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Aims: \ud Guidelines recommend that diabetes care processes (HbA1c, creatinine, cholesterol, BP, BMI, smoking habit, urinary albumin, retinal and foot examinations) are performed at least annually. This analysis assesses if their completion is associated with mortality.\ud \ud Materials and Methods: \ud A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 with type 2 diabetes, aged 17–99 years on 1st January 2009, diagnosed before 1st January 2009 and alive on 1st April 2013 was followed to 31st December 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, BP, serum cholesterol, BMI, duration of diagnosis, eGFR, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, investigated whether care processes recorded 1st January 2009 to 31st March 2010 were associated with subsequent mortality.\ud \ud Results: \ud Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes respectively. Completion of five or less, compared to eight, care processes (retinal screening not included as data not reliable) had a mortality hazard ratio of 1.37 (95% CI 1.28–1.46) in people with type 1 and 1.32 (95% CI 1.30–1.35) in people with type 2 diabetes. The hazard ratio was higher for respiratory disease deaths and lower in South Asian ethnic groups.\ud \ud Conclusions: \ud People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.

Background: Non-attendance at diabetes outpatient appointments is a sizeable problem worldwide and has been associated with suboptimal health outcomes. We aimed to describe the characteristics, health outcomes and reasons given for non-attendance at doctor- or nurse-led diabetes appointments, and interventions to improve attendance. Methods: PubMed, EMBASE, CINAHL and PsychInfo were searched from database inception to February 2019. Included articles were peer-reviewed, published in English, related to adults or young people with type 1 or type 2 diabetes, and addressed one of the above aspects of non-attendance. Studies were excluded if reporting on other types of diabetes or reviewing attendance at structured education, retinal screening, paediatric, antenatal, podiatry or dietetic clinics. Results: Thirty-four studies of varied designs were identified (15 observational, 1 randomized control trial, 9 qualitative, 5 surveys, 4 service improvements). The definition of non-attendance varied. Younger adults, smokers and those with financial pressures were less likely to attend. Non-attendance was associated with higher HbA 1c; other outcomes were varied but typically worse in non-attenders. Reasons for non-attendance in qualitative studies fell into three categories: balancing the costs and benefits of attendance, coping strategies, and the relationships between the person with diabetes and healthcare professionals. Interventions included appointment management strategies, service improvements, patient navigators and WebCam appointments. Conclusions: Non-attendance is only partially explained by logistical issues. Qualitative studies suggest complex psychosocial factors are involved. Interventions have progressed from simple appointment reminders in an attempt to address some of the psycho-social determinants, but more work is needed to improve attendance.

Pharmacists are the third largest group of healthcare professionals worldwide, but are underused in the delivery of diabetes care. The aim of this narrative was to describe how integration of community pharmacy services into existing healthcare models may improve diabetes care. Relevant literature exploring pharmacy-led interventions for diabetes were identified from a search of Medline, Embase and Cinahl online databases. This review highlights that community pharmacists are accessible, experts in medicine management, trusted by the public and able to achieve financial savings. They are poorly integrated into existing healthcare models, and commissioning arrangements can be poorly perceived by the public and those working in primary care. Community pharmacy interventions in type 2 diabetes have similar, if not greater effects compared to those delivered by other healthcare professionals. It was concluded that community pharmacy interventions in diabetes are feasible, acceptable and deliver improved health outcomes. Future work should build public recognition of pharmacists and improve communication between them and other healthcare professionals.

OBJECTIVE: There have been concerns about the effects of antipsychotics on weight gain and the development of type 2 diabetes (T2DM). This article aims to provide an up-to-date review on the evidence addressing this issue and the practical implications for the management of people taking antipsychotics in the context of T2DM.METHODS: We carried out searches on MEDLINE/PUBMED and the ClinicalTrials.gov website in August 2017 using the terms 'antipsychotic' and 'diabetes' or 'glucose' citing articles published after 2006 preferentially.RESULTS: Antipsychotics are associated with T2DM and are likely to exert a causal effect of uncertain magnitude. Children and adolescents appear especially vulnerable to these metabolic effects; as T2DM is not common in healthy younger people, the relative risk is more apparent. Antipsychotics act on glucose and insulin homeostasis in a variety of direct and indirect mechanisms. To reduce the increasing health inequalities among individuals with mental illness screening, monitoring and prevention of T2DM is important, as is improved diabetes care in this population.CONCLUSION: It remains unclear whether these antipsychotic medications exacerbate an underlying predisposition to the development of T2DM or have a direct effect. Potential risks need to be weighed up and balanced between improved and lasting mental health benefits and any detrimental physical health side effects. Achieving parity of esteem between mental and physical health is a worldwide priority if we wish to improve life expectancy and quality of life in people with severe mental illness.

Nearly every category of ICD-10 Chapter F (mental disorders) is associated with diabetes and with worse outcomes and premature mortality.1 In addition, many people with diabetes suffer from diabetes related distress. The quality of the diabetes care provided for people with mental illness is suboptimal regardless of whether the clinical presentation is in acute or mental health settings or primary care. However, when patients are admitted, there is often an urgent clinical need to optimise both conditions. We have chosen the inpatient setting because it is also a window of opportunity to effect better shared care planning and decision making. This working group gives guidance for reconfiguring of services to reduce the alarmingly high rates of morbidity and premature mortality related to diabetes in people with mental illnesses. We expect equivalent levels of care for diabetes in people with and without mental illness in order to improve mental health and reduce the risk of diabetes complications. We encourage good practice through collaborative working, raising awareness, improved communication, introducing mandatory training and skills competencies all embedded in a patient-centred approach. Local variation in diabetes outcomes in those with and without mental illnesses should be audited, and commissioners held to account if services are not meeting the needs of this high risk and vulnerable group. There is a need for more commissioning and research investment to develop and evaluate novel clinical innovations to better support our patients with both diabetes and mental illness. There is a need for a system and culture change in the NHS to genuinely integrate the mind and body and incentivise best practice. non-peer-reviewed

Introduction: Cardiovascular disease (CVD) risk assessment is becoming increasingly common in routine clinical practice. Consequently many individuals are likely to be identified as being at increased CVD risk and risk reducing strategies implemented with a view to preventing future CVD. There are many steps along the pathway from CVD risk assessment to the prevention of CVD events. First, CVD risk needs to be accurately estimated using an appropriate CVD risk calculator. Secondly CVD risk information needs to be effectively communicated to the individual identified as being at increased risk. Thirdly, the risk information communicated needs to be capable of motivating behaviour change and finally behaviour change needs to result in a reduction in CVD risk. The evidence base for many of these steps has yet to be fully established. Aims: The overall aims of this work were first to adapt the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine to better display risk and achievable risk. Secondly to investigate lay perceptions of risk and to develop two interventions designed to reduce CVD risk. The two interventions were a personalised 10-year CVD risk estimate and a brief lifestyle advice intervention. Finally, the capacity of these interventions to increase physical activity and improve CVD risk factors in adults at increased CVD risk was tested. Methods: Three focus groups were held to investigate lay perceptions of risk and to inform the design of the UKPDS Risk Engine interface and a brief lifestyle advice intervention designed to motivate risk reducing behaviours. The two interventions were then tested in a 2x2 factorial randomised controlled trial. Results: The focus group results demonstrated that public interest and understanding of risk was high. In addition participants expressed clear views regarding how risk information and lifestyle advice should be presented. 194 participants at increased 10-year CVD risk (≥ 20%) were recruited from 4 Oxfordshire general practices. Neither a personalised 10-year CVD risk estimate nor a brief lifestyle advice intervention was capable of increasing physical activity or reducing estimated 10-year CVD risk in this group. Conclusions: Whilst public interest in CVD risk appeared to be high this study was unable to demonstrate that a 10-year personalised CVD risk estimate or a brief lifestyle advice intervention was able to increase physical activity in adults at increased CVD risk.

Diet is important in the cause of many chronic diseases. Individual change in dietary behaviour has the potential to decrease the burden of chronic disease, particularly cardiovascular disease (CVD).We conducted a systematic review and aimed to answer the following clinical question: What are the effects of dietary advice in generally healthy adults without existing CVD or increased CVD risk factors to improve cardiovascular outcomes (mortality, cardiovascular events, and cardiovascular risk factors)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 14 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: advice to increase fibre intake alone, advice to increase fruit and vegetable intake alone, advice to reduce and/or modify fat intake alone, and advice to reduce sodium intake alone.

Hermione C Price, Vijay JayagopalCentre for Diabetes and Endocrinology, York Hospital, York, UKAbstract: We highlight a case of disabling myopathy following radioablative iodine treatment for follicular carcinoma of the thyroid. A 34-year-old man presented with a tender neck swelling, ultrasound and biopsy were suggestive of thyroid malignancy. Thyroidectomy was undertaken and histology confirmed follicular carcinoma of the thyroid. Treatment with ablative radioiodine followed and within days the patient developed disabling myopathy. Investigations to date do not reveal any other cause for the myopathy and there is no evidence to suggest that this is a paraneoplastic phenomenon. We believe this is the first reported case of ablative radioiodine-induced mypoathy.Keywords: thyroid neoplasms, muscular diseases, iodine radioisotopes