Comorbidities, complications and mortality in people of South Asian ethnicity with type 1 diabetes compared with other ethnic groups : a systematic review

Objective The aim of this systematic review is to explore the association of South Asian (SA) ethnicity on comorbidities, microvascular and macrovascular complications and mortality compared with other ethnic groups in people with type 1 diabetes mellitus (T1DM). Design Systematic review. Method A systematic literature search strategy was designed and carried out using Medline and Embase for full-text and abstract studies published in English from 1946 to February 2016. The initial search identified 4722 papers. We assessed 305 full-text articles in detail for potential inclusion. Ten papers met the inclusion criteria for review and an additional one paper was included from our secondary search strategy using the bibliography of included studies. In total, 11 studies were included. Eligibility criteria for selecting studies Studies were included if they were published in English, involved SA participants with T1DM and compared them with non- SA participants and assessed one of the outcomes of comorbidities, microvascular complications, macrovascular complications and mortality. Results SA with T1DM have higher mortality compared with white Europeans (WE), mainly contributed to by excess cardiovascular disease. SA have significantly higher glycated haemoglobin (HbA1c), lower high-density lipoprotein (HDL) and lower rates of neuropathy compared with WE. There were no differences in rates of retinopathy and nephropathy. Compared with Africans, SA had lower levels of microalbuminuria, HbA1c and systolic blood pressure and higher HDL levels. There were no significant differences in the remaining outcomes: cardiovascular disease, retinopathy, neuropathy and body mass index. Furthermore, SA have higher HbA1c levels than Malay and Chinese and higher waist hip ratio and lower HDL levels compared with Chinese only. Conclusion Our analysis highlights ethnic disparity in macrovascular outcomes that is so evident for type 2 diabetes mellitus may also be present for SA patients with T1DM. We highlight the need for a large, prospective, cohort study exploring the effect of ethnicity in a uniform healthcare setting

Clinical decision support systems in the care of hospitalised patients with diabetes

This thesis explored the role of health informatics (decision support systems) in caring for hospitalised patients with diabetes through a systematic review and by analysing data from University Hospital Birmingham, UK. Findings from the thesis: 1) highlight the potential role of computerised physician order entry system in improving guideline based anti-diabetic medication prescription in particular insulin prescription, and their effectiveness in contributing to better glycaemic control; 2) quantify the occurrence of missed discharge diagnostic codes for diabetes using electronic prescription data and suggests 60% of this could be potentially reduced using an algorithm that could be introduced as part of the information system; 3) found that hypoglycaemia and foot disease in hospitalised diabetes patients were independently associated with higher in-hospital mortality rates and longer length of stay; 4) quantify the hypoglycaemia rates in non-diabetic patients and proposes one method of establishing a surveillance system to identify non diabetic hypoglycaemic patients; and 5) introduces a prediction model that may be useful to identify patients with diabetes at risk of poor clinical outcomes during their hospital stay

The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use

Aims: Diabetic ketoacidosis (DKA) is a commonly encountered metabolic emergency. In 2014 a national survey was conducted looking at the management of DKA in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, costs of treating DKA were not reported. Methods: We used a ‘bottom up’ approach to cost analysis to determine the total expense associated with treating DKA in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. Results: Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days, respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of DKA was £2064 per patient (95% CI: £1800, 2563). Conclusion: Despite relatively short stays in hospital, costs for managing episodes of DKA in adults were relatively high. Assumptions made in calculations did not take into account prolonged hospital stay due to co-morbidities nor costs incurred as a loss of productivity. Therefore the actual costs to the healthcare system and society in general are likely to be substantially higher

Gestational dyslipidaemia and adverse birthweight outcomes : a systematic review and meta-analysis

Background Low and high birthweight is known to increase the risk of acute and longer‐term adverse outcomes, such as stillbirth, infant mortality, obesity, type 2 diabetes and cardiovascular diseases. Gestational dyslipidaemia is associated with a numbers of adverse birth outcomes, but evidence regarding birthweight is still inconsistent to reliably inform clinical practice and treatment recommendations. Objective The aim of this study was to explore the relationship between maternal gestational dyslipidaemia and neonatal health outcomes, namely, birthweight, metabolic factors and inflammatory parameters. Methods We searched systematically Embase, MEDLINE, PubMed, CINAHL Plus and Cochrane Library up to 1 August 2016 (with an updated search in MEDLINE at the end of July 2017) for longitudinal studies that assessed the association of maternal lipid levels during pregnancy with neonatal birthweight, or metabolic and inflammatory parameters up to 3 years old. Results Data from 46 publications including 31,402 pregnancies suggest that maternal high triglycerides and low high‐density‐lipoprotein cholesterol levels throughout pregnancy are associated with increased birthweight, higher risk of large for gestational age and macrosomia and lower risk of small‐for‐gestational age. The findings were consistent across the studied populations, but stronger associations were observed in women who were overweight or obese prior to pregnancy. Conclusions This meta‐analysis suggested that the potential under‐recognized adverse effects of intrauterine exposure to maternal dyslipidaemia may warrant further investigation into the relationship between maternal dyslipidaemia and birthweight in large prospective cohorts or in randomized trials

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

AIM: To examine, in a national survey, the outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance.  METHODS: Data were collected in a standardized form covering clinical and biochemical outcomes, risk and discharge planning. The form was sent to all UK diabetes specialist teams (n = 220). Anonymized data were collected on five consecutive patients admitted with DKA between 1 May 2014 and 30 November 2014.  RESULTS: A total of 283 forms were received (n = 281 patients) from 72 hospitals, of which 71.4% used the national guidelines. The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. The median times to starting 0.9% sodium chloride and intravenous insulin were 41.5 and 60 min, respectively. The median time to resolution was 18.7 h and the median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred, with 27.6% of patients developing hypoglycaemia and 55% reported as having hypokalaemia. There were also significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 h, but 95% were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information.  CONCLUSION: Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk

Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding:cohort study

Objectives To investigate whether the introduction of performance targets for anticoagulation in atrial fibrillation (AF) was associated with a change in use of the ‘resolved AF’ code.Design Retrospective cohort studies.Setting Data from The Health Improvement Network, a UK database of electronic patient records, from 2000 to 2016.Participants 250 788 adult patients aged ≥18 years with a diagnosis of AF, including 14 757 with an incident diagnosis of ‘resolved AF’.Main outcome measures Annual and monthly incidence of ‘resolved AF’ from 2000 to 2016. Among patients with ‘resolved AF’, for each year we calculated median duration of the preceding AF diagnosis and the proportion prescribed anticoagulants prior to ‘resolved AF’.Results Incidence of ‘resolved AF’ increased from 5.7 to 26.3 per 1000 person-years between 2005 and the introduction of AF performance targets in 2006. Compared with the years prior to the introduction of the performance targets, incidence has remained higher in every year since their implementation. Since 2007, monthly incidence has been highest between January and March. Between 2005 and 2006, median duration between AF and ‘resolved AF’ diagnoses increased from 276 days (9 months) to 1343 days (3 years 8 months). Among ‘resolved AF’ patients with CHA2DS2-VASc score ≥1, 81.9% (95% CI 81.1 to 82.6) had no current anticoagulant prescription, and 62.3% (95% CI 61.4 to 63.2) had no record of any anticoagulant prescription.Conclusion The introduction of AF performance targets was followed by a large increase in use of the ‘resolved AF’ code, particularly in the months immediately before practices make their anticoagulant performance target submissions. Although most AF patients are prescribed anticoagulants, few patients diagnosed with ‘resolved AF’ are prescribed anticoagulants and most have never been prescribed them. Untreated patients are much more likely to be coded as having ‘resolved AF’

Safety of D-ribose as a novel food pursuant to Regulation (EU) 2015/2283

Following a request from the European Commission, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to deliver an opinion on D-ribose as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The applicant intends to market the NF as ingredient in a variety of foods, food supplements and in certain foods for specific groups. The NF is produced by fermentation using a transketolase-deficient strain of Bacillus subtilis and marketed as Bioenergy Ribose (TM). The information provided on the batch-to-batch variability, specifications, stability, production process and history of the organism used as a source of the NF is sufficient and does not raise safety concerns. The Panel considers that the effects observed in a subchronic toxicity study in rats could be the consequence of nutritional imbalances, but toxicological effects could not be ruled out; from this study, the Panel derived a No observed adverse effect level (NOAEL) of 3.6 g/kg body weight (bw) per day. From the human studies indicating a potential decrease in glucose levels and/or the occurrence of transient symptomatic hypoglycaemia at intakes of 10 g of D-ribose, the Panel defined 70 mg/kg bw per day as the NOAEL with respect to hypoglycaemia that can be considered applicable for adults. For children, the Panel acknowledges the lack of human data directly relevant for this population group. Based on the NOAEL derived from the subchronic toxicity study in rats, an acceptable level of intake of 36 mg/kg bw per day was defined that would also take into account the potentially increased sensitivity of certain population groups to hypoglycaemia. The Panel concludes that the NF is safe for the general population at intake levels up to 36 mg/kg bw per day and considers that the safety of the NF at the intended uses and use levels as proposed by the applicant has not been established. (C) 2018 European Food Safety Authority. EFSA Journal published by John Wiley and Sons Ltd on behalf of European Food Safety Authority.Peer reviewe

Trends in the prevalence and pharmacological management of migraine during pregnancy in the UK, 2000–2018

Background: Migraine is common in women of reproductive age. This study aimed to (1) describe the prevalence of migraine in pregnant women in the UK, (2) identify drugs commonly prescribed for migraine during pregnancy and (3) identify characteristics associated with being prescribed medication for migraine during pregnancy. Methods: The Clinical Practice Research Datalink pregnancy register, a database of pregnancy episodes identified in anonymised primary care health records, was used. Crude and age-standardised prevalence of migraine during pregnancy and the proportion of women with migraine prescribed drugs used for migraine management were calculated for each year between 2000 and 2018. Logistic regression was used to describe the relationship between patient characteristics and being prescribed migraine medication during pregnancy. Results: 1 377 053 pregnancies were included, of which 187 328 were in women with a history of migraine. The age-adjusted prevalence increased from 11.4% in 2000 to 17.2% in 2018. There was an increase in the rates of prescription for numerous medications for the management of migraine. Older women (adjusted OR (aOR) 1.41 (1.20 to 1.66)), women of black (aOR 1.40 (1.32 to 1.48)) and South Asian ethnicity (aOR 1.48 (1.38 to 1.59)), those living in the most deprived areas (aOR 1.60 (1.54 to 1.66)), women who were obese (aOR 1.39 (1.35 to 1.43)), smokers (aOR 1.15 (1.12 to 1.18)) and those with comorbid conditions were more likely to receive a prescription during pregnancy. Conclusions: Rates of recorded migraine have increased over the past two decades as well as rates of prescribing in women with migraine. Higher prescribing rates are seen in certain groups, which has the potential to exacerbate health inequalities