Anna Brackenridge

Clinical trial comparing nicotine replacement therapy (NRT) plus brief counselling, brief counselling alone, and minimal intervention on smoking cessation in hospital inpatients

Background: Guidelines recommend that smoking cessation interventions are offered in all clinical settings to all smokers willing to make a quit attempt. Since the effectiveness of routine provision of behavioural counselling and nicotine replacement therapy (NRT) to smokers admitted to hospital has not been established, a randomised controlled trial of these interventions given together compared with counselling alone or minimal intervention was performed in hospital inpatients. Methods: Medical and surgical inpatients who were current smokers at the time of admission were randomised to receive either usual care (no additional advice at admission), counselling alone (20 minute intervention with written materials), or NRT plus counselling (counselling intervention with a 6 week course of NRT). Continuous and point prevalence abstinence from smoking (validated by exhaled carbon monoxide <10 ppm) was measured at discharge from hospital and at 3 and 12 months, and self-reported reduction in cigarette consumption in smokers was assessed at 3 and 12 months. Results: 274 inpatient smokers were enrolled. Abstinence was higher in the NRT plus counselling group (n=91) than in the counselling alone (n=91) or usual care (n=92) groups. The difference between the groups was significant for validated point prevalence abstinence at discharge (55%, 43%, 37% respectively, p=0.045) and at 12 months (17%, 6%, 8%, p=0.03). The respective differences in continuous validated abstinence at 12 months were 11%, 4%, 8% (p=0.25). There was no significant difference between counselling alone and usual care, or in reduction in cigarette consumption between the treatment groups. Conclusions: NRT given with brief counselling to hospital inpatients is an effective routine smoking cessation intervention.

Real-Time Continuous Glucose Monitoring Significantly Reduces Severe Hypoglycemia in Hypoglycemia-Unaware Patients With Type 1 Diabetes

OBJECTIVE To evaluate the effect of continuous glucose monitoring (CGM) on the frequency of severe hypoglycemia (SH) in patients with established hypoglycemia unawareness. RESEARCH DESIGN AND METHODS We conducted a retrospective audit of 35 patients with type 1 diabetes and problematic hypoglycemia unawareness, despite optimized medical therapy (continuous subcutaneous insulin infusion/multiple daily insulin injections), who used CGM for >1 year. RESULTS Over a 1-year follow-up period, the median rates of SH were reduced from 4.0 (interquartile range [IQR] 0.75–7.25) episodes/patient-year to 0.0 (0.0–1.25) episodes/patient-year (P < 0.001), and the mean (±SD) rates were reduced from 8.1 ± 13 to 0.6 ± 1.2 episodes/year (P = 0.005). HbA1c was reduced from 8.1 ± 1.2% to 7.6 ± 1.0% over the year (P = 0.005). The mean Gold score, measured in 19 patients, did not change: 5.1 ± 1.5 vs. 5.2 ± 1.9 (P = 0.67). CONCLUSIONS In a specialist experienced insulin pump center, in carefully selected patients, CGM reduced SH while improving HbA1c but failed to restore hypoglycemia awareness.

Effects of rosiglitazone and pioglitazone on lipoprotein metabolism in patients with Type 2 diabetes and normal lipids

Aims  Previous studies have suggested that plasma lipids are affected differently by the peroxisome proliferators‐activated receptor (PPAR)‐γ agonists pioglitazone and rosiglitazone. The aim of this study was to perform a quantitative lipoprotein turnover study to determine the effects of PPAR‐γ agonists on lipoprotein metabolism.

Cerebral cavernoma: an emerging long‐term consequence of external beam radiation in childhood

The long‐term effects of cranial external beam radiotherapy are emerging as survival rates for cerebral tumours improve. Cerebral cavernoma are a recognized consequence of cranial irradiation. Endocrinologists managing the life‐long complications of hypopituitarism associated with irradiation need to be aware and vigilant of the risks of cavernoma formation, in particular in the population with a history of childhood irradiation. We present three cases of young patients who were diagnosed with cerebral cavernoma many years after childhood irradiation treatment and review the current literature on this condition. We discuss implications for endocrine practice as rising numbers of patients survive childhood cancer and irradiation and are now attending adult endocrine services for long‐term management of secondary hypopituitarism.

The mechanism of non-islet cell hypoglycaemia caused by tumour-produced IGF-II

In 1991, a 55-year-old gentleman (body mass index, BMI 29·6 kg/m 2 ) presented with a lump on the back of his neck. Histology was indeterminate and he underwent wide excision and radiotherapy. In 2001 he developed a dull, uncomfortable ache on the right side of his neck and a magnetic resonance imaging (MRI) scan revealed a large paravertebral mass at the D2–D4 level compressing the spinal cord. Decompression surgery was performed and histology revealed an undifferentiated mesenchymal tumour with presence of necrosis and Ki67 index of 20%. In October 2004, the patient developed symptoms of abdominal discomfort and a computed tomography (CT) scan of the abdomen showed a necrotic retroperitoneal tumour (Fig. 1). There was no evidence of liver metastasis. The patient had also noticed hot flushes, sweating and lethargy, and random blood glucose was 2 mmol/l. He was admitted into the endocrine unit for investigation. On a sample with blood glucose of 2·2 mmol/l, his serum insulin concentration was less than 10 pmol/l and C-peptide levels were less than 94 pmol/l excluding a diagnosis of insulinoma and exogenous insulin administration. Liver function was normal (bilirubin: 6 μ mol/l [normal range < 23 μ mol/l]; alanine transaminase, ALT: 33 IU/l [normal range < 40 IU/l]; albumin: 40 g/l [normal range 34–48 g/l]; alkaline phosphate: 91 IU/l [25–120 IU/l]). Renal function was normal (sodium: 138 mmol/l; potassium: 4·8 mmol/l; urea: 4·0 mmol/l and creatinine: 70 mmol/l). Twenty-four hour catecholamines were normal. His serum cortisol was 638 nmol/l, GH measurements (DPC Immulite, Siemens, Wales, UK) were less than 2 ng/ml and sulphonylurea screen was negative. He had insulin-like growth factor-II (IGF-II) levels of 114·3 nmol/l (normal range 55–150 nmol/l) with a low IGF-I level of 2·3 nmol/l (normal range 9–40 nmol/l). Further immunoblot studies (Fig. 2) showed that IGF-II was predominantly in the higher molecular weight form (‘big’ IGF-II). An elevated level of ‘big’ IGF-II and elevated IGF-II/IGF-I ratio of 49·6 (normal < 10) confirmed the diagnosis. 1

Diagnosis of monogenic diabetes: 10-Year experience in a large multi-ethnic diabetes center

Monogenic diabetes accounts for approximately 1–2% of all diabetes, and is difficult to distinguish from type 1 and type 2 diabetes. Molecular diagnosis is important, as the molecular subtype directs appropriate treatment. Patients are selected for testing according to clinical criteria, but up to 80% of monogenic diabetes in the UK has not been correctly diagnosed. We investigated outcomes of genetic testing in our center to compare methods of selecting patients, and consider avenues to increase diagnostic efficiency.

Peripheral neuropathy in diabetes: it's not always what it looks like

Hereditary Neuropathy with liability to Pressure Palsies (HNPP) is an autosomal dominant neuropathy, associated with deletion of the Peripheral Myelin Protein‐22 (PMP‐22) gene, causing recurrent painless palsies with age of onset between 10 and 30 years old. Only a few cases of Type 2 Diabetes and HNPP have been described and the coexistence of HNPP and Type 1 diabetes has never been reported.

Real-time continuous glucose monitoring significantly reduces severe hypoglycemia in hypoglycemia-unaware patients with type 1 diabetes

Continuous glucose monitoring (CGM) was used in 9% of 17,317 participants (6% of children <13 years old, 4% of adolescents 13 to <18 years, 6% of young adults 18 to <26 years, and 21% of adults ≥26 years) who replied to a CGM device use questionnaire 1 year after enrollment in the T1D Exchange clinic registry (1). This is the highest penetration in a large patient population reported so far, demonstrating the increased use of real-time CGM in an advanced medical environment. Moreover, CGM use was associated with lower HbA1c in children (8.3% vs. 8.6%, p<0.001) and adults (7.7% vs. 7.9%, p<0.001), but also with a more affluent social status (1). Interestingly, only a quarter of self-reported CGM users downloaded data from their device at least once per month (1), indicating that the general CGM use largely remains intuitive. Regular CGM device downloading is associated with a considerable improvement in metabolic control (2) and may be one of the important determinants of sustained and efficient routine CGM use in T1D, also for prevention of severe hypoglycemia. However, many controversies remain in the population of non-insulin-treated patients with T2D, where a well-designed clinical trial investigating the use of CGM is yet to arrive. The present review focuses on the most recent articles describing factors that improve glycemic outcomes in persons using CGM as well as how CGM is being utilized to understand the progression of normal glucose tolerance to impaired glucose tolerance and to overt type 2 and type 1 diabetes in certain high-risk populations.