Holistic review of people with diabetes and chronic kidney disease reveals important multimorbidity and unmet clinical need: The ENHIDE diabetes renal telehealth pilot study.

Diabetes and kidney disease commonly coexist and management is complex given frequent additional comorbidity. The East and North Herts Institute of Diabetes and Endocrinology (ENHIDE) renal diabetes telehealth project examined the feasibility of data extraction from primary care records for virtual consultant review as a prelude to a telehealth case-based discussion with primary care teams. Data extraction identified 2,356 cases from 16 general practices, of which 14 took part in a skype telehealth case-based discussion session. The service was well received by primary care as a workable means of delivering patient care. In addition, significant unmet clinical needs were identified with opportunities to empower patient self-management of acute metabolic and foot issues, and better coordination of care between specialist diabetes and renal teams. The increasing clinical burden in all care settings and the commitment in the NHS plan for wider use of digital healthcare and streamlining of outpatient care highlight the need for service reconfiguration.

Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes.

AIMS/HYPOTHESIS: Women with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes. METHODS: This was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA1c level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme. RESULTS: A total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18-45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA1c levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in 'optimal' pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks' gestation; p = 0.003) with no other changes. CONCLUSIONS/INTERPRETATION: A pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes. DATA AVAILABILITY: Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-pregnancy-in-diabetes-audit .

Care of adolescents and young adults with diabetes - much more than transitional care: a personal view.

There is increasing recognition that type 1 diabetes mellitus (T1DM) acquired in childhood and adolescence requires a sophisticated approach that facilitates better self-management through adherence to generic principles in managing chronic disease in this age group, allied to the complex clinical needs of managing T1DM and related conditions. Transitional care should be seen as a process over time supported by both paediatric and adult diabetologists within a multidisciplinary team, given the complementary skills that can be brought to bear. Undoubtedly, there is a need for more effective training of all healthcare professionals working in this service. However, the accumulation of older teenagers over time and new diagnoses in those aged 19 years or more confirms that a new paradigm is necessary for the successful care of young adults beyond transitional care. Traditional clinical models will often not work for those in employment and higher education, with evidence that ongoing engagement following transfer to adult services often ceases. The alarming evidence of progressive complications in T1DM of longer duration in patients under the age of 40 years is a wake-up call to transform the care of this most vulnerable group.

The conflict between specialist diabetes services and acute-general internal medicine for consultant diabetologists in the UK in 2006.

An online survey of consultant diabetologists in the UK examined the interface between specialist services and acute-general internal medicine (acute-GIM). Out of 592 consultants, 289 (49%) responded. Of these, 94% contributed to acute-GIM, devoting equivalent time to acute-GIM and specialist diabetes services. Of the respondents, 10% provided a single-handed specialist service and 78% provided endocrine services. The survey found the input to acute-GIM was increasing, partly because other specialties were opting out. The increased commitment to acute-GIM compromised specialist diabetes activity through reduced consultant and training-grade time for outpatient activity and service development. The shift to primary care of chronic disease led to further conflict between acute-GIM and delivery of a specialist service, given the current systems for provision of consultant-led care. The large number of specialist trainees in diabetes and endocrinology will require innovative commissioning mechanisms that reflect the need to sustain and develop specialist diabetes and endocrine care in the appropriate settings as well as the continued input in acute trusts for acute-GIM.

Drug therapy for prevention of cardiovascular disease--should surrogate measures be abandoned?

It has been suggested that the most effective method of reducing cardiovascular disease (CVD) is to define overall CVD risk and apply fixed doses of anti-hypertensive, hypolipidaemic and anti-platelet therapies, using the evidence base from clinical outcome studies. Such studies have examined large numbers of patients with a wide representation of subgroups and demon-Welwyn strated equivalent benefits in all subsets. In so doing, there may be over-interpretation of the data leading to large-scale applicability of the findings to individuals who were not genuinely represented in the study populations. Most lipid-lowering studies have been unable to consider the possibility that optimal correction of dyslipidaemia would have been more effective than the use of a fixed dose of statins. Studies of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockade have produced contradictory findings regarding unique non-hypotensive beneficial CVD effects, and suboptimal control of mild hypertension was a frequent finding in the study populations. Scrutiny of concomitant therapy in studies that focus on a particular issue such as LDL (low-density lipoprotein) cholesterol or blood pressure supports the notion that benefits from the agent may be attenuated by other drugs. Widespread application of fixed doses of all these agents to at-risk cases will increase the incidence of inappropriate use and side effects. Clinical experience with modulators of the renin-angiotensin system in hypertensive diabetic renal disease confirms reduced efficacy, and more frequent deterioration of renal function than observed in clinical trials. Measurement of individual biomedical CVD risk factors along with overall risk estimation should continue to be the mainstay of clinical practice. This will allow appropriate case selection for different agents, optimisation of dosage or better assessment of compliance where treatment is less efficacious, and monitoring for adverse effects of therapy. Pragmatic individualisation of care should remain the basis for treating asymptomatic CVD risk factors.

Atypical familial juvenile hyperuricemic nephropathy associated with a hepatocyte nuclear factor-1beta gene mutation.

BACKGROUND: Familial juvenile hyperuricemic nephropathy (FJHN) is a dominantly inherited condition characterized by young-onset hyperuricemia, gout, and renal disease. The etiologic genes are unknown, although a locus on chromosome 16 has been identified in some kindreds. Mutations in the gene encoding hepatocyte nuclear factor (HNF)-1beta have been associated with dominant inheritance of a variety of disorders of renal development, particularly renal cystic disease and early onset diabetes; hyperuricemia has been reported in some kindreds. METHODS: To assess a possible role for the HNF-1beta gene in some FJHN kindreds we sequenced the HNF-1beta gene in subjects from three unrelated FJHN families with atypical features of renal cysts or abnormalities of renal development. We also compared serum urate levels in subjects with HNF-1beta mutations with populations of controls, type 2 diabetic subjects, and subjects with mild chronic renal failure without HNF-1beta mutations. RESULTS: A splice-site mutation in intron 2, designated IVS2+1G>T, showed complete co-segregation with FJHN in one family with diabetes. Serum urate levels were significantly higher in the HNF-1beta subjects compared with the normal control subjects (384 micromol/L vs. 264 micromol/L, P = 0.002) and the type 2 diabetic subjects (397 micromol/L vs. 271 micromol/L, P = 0.01). Comparison of serum urate levels in the HNF-1beta subjects with gender-matched subjects with renal impairment of other causes did not reach significance (402 micromol/L vs. 352 micromol/L, P = 0.2). CONCLUSION: Hyperuricemia and young-onset gout are consistent features of the phenotype associated with HNF-1beta mutations, but the mechanism is uncertain. Families with HNF-1beta mutations may fit diagnostic criteria for FJHN. Identification of HNF-1beta patients by recognizing the features of diabetes and disorders of renal development is important in resolving the genetic heterogeneity in FJHN.