Factors associated with glycaemic control in adults with Type 1 diabetes: a registry-based analysis including 7601 individuals from 34 centres in Norway.

AIMS: To use data from the Norwegian Diabetes Registry for Adults and Statistics Norway to assess factors associated with glycaemic control in type 1 diabetes. METHODS: The analyses included all individuals aged ≥18 years who had a type 1 diabetes duration of >2 years and a recorded value in the registry between 2013 and 2015 (n=7601). Predicted mean HbA1c levels for subgroups of participants were assessed using linear regression analysis. RESULTS: Young age (18-25 years), low education levels, smoking, living alone, exercising infrequently, monitoring glucose infrequently, high insulin requirements, low frequency of symptomatic hypoglycaemia, history of ketoacidosis and a BMI <18.5 kg/m2 were associated with a 2-12-mmol/mol (0.2-1.1%) higher HbA1c level. Those with 10-15 years of diabetes duration had 5-mmol/mol (0.5%) higher HbA1c level than those who had a diabetes duration of 2-5 years. Sex, participation (ever) in a diabetes education course, or ever experiencing serious hypoglycaemia were not associated with glycaemic control. CONCLUSIONS: We present representative national data on factors that were associated with glycaemic control. A better understanding and awareness of these factors, together with technological advances in diabetes management, could lead to more personalized management strategies, better glycaemic control and a lower risk of diabetes complications.

Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in Type 2 diabetes care in Norway.

AIMS: To assess population, general practitioner (GP) and practice characteristics associated with the performance of microvascular screening procedures and to propose strategies to improve Type 2 diabetes care. METHODS: A cross-sectional survey in Norway (281 GPs from 77 practices) identified 8246 people with a Type 2 diabetes duration of 1 year or more. We used multilevel regression models with either the recording of at least two of three recommended screening procedures (albuminuria, monofilament, eye examination) or each procedure separately as dependent variable (yes/no), and characteristics related to the person with diabetes, GP or practice as independent variables. RESULTS: The performance of recommended screening procedures was recorded in the following percentages: albuminuria 31.5%, monofilament 27.5% and eye examination 60.0%. There was substantial heterogeneity between practices, and between GPs within practices for all procedures. Compared with people aged 60-69 years, those aged < 50 years were less likely to have an albuminuria test performed [odds ratio (OR) 0.75, 95% CI 0.61 to 0.93] and eye examination (OR 0.79, 95% CI 0.66 to 0.95). People with macrovascular disease had fewer screening procedures recorded (OR 0.68, 95% CI 0.59 to 0.78). Use of an electronic diabetes form was associated with improved screening  (OR 2.65, 95% CI 1.86 to 3.78). GPs with high workload recorded fewer procedures (OR 0.59, 95% CI 0.39 to 0.90). CONCLUSIONS: Performance of screening procedures was suboptimal overall, and in people who should be prioritized. Performance varied substantially between GPs and practices. The use of a structured diabetes form should be mandatory.

Circulating acetaminophen metabolites are toxicokinetic biomarkers of acute liver injury.

Acetaminophen (paracetamol-APAP) is the most common cause of drug-induced liver injury in the Western world. Reactive metabolite production by cytochrome P450 enzymes (CYP-metabolites) causes hepatotoxicity. We explored the toxicokinetics of human circulating APAP metabolites following overdose. Plasma from patients treated with acetylcysteine (NAC) for a single APAP overdose was analyzed from discovery (n = 116) and validation (n = 150) patient cohorts. In the discovery cohort, patients who developed acute liver injury (ALI) had higher CYP-metabolites than those without ALI. Receiver operator curve (ROC) analysis demonstrated that at hospital presentation CYP-metabolites were more sensitive/specific for ALI than alanine aminotransferase (ALT) activity and APAP concentration (optimal CYP-metabolite receiver operating characteristic area under the curve (ROC-AUC): 0.91 (95% confidence interval (CI) 0.83-0.98); ALT ROC-AUC: 0.67 (0.50-0.84); APAP ROC-AUC: 0.50 (0.33-0.67)). This enhanced sensitivity/specificity was replicated in the validation cohort. Circulating CYP-metabolites stratify patients by risk of liver injury prior to starting NAC. With development, APAP metabolites have potential utility in stratified trials and for refinement of clinical decision-making.

Treatment intensification with an insulin degludec (IDeg)/insulin aspart (IAsp) co-formulation twice daily compared with basal IDeg and prandial IAsp in type 2 diabetes: a randomized, controlled phase III trial.

AIMS: To evaluate the efficacy and safety of two insulin intensification strategies for patients with type 2 diabetes previously treated with basal insulin--insulin degludec (IDeg) and insulin aspart (IAsp)--administered as a co-formulation (IDegAsp) or as a basal-bolus regimen (IDeg and IAsp in separate injections). METHODS: This 26-week, open-label, treat-to-target, phase IIIb, non-inferiority trial randomized patients (1 : 1) to IDegAsp twice daily with main meals (n = 138; IDegAsp group) or IDeg once daily and IAsp 2-4 times daily (n = 136; IDeg+IAsp group). RESULTS: After 26 weeks, the mean glycated haemoglobin (HbA1c) level was 7.0% (53 mmol/mol) for the IDegAsp group and 6.8% (51 mmol/mol) for the IDeg+IAsp group (Δ%HbA1c from baseline -1.31 and -1.50%, respectively). The non-inferiority of IDegAsp versus IDeg+IAsp was not confirmed for mean change in HbA1c [estimated treatment difference (ETD) 0.18, 95% confidence interval (CI) -0.04, 0.41; p = non-significant]. No significant differences were observed in the proportion of patients achieving HbA1c <7.0% (56.5 and 59.6%, respectively). IDegAsp treatment resulted in a significantly lower total daily insulin dose, a smaller change in body weight, numerically lower rates of confirmed hypoglycaemia (self-reported plasma glucose <3.1 mmol/l; rate ratio 0.81; p = non-significant), and nocturnal confirmed hypoglycaemic episodes (rate ratio 0.80; p = non-significant) versus IDeg+IAsp. Patient-reported outcome scores for social functioning were significantly higher for IDegAsp versus IDeg+IAsp (ETD 2.2; 95% CI 0.3, 4.1; p < 0.05). CONCLUSIONS: Both intensification strategies effectively improved glycaemic control. Although non-inferiority was not confirmed, there were no significant differences between the groups that could affect clinical utility.

Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison.

AIMS: Improving glycaemic control in people with Type 1 diabetes is known to reduce complications. Our aim was to compare glycaemic control among people with Type 1 diabetes using data gathered in regional or national registries. METHODS: Data were obtained for children and/or adults with Type 1 diabetes from the following countries (or regions): Western Australia, Austria, Denmark, England, Champagne-Ardenne (France), Germany, Epirus, Thessaly and Thessaloniki (Greece), Galway (Ireland), several Italian regions, Latvia, Rotterdam (The Netherlands), Otago (New Zealand), Norway, Northern Ireland, Scotland, Sweden, Volyn (Ukraine), USA and Wales) from population or clinic-based registries. The sample size with available data varied from 355 to 173 880. Proportions with HbA1c < 58 mmol/mol (< 7.5%) and ≥ 75 mmol/mol (≥ 9.0%) were compared by age and sex. RESULTS: Data were available for 324 501 people. The proportions with HbA1c 58 mmol/mol (< 7.5%) varied from 15.7% to 46.4% among 44 058 people aged < 15 years, from 8.9% to 49.5% among 50 766 people aged 15-24 years and from 20.5% to 53.6% among 229 677 people aged ≥ 25 years. Sex differences in glycaemic control were small. Proportions of people using insulin pumps varied between the 12 sources with data available. CONCLUSION: These results suggest that there are substantial variations in glycaemic control among people with Type 1 diabetes between the data sources and that there is room for improvement in all populations, especially in young adults.

The epidemiology and management of adult poisonings admitted to the short-stay ward of a large Scottish emergency department.

BACKGROUND AND AIMS: The emergency department of Aberdeen Royal Infirmary receives around 68,000 new adult admissions annually. All poisoning cases are admitted to a 14-bedded short-stay ward, except those admitted to intensive care or immediately discharged. This study aimed to analyse epidemiological trends and management of short-stay ward admissions for poisonings. METHOD AND RESULTS: Adult (>13 years) poisoning presentations admitted to the emergency department short-stay ward of Aberdeen Royal Infirmary from 1 January-31 December 2009 were retrospectively reviewed using patient discharge summaries. During 2009, there were 1062 poisoning cases, of which repeat episodes were responsible for 15%. The mean age of presentation was 33.9 years (SD 14.4) and there was a female preponderance (62%). Almost half of poisonings were polypharmacy, alcohol was involved in 40% of cases and overdoses most commonly involved paracetamol (43%). Management involved basic observations only (66%), N-acetylcysteine (24%), naloxone (4%) and activated charcoal (1%). Liaison psychiatry reviewed 84% presentations and admitted 9% to the psychiatric unit. CONCLUSIONS: The short-stay ward is important for acute management of poisonings and the data gained from this study should help to direct patient services appropriately.

Sledging is still a seasonal source of serious injury in Scottish children.

In 2002 it was highlighted that sledging results in serious injuries in the paediatric population and safety recommendations were made. The aim of this study was to re-examine the number, severity and aetiology of sledging-related trauma. This was a retrospective study performed in the Paediatric Emergency Department (PED) of the Royal Aberdeen Children's Hospital (RACH) during two periods totalling 12 days, when there was continuous snow ground cover. Records of all attendances were scrutinized to identify patients with sledging injuries. The nature, mechanism and severity of injury, and subsequent management were then analysed. Of 403 PED attendances, 45 (11%) were sledging related with 16 (36%) fractures and 13 (29%) head injuries. Eight patients (18%) were admitted to hospital and three (7%) required an operation. Collision with a stationary object was the most common reason for injury (51%), followed by the adoption of a dangerous sledging position or use of a stationary jump. No patients were wearing a helmet. In conclusion, there has been little change in the epidemiology and aetiology of paediatric sledging injuries since 2002. Work is needed to inform parents of the previously recommended safety measures that could reduce the morbidity of this activity without detracting from the enjoyment.

How accurate are the references in Emergency Medical Journal?

OBJECTIVE: To determine the accuracy of references in Emergency Medicine Journal during 2003. MATERIALS AND METHODS: All references cited in Emergency Medicine Journal during 2003 were examined carefully, and the accuracy of the citations was checked against reliable electronic and manual resources. References were categorised as correct or incorrect. The errors were classified as minor if the integrity of the reference was not greatly compromised and major if the error severely detracted from the quality of the reference. RESULTS: Overall, errors were found in 19% of all citations checked (n = 2561), and in 8% the errors were major and markedly detracted from the quality of the reference. CONCLUSIONS: Citation errors reflect badly on authors and the publishing journal and may reflect underlying flaws in other areas of the research published. It is hoped that identification of this problem will lead to attempts to improve the accuracy of reference citation in the emergency medicine literature and to an improvement in the credibility of research in our specialty.

Kaposiform haemangioendothelioma: case report and review of the literature.

Kaposiform haemangioendothelioma (KHE) is a rare vascular tumour, predominantly of infancy and early childhood, that has a close association with Kasabach-Merritt syndrome. Despite benign histology, this tumour frequently behaves aggressively, causing significant morbidity and mortality as a result of the compression and invasion of surrounding structures as well as from associated haematological and lymphoproliferative syndromes. There is a need for a high index of suspicion when presented with large, enlarging or abnormal vascular lesions in infancy and, less commonly, in adulthood. An early diagnosis of KHE can lead to prompt treatment, which may be life saving. To date, there have been only four reported cases of KHE occurring in patients over the age of 18 years. We report an otherwise well 26-year-old woman who presented with a KHE of the left thigh, and briefly review the literature. We believe this to be the second reported case of KHE in the UK and the first in an adult patient.

Comparison of urinary albumin excretion rate in overnight urine and albumin creatinine ratio in spot urine in diabetic patients in general practice.

OBJECTIVE: To evaluate whether measurement of albumin creatinine ratio (ACR) on a spot urine specimen can replace a timed overnight collection of urine albumin excretion rate (UAER) in patients with diabetes in primary care. DESIGN: Patients with diabetes attending Rønvik Health Centre were asked to bring a timed overnight collection of urine for measurement of UAER. They were also asked to void a urine specimen for measurement of albumin creatinine ratio. SETTING: Primary health care. SUBJECTS: One-hundred-and-six persons with diabetes (47 women, 59 men) aged 13 to 78 years. RESULTS: The sensitivity and specificity of ACR with cut-off values of 2.5 mg/mmol for men and 3.5 mg/mmol for women compared to UAER with cut-off value of 20 mg/24 h was 90%. CONCLUSIONS: Spot urine ACR analysed on a DCA 2000 can replace a timed (overnight) collection of urine and measurement of UAER when diabetic patients are reviewed in general practice. This simplifies procedures for the patient as a timed urine collection is no longer necessary. Another advantage is that the results are available after 7 min.

Standards for the electronic health record, emerging from health care's Tower of Babel.

This paper considers the standardization of an Electronic Health Record (EHR). Relations between several distinct medical datasets and information systems are mapped in order to derive a more precise definition of the EHR. Two international efforts to establish standards for the EHR are presented and critiqued. Strategies for standardizing the EHR are analyzed and recommendations are provided for approaching the standardization process.

[Guidelines for diagnosis and treatment of sore throat]. / Retningslinjer for diagnostikk og behandling av sår hals.

BACKGROUND: Available guidelines for the diagnosis and treatment of sore throat give conflicting recommendations. Our aim was to develop evidence-based guidelines. MATERIAL AND METHODS: We searched The Cochrane Library, Medline and other sources for systematic reviews and other evidence that met explicit inclusion criteria for all of the relevant options and outcomes we identified. The validity of included studies was assessed. Draft recommendations based on assessment of this evidence were widely circulated and discussed in focus groups with patients and physician assistants. RESULTS: Throat infections are self-limiting and complications rare. Penicillin shortens the duration of symptoms in tonsillitis caused by beta-haemolytic streptococci and reduces the risk of complications. Penicillin has adverse effects and increases the risk of reinfections. Patients with sore throat should usually be treated without antibiotics. Visiting a physician is normally unnecessary. Antibiotics should be considered in serious cases or if the patient prefers this, but should only be prescribed for throat infections caused by beta-haemolytic streptococci. The diagnosis should be based on clinical criteria and a rapid antigen test in cases of doubt. INTERPRETATION: Benefits of antibiotics must be weighed against harms. Patients should be given good information and involved in decision/making if they want antibiotics.

[Is treatment of diabetes too complicated for general practitioners?]. / Er diabetesbehandling for vanskelig for allmennpraktikeren alene?

The prevalence of type 2 diabetes is increasing rapidly. In order to reduce the morbidity and mortality of type 2 diabetes, it is important to treat both hyperglycaemia and risk factors for cardiovascular disease. This means that diabetes care is becoming increasingly comprehensive and complicated. Studies in Norway show that diabetes care in general practice could be improved. The primary care system needs more resources and better organisation to be able to meet the demands for improved quality and more comprehensive care. We suggest more active use of nurses and other health care professionals, as well as changes in the remuneration system for general practitioners. Remuneration for an annual review of patients with diabetes will stimulate quality improvement work. The division of work between primary health care and hospital clinics should be clarified.

[Guidelines for diagnosis and treatment of acute urinary tract problems in women]. / Retningslinjer for diagnostikk og behandling av akutte vannlatingsplager hos kvinner.

BACKGROUND: Available guidelines for the management of symptoms of lower urinary tract infections (UTI) in women give conflicting recommendations. MATERIAL AND METHODS: We searched The Cochrane Library, Medline and other sources for evidence that met explicit inclusion criteria for the relevant options and outcomes identified. The validity of included studies was assessed. Draft recommendations were widely circulated and discussed in focus groups with patients and physician assistants. RESULTS: The probability that a woman with dysuria or frequency has bacteriuria, is 80%. The probability of UTI given a negative result of a dipstick test is 50%. Evidence suggests that antibiotics will rapidly relieve symptoms, but there are limited data from placebo-controlled randomised trials. Population based studies show that many women do not visit physicians for symptoms of UTI. Women with symptoms of UTI can be treated with antibiotics without examination of the urine. Women with earlier episodes of UTI can be offered treatment by telephone. Antibiotics for three days is sufficient based on eradication of bacteriuria. Women should be seen by a physician if the symptoms are atypical. INTERPRETATION: Implementing these guidelines could result in better service to women with UTIs. More evidence about the effects of antibiotics and other treatments is needed.

[Guidelines for diagnosis and treatment of sore throat]. / Retningslinjer for diagnostikk og behandling av sår hals.

BACKGROUND: Available guidelines for the diagnosis and treatment of sore throat give conflicting recommendations. Our aim was to develop evidence-based guidelines. MATERIAL AND METHODS: We searched The Cochrane Library, Medline and other sources for systematic reviews and other evidence that met explicit inclusion criteria for all of the relevant options and outcomes we identified. The validity of included studies was assessed. Draft recommendations based on assessment of this evidence were widely circulated and discussed in focus groups with patients and physician assistants. RESULTS: Throat infections are self-limiting and complications rare. Penicillin shortens the duration of symptoms in tonsillitis caused by beta-haemolytic streptococci and reduces the risk of complications. Penicillin has adverse effects and increases the risk of reinfections. Patients with sore throat should usually be treated without antibiotics. Visiting a physician is normally unnecessary. Antibiotics should be considered in serious cases or if the patient prefers this, but should only be prescribed for throat infections caused by beta-haemolytic streptococci. The diagnosis should be based on clinical criteria and a rapid antigen test in cases of doubt. INTERPRETATION: Benefits of antibiotics must be weighed against harms. Patients should be given good information and involved in decision-making if they want antibiotics.

[Hemolytic-uremic syndrome caused by verotoxin-producing Escherichia coli intestinal infection]. / Hemolytisk-uremisk syndrom forårsaket av verotoksinproduserende Escherichia coli-tarminfeksjon.

Enteric infections with verotoxin-producing Escherichia coli can progress to the haemolytic-uraemic syndrome. Several reports suggest that the incidence of verotoxin-producing E coli infections is increasing in the USA and Europe. Small epidemics of haemolytic-uraemic syndrome are usually traced to the ingestion of beef or dairy products. Epidemics of diarrhoea-associated haemolytic-uraemic syndrome have not yet been reported in Norway. We describe, for the first time in Norway, a sporadic case of haemolytic-uraemic syndrome that was associated with a verotoxin infection. Despite several life-threatening relapses the patient eventually made a good recovery after treatment with supportive therapy, plasma exchange, plasma infusions, corticosteroids, vincristine and ciprofloxacin. The authors stress the importance of continuing with intensive supportive therapy even when the prognosis seems hopeless.