BJD

We were fortunate to have persuaded a group of distinguished experts to participate. The opening lecture was delivered by Professor Per-Henrik Groop from Helsinki, who is a leading expert in the field of diabetic nephropathy. The new QA session replaced the popular ABCD debate, and I hope was equally popular; it tackled the tricky topic of the value of early multiple interventions in diabetes. Professor Groop was joined by Professor Clifford Bailey for this interesting and interactive session. The late morning session covered a variety of clinical issues including new developments in the management of diabetic retinopathy, lipid therapeutics update and integrated pathways for severe hypoglycaemia.

The session after lunch (and networking, posters and stands) was a new session format which included four presentations of original research from our younger members. Unfortunately, the 5th Niru Goenka lecture had to be re-arranged due to unexpected circumstances. However, we were lucky that Professor Dev Singh filled that slot with a most thought provoking and entertaining talk on Glycation Gap, with some fascinating data to support his hypothesis. I have no doubt that we will hear more about this in the future and there may yet be another important "biological variation factor" in measurement which we conveniently ignore, which may turn out to explain clinical outcomes. A big thank you to Professor Dev Singh for this successful rescue mission. After refreshments (and networking, posters and stands), we were treated to an equally interesting topic of an update on adrenal disease, and the finale was a very informative session on “A year in type 1 diabetes”.

4th Exercise in Type 1 Diabetes (ExTOD) Annual Meeting

The 4th ExTOD Annual Meeting took place in Birmingham on Friday 13th October and was a huge success. The meeting was attended by over 300 delegates and differed from previous years. ABCD has joined hands with the Juvenile Diabetes Research Foundation (JDRF) to support the ExTOD group to make this meeting bigger and better. Watch the next news bulletin for the highlights of this meeting. ABCD hopes to build on the success of this year’s meeting in fulfilling its commitment to multiprofessional education and patient care.

Insulin Pump Network (IPN) UK and ABCD Spring Meeting: 23/24 May 2018 Grand Central Hotel Glasgow

Please make note of these important dates when we move to this exciting venue in Glasgow. We are working with the Caledonian Endocrine Society to come up with a balanced programme for diabetes and endocrine topics. As usual, the IPN meeting will take place the day before the ABCD meeting.

National Diabetes Consultant Mentorship Programme (NDCMP) and Continuous Professional Development (CPD) funding

ABCD is working very closely with Lilly and have secured the funding to run this programme for 2017–18 and 2018–19. We are also in discussion with other corporate sponsors to secure the long-term future of this innovative programme.

Non-availability of continuous glucose monitoring (CGM)

It has been brought to my attention that some CCGs are reluctant to fund CGM for those patients who have disabling and recurrent hypoglycaemia. We need to educate and remind our colleagues on the commissioning side that hypoglycaemia is a serious issue and that these people have an extremely poor quality of life and are prone to recurrent hospital admissions and ambulance calls, thereby increasing NHS expenditure. In addition, we have NICE appraisal technology with clear-cut indications, which has been shown to be of benefit in the clinical management of this group of patients. ABCD would like to hear more about this if you are having difficulties in your patch.

Free Style Libre (FSL)

FSL became available on the NHS on 1 Nov-ember 2017. There are a variety of opinions about the use of this novel technology to help people manage their diabetes, and there are anxieties about how this locally commissioned technology will be implemented. It is vital that we must avoid the post code lottery and take a unified approach to avoid this. T1 collaborative, led by our ex-Chair Dr Rob Gregory and supported by the ABCD executive team and IPN UK, are aspiring to produce guidance for dissemination, despite challenging time frames.

Replacement for ABCD honorary treasurer

Dr Tony Robinson will be stepping down from his role after a very successful 4 years in post. I thank him on your behalf for his hard work and pragmatism. This means ABCD will be seeking a new treasurer due to start next May, and calls for this role will be going out in late November and early December. Why not consider this important role to support and contribute to the executive team of ABCD.

John Wales Memorial Lecture

I am delighted to announce that ABCD has decided to honour its first chairman who sadly passed away this year by introducing a John Wales Memorial Lecture at its Spring Meeting in May 2018 or 2019. This lecture will take place just after our annual AGM and before our section dinner.

From the desk of Umesh Dashora

Rowan Hillson Award 2017

Joint British Diabetes Societies (JBDS) inpatient group has decided to continue the Rowan Hillson Award to identify best practices in diabetes care and share them nationally. Please watch this space for further announcements and encourage your teams to participate in this initiative which has been running successfully for the last three years. For further information contact u.dashora@nhs.net.

New JBDS guidelines on diabetes control during delivery published

Neonatal hypoglycaemia continues to remain a significant issue on labour wards. New guidelines on glycaemic management in pregnant women with diabetes on obstetric wards and delivery units are now published. JBDS hopes and believes that, with these guidelines, standard national practice and better care and outcome will follow. We encourage all delivery units to use the audit tool attached to the guidelines to improve practice in this area.

From the desk of Rebecca Reeve

Diabetes Quality in Care Awards

NHS teams from Liverpool, County Durham, Oxford and Southampton were among those recognised at the seventh annual Quality in Care (QiC) Diabetes Awards. The 2017 QiC Diabetes Awards also saw Birmingham consultant Dr Sandip Ghosh named Diabetes Healthcare Professional of the Year and the North West London Collaboration of CCGs pick up the Diabetes Team Initiative of the Year. This year QiC Diabetes was proud to work with NHS England, who gave their support to a brand new prize, the NHS England Outstanding Contribution Award for Services in Diabetes, which went to NHS Diabetes’ former Communications Manager Oliver Jelley. Held at Sanofi’s UK headquarters in Guildford, Surrey on Thursday 12 October, QiC Diabetes recognises initiatives that improve the quality of life for people living with diabetes, as judged by the NHS, patients and industry. For a full list of winning, highly commended, commended and finalist entries to the 2017 QiC Diabetes Awards visit www.qualityincare.org/diabetes.

NHS Diabetes Prevention Programme

The NHS Diabetes Prevention Programme (NHS DPP) is delivering on its commitment to make England the first country to have a national scale diabetes prevention programme. The first full year of the NHS DPP has been positive; more than 45,000 people were referred onto the programme in its first financial year, of which more than 20,000 took up the offer and attended the first initial assessment. 75% of England now has a NHS DPP provider in place and this is expected to reach full coverage by 2020 with an expected 100,000 interventions available each year after.

The scheme, which is run collaboratively by NHS England, Public Health England and Diabetes UK, is the first of its kind to target those at risk of developing diabetes and is part of a wider package of measures to support people with diabetes and those at risk, to stay fit and well.

Those referred onto the programme get tailored, personalised help to reduce risk. This includes education on healthy eating and lifestyle choices, reducing weight through bespoke physical exercise programmes and portion control, which together have been proven to reduce the risk of developing the disease. Data on retention and outcomes is not yet available due to the nature of the programme and data collection. It will be published in future reports. To find out more about the programme visit www.england.nhs.uk/ndpp.

Action Plan on Cardiovascular Prevention published

Public Health England (PHE) has published its Action Plan for Cardiovascular Disease Prevention, 2017 to 2018. The document highlights PHE’s past work to address cardiovascular disease (CVD), including 1.3m people receiving an NHS Health Check in 2016–17; 22,849 people signed up to the NHS Diabetes Prevention Programme; and the launch of the Heart Age tool which has been viewed by 2.9m people. Major initiatives planned for 2018 include: an evidence review of international case studies on CVD prevention; implementation of the Five Year Forward View next steps, including addressing familial hypercholesterolemia; and supporting the implementation of the NHS Health Checks programme.

Hypo Awareness Week

More than 340 sites have been taking part in a national campaign to raise awareness of hypoglycaemia. Hypo Awareness Week 2017 started on Monday 2 October and ran to Sunday 8 October, with hospitals, GP surgeries, charities and a few prisons all taking part. The campaign aims to raise awareness of hypoglycaemia in the UK by educating healthcare professionals about the short-term complication of diabetes. A total of 342 sites took part, up from 136 sites in 2016 and beating the previous record of 200-plus from the first year it took place in 2012. Around one in six hospital beds are occupied by a person with diabetes (17%), according to the 2016 National Diabetes Inpatient Audit (NaDIA) report. Hypo Awareness Week has been taking place annually since 2012 and during this period the prevalence of all hypoglycaemic episodes in hospital has decreased by 6%, according to the 2016 NaDIA report. Latest results from the bedside survey indicate that hypoglycaemic episodes in hospitals, both mild and severe, have decreased from 26% in 2011 to 20% in 2016. Mild hypoglycaemia has fallen from 23% in 2011 to 18% in 2016, while severe hypoglycaemia has dropped from 11% in 2011 to 8% in 2016. Participating hospitals and GP surgeries have been staging training events to raise awareness of the condition. Resources, including leaflets, guidelines and educational slides, have been used to help spread the word. They have been promoting the message on social media using the hashtags #HAW17 and #HypoAwarenessWeek

Pledge to allow every patient to access records through an app by end of 2018

Jeremy Hunt MP, Health Secretary, has pledged that, by the end of 2018, every patient in England should be able to access their medical records, book an appointment with a GP, order repeat prescriptions and access support for managing a long-term condition via an app. Speaking at the Health and Care Innovation Expo, he also announced the launch of MyNHS open data challenge, a £100,000 fund available for the most creative apps and digital tools to improve health services.

NICE update type 2 diabetes prevention guidelines

NICE has published its updated guideline on type 2 diabetes: prevention in people at high risk. The guideline aims to assist healthcare professionals to identify adults at high risk, and then provide those at high risk with an appropriate intensive lifestyle change programme to prevent or delay the onset of type 2 diabetes.

New research finds that patients aren’t given adequate control of their health and care

National Voices, a coalition of health and care charities, has published research suggesting that people are not given adequate control of their own health and care. The research examined whether policies intended to improve ‘person-centred care’ were in place and valued by patients themselves. Its key findings included: 3% of people with one or more long-term condition reported having a written plan; 39% of patients said their GP was ‘very good’ at involving them in decisions; and 38% of those taking medicines home received an explanation on side effects to watch out for. More positively, the study found that more than three quarters of patients said their healthcare professional listened to them. The report calls for more reporting on person-centred care measures and for variation in standards of care to be addressed.

Leading clinicians join GIRFT

Leading clinicians from across the NHS have joined the Getting It Right First Time (GIRFT) programme to lead reviews into a range of medical and surgical specialities. GIRFT has announced the appointment of surgical leads and senior advisors for 14 new work streams. GIRFT is a national programme designed to improve medical care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. Importantly, GIRFT is led by frontline clinicians who are expert in the areas they are reviewing. This means the data that underpin the GIRFT methodology are being reviewed by people who understand those disciplines and manage those services on a daily basis. The GIRFT team visit every trust carrying out the specialties they are reviewing, investigating the data with their peers and discussing the individual challenges they face.

Diabetes and Endocrinology Work Stream

Blindness from diabetes halves in Wales

New research published in the BMJ has found that the number of people in Wales diagnosed as blind or living with sight loss as a result of diabetes has almost halved between 2007 and 2015, following the introduction of a new national diabetic retinopathy screening programme in 2003. Headline findings are as follows:

Fellowship Report: Winston Churchill Memorial Fellowship Trust (Dr Tim Robbins)

The Winston Churchill Memorial Fellowship funds UK citizens to investigate inspiring practice in other countries and return with innovative ideas for the benefit of people across the UK. Dr Tim Robbins, a Diabetes and Endocrinology trainee at University Hospitals Coventry and Warwickshire NHS Trust travelled to the United States, visiting the American Diabetes Association, Beth Israel Deaconess Medical Centre, Harvard Medical School, the Patient Centered Outcome Research Institute and Cerner Corporation. Key learning points included the opportunities for wider adoption of digital health innovation in the UK targeting diabetes care, alongside increasing patient responsibility for their education through ‘patient competency’ frameworks. Further information on the Fellowship can be found at www.wcmt.org.uk or by contacting timothy.robbins@nhs.net.

Interesting recent research

(Umesh Dashora)

A rapid-fire collection of interesting recent developments in diabetes

A retrospective cohort study showed that prescriptions were continued even after a possible adverse reaction to statins in over 70% of patients. Patients who persevered with continued prescriptions had a lower cumulative incidence of cardiovascular events compared to those who stopped (12.2% vs 13.9%, p<0.001) in the 4 years following the adverse reaction.

In a study published in Diabetologia, the authors from Cambridge reported their work on systematically identified and pooled randomised controlled trials which attempted to see the impact of metformin therapy on reducing cardiovascular events. Although the relative risk of all outcomes with the exception of strokes favoured metformin over placebo or life style, none achieved statistical significance.

In a 12-week placebo-controlled double-blind phase 3 trial published in Menopause, a vaginal oestradiol preparation, TX-004HR, was associated with greater acceptance and patient satisfaction mainly due to reduction in vaginal dryness and led to reduced dyspareunia.

A transcutaneous browning agent patch has been shown to induce browning in adipose tissue. This microneedle-based patch delivers browning agents to the subcutaneous adipocyte and switches on browning at the target site. As a result, fat pad size is reduced, whole body energy expenditure is increased and type 2 diabetes improves in a diet- induced obesity mouse model.

Sodium intake was shown to be linked to a 43% and 73% increase in the risk of developing type 2 diabetes and latent autoimmune diabetes in adults (LADA), respectively, for each extra 2.5 g of salt consumed daily in research presented at this year’s annual meeting of the European Association for the Study of Diabetes (EASD).

In a 30-week randomised controlled trial published in the International Journal of Obesity, the authors showed that the efficiency of weight loss can be enhanced if the reduction (33%) in calorie intake is intermittent rather than continuous. The intermittent group had greater weight loss (14.1 vs 9.1 kg, p<0.001) and fat mass reduction (12.3 vs 8.0 kg, p<0.01). The authors concluded that the ‘rest periods’ may reduce compensatory metabolic responses and thus improve the chance of maintaining weight loss.

In an observational exploratory study over 11 years presented at the EASD meeting, women who regularly drank caffeinated coffee and tea had lower mortality (51%, 57% and 66% for 1, 1–2 and >2 cups of coffee per day and 80% for high consumption of tea), particularly from cardiovascular disease and cancer, for coffee and tea respectively after adjusting for multiple factors.

In research published in the Journal of the Federation of American Societies for Experimental Biology, chemicals found in green tea (i.e., epigallocatechin-3-gallate (EGCG)) were shown to reduce the cognitive defects induced by high fat and high fructose diet by regulating insulin receptor substrate-1 (IRS), cAMP response element binding protein (CREB) and brain derived neurotropic factor signalling pathways (among other chemicals) in a study performed on mice.

In a paper published in Nature Communications the researchers claim that insulinomas may hold the genetic code that may help treat and prevent diabetes. They have surveyed 38 human insulinomas and found that, at pathway level, the majority display genetic mutations and changes most prominently in the polycomb and trithorax families. These changes are associated with cell proliferations revealing candidate genes for beta cell regeneration.

Researchers showed that 10 of 11 indoor house dust extracts stimulated 3T3-L1 pre-adipocyte cells and led to significant triglyceride accumulation and/or proliferation at environmentally relevant levels (<20 μg of dust/well). This poses a potentially new environmental health hazard.

In a study published in Diabetologia, the researchers showed that people who consumed 14 drinks per week in men and 9 drinks per week in women had the lowest risk of developing diabetes (HR 0.57 and 0.42, respectively) compared with no alcohol intake. Men and women who consumed alcohol on 3–4 days per week had a lower risk of developing diabetes than those who consumed alcohol on <1 day per week (HR 0.73 and 0.68, respectively) after adjusting for confounders and weekly alcohol intake.

In a randomised controlled trial published in the Journal of Clinical Investigation, galantamine has been shown to reduce inflammation and insulin resistance in people with metabolic syndrome. Galantamine-treated patients had lower TNF (−2.57 pg/ml, p=0.035) and leptin (−12.02 ng/ml, p<0.0001) and higher adiponectin (2.71 μg/ml, p<0.0001) and IL-10 (1.32 pg/ml, p=0.002) compared with placebo. Galantamine also lowered insulin and HOMA-IR values.

In a prospective population-based cohort study over 16 years published in Annals of Internal Medicine, researchers showed that coffee consumption (both caffeinated and decaffeinated) is associated with lower total (HR 0.88, 0.82 and 0.82 for 1 cup, 2–4 cups and >4 cups per day, respectively, p<0.001)) and cause-specific (heart disease, respiratory disease, stroke, diabetes and kidney disease) mortality among various populations (African-Americans, Japanese Americans, Latinos and whites).

In a paper published in Neuropsychopharmacology, the researchers showed that high intensity interval training exercise, but not moderate exercise, is associated with decreased cerebral μ-opioid receptor (MOR) binding of MOR selective ligand in frontolimbic regions involved in pain, reward and emotional processing and is correlated with increased euphoria.

In a Danish register-based non-randomised controlled trial population, screening for diabetes in high-risk middle-aged adults was not associated with lower mortality or cardiovascular events in the screening group as a whole compared with the no-screening group (HR 0.99 and 0.99, respectively, NS).

Patients who were diagnosed with diabetes in a screening programme had a lower risk of cardiovascular disease and mortality compared with those who were diagnosed clinically in the no-screening group (HR 0.84 and 0.79, respectively) in a Danish study.

In a paper published in Diabetologia the authors found that clinically detected patients with diabetes (n=8642) had worse health outcomes than those who were diagnosed through a 10-yearly screening programme starting at the age of 30 in Sweden (n=1,024) in the same period (all-cause mortality hazard ratio 2.07). Even among the clinically detected cases, nearly half were never screened and had higher all-cause mortality compared with the other half who were participating in the screening programme but were diagnosed between screening episodes (HR 2.31 vs. 1.70). The patterns were similar for cardiovascular disease, renal disease and retinopathy.

In a recent prospective nationwide study, Professor Murphy and colleagues report that stillbirth rates have significantly reduced compared with 2002 and 2003 but other adverse outcomes have largely remained unchanged in pregnancies with diabetes. Glycaemic control before and during pregnancy remains suboptimal and needs to be improved. The percentage of women achieving HbA1c <48 mmol/mol in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7–22.2] for type 1, 37.0% [27.3–46.2] for type 2). The numbers of infants born preterm (21.7% vs. 39.7%) and large for gestational age (23.9% vs. 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p<0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs. 25.8/1000 births for type 1, p=0.0012; 10.5 vs. 29.2/1000 births for type 2, p=0.0091).

In a multicentre open-label randomised controlled trial published in the Lancet, the authors show that pregnant women who were assigned to the CGM group in addition to capillary blood glucose monitoring spent more time in target (68% vs. 61%, p=0.0034), less time hyperglycaemic (27% vs. 32%, p=0.0279), had comparable severe hypoglycaemia episodes (18 vs. 21) and time spent hypoglycaemic (3% vs. 4%, NS) compared with those in the capillary blood glucose monitoring arm. Neonatal outcomes were also better in the CGM group, with lower incidence of large for gestational age (OR 0.51, p=0.021), fewer neonatal intensive care admissions lasting more than 24 h (OR 0.48, p=0.0157) and fewer incidences of neonatal hypoglycaemia (OR 0.45, p=0.0250). The CGM group also had a one-day shorter length of hospital stay (p=0.0091). There were no apparent benefits of CGM in women who were planning pregnancy. The most common adverse event was skin reaction, which was higher in the CGM group (48% vs. 8%).

YDEF NEWS

Improving interest in our specialty

Recent data from the ST3 recruitment website (www.st3recruitment.org.uk) revealed that the specialty only filled 77% of places after two rounds in 2016. Compare this with other specialties and it becomes even more concerning: cardiology filled 100% of posts, gastroenterology 99% and geriatric medicine 83%. A recent YDEF conducted survey found that doctors and students wanted more experience and teaching on the subject in order to gain more understanding of the specialty.

As a result of this, we at YDEF planned a first national taster day, not only to increase awareness of the specialty but also enthusiasm and potentially improve recruitment figures for the future. With support from the Society for Endocrinology (SfE) and Association of British Clinical Diabetologists (ABCD) as well as Diabetes UK, plans were made for this inaugural event.

Taking place on 30 September 2017 in Birmingham, 70 medical students and junior trainees got to experience a ‘taster day’ of our specialty. With talks from a wide variety of enthusiastic and esteemed speakers, the aim of the day was to improve understanding whilst also providing tips for those interested in a career in the specialty.

The day was a success with a variety of light-hearted talks on our specialty including CV building, technology, patient experiences and clinical endocrinology. Attendees were enthused by the day and encouraged to think about the specialty as a career choice, with over 66% of attendees answering either ‘likely’ or ‘definitely’ when asked if they were likely to pursue a career in the specialty. Over 54% specifically stated the taster day as key to their decision.

Though this is a heartening start, we must aim to develop taster events locally to further encourage junior trainees to choose this specialty. YDEF have worked with colleagues in the North East to plan a regional taster day later in November. If you are interested in setting up your local taster day and need some advice or want to find out more about our taster day, please do not hesitate to contact us.

UPCOMING COURSES

YDEF Retinopathy 27–28 November

Now in its sixth year, this is the only retinopathy course specifically for registrars in our specialty. It continues to remain one of YDEF’s popular courses and was once again oversubscribed this year. Continuing to educate trainees on the specifics of retinopathy including grading and screening, this year the guest lecture details the relationship between obstructive sleep apnoea, bariatric surgery and retinopathy.

YDEF Wales 8–9 December

Another popular course, YDEF Wales this year is an excellent mix of diabetes, endocrinology and practical skills. From cystic fibrosis to pituitary tumours and talks on becoming a new consultant, the course remains a highlight for trainees across the UK.

NEYD 2018

We will soon be opening registration for a chance for trainees to enhance their presentation skills to an international audience. The next NEYD meeting will be taking place in the Netherlands and is an opportunity to exhibit and discuss your research in a relaxed environment. Abstracts that have already been submitted to conferences are welcome

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!

From the desk of the Chairman, Dinesh Nagi

Autumn meeting of ABCD (London, 10 November)