It is Diabetes week and it has been amazing and humbled to see various fundraising and awareness raising campaigns. JDRFUK and DiabetesUK have made a very effective and emotional video to raise awareness of type 1 diabetes so diagnosis is not delayed. In the early 90s there was a campaign in Parma region of Italy to raise awareness and was deemed to be very effective and has since been the benchmark for diabetes awareness campaigns. I think this new video will capture the imagination and hopefully will go viral!
I attended the Inpatient Diabetes in Scotland conference yesterday in Stirling. Nowadays I find small focused one day meetings actually more useful than vast annual jamborees! It was good to hear and share best practice and also in a way heartened to note that we are all in the same boat. Some of the important points (from all the excellent presentations) that I took home were
1. between 2003 and 2010 there was a 33% increase in incidence of Diabetic Ketoacidosis (DKA) in UK. Unclear why.
2.Thankfully mortality rates are unchanged in most reports and in USA and Taiwan a probable decrease in mortality. Mortality is significantly higher in over 70s
3. Scotland wide DKA protocol has been implemented and audit standards have been set. Public awareness is key- the Parma experience is a model.
4. Hypoglycemia is common in inpatients and management should be improved. Use of Hypobox has improved management but much more needs to be done. The direct cost associated with management of Severe Hypoglycemia is around £900 (Hammer etal J Med Econ 2009)
5. The English National Diabetes Inpatient Audit (NaDIA) has led to improvement in different areas of inpatient care. The Scots were advised to carry out their own McNaDIA! We are doing it our hospital next month.
6. The updated version of SCI-DC– the diabetes database in Scotland will have an inpatient module- excellent for identifying inpatients with diabetes. This hopefully can lead to a proactive management of diabetes in-hospital by teams as opposed to reactive management currently.
7. Think Glucose toolkit pilot has driven change in Dumfries and Galloway and may be rolled out in Scotland. Results from other pilots are awaited. Its crucial that local teams look at their service and adapt the campaign to suit their needs.
8. Jason Leitch gave an entertaining talk about the Scottish Patient Safety Program and its successes ( I had tweeted them earlier). Teams were good at implementing SPSP methodology for technical aspects of care but need to also apply it to patient centred care. NHS funding is “protected” in Scotland and only programs that improve both quality and efficiency will be looked at favorably.
9. Cost of inpatient diabetes care in Scotland is £301 million ie 12% of Scottish inpatient expenditure annually. http://eprints.gla.ac.uk/53646/
A video recording of this meeting will be available soon for all the enjoy. Lots to mull over but a very informative day. Nearly 150 delegates were present and glad to see patients and Diabetes UK were there to engage with the diabetes health care professionals (and a few anesthetists!)
The current issue of the journal Cell has a very interesting paper on the concept of personalomics. Personalised medicine has one of the buzz words in medicine, but a concept that has promised so much but delivered little. That is until now. With significant decrease in cost of gene sequencing we will be hearing about this more and more in the coming few years. in this study the scientists analyzed the genomic, transcriptomic, proteomic, metabolomic, and autoantibody profiles from a single individual over a 14 month period in relation to type 2 diabetes. This was presented as an Integrative personal omics profile (iPOP)- (why does “i” keep propping up wherever a cool concept is discussed). Nevertheless this is fascinating concept and hopefully it is filtered down to clinical practice in the next few years.
Anyone watch Horizon on BBC last week? It was titled “Truth about exercise”. I suggest you all watch it. Two concepts discussed and experimented on in the program were HIIT (High Intensity Interval Training) and NEAT (Non-exercise Activity Thermogenesis).
The work of Prof James Timmons in the field of HIIT was fascinating. HIIT improves aerobic fitness and insulin sensitivity after as little as 15 minutes exercise at maximal intensity over 2 weeks. Definitely much more than the 150 minutes recommended by DOH. It’s probably not for all but for a few may be just short enough to maintain interest. Prof Timmons has also identifies 11 genes that predict an individuals response to HIIT in terms of aerobic fitness and hopes before long to have a commercially available genetic test to see if you are a responder to HIIT in terms of aerobic fitness. Insulin sensitivity improved in all studied, so there is still considerable benefit with HIIT. . The original paper can be accessed here.
NEAT is referred to as The Crouching Tiger Hidden Dragon of Societal Weight Gain! Small steps everyday can improve fitness, maybe help in weight loss or weight maintenance at the very least. In Horizon James Levine explained how the chair ( a metaphor for sedentary behavior) is a killer. He suggests that we develop individual strategies to promote standing and ambulating time by 2.5 hours per day and also re-engineer our work, school, and home environments to render active living the option of choice. What we all need is a Walkstation!
So hopefully, by being a bit NEATer and taking a HIIT we all can improve our aerobic fitness and insulin sensitivity (but eat a lot less and smart if you want to lose weight).
The direct renin inhibitor Aliskiren was first granted regulatory approval as anti-hypertensive therapy in 2007. The approval was granted on basis of aliskiren’s effectiveness through six, placebo-controlled, eight-week clinical trials involving more than 2,000 patients with mild to moderate hypertension. The anti-hypertensive effect was maintained for up to one year across all demographic subgroups.
Interim analysis of the ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) study has shown higher adverse event rate in these high-risk patients receiving aliskiren (Rasilez/Tekturna, Novartis) combined with standard care. Specifically, an increased incidence for nonfatal stroke, renal complications, hyperkalemia and hypotension among those who had received 18 to 24 months of treatment with aliskiren as well as standard therapy.
Another blockbuster drug bites the dust! We have had a few patients on Aliskiren and now all are off it! One of my patients said “What next doctor? I was on Rosiglitazone and was taken off it and now this?” Glad I had counseled my patients when starting a new drug. Well, at least Metformin continues to provide good news.
The Food and Drug Administration in the US has delayed granting approval for a new class of anti-diabetic medication- the SGLT2 inhibitor Dapagliflozin. The advisory committee cited a possible increased risk of bladder and breast cancers and of liver injury. The FDA are being very careful due the Avandia affair. Will we ever see this in the market? I am not very hopeful.
Three papers published in Archives of Internal Medicine looks at the effectiveness of different patient education/counseling strategies on diabetes self-management and glycemic control (hemoglobin A1c [HbA1c] levels).
The real question being asked is “What type of patient education or counseling program will improve glycemic control for patients with diabetes in whom usual diabetes care is failing in high-functioning clinical settings?”
Counseling-based behavior change interventions depend heavily on a patient’s readiness to change and self-efficacy related to diabetes self-management and hence its not surprising that the various interventions only had limited success.
What we need is a way to filter out essential ingredients of the education program that are crucial particularly with regard to the educator counseling, intensity of support provided, and level of individual tailoring.