Iain Cranston

Use of an Insulin Bolus Advisor Improves Glycemic Control in Multiple Daily Insulin Injection (MDI) Therapy Patients With Suboptimal Glycemic Control: First results from the ABACUS trial

OBJECTIVE Use of automated bolus advisors is associated with improved glycemic control in patients treated with insulin pump therapy. We conducted a study to assess the impact of using an insulin bolus advisor embedded in a blood glucose (BG) meter on glycemic control and treatment satisfaction in patients treated with multiple daily insulin injection (MDI) therapy. The study goal was to achieve >0.5% A1C reduction in most patients. RESEARCH DESIGN AND METHODS This was a 26-week, prospective, randomized, controlled, multinational study that enrolled 218 MDI-treated patients with poorly controlled diabetes (202 with type 1 diabetes, 16 with type 2 diabetes) who were 18 years of age or older. Participants had mean baseline A1C of 8.9% (SD, 1.2 [74 mmol/mol]), mean age of 42.4 years (SD, 14.0), mean BMI of 26.5 kg/m2 (SD, 4.2), and mean diabetes duration of 17.7 years (SD, 11.1). Control group (CNL) patients used a standard BG meter and manual bolus calculation; intervention group (EXP) patients used the Accu-Chek Aviva Expert meter with an integrated bolus advisor to calculate insulin dosages. Glucose data were downloaded and used for therapy parameter adjustments in both groups. RESULTS A total of 193 patients (CNL, n = 93; EXP, n = 100) completed the study. Significantly more EXP than CNL patients achieved >0.5% A1C reduction (56.0% vs. 34.4%; P < 0.01). Improvement in treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire scale) was significantly greater in EXP patients (11.4 [SD, 6.0] vs. 9.0 [SD, 6.3]; P < 0.01). Percentage of BG values <50 mg/dL was <2% in both groups during the study. CONCLUSIONS Use of an automated bolus advisor resulted in improved glycemic control and treatment satisfaction without increasing severe hypoglycemia.

The diagnosis and management of inpatient hyponatraemia and SIADH

Hyponatraemia is a very common medical condition that is associated with multiple poor clinical outcomes and is often managed suboptimally because of inadequate assessment and investigation. Previously published guidelines for its management are often complex and impractical to follow in a hospital environment, where patients may present to divergent specialists, as well as to generalists.

Automated bolus advisor control and usability study (ABACUS): does use of an insulin bolus advisor improve glycaemic control in patients failing multiple daily insulin injection (MDI) therapy? [NCT01460446]

BackgroundPeople with T1DM and insulin-treated T2DM often do not follow and/or adjust their insulin regimens as needed. Key contributors to treatment non-adherence are fear of hypoglycaemia, difficulty and lack of self-efficacy associated with insulin dose determination. Because manual calculation of insulin boluses is both complex and time consuming, people may rely on empirical estimates, which can result in persistent hypoglycaemia and/or hyperglycaemia. Use of automated bolus advisors (BA) has been shown to help insulin pump users to more accurately meet prandial insulin dosage requirements, improve postprandial glycaemic excursions, and achieve optimal glycaemic control with an increased time within optimal range. Use of a BA containing an early algorithm based on sliding scales for insulin dosing has also been shown to improve HbA1c levels in people treated with multiple daily insulin injections (MDI). We designed a study to determine if use of an automated BA can improve clinical and psychosocial outcomes in people treated with MDI.Methods/designThe Automated Bolus Advisor Control and Usability Study (ABACUS) is a 6-month, prospective, randomised, multi-centre, multi-national trial to determine if automated BA use improves glycaemic control as measured by a change in HbA1c in people using MDI with elevated HbA1c levels (#62;7.5%). A total of 226 T1DM and T2DM participants will be recruited. Anticipated attrition of 20% will yield a sample size of 90 participants, which will provide #62;80% power to detect a mean difference of 0.5%, with SD of 0.9%, using a one-sided 5% t-test, with 5% significance level. Other measures of glycaemic control, self-care behaviours and psychosocial issues will also be assessed.DiscussionIt is critical that healthcare providers utilise available technologies that both facilitate effective glucose management and address concerns about safety and lifestyle. Automated BAs may help people using MDI to manage their diabetes more effectively and minimise the risk of long-term diabetes related complications. Findings from a recent study suggest that BA use positively addresses both safety and lifestyle concerns; however, randomised trials are needed to confirm these perceptions and determine whether bolus advisor use improves clinical outcomes. Our study is designed to make these assessments.Trial registrationNCT01460446

Gastrointestinal symptoms and pancreatic exocrine insufficiency in type 1 and type 2 diabetes

Our review of clinical practice demonstrates that gastrointestinal (GI) symptoms were common in patients with type 1 and type 2 diabetes seen within our diabetes service. In those patients who are symptomatic, we observed that 42% had low faecal elastase 1 levels consistent with the diagnosis of pancreatic exocrine insufficiency (PEI). The presence of steatorrhoea and weight loss alone were insufficient to screen for PEI, and other GI symptoms (such as diarrhoea, abdominal cramps/pain and bloating) need to be additionally sought. Copyright

Glucose data and the individualised diabetes consultation. How should we use it? What is enough? Can we ever have too much?

As advisors to individuals with a chronic disease, diabetes health care professionals need to be confident in the assessment and interpretation of clinical data that may then impact on the management advice we offer. This has always been the case, but there is at present a rapid development in information technologies offering us ever greater volumes of data. Alongside this is a clear direction of travel towards individualised care planning to improve population outcomes, and it is important that from time to time we step back from the ‘clinical coalface’ and reflect on which data are important, which help us give good advice and how we can most effectively utilise the data in the pursuit of continual improvement in our practice. Although computer‐presented SMBG data have been slow to be adopted (such data having been available for over 15 years) it is likely that, as the simplicity of presenting the information improves over time, the incorporation of such data into consultations will progressively alter how such consultations take place. While the basic structures and practice of good clinical communication will remain central to the process, our effectiveness will improve by attention to the specifics of the issues at hand.

Use of an integrated strip-free blood glucose monitoring system increases frequency of self-monitoring and improves glycemic control: Results from the ExAct study

Aims We investigated the impact of using an integrated, strip-free system compared to the use of single-strip systems on testing frequency and glycemic control in individuals with insulin-treated diabetes. Methods This multinational, comparative, cluster-randomized, observational study included 311 patients with type 1 and insulin-treated type 2 diabetes who were performing SMBG at suboptimal frequencies. Sites were cluster-randomized to “integrated strip-free” system (EXP group) or any “single-strip” system (CNL group). Testing frequency and HbA1c were measured at baseline, 12 weeks and 24 weeks. Results At week 24, the EXP group showed an increase in SMBG frequency from baseline of 4.17 tests/week (95% CI 2.76, 5.58) compared with an increase of 0.53 tests/week (95% CI −0.73, 1.79) among CNL patients, resulting in a between-group difference of 3.63 tests/week (p < 0.0002). Mixed-effects models for repeated measurements (MMRM) controlling for baseline frequency of testing, country and clinical site confirmed a higher SMBG testing frequency in the EXP group compared to the CNL group, with a between-group difference of 2.70 tests/week (p < 0.01). Univariate analysis showed greater HbA1c reductions in the EXP group than CNL group: −0.44% (95% CI −0.59, −0.29) vs. −0.13% (95% CI −0.27, 0.01), respectively, p < 0.0002. MMRM analyses confirmed these HbA1c reductions. A greater percentage of EXP than CNL patients achieved HbA1c reductions of ≥0.5%: 45.1% vs. 29.1%, respectively, p < 0.01. Conclusions The use of an integrated, strip-free SMBG system improved testing adherence and was associated with improvements in glycemic control.

Response to 'How we define hyponatremia?'.

P. Grant, J. Ayuk, P.-M. Bouloux, M. Cohen, I. Cranston, R.D. Murray, A. Rees, N. Thatcher and A. Grossman Royal Sussex County Hospital, Brighton, UK, Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK, Diabetes and Endocrinology, Royal Free London NHS Foundation Trust, London, UK, Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Hampshire, UK, Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK, Department of Endocrinology and Diabetes, Cardiff University School of Medicine, Cardiff, UK, DepartmentofMedicalOncology,ChristieHospital,NHSTrustManchester,Manchester,UK, Departmentof Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK

A single pathology specialty service for hyperthyroid patients improves care and outcomes compared to general endocrine clinics: results and implications of an audit: re-audit cycle of clinical outcomes for differing hyperthyroid care models

•Introduction of dedicated “weekly multidisciplinary clinic” hyperthyroid service to streamline care and allow for appropriate followup as well as opportunity for liason with other specialists for those who require it. • Mean FU duration was 7 weeks (new service) vs 20 weeks (old) for those with abnormal TFTs • Mean FU duration was 8 weeks (new service) vs 30 weeks (old) for euthyroid patients • 66% attended all 3 OPAs (new service) compared to 44% (old service)