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Stress hyperglycaemia, is a common phenomenon, frequently associated with adverse outcomes in a number of prevalent conditions including myocardial infarction and stroke. Knowledge on stress hyperglycaemia evolved in tandem with knowledge relating to homeostasis, stress and disease and involved some of the world's most eminent thinkers. Despite this, it still remains under-recognised. This paper illustrates significant points in the history of stress hyperglycaemia, from antiquity through to the present day, as well as the challenges faced in translating research into clinical benefit for patients. Profiles of significant protagonists including Claude Bernard, Walter Cannon and Hans Seyle are presented, as well their roles in the emergence of modern-day terminology and pathophysiological models. Major themes such as ‘fight or flight’ and homeostasis are central to this discussion. Closer to the present day, the role of stress hyperglycaemia in a number of common medical conditions is explored in more detail. Contention around evidence for treatment and the future risk of diabetes mellitus are also discussed.

Hypercalcaemia is a common problem which may present to the Acute Medical Unit. Primary hyperparathyroidism (PHPT) and malignancy are the commonest causes of hypercalcaemia, accounting for over 90% of cases. Assessment of parathyroid hormone (PTH) levels is key to determining whether hypercalcaemia is parathyroid-mediated. Initial systematic assessment and adequate rehydration are important to help make the underlying diagnosis and determine longer-term management. The medical management of primary hyperparathyroidism not requiring surgery, with Cinacalcet is highlighted.

Data obtained during the care of people with diabetes mellitus may be used to advance research, improve quality, encourage innovation and support better self-care. However, the perspective of people living with diabetes is less well understood. This study examines the views of people with diabetes regarding access to electronic health records (EHRs) for health care and research. Survey data from a sub-group of 404 individuals with diabetes were analysed from a dataset of 5331 West London participants randomly sampled in a cross-sectional survey. These findings were explored in more detail in a focus group discussion involving people with diabetes. Sixty-seven percent of people with diabetes would support the inclusion of their full records on a national EHR for purposes of personal health provision. The vast majority (91%) would prefer to have access to their own full medical history rather than a truncated version. Seventy-nine percent said they would allow their EHR to be used for research: 51% allowing their records to be shared without identifiers and 28% being supportive of access to their identifiable information. A number of themes emerged from the focus group discussion on integrated EHRs, including expectations for improved communication with health professionals, increased participation in the consultation process, responsibility for self-care and data sharing for the greater good. In conclusion, wider sharing of health information may address some of the challenges diabetes care entails, although striking a balance between information fragmentation and sharing remains crucial to improve health, research and quality outcomes. Copyright © 2016 John Wiley & Sons.

Hypercalcaemia is a common problem which may present to the Acute Medical Unit. Primary hyperparathyroidism (PHPT) and malignancy are the commonest causes of hypercalcaemia, accounting for over 90% of cases. Assessment of parathyroid hormone (PTH) levels is key to determining whether hypercalcaemia is parathyroid-mediated. Initial systematic assessment and adequate rehydration are important to help make the underlying diagnosis and determine longer-term management. The medical management of primary hyperparathyroidism not requiring surgery, with Cinacalcet is highlighted.

Every person with diabetes in the United Kingdom should have access to annual digital retinal photographs to screen for diabetic retinopathy. Our experience is that medical students, junior hospital doctors and general practitioners are all concerned that they may not be able to interpret these pictures. We examined several different groups to determine their baseline level of knowledge and to see if minimal education could improve their ability to diagnose diabetic retinopathy in retinal photographs. Twenty-eight fourth-year medical students, 16 foundation year 1 (FY1) doctors, 17 core medical trainees/specialist medical registrars and 12 general practitioners were each shown 20 retinal images. All images were 45° macula centred retinal photographs: 10 normal and 10 with diabetic retinopathy. Participants were asked to classify them as normal or abnormal (diabetic retinopathy present) both before and after a five-minute educational session on the lesions seen in diabetic retinopathy. The results showed that 3.6% (1/28) of medical students pre-education and 25% (7/28) post-education achieved a sensitivity >80% and specificity >95%, as per national guidelines. Mean sensitivities improved from 78% to 89% for fourth-year medical students, 71.9% to 83.1% for FY1 doctors, 88% to 91% for core medical trainees/specialist registrars and 61% to 82% for general practitioners. Health care professionals are increasingly able to access retinal images and are concerned that they may not be able to interpret these images. While the baseline ability of these groups to screen for diabetic retinopathy was variable, their accuracy was significantly improved with a simple and brief intervention. These results suggest that all participants should revise their knowledge on this topic and others should think about doing so. Copyright © 2010 John Wiley & Sons.

benefits of thrombolysis in people with diabetes and an acute myocardial infarction are well grounded. Life saving treatment may be inappropriately withheld due to concerns regarding retinal haemorrhage and subsequent visual impairment. We believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis, irrespective of their retinal appearance. We therefore audited our junior doctors to assess their views on thrombolytic treatment in patients with differing degrees of diabetic eye disease. The participating doctors were provided with the case of a man with long-standing type 2 diabetes and an acute anterior myocardial infarction, along with five unlabelled retinal photographs including a normal eye, background diabetic retinopathy, pre-proliferative retinopathy, proliferative retinopathy, and maculopathy. The doctors were then asked if the patient should or should not receive thrombolysis. One quarter of the doctors surveyed would not give thrombolysis in the presence of a normal retina or background disease. A quarter would not give thrombolysis with maculopathy and two thirds would not treat in the presence of pre-proliferative retinopathy. Over two thirds would not treat those with proliferative disease. Although more senior doctors were more likely to give thrombolysis in the presence of increasing diabetic eye disease than their juniors colleagues, these results suggest that some patients may not receive appropriate potentially life saving therapy. Better education of junior doctors to avoid this oversight is therefore necessary. Copyright © 2007 John Wiley & Sons. Practical Diabetes Int 2007; 24(5): xxx-xxx

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89 % would thrombolyse such a patient with normal fundi, 55 % with background diabetic retinopathy, 54 % if this also involved the macula, and 26 % if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately. Copyright © 1998 John Wiley & Sons, Ltd.

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89% would thrombolyse such a patient with normal fundi, 55% with background diabetic retinopathy, 54 % if this also involved the macula, and 26% if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately.

Random blood glucose (RBG) assays are commonly used to screen for diabetes mellitus. Guidelines for investigation of patients with a RBG < 7.8mmol/l are included in a handbook given to all junior doctors in our hospital. We assessed how well this recommendation was known amongst junior doctors requesting and interpreting these tests, and also their knowledge of the World Health Organisation (WHO) criteria for the diagnosis of diabetes. Of the 58 doctors asked, 55% did not know the correct cut-off for investigation of a RBG (19% used 10.0mmol/l and 12% used 11.1mmol/l). Knowledge of the WHO criteria for diagnosing diabetes was also poor, with only 72% (42/58) knowing the fasting venous plasma level and 52% (30/58) the two-hour post-prandial level. Many people have a RBG performed but these results suggest a significant proportion will not be adequately investigated. Junior doctors' knowledge of this important information should therefore be re-assessed and improved when necessary.

The patient A 76 year old hypertensive woman presented with massive haemoptysis and right-sided pleuritic chest pain. Investigations A chest radiograph and computed tomography (CT) were performed. Comment In the majority of cases of thoracic aortic dissection, the predominant presenting symptom is chest pain, occurring in over 90% ofcases. Haemoptysis is a rare but well-documented complication, occurring in 6% of cases.' It may rarely be the sole presenting feature2 and may occur in association with a mediastinal haematoma.

The prevalence of diabetes mellitus increases with advancing age but often remains undiagnosed. We examined the use of a blood glucose assay, performed on admission in 515 consecutive acute admissions, aged 65 years and over as an initial screening test for diabetes mellitus. Of these, 7.6% were previously known to have diabetes and 4.7% were newly diagnosed on the basis of subsequent fasting blood glucose estimations. Using a random blood glucose level ≥8.0mmol/1, 18.5% of those screened needed further investigation. Although this method has been used for many years to screen for diabetes a formal comparison with a glucose tolerance test is needed before it can be used as the sole screening test.