reached., (© 2013 The Authors. Diabetic Medicine © 2013 Diabetes UK.)

Aim: Hospital inpatient care for children with diabetes is frequently mentioned by parents as unsatisfactory. The aim of this study was to examine the reasons for inpatient admission of children with diabetes and to understand patient and carer experience in order to improve services., Methods: Questionnaires were given to medical teams, parents and children during admissions of children with diabetes under 16 years of age in three regions of England., Results: There were 401 admissions over 6 months from 3247 patients: 334 (83%) emergency admissions and 59 (15%) elective; the reason is unknown in eight (2%). One hundred and forty-three (36%) were emergency admissions with diabetic ketoacidosis/hyperglycaemia. Clinical teams reported adverse events around insulin administration in 25, hypoglycaemia (sometimes recurrent) in 120 and food provision in 14 admissions. Others included seven incidents around elective surgery. Diabetes clinical teams were not always informed about admissions and only 33% were informed within 2 h. Parents and children reported fewer problems: 62% were involved in care most of the time and 87% were able to give insulin. Most negative comments were about poor staff management of out-of-range blood glucose levels, knowledge of insulin pumps and care of children waiting in the emergency department., Conclusions: There were a large number of admissions and the majority were emergencies. Parents generally felt that they receive good care, although with some lack of knowledge amongst the ward staff. There were an unacceptable number of adverse incidents reported. We recommend that education of ward staff in diabetes is carried out regularly with reference to the standards of care., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Aim: To examine the evidence on culturally competent interventions tailored to the needs of people with diabetes from ethnic minority groups., Methods: MEDLINE (NHS Evidence), CINAHL and reference lists of retrieved papers were searched from inception to September 2011; two National Health Service specialist libraries were also searched. Google, Cochrane and DARE databases were interrogated and experts consulted. Studies were included if they reported primary research on the impact of culturally competent interventions on outcome measures of any ethnic minority group with diabetes. Paper selection and appraisal were conducted independently by two reviewers. The heterogeneity of the studies required narrative analysis. A novel culturally competent assessment tool was used to systematically assess the cultural competency of each intervention., Results: Three hundred and twenty papers were retrieved and 11 included. Study designs varied with a diverse range of service providers. Of the interventions, 64% were found to be highly culturally competent (scoring 90-100%) and 36% moderately culturally competent (70-89%). Data were collected from 2616 participants on 22 patient-reported outcome measures. A consistent finding from 10 of the studies was that any structured intervention, tailored to ethnic minority groups by integrating elements of culture, language, religion and health literacy skills, produced a positive impact on a range of patient-important outcomes., Conclusions: Benefits in using culturally competent interventions with ethnic minority groups with diabetes were identified. The majority of interventions described as culturally competent were confirmed as so, when assessed using the culturally competent assessment tool. Further good quality research is required to determine effectiveness and cost-effectiveness of culturally competent interventions to influence diabetes service commissioners., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Background and Objectives: The growth factors derived from platelets and plasma proteins mediate the wound-healing process that is characterized by the sequential migration and differentiation of several cell populations that give rise to angiogenesis, collagen synthesis, wound contraction, and re-epithelialization. To evaluate the efficacy of the blood-derived factors in wound healing, we examined a novel wound dressing consisting of concentrated human plasma proteins and platelet releasate (CPPP)., Materials and Methods: To generate CPPP, plasma proteins and platelets in the peripheral blood (n = 5) were concentrated with the cold ethanol precipitation method. The thrombin obtained from the same blood unit and calcium chloride (CaCl(2)) were mixed to a concentrate. The CPPP has enough strength to dress cutaneous wounds and contains large amounts of cytokines and fibronectin. We applied the CPPP to excisional skin wounds in genetically healing-impaired model mice (n= 5) and the wounds were evaluated 10 days after the operation., Results: The area of CPPP-treated wounds decreased significantly compared with that of the control wounds (65% vs. 94% of the original size, respectively, P= 0.032). The immunostained section revealed a striking effect of CPPP on vascularization compared with the control wounds (13.2 vs. 2.7 vessels per mm(2) as mean vascular density observed in the sections, respectively, P= 0.013)., Conclusions: Our results suggest that CPPP is a promising biologically active dressing for full-thickness skin wounds. CPPP can be an entirely autologous biological dressing, suggesting that it is free from the risk of transmission of pathogens through blood products.

Objective: To review recently published data on emphysematous cystitis (EC), a potentially life-threatening condition characterized by air within the bladder wall, and that most typically affects middle-aged diabetic women., Methods: All articles published in English between 1956 and 2006 were identified using a Medline search for keywords "emphysematous cystitis", and "cystitis emphysematosa." Epidemiological, clinical, diagnostic, pathological and therapeutic data were evaluated, including risk factors such as the presence of diabetes mellitus or other comorbid emphysematous infections of the urinary tract., Results: In all, 102 published papers, including 135 cases of EC, were reviewed; the median patient age was 66 years, 64% were women and 67% had diabetes mellitus. Most cases were diagnosed using plain films of the abdomen (84%), although more recently, computed tomography was the primary imaging method. Escherichia coli was the most commonly isolated organism. Most patients were treated with medical management alone (90%), while 10% of infections were treated with a combination of medicine and surgery. The overall death rate was 7%., Conclusions: EC is the most common and typically the least severe gas-forming infection of the urinary tract. Prompt diagnosis and treatment is warranted to prevent the potential morbidity and mortality of this infectious condition.

Aim: To examine in-patient diabetes services in all UK acute hospitals., Methods: We asked the diabetes specialist team in all UK acute hospitals to complete a structured questionnaire on in-patient diabetes management guidelines, in-patient referral patterns, diabetes in-patient specialist nurse (DISN) services and diabetes bed occupancy in their hospital., Results: Of the 262 UK acute hospitals, 239 (91.2%) provided data (2005-2006). UK teams reported high levels of clinical risk associated with in-patient diabetes care. One-third did not have diabetes management guidelines for day surgery, endoscopy, barium studies or immediate management of the diabetic foot. Patients admitted with diabetic ketoacidosis were not immediately referred to the specialist team in one-third of hospitals. About half had no routine access to podiatry or dietetic care for in-patients with diabetes. The majority of UK hospitals either never adopted Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI)-1 protocols or had recently changed practice, and half do not endorse the use of in-patient subcutaneous insulin 'sliding-scales'. One in five UK hospitals survey in-patient diabetes treatment satisfaction. DISN numbers have increased rapidly-126 hospitals (51.4%) had a DISN, most (69.1%) appointed since 2002. Most (80.2%) hospitals without a DISN used the out-patient specialist nurse team to provide in-patient care., Conclusions: This survey has identified substantial gaps in in-patient diabetes care in the UK. The rapid increase in DISN numbers indicates increasing attention to in-patient diabetes care in UK hospitals.

The Clinical Guidelines Task Force of the International Diabetes Federation has created an evidence-based Global Guideline for the care of people with Type 2 diabetes around the world. The recommendations developed for three levels of care (standard, comprehensive, and minimal), which can be applied in settings with different resources, are presented here. The source document is published elsewhere.

Aim: To undertake a pilot study to determine the feasibility of a definitive trial of the effect of close glycaemic control on healing of foot ulcers in diabetes., Methods: All patients attending a dedicated multidisciplinary clinic for the management of established ulcers over a 20-week period were systematically screened for inclusion in a randomised, single-blinded study., Findings: Two hundred individuals with foot ulcers attended the clinic during the recruitment period, but only nine met the predefined inclusion and exclusion criteria. One of these was withdrawn because of an adverse event immediately before recruitment, two proved incapable of administering insulin injections and were withdrawn prior to randomization. Four withheld consent, and one was advised to withhold consent by his community nurse. One was randomised and completed the 3-month study. The study was abandoned at 20 weeks when it was decided that it would be unlikely that a sufficient number of suitable patients would ever be recruited, and that it would therefore be unethical to approach further subjects., Conclusions: It was concluded that although evidence is required to guide future practice in this field, the study design chosen was not feasible.

Aims: To assess whether compliance with management guidelines for hyperglycaemia in acute medical emergencies was affected by prior diagnosis of diabetes, and to assess the effect of an educational campaign upon management., Methods: Prospective study of management of adult patients admitted to an acute medical admissions unit in 2002, with repeat in 2003 after an educational campaign., Results: The management of 251 patients in 2002 and 357 patients in 2003 was examined. In patients with no prior diagnosis of diabetes, unsatisfactory management was observed in 60% compared with only 30% of those with known diabetes (P < 0.02). In 2003 these proportions fell to 46 and 16%, respectively, but remained significantly different (P < 0.02). Overall, 30 of 70 (42.9%) patients with hyperglycaemia were managed strictly according to the guidelines in 2002 compared with 33 out of 59 (55.9%) in 2003 (P = 0.14). Satisfactory management was delivered in 55.7% in 2002 and 78% in 2003 (P < 0.01)., Conclusions: The reluctance of doctors to manage incidental hyperglycaemia in acute medical admissions was especially common when the patient was not known to have diabetes. This was only modestly improved by an educational campaign, even though this group are known to have a greater response in terms of morbidity and mortality. Widespread debate of this issue is required to minimize morbidity and mortality due to hyperglycaemia.