-
P134
Vitamin B12 is lower in metformin treatedpatients but
haemoglobin is unaffectedRP Narayanan1, SG Anderson2, E Onyekwelu3
and AH Heald1,3
1Vascular Research Group, University of Manchester, Manchester,
UK,2Cardiovascular Sciences Group, University of Manchester,
Manchester, UK,3Department of Medicine, Leighton Hospital, Crewe,
UK
Introduction: Metformin treatment has recently been linked
withvitamin B12 deficiency. Given the widespread use of metformin
in
treatment of Type 2 diabetes and the implications for
haematological
health, we determined how long-term metformin treatment
affectsvitamin B12 and haemoglobin (Hb) levels in primary care.
Methods: We used pseudo-anonymised data drawn from primarycare
records in practices based in central and eastern Cheshire. We
compared vitamin B12 levels in 7,823 patients with Type 2
diabetestaking metformin for more than 12 months, and 4,930 Type 2
diabetes
patients not taking metformin. The mean age was 63.6 years
(range
1780 years). The study involved 7,456 men and 5,297 women.
Comparison between groups used t tests.
Results: Vitamin B12 levels when checked were significantly
lower inmetformin treated patients (2,767 subjects, mean 355.1
ng/l, 95 per
cent CI 347.1363.1 ng/l) than non-metformin treated patients
(1,567
subjects,mean419.1 ng/l, 95per centCI407.8430.3 ng/l),P <
0.001.There was no difference in folate levels (P = 0.17).
Interestingly MCVwas lower in metformin vs. non-metformin treated
patients (90.1fL vs.
91.3fL) as was MCH (90.7pg vs. 90.3pg), P < 0.001. There was
nodifference in Hb (136.1 vs. 135.6 g/l). Mean HbA1c was 7.47 per
cent(58 mmol/mol) and 6.88 per cent (52 mmol/mol) in the metformin
and
non-metformin groups respectively (P < 0.001).
Conclusion: While vitamin B12 levels were lower in
metformintreated patients, there was no difference in circulating
Hb. This has
implications for long-term monitoring requirements in
metformintreated patients.
Clinical care and other categories posters: audit
P135
National Diabetes Audit (NDA): diabetes isunder-recorded on
death certificates ofpeople with diabetesB Young1, D Eayres2, J
Barrett3, C Buttery3 and J Henderson3
1Department of Diabetes and Endocrinology, Salford Royal
Hospital, Salford,
UK, 2Public Health Information, NHS Information Centre, Leeds,
UK, 3Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK
Background: Diabetes is implicated in the cause of death for
mostpeople with diabetes but death certificates may under-report
diabetes as
a comorbidity.
Methods: The 20078 NDA included 1.42 million people
withdiabetes, 65 per cent of the 2.19 million people diagnosed to
have
diabetes in England. The NHS numbers of the people with
diabetes
included in the 20078 NDA who were alive at 1 November 2008
werematched by Office of National Statistics for deaths registered
up to the
end of June 2010.
Results: During the 1 year follow-up period from 1 November
2008to 31 October 2009 a total of 49,282 deaths were
recorded.Assuming that those included are representative of the
general
diabetic population, then by extrapolation (multiplying by
2.1/1.41)
we can estimate that the total number of deaths of people
with
diagnosed diabetes in England is of the order of 70,00075,000
peryear. This represents approximately 1516 per cent of all
deaths
occurring annually in England. By comparison, in the calendar
year
2009, only 30,894 (6.7 per cent) of the 460,000 deaths
officially
registered in England included diabetes somewhere on the
deathcertificate, with 4,934 (1.1 per cent) having diabetes
recorded as the
underlying cause of death. These figures suggest that less than
half of
deaths of people with diabetes mention diabetes on the death
certificate.
Conclusions: Diabetes is related to almost one-sixth of deaths
inEngland and its impact on total mortality is significantly
under-
estimated by reliance on death certificates.
P136
National Diabetes Audit (NDA): comparisonbetween all-cause
mortality in people withdiabetes and the general population
inEngland; more than 20,000 excess deaths inpeople with diabetes
and higher risks inType 1 diabetesD Eayres1, J Barrett2, C
Buttery2, J Henderson2 and B Young3
1Public Health Information, NHS Information Centre, Leeds, UK,
2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK,
3Department of
Diabetes and Endocrinology, Salford Royal Hospital, Salford,
UK
Background: The present impact of diabetes on overall mortality
isnot known.
Methods: The 20078 NDA included 1.42 million people
withdiabetes.UsingNHSnumbers theOfficeofNationalStatistics
identified
49,282 deaths in this cohort during the year beginning 1
November
2008. The diabetes cohorts mortality experience is compared with
thegeneral populations using directly age-standardised rates (DSRs)
and
indirectly age-standardised mortality ratios (SMRs), with
England
2009 as the standard population/rates.
Results: The crude death rate for all people with diabetes was
3,553per 100,000 per year (background England rate 886). People
with
Type 1 diabetes had the highest mortality with a DSR of
2,016
compared with 1,462 for people with Type 2 diabetes and 886 for
the
background England population. The SMRs suggest that,
comparedwith the background mortality rates, there are
approximately 2.5
times as many deaths in people with Type 1 diabetes and 1.5
times as
many in people with Type 2 diabetes. In total there were more
than16,000 more deaths of people with diabetes than would have
occurred
if their mortality risk was equal to the general
populations.
Extrapolating this to include people with diabetes not in the
audit
suggests that there are about 21,000 excess deaths in people
withdiabetes in England each year.
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2012 The Authors.72 Diabetic Medicine 2012 Diabetes UK. Diabetic
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mimran74Typewritten TextRefer to page 80, poster 162
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Conclusions: The contemporary risk of death in people with
diabetesis substantially greater than in the general population and
represents an
opportunity for improvingnational healthoutcomes.The risk inType
1is 1.7 times greater than in Type 2 diabetes.
P137
National Diabetes Audit (NDA):investigation by age and sex of
excessdeaths in people with diabetes in England;greater effects in
the young and in Type 1femalesD Eayres1, J Barrett2, C Buttery2, J
Henderson2 and B Young3
1Public Health Information, NHS Information Centre, Leeds, UK,
2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK,
3Department of
Diabetes and Endocrinology, Salford Royal Hospital, Salford,
UK
Background: The effects of age and sex on excess mortality
indiabetes were investigated.
Methods: Using NHS numbers from the 20078 NDA the Office
ofNational Statistics identified 49,282 deaths during the year
beginning 1November 2008. The diabetes cohorts mortality was
investigated
using age- and sex-specific mortality rates, directly
age-standardised
rates (DSRs) and indirectly age-standardised mortality ratios
(SMRs),
with England 2009 as the standard population.
Results: Compared with the background population males
andfemales with Type 1 diabetes are 2.5 times more likely to die
and
with Type 2 diabetes 1.4 and 1.5 times respectively. In all
instances this
excess mortality is inversely related to age: in the 1534 age
group,mortality in females with Type 1 diabetes is approximately 9
times the
femalebackground rate, inmales 4 times; for Type2diabetes the
figures
are approximately 6 and 3.6 times respectively; in the 85+ age
group all
of the ratios drop to less than 2. Compared to the general
populationexcess male mortality in Type 1 diabetes is less: no
excess in the 1534
age group and a gradual increase to 1.3 times in the over 85s;
for Type 2
diabetes excess male mortality is constant over all age groups
at
approximately 1.2 times the female rate.
Conclusions: Compared with the general population
thecontemporary risk of death in people with diabetes is greater at
all
ages in both sexes but the relative risk is greatest in the
young and in
females with Type 1 diabetes.
P138
Audit of a diabetic renal clinic: an appraisalof the AABC
treatment paradigmK Al-Hourani1, T Mehrali2, A Murtaza2 and P
De2
1Merton College, University of Oxford, Oxford, UK, 2Diabetes and
Endocrine
Unit, City Hospital, Birmingham, UK
Aim: To audit the outcome of our diabetic renal clinic using
AABC(HbA1c and aspirin, blood pressure, cholesterol/lipids)
strategy.
Methods: Baseline data T0 in 2009 were compared with final data
T1end 2010 from clinic letters and electronic data of 186
patients
attending this clinic between 2009 and 2010.
Results: In all, 173/186 (93 per cent) had Type 2 diabetes (male
118);53 per cent of patients were South Asian, 23 per cent
Caucasian, 23 percent Afro-Caribbean. Mean HbA1c was T0 7.96 per
cent vs. T1 8.23
per cent, P = 0.3. Significant improvements in blood pressure
control(mean SBP T0 141.5 vs. T1 136.8, P = 0.04; mean DBP T0 74.3
vs. T168.3, P = 0.0002) and triglycerides (mean TG T0 2.33 vs. T1
1.7,
P = 0.05) occurred. TC levels remained unchanged (T0 4.08 vs.
T14.05, P 0.41). Creatinine and eGFR worsened (creatinine T0 141.53
vs.T1 156.47, P = 0.043; D mean eGFR T0 to T1 of 2.46 ml/min/year,P
= 0.04). At T0, 76/186 (38 per cent) exhibited overt
albuminuria(ACR > 30); at T1 it was 7/172 (4 per cent). However,
mean ACR did
not alter significantly (T1 60.23 vs. T0 50.23, P = 0.19). A
total of 93/174 (53 per cent) were on ACEi and 61/174 (35 per cent)
on ARB.
Prescription of statins and aspirin at T0 and T1 were 74.1 per
cent and
76.4 per cent and 59.8 per cent and 53.4 per cent respectively.
Just 51/
186 (27 per cent) were referred to the low clearance clinic and
14/186(7.5 per cent) died.
Conclusions: According to our AABC strategy, significant
decreasesin blood pressure and triglycerides were observed during
the audit
period with little change in HbA1c. A quarter of patients
receivedstatins but prescription of aspirin remained comparatively
low.
P139
Audit of the continuous subcutaneousinsulin infusion
multidisciplinary service atthe University Hospitals Bristol
NHSFoundation Trust (UHB)A Thomson-Moore, E Jones and N
Thorogood
Diabetes and Endocrinology, University Hospitals Bristol NHS
Foundation
Trust, Bristol, UK
Aim: To audit the UHB continuous subcutaneous insulin
infusion(CSII) service against 2008 NICE standards.
Method: This was a retrospective analysis of patient
recordsperformed using the standard NICE 2008 audit proforma.
Results: On 25 August 2011 92 patients, 37 males and 55
females,mean age at start of CSII 39.6 (range 964), were being
actively
supported. Fifty (54 per cent) started after the 2008 NICE
guidelines.
All UHB starts had received self-management education. Seven
had
started too recently to assess outcome. For three the indication
for CSIIwas unknown, and data were incomplete for one patient. Of
the
remaining 81 patients, 64/81 (79 per cent) were achieving
NICE
specified treatment goals. Mean HbA1c pre-CSII was 8.4 per
cent
(range 5.713.3 per cent) decreasing to 7.6 per cent (range
5.19.5 percent) at 1 year. An improvement in hypoglycaemia
awareness and
frequency was reported by 95 per cent. Currently 17 are not
achieving
treatmentgoals.Eleven (12per cent)neverhave (nine
startedpre-2008).The remainder, despite initial goal achievement,
show subsequent drift
to HbA1c > 8.5 per cent. All but one are reluctant to
consider
withdrawal of CSII.
Conclusion: In total, 79 per cent of the UHB cohort overall, and
90per cent of patients who started post-2008 NICE guidelines,
wereachieving treatment goals. There was no correlation with age
or
socioeconomic class. Average HbA1c reduction at 1 year was 0.8
per
cent. Greater team experience, and 2008 NICE guidance, has led
tohigher goal achievement through better patient selection. A
written
contract enablingwithdrawal of CSII if treatment objectives are
notmet
is essential, as patients are reluctant for it to be taken away.
We do not
knowthe long-termeffectof engagementwithdiabetes services ifCSII
iswithdrawn.
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2012 The Authors.Diabetic Medicine 2012 Diabetes UK. Diabetic
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P140
Safer administration of insulin: using anaudit to get the basics
right and reduce risksof patient harmAC Reid, A Barridge, S
Burmiston, C Hamilton and M Knapper
Department of Diabetes and Endocrinology, Guys and St Thomas
NHS
Foundation Trust, London, UK
Aim: In 2010 the National Patient Safety Association
highlightedinsulin errors, including the misuse of 1ml syringes,
and a consensus
guideline on injection technique was published. In 2011
Maladministration of Insulin was added to the NHS never
eventslist. The aim is to identify the type of syringes and needles
available and
how syringes are stored in all clinical areas of our trust, and
to develop
trust recommendations to promote safety and good practice.
Methods: Matrons for all wards and departments completed
anaudit, detailing types of insulin syringes and needles available,
how they
are identified and stored and the estimated risk of syringe
mis-selection.
Results: In all, 90 per cent (55/61) returned audits; three
areas did notstock insulin syringes. Of 52 responses analysed, 50
(96 per cent)
separated insulin syringes from 1ml syringes, 45 (93 per cent)
reportedthe storage area was labelled to identify content, 40 (90
per cent)
reported labelling included the word insulin, and 44 (92 per
cent)
reported that the label reflected contents. One ward reported
insulinand 1ml syringes were mixed together. Twenty-nine (54 per
cent)
stocked 50 unit syringes, 29 (44 per cent) 100 unit syringes and
four (2
per cent) 30 unit syringes, with 49 (96 per cent) using BD
syringes, 27
(62 per cent) had 8mm needles, 15 (34 per cent) 12.7mm needles
andtwo (4 per cent) other. Syringes were individually wrapped in 47
(90 per
cent) areas, unwrapped in six (11 per cent), sealed multipacks
in two (4
per cent) andopenedmultipacks in three (8 per cent).The risk of
syringe
mis-selection was estimated to be low by 78 per cent, moderate
by 10per cent, and significant by 12 per cent.
Summary: Eleven areas identified practice with moderate
orsignificant risk of harm. Fifteen areas used needle lengths
with
potential for IM injections. We will implement trust-wide policy
toremove variation, improve practice and prevent potentially fatal
errors.
P141
National Diabetes Audit (NDA): routine careis less effective and
outcomes are poorer inyounger people compared with olderpeople who
have diabetes in EnglandB Young1, A Uddin2, J Barrett2 and J
Henderson2
1Diabetes and Endocrinology, Salford Royal Hospital, Salford,
UK, 2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK
Background: The latest NDA data have been investigated to
seewhether diabetes care and outcomes are age related.
Methods: In 200910 the NDA included 1.9 million people, 83
percent of those with diagnosed diabetes in England. The NDA
usesprimary care, specialist care and hospital admission data
collected
electronically with an approved data set comprising NICE
recommended care processes, treatment targets and diabetic
complications.
Results: Some 24 per cent of people with diabetes are less
than55 years old. These younger people less frequently received the
nine
core processes of care (all care processes were completed in 20
per cent
aged 1624 years, 38 per cent aged 2554 years but 55 per cent
aged5584 years). Achieving the HbA1c < 7.5 per cent (58
mmol/mol)
treatment target was less likely in younger people (Type 1
diabetes, age
30per cent;Type 2diabetes, age
< 55 year, 70 year, >70 per cent). The
-
Methods: All the patients who had an OGTT requested between
1January 2010 and 30 September 2010 were included in this audit.
All
OGTTs requested in pregnancy were excluded. The data source
wasthe Pathology Laboratory in Furness General Hospital in
Barrow-in-
Furness, which was checked for all plasma glucoses checked for
the
patients in the preceding year. Early identification of people
withType 2 diabetes Diabetes UK 2006 was used as the standard for
this
audit.
Results: The total number of OGTTs requested was 354.
Afterexcluding the OGTTs requested in pregnancy (n = 40), the
totalnumber of patients selected for the audit was 314. The mean
age of thepatients was 63.4 years and 54 per cent were female.
There was poor
documentation of the indication for OGTT in 57.3 per cent of
requests.
The OGTT was not indicated in 52.5 per cent of these individuals
forwhom 29.7 per cent of fasting plasma glucose results were normal
and
23.0 per cent were suggestive of Type 2 diabetes. In all, 37.2
per cent of
those deemed suitable and 61.8 per cent of those unsuitable for
OGTT
had normal OGTT results.
Conclusion: The requests for OGTT need to be refined as this
wouldprevent unnecessary investigation and wastage of time both for
the
patients and the healthcare staff.
P144
Audit of inpatient management of diabetesin the elderlyA Mackett
and KS Myint
Diabetes and Endocrinology, Norfolk and Norwich University
Hospitals NHS
Foundation Trust, Norwich, UK
Aim: We evaluated elderly (> 70 years) inpatient diabetes
care atNorfolk and Norwich University Hospitals NHS Foundation
Trust
over 6 months (October 2010 to April 2011).
Method: Patients were identified from clinical coding
retrospectively.The case notes of 30 emergency admissions (EAs)
were randomly
selected and analysed.
Results: In total, 3,333 patients were identified (49 per cent
EAs, 13per cent elective, 38 per cent day admissions). Among EAs,
97 per centwere Type 2 and 52 per cent were female, with a mean
length of stay
(LOS) of 9.06 days (range 088) vs. a trust mean of 5 days; 20.7
per
cent were admitted 2 times. Among 30 patients analysed, 20 per
centand 30 per cent admissions were diabetes and cardiovascular
relatedrespectively. The triage specialties were elderly medicine
(50 per cent),
cardiology (33 per cent) and endocrinology (6 per cent). 27 per
cent
were on insulin, 17 per cent received intravenous insulin (40
per cent
were inappropriate). Ten (30 per cent) had hypoglycaemic
episodes(five had more than seven, one had >24, one required
intravenous
dextrose four times).Only in50per centwereguidelines
followed.Dose
adjustment was not done in 50 per cent with consecutive day
hypos. 30
per cent experienced hyperglycaemia (consecutive days
glucoseconsistently >11.1 mmol/l) and all were acted upon. 96
per cent had
regular glucose monitoring. Eight (38 per cent) had prescribing
errors
(four insulin, four oral agents). 24 per cent had feet
examinationdocumented. All 10 per cent with active foot disease
were reviewed by a
foot team. LOS was 16.5 days (insulin treated) and 6.5 days
(without
insulin). 25 per cent had delayed discharges after being
declared
medically fit (mean 9.8 additional days) and of these 40 per
cent wereglycaemic control related. Five (17 per cent) died after
discharge. 60 per
cent of them had unstable glycaemic control.
Conclusions: This audit highlighted issues of
hypoglycaemia,prescribing errors, high mortality and delay
discharges in elderlydiabetes inpatients. More focused education
for staff is recommended.
P145
What proportion of patients fail NICEcriteria for continuing
GLP-1 treatmentbeyond 6 months and whyL Wessels, S Keigan, SV
OBrien and KJ Hardy
Diabetes Centre, St Helens Hospital, St Helens, UK
Aims: Glucagon-like peptide 1 (GLP-1) agonist treatment in Type
2diabetes is associated with improved glycated haemoglobin
(HbA1c)
and weight loss. National Institute for Health and Clinical
Excellence(NICE) guidance exists for starting GLP-1 therapy and for
its
continuation beyond 6 months. At 6 months, patients must have
lost
at least 3 per cent body weight and improved HbA1c by at least
1.0 percent.
Methods: We assessed the impact of NICE continuation criteria in
61patients, mean age (SD) 57 (10) years, diabetes duration 11 (6)
years,
baseline median (range) weight 118kg (76192), body mass index42
kg/m2 (3068) and HbA1c 9.6 (7.614) per cent, who met NICE
initiation criteria and had received at least 6 months
treatment.
Results: Thirty-three patients (60 per cent) met continuation
criteria.After a median 8 (648) months follow-up, these patients
had lost7.2kg (2.926.3)andHbA1chad fallenby1.4 (15.6)per cent.Of
those
failing NICE continuation criteria, 23 per cent failed on weight
alone,
55 per cent on HbA1c alone and 27 per cent on both. Baseline
characteristics could not predict treatment failure. Median
weight lossafter 10 (639) months follow-up in those failing on
HbA1c alone was
6.8kg (2.424.5) (similar to
thosewhometNICEcontinuationcriteria).
Conclusions: We conclude that in our clinic most patients
cancontinue GLP-1 treatment, but approximately 40 per cent fail to
meetNICE continuation criteria, most as a result of poor HbA1c
response
despite marked weight loss.
P146
The impact of the diabetes outreach teamon long-term glycaemic
controlH Siddique1, AA Tahrani2, W Leong2, K Crowley1, G
Wheatley1
and C Holmes1
1Diabetes, Dudley Group of Hospital NHS Trust, Dudley, UK,
2Diabetes,
University Hospital of Birmingham, Birmingham, UK
Aim: The aim of this audit was to assess the effectiveness of
serviceprovided by the dedicated Diabetes Outreach Team at Russells
Hall
Hospital, Dudley, UK.
Methods: We performed a retrospective audit of all inpatients
whowere seen by our Diabetes Outreach Team between June 2007
and
December 2010. Blood samples including HbA1c at the initial
visit and
subsequent follow-up (at our Diabetes Clinic) at 3 to 6 months
were
collected.
Results: Over 3.5 years, baseline data were available for
2,490patients, and 1,224 patients had follow-up data. Of these, 199
had
Type 1 diabetes and 990 Type 2 (16.7 vs. 83.3 per cent); 35
patients had
unspecified type. Thirty-two patients were referred for new
onset Type1 diabetes, 91 for Type 2 (2.6 vs. 7.4 per cent); 235
(19.2 per cent) were
referred because of hypoglycaemia. Mean age was 65.2 (+19.03)
years.
Of the total sample, after excluding hypoglycaemia related
admissions,
using paired t test the baseline HbA1c was 9.27 ( 2.57) and
follow-upHbA1c 8.32 ( 2.03) (P < 0.001). Patients with new onset
Type 1diabetes dropped their HbA1c from 12.55 per cent to 7.43 per
cent and
new onset Type 2 from 10.7 per cent to 7.29 per cent, while
patientsknown tohave diabetes alsodropped their HbA1c from 8.99 per
cent to
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2012 The Authors.Diabetic Medicine 2012 Diabetes UK. Diabetic
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8.46 per cent (P < 0.001 for all comparisons). When the
samples wereanalysed based on their age (75), once again there was
astatistically significant drop in HbA1c.
Conclusion: Byprovidingacomprehensive care,
structurededucationand appropriate intervention though our Diabetes
Outreach Team, we
have shown a significant reduction in objective markers of
long-term
glycaemic control for recently hospitalised patients.
P147
A clinical audit of the insulin pump servicein LanarkshireA
White, H Innes, P Reid, K Gallagher, L Wilson, L Doran,E McIntyre
and T Sandeep
Department of Diabetes, Monklands Hospital, Airdrie, UK
Aim: This audit aimed to identify (1) indications for
startingsubcutaneous insulin infusion (CSII) therapy, (2) the
effectiveness of
structured education prior to pump start, (3) improvement in
glycaemic
control and (4) improvement in hypoglycemia.
Method: A retrospective audit was carried out with data from
45individuals identified as using the insulin pump service at the
Diabetes
Centre at Monklands Hospital. Audit standards were based on
the
SIGN and NICE guidelines.
Results: The predominant reason for starting CSII therapy
whichapplied to 26 individuals was recurrent severe hypoglycaemia,
followed
by HbA1c > 8.5 per cent despite structured education (DAFNE)
which
applied to seven individuals. Prior to starting CSII therapy
27
individuals had completed DAFNE training. After 1 year of
CSII,HbA1c had improved from 8.8 per cent at baseline to an average
of 7.8
per cent (n = 36). Baseline HbA1c in the DAFNE group was 8.80
percent (n = 26), improving to 7.76 per cent (n = 24); it was 8.79
per centin thenon-DAFNEgroup(n = 15), improving to7.88per cent (n =
12).Hypoglycaemia frequency was formally recorded as being less
than one
per 6 months in six patients.
Conclusions: CSII is an effective treatment option for people
withType 1 diabetes shown here to provide a 1 per cent improvement
inHbA1c. Recurrent hypoglycaemia was the most likely reason to
start
CSII and most individuals had completed DAFNE. More robust
recording of hypoglycaemia frequency and patient satisfaction
surveysare needed and are being implemented.
Clinical care and other categories posters: auto-immunity
P148
The evaluation of the utility of islet cellauto-antibody
measurements in clinicalpracticeSA Nathwani1, D Kariyawasam2 and S
Thomas2
1Medical School, Kings College London University, London, UK,
2Diabetes
and Endocrine Department, Guys and St Thomass Hospital, London,
UK
Aim: The earlier onset of Type 2 diabetes and increasing
atypicalpresentations of diabetes, eg ketosis-prone diabetes, have
led to an
increase in the number of auto-antibody tests being
performed.However, the role of testing in routine clinical practice
remains
unclear. This study aimed to assess the clinical usefulness of
auto-
antibody testing in an inner-city hospital serving a diverse
ethnic
population.
Methods: The role of auto-antibody testing in affecting changes
inmanagement, defined as treatment change, referral to a
specific
education programme or change in diagnosis, were assessed.
All
patients presenting from 2007 to 2009 were identified from
theDiabeta3 database. Of these, 201 patients with either diagnosis
under
40 years of age (n = 176) or above 40 years of age with
ketones(n = 25) were identified.
Results: A total of 108 (54 per cent) had an auto-antibody
testordered. Antibody testing predicted a change in management
(P = 0.003); 45 per cent (n = 49) of the tested population had
one ormore changes in their diabetes management following the test.
Themost common change was a change in treatment (55 per cent) in
the
majority the withdrawal or addition of insulin. In all, 51 per
cent of
auto-antibody positive individuals had a change in management
in
comparison with 43.2 per cent auto-antibody negative (P <
0.001); 22per cent of auto-antibody tested individuals had a change
in diagnosis,
eg from Type 1 to Type 2 diabetes.
Conclusions: Auto-antibody testing did lead to changes in
diagnosisand or management whether positive or negative. As
classicalpresentations of diabetes change there may be a greater
role for
testing and a need for awareness of the limitations of the
test.
2012 The Authors.76 Diabetic Medicine 2012 Diabetes UK. Diabetic
Medicine, 29 (Supp. 1), 30177
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Clinical care and other categories posters: beta cells,
islets and stem cells
P149
Resolution of hypoglycaemia, improvementin glycaemic control and
assessment ofmetabolic graft function in islet transplantrecipients
in the UK islet transplantconsortium programmeAMS Brooks1, SA
Amiel2, S Forbes3, P Johnson4, M Rosenthal5,M Rutter6, R Smith7 and
JAM Shaw1
1Institute of Cellular Medicine, Newcastle University,
Newcastle-upon-Tyne,
UK, 2Diabetes Research Group, Kings College London, London,
UK,3Endocrinology Unit, University of Edinburgh, Edinburgh, UK,
4Oxford Centre
for Diabetes, Endocrinology and Metabolism, University of
Oxford, Oxford,
UK, 5Department of Endocrinology, Royal Free Hospital, Royal
Free
Hampstead NHS Trust, London, UK, 6Manchester Diabetes Centre,
University
of Manchester, Manchester, UK, 7Academic Renal Unit, University
of Bristol,
Bristol, UK
Refer to Oral number A15
Clinical care and other categories posters: cardiovascular
P150
Association of carotid plaque morphologywith cardiovascular
disease and vascularrisk factors in older people with Type
2diabetes: the Edinburgh Type 2 DiabetesStudyCM Robertson1, MWJ
Strachan2, L Nee3, J Morling1, S Masle1
and JF Price1
1Centre for Population Health Sciences, University of Edinburgh,
Edinburgh,
UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK,
3Department
of Radiology, Western General Hospital, Edinburgh, UK
Refer to Oral number A81
P151
Socioeconomic status and cardiovascularmortality in people with
Type 2 diabetes inScotlandC Jackson1, J Walker2, C Fischbacher3 and
S Wild2
1Scottish Collaboration for Public Health Research and Policy,
Medical
Research Council, Edinburgh, UK, 2Public Health Sciences,
University of
Edinburgh, Edinburgh, UK, 3Information Services Division, NHS
National
Services Scotland, Edinburgh, UK
Refer to Oral number A82
P152
Effect of exenatide on cardiovascularparameters: evidence from a
small cohortstudyI Ramracheya
Centre for Diabetes and Endocrinology, Royal Berkshire NHS
Foundation
Trust, Reading, UK
Aim: The glucagon-like peptide 1 (GLP-1) analogue exenatide
isrecommended by the National Institute for Health and
ClinicalExcellence as an add-on therapy to optimise diabetes
control and
weight reduction. This study examined the effects of exenatide
on
cardiovascular parameters in a cohort of patients with
diabetes.
Methods: Patients were identified at a general hospital. Data
werecollected retrospectively from notes, a local diabetes database
and
laboratory results. Follow-ups lasted up to 12 months. Data
were
analysed using Excel 2010.
Results: Forty patients were identified (male-to-female ratio
26:14).Age ranged between 35 and 75 years (average SEM: 59.1
1.7).Diabetes duration varied between 1 and 19 years (9.2 0.7).
Otherparameters were as follows: weight 124.8 4.0 kg; body mass
index41.3 7.7 kg/m2; HbA1c 9.6 0.2 per cent. Twenty-five
patientswere identified for comparisonbetween0and6
monthsand18patients
for 012 months. Blood pressure recordings at baseline were (mm
Hg)
systolic 142 2.9; diastolic 80 1.6. Systolic readings at 6
monthsshowed a modest drop of 3.2 mm Hg (baseline 143.3 3.8
vs.140.1 3.9) and at 12 months there was a significant drop of 6
mmHg (baseline 146.6 6.2 vs. 140.5 5.5; P < 0.05). No change
wasnoted in diastolic blood pressure. Triglyceride levels dropped
by 9 per
2012 The Authors.Diabetic Medicine 2012 Diabetes UK. Diabetic
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cells, islets and stem cells
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cent (P < 0.05) at 3 and 6 months and 10 per cent (P <
0.05) at12 months. There was a small reduction in total cholesterol
levels at3 months. At 6 months and 12 months total cholesterol
fell
significantly (P < 0.05) by 5 per cent (3.9 0.1 vs. 3.7 0.1)
and 8per cent (3.9 0.1 vs. 3.6 0.1) respectively. LDL levels
wereunaffected in this cohort.
Conclusions: Exenatide treatment can significantly and
time-dependently improve cardiovascular risk factors. Further
studies are
needed to assess the long-term cardiovascular benefits of
exenetide.
P153
Frequency and characteristics of carotidartery plaque in older
people with Type 2diabetes: the Edinburgh Type 2 DiabetesStudyCM
Robertson1, MWJ Strachan2, L Nee3, J Morling1, S Masle1
and JF Price1
1Centre for Population Health Sciences, University of Edinburgh,
Edinburgh,
UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK,
3Department
of Radiology, Western General Hospital, Edinburgh, UK
Introduction: Carotid plaque presence and characteristics may
beimportant in cardiovascular risk prediction, in particular
echolucent
and/or heterogeneous plaque. However, little is known about
theprevalence and characteristics of carotid plaque in people with
Type 2
diabetes.
Methods: In total, 939 subjects aged6176 years
fromtheEdinburghType 2 Diabetes Study underwent ultrasound
assessment of their left
and right carotid arteries. Plaque presence, thickness,
echolucency and/
or heterogeneity were assessed within 2cm of the bifurcation in
the
common, internal and external carotid arteries. Measurements
wererepeated in 830 subjects after 4 years.
Results: Plaque was most common at the right and left
bifurcation(90.4 vs. 92.4 per cent respectively) and in the
internal carotid arteries
(59.6vs. 61.7per cent), and least common in thecommon(31.9vs.
42.2per cent) and external carotid arteries (28.8 vs. 26.1 per
cent); mean
maximum plaque thickness (mMPT) was 2.47mm (95 per cent CI
2.412.54). Overall, 35.6 per cent of participants had
echolucent
plaque and 43.0per cent had heterogeneous plaque. Plaque
distributionat follow-up was similar to baseline; however, the
percentage with
plaque present was increased and mMPT significantly increased
to
2.82mm (95 per cent CI 2.742.89). Subjects with echolucent
or
heterogeneous plaque had a greater mMPT compared with those
withpredominantly echogenic plaque (2.7 vs. 2.3, 2.9 vs. 2.1
respectively,
P < 0.001).
Conclusions: Carotid plaque is highly prevalent in older people
withType 2 diabetes, especially at the carotid bifurcation and
internalcarotid arteries. Plaque presence and thickness increase
with age and
those people with high risk plaques have higher plaque
thickness. Given
the high prevalence of carotid plaque, investigation into its
clinical
significance in people with Type 2 diabetes, including as a
predictor ofsubsequent events, is warranted.
P154
Sex differences in cardiovascular diseaserisk factor profiles in
those with Type 1diabetes in ScotlandHM Colhoun
Population Health Sciences (PHS), University of Dundee, Dundee,
UK
Aim: We previously reported that the relative risk for
cardiovasculardisease (CVD) continues to be higher in women than
men with Type 1
diabetes in Scotland compared with the general population. To
explore
reasons for this we examined whether CVD risk factor profiles
andachievement of treatment targets differ by sex in Type 1
diabetes.
Methods: We used clinical data and issued prescriptions data
fromthe Scottish Care Initiative Diabetes Collaboration (SCI-DC)
which
captures data on the majority of patients with diabetes in
Scotland.Comparisons between sex were by logistic and linear
regression with
age and diabetes duration adjustment. Analyses were restricted
to those
aged 20 and over.
Results: Currentsmokingwasmorecommoninmenthanwomenatallages [31
vs. 26 per cent; odds ratio (OR) 0.81, 0.760.86, P <
0.001].Below age 50 years only hypertension (SBP > 130mm Hg
or
DBP > 80mm Hg) was more common in men than women (63 vs.
51
per cent; OR 0.6, P < 0.001) and non-HDL cholesterol was
higher(beta = + 0.11 mmol/l, P < 001). More women than men were
obese(26 vs. 20 per cent, OR 1.35, 1.31.4, P < 0.001) and had
aneGFR < 60 ml/min/1.73m2 (19 vs. 12 per cent, OR 1.8,
1.72.0,
P < 0.001). Above age 50 years only fewer women (21 per cent)
thanmen (25 per cent) met a target HbA1c < 7.5 per cent (OR
0.76, 0.60.9,
P = 0.013).
Conclusions: The worse risk factor profile for obesity,
glycaemiccontrol and renal function in women than men with Type 1
diabetesmay contribute to their greater elevation in CVD risk.
Acknowledgement: On behalf of the Scottish Diabetes
ResearchNetwork.
P155
New onset hyperglycaemia in a multi-ethniccohort presenting with
acute coronarysyndromeA Mathew and P De
Diabetes and Endocrine Unit, City Hospital, Birmingham, UK
Aim: Disturbancesofglucosemetabolismarewidelyprevalent
inacutecoronary syndrome(ACS)andrelate toadverseoutcome,
irrespectiveof
presence or absence of previously diagnosed diabetes. The aim of
thisstudy was to find degrees of glucose intolerance amongst
patients
without diabetes admitted to the coronary care unit with ACS in
our
hospital population.
Methods: All patients admitted to the coronary care unit with
ACS(between May 2009 and October 2010) underwent fasting plasma
glucose, HbA1c and oral glucose tolerance test (OGTT) on day 3
of
admission and had a repeat OGTT 2 weeks later following
discharge.
Results: Forty-two of 52 patients admitted had an inpatient
OGTT.49 per cent of patients were Caucasian, 45 per cent South
Asians and 6
per centAfro-Caribbean.52per centand38per centwere
foundtohave
impaired glucose tolerance (IGT) and diabetes, respectively.
Repeat
OGTT 2 weeks later showed 48 per cent now had normal
glucosetolerance while 27 per cent and 25 per cent were found to
have IGT/IFG
and diabetes respectively. 75 per cent of those who developed
diabetes
wereSouthAsians,and25percentwereCaucasian (no
familyhistoryof
diabetes in 62 per cent). Fifteen of 53 patients (28 per cent)
with eitherIGT or diabetes normalised on repeat OGTT. Using a
cut-off HbA1c
of > 6.5 per cent for diabetes diagnosis, 12/46 (26 per cent)
patients
would be diabetic.
Conclusion: There is a high incidence of undiagnosed diabetes
andIGT among patients admitted with ACS in our multi-ethnic
population,
particularly South Asians. Every effort must be made to identify
these
patients early, inculcate lifestyle measures appropriately
and
aggressively target and treat cardiovascular risk factors.
2012 The Authors.78 Diabetic Medicine 2012 Diabetes UK. Diabetic
Medicine, 29 (Supp. 1), 30177
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P156
Relieving the stress: the effect of primarypercutaneous coronary
intervention onblood glucose levels in ST elevationmyocardial
infarctionAK McGregor1, R Edwards1, H Thomas1, IF Purcell1 andNJ
Leech2
1Cardiothoracic Services, Newcastle-upon-Tyne Hospitals NHS
Foundation
Trust, Newcastle-upon-Tyne, UK, 2Diabetes and Endocrinology,
Newcastle-
upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne,
UK
Aim: Studies demonstrating the benefit of insulin/dextrose
infusion inpatients with hyperglycaemia and ST elevation myocardial
infarction(STEMI) precede the widespreaduse of primary percutaneous
coronary
intervention (PCI). The effect of immediate reperfusion on
blood
glucose is not known. We propose that immediate PCI for STEMI
may
lower blood glucose and reduce the requirement for
insulin/dextroseinfusion.
Methods: We measuredcapillarybloodglucoseonadmissionand1 hafter
PCI balloon inflation in consecutive patients presenting with
STEMI. Pre and post PCI blood glucose were compared by paired t
test.Insulin/dextrose infusion was only initiated if the post PCI
blood
glucose was greater than 10 mmol/l.
Results: Paired blood glucose values were available for 98
patients.Eight patients had a history of diabetes of which four had
admissionblood glucose greater than 10 mmol/l. Overall, blood
glucose fell from
8.7 2.87 mmol/l (mean SD, range 4.520.3 mmol/l) to 8.1 2.61
mmol/l (mean SD, range 5.024.4 mmol/l, P = 0.002). Inthe 19
patients with admission glucose greater than 10 mmol/l,blood
glucose fell from 13.3 3.1 mmol/L (mean SD, range10.420.0 mmol/l)
to 10.8 4.6 mmol/l (mean SD, range5.324.4 mmol/l, P = 0.0008). In
11 of these patients (58 per cent)post PCI glucose fell to less
than 10 mmol/l.
Conclusions: In patients admitted with STEMI undergoing
PCI,blood glucose falls significantly immediately post reperfusion
even in
those hyperglycaemic on admission. We propose that
reperfusion
reduces stress hyperglycaemia and allows blood glucose to fall
in themajority of patients. The benefits of insulin/dextrose
infusions before
and after PCI therefore need further study.
P157
Estimating absolute cardiovascular riskreduction in young South
Asians with newlydiagnosed glucose disordersDR Webb1, LJ Gray2, K
Khunti2, A Farooqi2 and MJ Davies1
1Cardiovascular Sciences, University of Leicester, Leicester,
UK, 2Health
Sciences, University of Leicester, Leicester, UK
Aims: Screening is recommended within groups at high risk of
Type 2diabetes as earlier intervention theoretically improves
outcomes.
Despite a significant burden of metabolic disease, research
exploring
these effects in young ethnic minority groups is lacking. We
modelledestimated absolute 10 year cardiovascular risk reduction
(CVRR)
associatedwithpharmacological interventions
in2540-year-oldSouth
Asians identified with impaired glucose regulation (IGR) or
diabetes
through screening.
Methods: Effect estimates were derived from outcome trials
ofindividual risk factors in established diabetes (additive model)
and a
published randomised trial of multi-factorial intervention in
screen-
detected cases (cumulative model). Baseline biomedical
characteristicsrequired to calculate CVRR via the Framingham
CVD-ethrisk equation
were obtained from participants of a systematic screening
programme
(ADDITION Leicester). IDF diagnostic criteria were applied with
an
HbA1c of 6.06.5 per cent representing IGR and >6.5 per cent
diabetes.
Results: Population-based random sampling produced a
screenedcohort of 359 with undiagnosed diabetes and IGR frequencies
of 3.1
per cent (n = 11) and 12 per cent (n = 42) respectively.
Calculatedbaseline 10 year cardiovascular risk was 4.91 per cent
(SD 3.91) fordiabetesand4.44per cent (SD4.14) for IGR.The additive
effects model
of lipid,bloodpressure,glucose
loweringandaspirinresultedinaCVRR
of 2.7 per cent (range 2.03.2) for diabetes and 1.1 per cent
(range 0.1
1.7) for IGR. The cumulative effects model reflecting 5-year
intensivemulti-factorial intervention resulted in a CVRR of 0.7 per
cent (range
0.2 to 1.4) for diabetes and 0.5 per cent (range 0.1 to 1.0) for
IGR.
Conclusion: Assuming extrapolation of intervention efficacy
acrosspopulations is valid, clinically significant reductions in
absolutecardiovascular risk are likely within this group using
existing
treatments. The number needed to treat ranges from 37 to 143
for
diabetes and from 91 to 200 for IGR.
Clinical care and other categories posters: case reports
P158
The first case of fetal genetic testing toguide insulin
treatment in gestationaldiabetesAJ Chakera1,2, BA Knight1,2, RH
Sturley3, S Ellard4 andAT Hattersley1,2
1Peninsula National Institute for Health Research (NIHR)
Clinical Research
Facility, Peninsula College of Medicine and Dentistry,
University of Exeter,
Exeter, UK, 2Research and Development Directorate, Royal Devon
and Exeter
NHS Foundation Trust, Exeter, UK, 3Department of Obstetrics
and
Gynaecology, Royal Devon and Exeter NHS Foundation Trust,
Exeter, UK,4Department of Molecular Genetics, Royal Devon and
Exeter NHS Foundation
Trust, Exeter, UK
Refer to Oral number A17
P159
Important lessons from a rare case ofCharcot osteoarthropathy of
the wrist indiabetesME Edmonds1, V Kavarthapu2, J Compson2, G
Vivian3, D Elias4
and NL Petrova1
1Diabetic Foot Clinic, Kings College Hospital, London, UK,
2Department of
Orthopaedics, Kings College Hospital, London, UK, 3Department of
Nuclear
Medicine, Kings College Hospital, London, UK, 4Department of
Radiology,
Kings College Hospital, London, UK
Refer to Oral number A18
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2012 The Authors.Diabetic Medicine 2012 Diabetes UK. Diabetic
Medicine, 29 (Supp. 1), 30177 79
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P160
Improved metabolic response to exercise onsulfonylurea drugs
compared with insulin inHNF1A-MODYAN Lumb1, G Thanabalasingham2,3,
IW Gallen1 andKR Owen2,3
1Diabetes Centre, Wycombe Hospital, Buckinghamshire Healthcare
NHS
Trust, High Wycombe, UK, 2Oxford Centre for Diabetes,
Endocrinology and
Metabolism (OCDEM), University of Oxford, Oxford, UK, 3Oxford
National
Institute for Health Research (NIHR) Biomedical Research Centre,
Churchill
Hospital, Oxford, UK
Refer to Oral number A19
P161
6q24 transient neonatal diabetes, due tohypomethylation of the
maternal TND locus,is characterised by impaired insulinsensitivity
and secretionYS Cheah1,2, T Evans3, L Docherty4, DJG Mackay4, IK
Temple4
and SA Amiel1,2
1Diabetes Research Group, Kings College London, London, UK,
2Department
of Diabetes, Kings College Hospital NHS Foundation Trust,
London, UK,3Paxton Green Group Practice, Lambeth Primary Care
Trust, London, UK,4Faculty of Medicine, University of Southampton,
Southampton, UK
Refer to Oral number A20
P162
Hypoglycaemia documented withcontinuous glucose sensing in a
case ofdead in bedN Waheed, MI Butt, E Jones, A Newton, S Wong and
C Dayan
Diabetes Department, United Bristol Healthcare NHS Trust,
Bristol, UK
We report a 41-year-old man who was found dead in his bed with
acontinuous glucose monitoring device in situ. He had Type 1
diabetesdiagnosed at age 14 years. He had poor glycaemic control
during his
teenage years and suffered from severe hypoglycaemic episodes
andreduced hypoglycaemic awareness resulting in three road
traffic
accidents. His diabetes was complicated by retinopathy,
nephropathy
and neuropathy. He began continuous subcutaneous insulin
pump
therapy in 2005 and linked continuous real-time glucose
monitoring inJune 2009. He lived alone and was last seen alive and
well by his
family 7 days prior to being found dead in bed with no signs of
any
violent injury. The post-mortem download of his glucose
monitoring
device and insulin pump showed frequent hypoglycaemic
episodesover the preceding few days. On the last day of pump and
sensor
interaction, he was noted to be hypoglycaemic around 16:00 h and
he
temporarily stopped and then restarted his pump. Despite the
evidence
of alarms from the continuous glucose monitor, he
remainedpersistently hypoglycaemic. At 17:00 h, he administered 10
units of
insulin bolus on two occasions while still hypoglycaemic. This
was the
last recorded interaction between the patient and the
pump/sensorsystem. He was found dead in bed 7 days later.
Post-mortem
examination was consistent with death several days before
and
showed no specific cause of death. Hypoglycaemia is known to
precipitate sudden cardiac arrhythmias which in our patient may
havebeen the cause of death.
P163
Managing insulin and carbohydraterequirements for an athlete
with Type 1diabetes: cycling from John OGroats toLands EndR
Ritchie1, J Hadley2, S Woodman1 and R Holt3
1Nutrition and Dietetics, University Hospital Southampton NHS
Foundation
Trust, Southampton, UK, 2Community Diabetes Service Solent NHS
Trust,
Solent, Southampton, UK, 3Institute of Developmental Sciences,
University of
Southampton, Southampton, UK
Background: The management of Type 1 diabetes whilst
performinghigh intensity and long duration exercise, in particular
preventing
hypoglycaemia and hyperglycaemia to optimise performance, is
challenging. To achieve this, a fine balance between
carbohydrateintake and basal/bolus insulin is required.
Case report: A 28-year-old man with Type 1 diabetes was
referredwith fluctuating blood glucose levels (BGL) ( 20
mmol/l,
HbA1c 8.8 per cent, 73 mmol/l) during intensive prolonged
exercise.He planned to cycle 900 miles over nine consecutive days.
Guided by
self-monitored blood glucose results collected during practice
cycles,
on race days he reduced the basal insulin by approximately 1720
percent and bolus doses by 60 per cent (breakfast), 50 per cent
(lunch)
and 10 per cent (evening meal). The target BGL range prior to
the
race was 12 mmol/l and finish 59 mmol/l. The blood glucose
target
was 58 mmol/l. To prevent hypoglycaemia he was consumingnumerous
large quantities of fast acting glucose (> 80 g) throughout
the day. To maintain the BGL within target range and avoid
hypoglycaemia and hyperglycaemia he was advised to consume 20
g
fast acting carbohydrate every 20 min in the form of liquid,
gels orglucose tablets. He was also advised to consume complex
carbohydrate-dense meals in order to help provide a steady
energy
release through the day.
Conclusion: This case illustrates that reductionsofup to60per
centofrapid insulin and 1720 per cent of basal insulin may be
required to
reduce the risk of hypoglycaemia during and post intensive
exercise.
The findings suggest that a regular intake of 20 g fast
acting
carbohydrate intake may help stabilise blood glucose
levelconcentration during intensive exercise.
P164
Use of insulin pump therapy in patients withcystic fibrosis
related diabetes: a case seriesS Gupta and R Canavan
Endocrinology and Diabetes Centre, St Vincents University
Hospital, Dublin,
Ireland
Cystic fibrosis related diabetes (CFRD) is associated with
6-foldincrease in morbidity and mortality. Numerous case reports
have
shown improvement of glycaemic control and quality of life
using
continuous subcutaneous insulin infusion (CSII). We report
our
experience of a 3-year follow-up with CSII use in a series of
CFRDpatients at our institute. The first patient, female 18 years
old,
diagnosed with CFRD at age 15, was commenced on multiple
daily
insulin injections (MDI) in view of her catabolic state [body
mass
index (BMI) 19 kg/m2] and poor glycaemic control (HbA1c 9.3
percent). Her nutritional status continued to decline and within a
year
CSII was commenced. During a 2-year follow-up, BMI improved
to
24 kg/m2, HbA1c failed to improve and FEV1 (69 per cent of
predicted) remained stable. The second patient, male 18 years
old,diagnosed with CFRD at an early age, was commenced on CSII at
a
time of declining lung function (FEV1, 50 per cent of predicted)
and
malnutrition (BMI 18.2 kg/m2). Multiple hospital admissions
were
DIABETICMedicine Clinical care and other categories posters:
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reportsDIABETICMedicine Clinical care and other categories posters:
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2012 The Authors.80 Diabetic Medicine 2012 Diabetes UK. Diabetic
Medicine, 29 (Supp. 1), 30177
mimran74Rectangle
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required to manage complications of decompensated liver
disease.
BMI improved minimally (19 kg/m2) and HbA1c fell (7.4 to 5.5
percent). He subsequently underwent successful liver
transplantation.
Another patient passed away within 2 years of commencing CSII
of
end-stage respiratory disease. Use of CSII in patients with CFRD
has
potential benefits in this highly complicated group. The
indicationsfor CSII to date have not been widely defined but should
be both
disease and patient centred. Our experience shows that CSII may
be a
safe and effective therapeutic alternative to MDI treatment in
CFRD
patients.
P165
MODY: its not always what it says on thetinJT Cameron1, M
Shepherd2, S Ellard2 and E Pearson1
1Diabetes, NHS Tayside, Perth, UK, 2Diabetes Genetics,
Peninsular Medical
School, Exeter, UK
Background: Maturity-onset diabetes of the young (MODY) is
oftenmis-diagnosed as Type 1 diabetes (T1D). The discovery of an
HNF1Amutation can result in successful transfer from insulin to
sulfonylureas.
Yet sometimes the diagnosis of MODY is not clear cut, and
treatment
change is not always successful. We report a MODY pedigree
with
four different presentations of diabetes.
Case reports: The proband was diagnosed with T1D aged 18
years.Persistent insulin secretion prompted MODY testing resulting
in
discovery of an HNF1A mutation. He transferred off insulin and
is well
controlled on gliclazide. His cousin had insulin-treated
diabetes and thesame mutation. She stopped insulin treatment but
was not sensitive to
sulfonylureas with deteriorating glycaemic control on maximum
dose.
Surprisingly her GAD antibodies, which had been negative at
diagnosis,were now positive, indicating that she has both HNF1A
MODY (like
her father) and T1D (like her mother). Their aunt was diagnosed
at
46 years with Type 2 diabetes but has the HNF1A mutation.
Despite
her age (64 years), she was extremely sulfonylurea sensitive.
Anothercousin had transient neonatal diabetes diagnosed at 6 weeks,
which
remitted at 8 weeks but relapsed at 11 years. He is heterozygous
for
both the HNF1A mutation and an activating ABCC8 mutation. He
is
awaiting transfer off insulin.
Conclusion: This family demonstrates the importance of
offeringgenetic testing to all family members with diabetes. Dual
diagnoses are
possible and a thorough assessment of each individual is
required to
ensureanaccuratediagnosis ismadewhichwill also influence
treatmentchoices.
P166
Insulin-type cutaneous amyloid from insulininjectionsIW Seetho1,
A Coup2 and SA Olczak3
1Department of Diabetes and Endocrinology, Derby Hospitals
NHS
Foundation Trust, Royal Derby Hospital, Derby, UK, 2Department
of Cellular
Pathology, Pilgrim Hospital, Boston, UK, 3Department of Diabetes
and
Endocrinology, Pilgrim Hospital, Boston, UK
A 54-year-old man with Type 2 diabetes had been on insulin
aspart(810 units at meal times) and detemir 26 units daily for
about 5 years.
HbA1c was 8.0 per cent (IFCC 64 mmol/mol). A soft tissue
swelling
was noticed in the region of the left iliac fossa where he
administered his
insulin injections. The excised specimen consisted of fatty
tissue 52mmin maximum dimension, which contained a firm, yellowish
central
lesion on sectioning. Microscopy of this showed a nodular
lesion
composed of amorphous eosinophilic material within fat, with a
minorpatchy lymphocytic infiltrate around the periphery. This
material
stained positively with Congo Red and under high intensity
polarised
light showed the apple-green birefringence characteristic of
amyloid.
Immunohistochemistry was performed with serum amyloid A
protein(SAA) and anti-insulin monoclonal antibodies, both of which
were
positive, indicatingamyloidosisof the insulin type.His serum
amyloidP
component (SAP) scintigraphy scan showed no visceral amyloid
deposits. There was no evidence of systemic amyloidosis and
plasmacell dyscrasia. His electrocardiogram and echocardiogram
showed no
evidence of cardiac amyloid. This man had insulin-type
cutaneous
amyloid which is a localised form of amyloid. There are few
reports inthe literature of the association of cutaneous
amyloidosis with porcine
and human recombinant insulin. Although uncommon, it is
important
to be aware of this complication when assessing patients
insulin
injection sites so that this diagnosis is not missed and the
patient canthen be investigated accordingly.
P167
GLIS3 mutations: a rare cause of neonataldiabetesO Ajala1, J
Jones2, S Ellard3, C Shaw-Smith3 and BA Millward1
1Diabetes Clinical Research Centre, Peninsula College of
Medicine and
Dentistry, Plymouth, UK, , 2Primary Care Trust, Cornwall and
Isles of Scilly,
UK, 3Peninsula College of Medicine and Dentistry, University of
Exeter, Exeter,
UK
Background: Permanent neonatal diabetes (PNDM) caused
byrecessive GLIS gene mutations (which encode a zinc finger
transcription factor) is rare; five families have been reported
to date.Cardinal featuresareneonatal diabetesandcongenital
hypothyroidism;
additional features include congenital glaucoma, hepatic
fibrosis,
polycystic kidneys, developmental delay and facial dysmorphism.
Wereport an unusual case with neonatal diabetes without thyroid
abnormalities.
Case history: SM, now 33 years, weighed 2,750 g at birth. She
wasdiagnosed with diabetes at 1 week and treated with insulin.
Choanalatresia was noted at 9 days and surgically corrected. By 4
years, she
failed to meet developmental milestones. Genetic screening of
the
KCNJ11,ABCC8, INS,GCKand IPF1genes in20062008revealedno
abnormalities. DNA was retested in 2011 by array CGH revealing
apaternally derived 4Mb deletion of chromosome 9p, encompassing
GLIS. Sequence analysis identified a novel R589W missense
mutation
inherited from her unaffected mother. Her (unaffected) father
died an
unrelated death; hence samples were unavailable for testing.
Thyroidultrasound, function and autoantibodies were normal; she had
no other
abnormalities and normal menstrual function.
Discussion: Genetic testing for PNDM is routine practice
sinceidentification of a mutation in the KCNJ11 or ABCC8 genes
(whichaccount for G50 per cent of cases) allowed better treatment
withsulfonylureas rather than insulin. There are multiple other
causes of
PNDM, many syndromic. Our patient has biallelic GLIS3
mutations,usually associated with the very rare syndrome of
neonatal diabetes and
congenital hypothyroidism. This patients normal thyroid
function
illustrates further phenotypic heterogeneity of this
syndrome.
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P168
Ketoacidosis is not always due to diabetesO Ajala and DE
Flanagan
Department of Diabetes and Endocrinology, Plymouth Hospitals NHS
Trust,
Plymouth, UK
Background: Diabetic ketoacidosis (DKA) is anacute
life-threateningcomplication of diabetes. In some situations an
alternative diagnosis
needs to be considered. Alcohol related ketoacidosis may be
seen
following an alcoholic binge in an otherwise
under-nourishedindividual. The presenting history should
differentiate these two
conditions but this is not always available. We report a case
of
ketoacidosis inappropriately labelled as resulting from new
onset of
diabetes.
Case history: A 29-year-old female was admitted after being
foundunconscious in the street. The paramedics found evidence
suggestive of
alcohol intoxication. Initial investigations were metabolic
acidosis
(arterial pH 7.1, bicarbonate 3 mmol/l), hyperglycaemia
(capillaryglucose 12 mmol/l, venous glucose 14.8 mmol/l), ketonuria
(ketones
4+) and deranged liver function (GGT > 2000iu/l, ALT 175iu/l,
AST
197iu/l, ALP 174u/l). A diagnosis of diabetic ketoacidosis was
madeand she was managed with intravenous fluids and insulin.
Diabetology
review felt the diagnosis of new onset diabetes was not secure
(although
there was no documentation of initial hypoglycaemia or
dextrose
administration). Insulin was discontinued with very close
monitoring ofcapillary glucose. Diabetes was excluded following
normal capillary
glucose readings over a 24 h period ( 5 mmol/l), normal
fastingglucose (4.9 mmol/l), normal HbA1c (4.8 per cent), C-
peptide > 500pmol/l and negative diabetes auto-antibodies
(GADand islet cells).
Discussion: A possible explanation for initial hyperglycaemia
mightbe the administration of intravenous dextrose prior to
admission to
medical assessment (although this was not documented in the
medicalnotes). It is important to consider other causes of
ketoacidosis
including alcohol and starvation, both of which were likely
triggers in
this patient.
P169
Glycogenic hepatopathy: a rare andpotentially reversible
complication ofpoorly controlled diabetesB Paranandi1, J Hannah2, S
Ashton-Cleary2, R Rea2 andA Austin1
1Hepatology, Royal Derby Hospital, Derby, UK, 2Diabetes and
Endocrinology,
Royal Derby Hospital, Derby, UK
Glycogenic hepatopathy is a rare and under-recognised
complication of
poorly controlled diabetes which is characterised by a
pathological
overloading of hepatocytes with glycogen. It is radiologically
and
clinically difficult to distinguish from fatty liver but there
are uniquehistological features on liver biopsy that are distinct
from
steatohepatitis. It can resolve following optimal glycaemic
control
and this is demonstrated below. LN is a 29-year-old Caucasian
femalewith known coeliac disease and poorly controlled Type 1
diabetes who
presented with abdominal swelling and discomfort,
significantly
deranged liver function tests in a predominantly hepatitic
pattern,
persistently erratic blood sugars and ketonuria. Non-invasive
liverscreening for viral, autoimmune and other well-recognised
causes of
liver disease was unremarkable. Clinical examination revealed
smooth
hepatomegaly (10cm below the costal margin). Abdominal
ultrasound
revealed marked hepatomegaly with diffuse echogenicity,
mildsplenomegaly and patency of the portal and hepatic veins.
Liver
biopsy showed a patchy lobular neutrophil infiltrate, extensive
clearing
of hepatocyte cytoplasm and glycogenation of nuclei. There was
no
evidence of fatty change, inflammation or fibrosis. A diagnosis
ofglycogenic hepatopathy was made. Medical management was
targeted
predominantly towards improving glycaemic control. Following
limited progress with various standard insulin regimes, a
continuous
subcutaneous insulin infusion pump was commenced. Six months
later,her blood sugars had stabilised and she was demonstrating
significantly
improved glycaemic control with an absence of urinary ketones.
Her
LFTs had normalised, there was radiological resolution of
her
hepatomegaly with bedside examination revealing an
impalpableliver and no other hepatic sequelae.
P170
Autoimmune pancreatitis and diabetesN Kaimal, A Kyriacou, C
Babbs, S Taggart and B Young
Diabetes and Endocrinology, Salford Royal Hospital, Salford,
UK
Case history: A 68-year-old South Asian gentleman presented
withreduced appetite, 10kg weight loss and a recent diagnosis of
diabetes
(pre-meal blood sugars in the range of 78 mmol/l). He had never
been
overweight and there was no family history of diabetes. He had a
past
history of tuberculous adenitis in his right supraclavicular
fossa 3 yearsago, for which he had a full course of
anti-tuberculous therapy. He also
had a past history of idiopathic thrombocytopenic purpura.
Presenting
chest X-ray showed mediastinal lymphadenopathy, which
wasconfirmed on CT.
Investigations: CT showed mediastinal and hilar
lymphadenopathybut also showed bulky pancreas with peripancreatic
oedema. Lymph
node aspirate was negative for tuberculosis but positive for
silica. ESRwas elevated at 75, amylase was normal and globulins
were raised at
48 g/l. Electrophoresis confirmed a polyclonal IgG increase.
IgG
subclass 4 was grossly elevated at 27.1 g/l (0.002.91 g/l).
Treatment and progress: The grossly elevated IgG subclass 4 in
thecontext of his clinical presentation with diffuse pancreatic
swelling was
highly suggestive of a diagnosis of autoimmune pancreatitis. He
was
commenced on high dose prednisolone (40mg/day) and also started
on
insulin whilst on steroids. Repeat CT done 3 months later showed
clearimprovement in the inflammatory changes of the pancreas as
well as the
hilar and mediastinal lymphadenopathy.
Conclusions: Pancreatic endocrine deficiency may rarely
besecondary to autoimmune pancreatitis. Although uncommon,
thisdisorder is usually treatable and hence merits consideration
when the
presentation of diabetes is unusual.
P171
Acromegaly: a rare but important cause ofinsulin resistance in
Type 1 diabetesJ Prague1, MSB Huda2, A McGregor1 and D Hopkins2
1Department of Endocrinology, Kings College Hospital, London,
UK,2Department of Diabetes, Kings College Hospital, London, UK
Although insulin resistance is a typical feature of
acromegaly,
deterioration in metabolic control in established Type 1
diabetes
due to this can easily be missed. We report a 27-year-old female
withType 1 diabetes of 18 years duration, who was referred for
tertiary
opinion and consideration of pump treatment due to
deterioration
of glycaemic control (HbA1c 10.2 per cent) and with
increasing
insulin requirements. Inpatient investigation confirmed high
insulinrequirements; intravenous insulin at 3 units/h was required
to
maintain fasting euglycaemia. Following basal insulin
optimisation,
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continuous glucose monitoring revealed persistently raised
postprandial glucose, despite progressive increase in prandial
insulin(3 units: 10 g carbohydrate). On examination, the patient
was normal
weight (body mass index 22 kg/m2) and blood pressure was
103/
62mm Hg. Subtle coarsening of facial features were noted
together
with soft tissue thickening of the hands, previously attributed
tocheiroarthropathy. Subsequent investigation confirmed
acromegaly.
Serum IGF-1 was elevated at 697 mcg/l (94252 mcg/l) and
serum
GH paradoxically rose from 75 mcg/l to 85 mcg/l during a 75 g
oral
glucose tolerance test. MRI identified a 17mm 18mm sella
mass.Following successful trans-sphenoidal surgery, GH and
IGF-1
normalised and there was an immediate fall in insulin
requirements, basal insulin falling from 109 to 23 units/24 h
andprandial insulin ratio falling to 1 unit/10 g carbohydrate.
HbA1c fell
to 7.6 per cent within 3 months. Histology confirmed an
adenoma
staining positive for GH on immunohistochemistry. This case
highlights the importance of identifying the underlying cause
ofinsulin resistance in patients with decline in control and
changing
insulin requirements; initial clinical signs of acromegaly may
be subtle
but this should be considered.
P172
Boerhaaves syndrome and diabetesS Zhyzhneuskaya, R Sinha, J
Chapman and R Nayar
Diabetes and Endocrinology, City Hospitals Sunderland NHS
Foundation
Trust, Sunderland, UK
Introduction: We present a rare but important complication
ofdiabetic ketoacidosis (DKA), which should be considered and
sought
for in acute presentations of DKA associated with vomiting.
Case history: A 20-year-old man with known Type 1
diabetespresented with DKA. He reported severe vomiting for 3 days
followed
by chest discomfort prior to presentation. On examination he
was
tachypneoic with Kussmauls type of breathing pattern.
Investigationsconfirmed DKA with a high C-reactive protein and
leucocytosis. No
reference to supraclavicular subcutaneous emphysema or
Hammans
crunch sign was made on admission. Chest radiography revealed a
rim
of air along the lateral border of the heart.
Management: Our patient was kept nil by mouth and continued
onintravenous broad spectrum antibiotics. Water soluble contrast
studies
on the following day did not reveal an oesophageal leak.
Subsequent
chest radiographs revealed resolution of the pneumomediastinum
withclinical and symptomatic improvement.
Discussion: The source of air in the mediastinum
orpneumomediastinum can be lungs, bronchial tree or oesophagus.
Spontaneous pneumomediastinum is uncommon; it results from
alveolar rupture, otherwise known as the Macklin phenomenon.
Airmay track into subcutaneous tissue leading to cervical or
supraclavicular emphysema, or pericardium, peritoneal cavity
and/or
epidural space.
Summary: Nearly 70 years ago, Hamman described a patient inwhom
pneumomediastinum was associated with DKA. These two
entities may coexist more frequently than previously thought.
Hence a
high index of suspicion should exist in all patients presenting
with DKA
with vomiting and chest discomfort.
P173
Person with Type 1 diabetes andhypoglycaemia unawareness who
regainedhypoglycaemia awareness and improvedglycaemic control post
DAFNE course: a casereportKE Jones, S Fleming and J Morgan
Diabetes Resource Centre, Northumbria Healthcare NHS Foundation
Trust,
North Tyneside, UK
JM is a 57-year-old White male who was diagnosed with Type 1
diabetes in 1977. He had his insulin changed from porcine to
analogues
in 2007 and started to experience hypoglycaemia unawareness in
2008;
his driving licence was revoked in June 2010. At his request
hewas converted back to porcine neutral in 2010 with no
resulting
improvement in his hypoglycaemia awareness. JM attended a
DAFNE
(Dose Adjustment for Normal Eating) education course in July
2010
where he was advised to aim for a pre-meal blood glucose level
target of7.5 mmol/l and toavoidhisbloodglucose level
fallingbelow4.5 mmol/
l. On the first day of the course he converted back to rapid
acting
analogue insulin. Prior to the course his HbA1c was 66 mmol/mol
(8.2per cent) and in
theprecedingyearhehadrequiredparamedicassistance
for hypoglycaemia episodes three times. One year post course
his
hypoglycaemia warning signs have fully returned, he has had
no
episodes of hypoglycaemia requiring paramedic assistance and
hisdriving licence had been reinstated. JMs HbA1c is within target
and
lower than prior to the course at 53 mmol/mol (7.0 per cent) and
his
PAID score has improved from 40.0 prior to the course to 17.5 1
year
post course.
Conclusion: Undertaking the DAFNE course and following
theprinciples has improved JMs diabetes control, improved his
hypoglycaemia awareness, improved his quality of life and
enabled
him to resume driving.
P174
Ketoacidosis in non-diabetic pregnancyF Le Neveu1, B Hywel2 and
J Harvey1
1Department of Endocrinology and Diabetes, Wrexham Maelor
Hospital, Betsi
Cadwaladr University Health Board, Wrexham, UK, 2Department of
Medicine,
Wrexham Maelor Hospital, Betsi Cadwaladr University Health
Board,
Wrexham, UK
Introduction: Euglycaemic diabetic ketoacidosis has been a topic
ofdiscussion for over 30 years. Historically it was suggested to
occur at a
blood glucose less than 16.6 mmol/l. More recently definitions
of
glucose less than 13.9 mmol/l or less than 11.1 mmol/l have
beensuggested. Cases has been reported with various causes and
contributing factors. A number of these cases have occurred
during
pregnancy.
Case report: A healthy 33-year-old who was 30 weeks pregnant
withher second child presented with a week-long history of
flu-like
symptoms, productive cough and rigors. On examination she
had
blood pressure 103/53, respiratory rate 30 and temperature
39.1C(102F), with lobar pneumonia and subsequent empyema. She
requiredinotropic support on ITU. She had urinary ketones since
admission and
her plasma beta-hydroxy butyrate was 5.3 mmol/l. Glucose levels
were
normal throughout; arterial pH 7.32; BE-12 with a
compensatedmetabolic acidosis; lactate 0.8; eGFR > 60. Her
non-diabetic
ketoacidosis was successfully treated with intravenous insulin 6
unit/
h, 10 per cent dextrose with potassium. On day 9 of admission
a
31-week gestation infant was successfully delivered.
Conclusions: Ketoacidosis occurs in periods of stress when
counter-regulatory hormone levels rise causing free fatty acid
release and ketone
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production by the liver. With fasting, insulin levels are
suppressed.
Euglycaemic ketoacidosis is more common in pregnancy
probablybecauseof the insulin resistant stateand theeventsof
relative starvation.
The metabolic acidosis needs to be recognised and differentiated
from
other causes. Guidelines on ketoacidosis do not always recognise
that it
can occur with euglycaemia.
P175
Eruptive xanthoma preceding acutepresentation of
severehypertriglyceridaemia with new onsetdiabetes complicated by
pancreatitis: a casereportR Ahluwalia1 and L Overend2
1Diabetes and Endocrinology, Royal Liverpool and Broadgreen
University
Hospital, Liverpool, UK, 2Diabetes and Endocrinology, St Helens
and
Knowsley Teaching Hospitals NHS Trust, Prescot, UK
Diabetes is a well-recognised cause of secondary
hyperlipidaemia
including hypertriglyceridaemia mainly as a result of
altered
activity of insulin dependent enzymes such as lipoprotein
lipase.
Hypertriglyceridaemia is an uncommon cause of
pancreatitisaccounting for 14 per cent of cases especially with
triglyceride levels
> 55 mmol/l (normal < 2.3). Poorly controlled diabetes
with type 4
hyperlipidaemia is a risk factor for hypertriglyceridaemia
inducedpancreatitis. In addition the possibility of normal amylase
levels on
presentation of hypertriglyceridaemia-induced pancreatitis
makes
diagnosis challenging. We report a case of a 40-year-old
Caucasian
male presenting with hypertriglyceridaemia-induced pancreatitis
withnew onset diabetes. He presented to the emergency department
with
severe abdominal pain and projectile vomiting. He was
hyperglycaemic
and had raised amylase levels. Corroborating abdominal
imaging
established the diagnosis of acute pancreatitis which was
managedconservatively. Given a paired triglyceride level of 39.2
mmol/l,
hypertryglyceridaemia was presumed to be the likely cause. He
had a
baseline glycosylated haemoglobin of 13.2 per cent (121
mmol/molIFCC value) alluding to undiagnosed diabetes prior to
current
admission. He also reported a widespread rash consistent
with
eruptive xanthoma, appearing months before his acute
presentation.
He received a short course of insulin therapy followed by oral
agents fordiabetes. His dyslipidaemia and the rash improved with
lipid lowering
agents. Cutaneous manifestations such as eruptive xanthoma
associated with dyslipidaemia may precede the diagnosis of
the
underlying lipid disorder. Given the association with diabetes
as wellas the risk of potentially life threatening pancreatitis if
left untreated,
xanthomas warrant a detailed metabolic evaluation following
diagnosis. They also offer an excellent opportunity for early
diagnosis
and intervention, to avert future complications.
P176
Previously unrecognised HNF1B in adiabetes clinic: the value of
systematictesting in patients with young-onsetdiabetesS Tiley1,2, M
Shepherd1,2, UNITED Research Team1,2,TM McDonald3, S Ellard4 and AT
Hattersley1,2
1Peninsula National Institute for Health Research (NIHR)
Clinical Research
Facility, Peninsula College of Medicine and Dentistry,
University of Exeter,
Exeter, UK, 2Research and Development, Royal Devon and Exeter
Foundation
Trust, Exeter, UK, 3Department of Clinical Chemistry, Royal
Devon and Exeter
Foundation Trust, Exeter, UK, 4Molecular Genetics, Royal Devon
and Exeter
Foundation Trust, Exeter, UK
Background: HNF1B accounts for G1 per cent of
maturity-onsetdiabetes of the young (MODY) and is typically
characterised by renalcysts and diabetes, although the renal
disease is highly variable. The
UNITED project aims to improve diagnosis by offering a
systematic
series of tests for those diagnosed < 30 years and selecting
patients toproceed to genetic testing.
Case study: A 29-year-old man presented with a 6 months history
ofpolyuria, polydipsia and loss of appetite; RBG 20.1 mmol/l,
Hba1c
16.2 per cent (157 mmol/l), urinalysis 4 + glucose, 1 + ketones,
bodymass index 23.4 kg/m2, GAD negative. There was no family
history of
diabetes. A diagnosis of Type 1 diabetes made and insulin
was
commenced.
UNITED study involvement: He was recruited to UNITED andprovided
2 h postprandial urine for urinary C-peptide creatinine ratio
which indicated significant insulin production, 2.24
nmol/mmol,
3 years post diagnosis. GAD65 and IA2 were both negative. As
he
was making endogenous insulin and was antibody negative, DNA
wastested for mutations in the commonest MODY genes. A deletion
of
exons 19 of HNF1B was identified.
Follow-up: Renal ultrasound showed multiple renal cysts in the
leftkidney; the right kidney appeared entirely normal, renal
function wasnormal, creatinine 87 lmol/l. Faecal elastase 106 mcg/g
indicatedmoderate pancreatic insufficiency. Both parents tested
negative for the
deletion indicating that this was a de novo mutation.
Conclusion: Use of a systematic series of tests in those with
young-onset diabetes can indicate individuals who may benefit from
genetictesting and identify previously unrecognised cases of
monogenic
diabetes. Recognising HNF1B is important as this allows
appropriate screening, follow-up and discussion of risk to
otherfamily members.
P177
Dual onset of autoimmune hepatitis anddiabetes in an 18 year old
patientM Reddy, C Feeney and D Gable
Department of Diabetes, Endocrinology and Metabolic Medicine, St
Marys
Hospital, Imperial College Healthcare NHS Trust, London, UK
An 18-year-old Afro-Caribbean man, with a body mass index of
19,
presented with a 2-week history of jaundice, pale stools, weight
loss
and abdominal pain. Initial blood results revealed deranged
liver
function tests as follows: ALT 1739iu/l (normal range
040),bilirubin 242 lmol/l (017), albumin 30 g/l (3551), ALP
126u/l(30130) and INR 1.4. An autoimmune liver screen revealed
positive
smooth muscle antibodies and hence a working diagnosis
ofautoimmune hepatitis was made. An ultrasound and CT liver
were
normal and he underwent a liver biopsy which confirmed
severe
acute lobular hepatitis with areas of collapse. Prednisolone
40mg
daily was commenced and 2 days later it was noted that his
capillary
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blood glucose measurements were elevated to above 20 mmol/l.
Diabetic ketoacidosis was ruled out and subcutaneous insulin
wascommenced. Of note, he had positive GAD antibodies of >
250u/ml
but islet cell antibodies were negative. On further
autoimmune
screening, parietal cell antibodies were positive but intrinsic
factor
and tissue-transglutaminase antibodies were negative. B12
andthyroid function were within the normal range. His diabetes
is
most likely Type 1 diabetes in view of the positive GAD
antibodies,
body habitus and the well-established association between
autoimmune conditions.
Conclusion: Although Type 1 diabetes is commonly associated
withautoimmune conditions such as Graves, Addisons and coeliac
disease,
it is less commonly seen in association with autoimmune
hepatitis. This
case highlights the importance of being alert to, and screening
ifnecessary for, other potential coexisting autoimmune
conditions.
P178
Does exercise preserve the honeymoonperiod in Type 1 diabetes? A
presentation ofthree clinical casesA Kennedy and P Narendran
School of Clinical and Experimental Medicine, University of
Birmingham,
Birmingham, UK
The honeymoon period in Type 1 diabetes (T1D) is a period of
partial
remission of diabetes with near normal blood glucose and low
insulin
requirements (
-
Case 2: A 28-year-old primagravida with well-controlled Type
1diabetes of 18 years duration, microalbuminuria and previous
treatment of right-sided maculopathy presented with maculopathy
at20 weeks gestation. VA was 6/6, 6/6 with bilateral macular
microaneurysms. No oedema was evident on slit-lamp
examination
but OCT revealed early fluid accumulation. At 29 weeks she
reported asudden deterioration in vision with a drop in VA to 6/9,
6/15. OCT
showeddiffusemacularoedema.Treatmentwithoral furosemide40mg
daily was instituted. By 34 weeks VA had improved to 6/6,
6/7.5
although OCT indicated progression of macular oedema.
Discussion: Macular oedema may arise or worsen in pregnancy.
Thebenefit of grid laser treatment during pregnancy is disputed. A
medical
approach is therefore attractive. A fall in maternal plasma
volume may
retard fetal growth but both our women had babies of normal
birthweight.
P181
An insulin gene mutation presenting asmaturity-onset diabetes of
the youngSA Mughal1,2, A Webster3, S Ellard4 and KR Owen1,2
1Oxford Centre for Diabetes Endocrinology and Metabolism,
University of
Oxford, Oxford, UK, , 2Oxford National Institute for Health
Research (NIHR)
Biomedical Centre, Churchill Hospital, Oxford, UK, 3Oxford
Radcliffe Hospitals
(NHS Trust), Oxford, UK, 4Institute of Biomedical and Clinical
Science,
Peninsula Medical School, Exeter, UK
Mostpatientswith insulingene
(INS)mutationshaveneonataldiabetes.
However, a few patients present with clinical characteristics
similar tomaturity-onset diabetes of the young (MODY). We present a
family
clinicallydiagnosedas MODYwhoonfurther investigationwere
found
to have a novel INS mutation. A 20-year-old lean woman was
referred
to our monogenic diabetes clinic with symptoms of
postprandialreactive hypoglycaemia. She was concerned because her
father and
sister had similar symptoms before developing diabetes. Her
sister was
diagnosed with non-insulin requiring diabetes at age 15. Their
father
was diagnosed with Type 2 diabetes at 35 years and was
well-controlled on metformin. MODY was suspected, but mutations
in
common MODY genes were not found. Further genetic
investigation
revealed that both her sister and father had the H29Q INS
mutation.Our patient underwent an extended oral glucose tolerance
test. Fasting
glucose was 5.5 mmol/l, 17 mmol/l at 2 h and 6.6 mmol/l at 4
h.
Insulin and C-peptide levels were 20pmol/l and 0.29nmol/l
fasting
rising to a maximum of 206pmol/l and 1.74nmol/l respectively at
2 h.HbA1c was 6.3 per cent. No symptoms or biochemical confirmation
of
hypoglycaemia was made. Diagnostic genetic testing confirmed
the
same INS mutation in our patient. INS mutations account for G1
percent