Real-world outcomes of continuous glucose monitoring in adults with diabetes mellitus attending an Irish tertiary hospital.

BACKGROUNDS AND AIMS: The American Diabetes Association/European Association for the Study of Diabetes recently recommend the preferential use of continuous glucose monitoring(CGM) over self-monitoring of blood glucose for the management of type 1 diabetes (T1DM). For most adults with T1DM, the recommended target time in range is > 70% with < 4% time below range. In Ireland, CGM use has become increasingly popular since 2021. We aimed to audit adult CGM use and analyse CGM metrics in our cohort of adults with diabetes attending a tertiary diabetes centre. METHODS: People with diabetes who were using DEXCOM G6 CGM devices, and sharing their data with the healthcare team on the DEXCOM CLARITY for healthcare professionals platform were included in the audit. Clinical information, glycated haemoglobin (HbA1c) and CGM metrics were gathered retrospectively from medical records and the DEXCOM CLARITY platform. RESULTS: Data were available for 119 CGM users, 96.9% with T1DM, median age 36 years (IQR = 20) and median diabetes duration 17 years (IQR = 20). Fifty-three per cent of the cohort was male. Mean time in range was 56.2% (SD = 19.2) and mean time below range was 2.3% (SD = 2.6). Mean HbA1c in CGM users was 56.7 mmol/mol (SD = 13.1). This represented a decrease of 6.7 mmol/mol compared to the last HbA1c measurements available pre-commencement of CGM (p ≤ 0.0001, CI 4.4-8.9). The percentage of people in this cohort with a HbA1c < 53 mmol/mol was 40.6% (n = 39/96), compared to 17.5% (n = 18/103) pre-commencement of CGM. CONCLUSIONS: Our study highlights the challenges in optimising the use of CGM. Our team aims to focus on providing additional education to CGM users, more frequent touch-base virtual reviews and increasing access to hybrid closed-loop insulin pump therapy.

Familial hypocalciuric hypercalcaemia type 1 caused by a novel heterozygous missense variant in the CaSR gene, p(His41Arg): two case reports.

BACKGROUND: Familial hypocalciuric hypercalcaemia (FHH) is a rare, inherited disorder of extracellular calcium sensing. It is clinically characterised by mild to moderate parathyroid hormone dependent hypercalcaemia, an autosomal dominant pattern of inheritance, and a normal to reduced urinary calcium excretion in spite of high serum calcium. CASE PRESENTATION: We report two cases of FHH in a family caused by a novel pathogenic missense variant in the CaSR gene, p. His41Arg. Case 1, describes a 17 year old female with no significant past medical history, admitted with acute appendicitis requiring laparoscopic appendectomy and reporting a six month history of polydipsia. Routine investigations were significant for hypercalcaemia, corrected calcium 3.19 mmol/L (2.21-2.52mmol/L), elevated parathyroid hormone of 84pg/ml (15-65pg/ml) and a low 24-hour urine calcium of 0.75mmol/24 (2.50-7.50mmol/24). She was initially managed with intravenous fluids and Zolendronic acid with temporary normalisation of calcium though ultimately required commencement of Cinacalcet 30 mg daily for persistent symptomatic hypercalcaemia. Genetic analysis was subsequently positive for the above variant. Case 2, a 50-year-old female, was referred to the endocrine outpatient clinic for the management of type 2 diabetes and reported a longstanding history of asymptomatic hypercalcaemia which had not been investigated previously. Investigation revealed hypercalcaemia; corrected calcium of 2.6 mmol/L (reference range: 2.21-2.52 mmol/L); PTH of 53.7ng/L (reference range: 15-65 ng/L) and an elevated 24-hour urine calcium of 10 mmol/24 (2.50-7.50 mmol/24hr) with positive genetic analysis and is managed conservatively. Despite sharing this novel mutation, these cases have different phenotypes and their natural history is yet to be determined. Two further relatives are currently undergoing investigation for hypercalcaemia and the family have been referred for genetic counselling. CONCLUSION: Accurate diagnosis of FHH and differentiation from classic primary hyperparathyroidism can be challenging, however it is essential to avoid unnecessary investigations and parathyroid surgery. Genetic analysis may be helpful in establishing a diagnosis of FHH in light of the biochemical heterogeneity in this population and overlap with other causes of hypercalcaemia.

Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland.

BACKGROUND: This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity. SUMMARY: It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity. KEY MESSAGES: People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.