2019

Ketoacidosis in patients on SGLT2 inhibitor: Experience from a district general hospital (2019)

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Type of publication:
Conference abstract

Author(s):
*Kandaswamy L.; *Al-Salihi A.; *Singh P.K.; *Rangan S.; *Moulik P.K.

Citation:
Diabetic Medicine; Mar 2019; vol. 36 ; p. 174

Abstract:
Introduction: European Medicines Agency recognised diabetic ketoacidosis (DKA) as a rare and serious side effect of SGLT2 inhibitors (SGLT-2i). In six months, five cases of DKA in Type 2 diabetes on SGLT-2i were diagnosed at Royal Shrewsbury hospital. Case reports: Case 1: A 63 year old lady on metformin, dapagloflozin, gliclazide with HbA1c-102mmol/mol presented with nausea, vomiting and breathlessness was treated for DKA and pneumonia with pH 7.24, blood sugar-16mmol/l, bicarbonate-17 and ketones-3.6. Case 2: A 61 year old lady on liraglutide, gliclazide, canagliflozin with HbA1c 98mmol/mol presented with nausea, vomiting and polyuria had pH 6.9, blood sugar-16.4mmol/l, bicarbonate-<3 and ketones-5.4. Cases 3, 4 and 5: Patients established on insulin treatment with compliance issues (significantly reducing and missing insulin) had DKA. One of them had associated infection.
Discussion(s): Infection predisposed to DKA in two patients. Two patients had long duration of diabetes and poorly controlled glucose on maximum oral therapy indicating reduced beta cell reserve and three were already on insulin but reduced or missed the doses. All patients were treated according to DKA protocol and made full recovery, SGLT2i was stopped and insulin commenced in two of them and continued with others. Sick day rules emphasised.
Conclusion(s): SGLT2i lowers plasma glucose through glycosuria and promotes ketogenesis. Declining beta cell reserve with increasing duration of diabetes and relative insulin deficiency at the time of stress increases the risk of DKA. Patients on SGLT-2I should be educated of these risks particularly when they have a long duration of diabetes and are established in insulin therapy.

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Variable clinical presentations of renal cyst and diabetes (RCAD) syndrome in two patients (2019)

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Type of publication:
Conference abstract

Author(s):
*Al-Salihi A.; *Kandaswamy L.; *Qamar S.; *Rangan S.; *Moulik P.; *Singh P.K.

Citation:
Diabetic Medicine; Mar 2019; vol. 36 ; p. 86

Abstract:
Maturity onset diabetes of the young Type 5 (MODY 5), known as RCAD syndrome, results from mutations in the hepatocyte nuclear factor 1-beta (HNF1B), most commonly 17q12 deletion. We present two patients with this syndrome: Patient 1: A 31 year old male presented with symptomatic hyperglycaemia. He was diagnosed with diabetes three months previously and had been treated with a sulphonylurea. His past medical history included deranged liver function tests (LFT), azoospermia and a single functioning dysplastic kidney. He had a family history of diabetes in first-degree relatives. Genetic tests confirmed HNF1B heterozygous whole gene deletion. Patient 2: A 34 year old male with diabetes diagnosed two years previously was referred for his
complex medical background. He had a history of renal problems (renal agenesis on right and cysts on left), gout and deranged LFT. His glycaemic control was adequate on Linagliptin monotherapy. Despite the absence of relevant family history, he has been referred for genetic testing.
Discussion(s): RCAD syndrome comprises 2% of all cases of MODY and features renal cysts and diabetes alongside a spectrum of other conditions such as renal dysplasia/hypoplasia/agenesis, reproductive tract anomalies, psychiatric problems, deranged LFTs and other metabolic abnormalities in various combinations. Genetic mutations can be inherited or sporadic. Absence of family history and variability in clinical manifestations can lead to delayed recognition.
Conclusion(s): Patients with RCAD syndrome can present with a varied combination of clinical features. Clinical suspicion, irrespective of family history, is key to diagnosis and management.

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A 5-year follow-up of vulval swelling due to extraskeletal myxoid chondrosarcoma: A rare case report (2019)

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Type of publication:
Journal article

Author(s):
O'Neill D.; El-Ghobashy A.; Elghobashy M.; Abdelsalam H.; *Metelko M.

Citation:
Molecular and Clinical Oncology; May 2019; vol. 10 (no. 5); p. 483-486

Abstract:
Vulval extraskeletal myxoid chondrosarcoma (EMC) is a rare cause of vulval swelling, reported <10 times in the literature to date. EMC in this location is frequently misdiagnosed due to its rarity, and patients may incur delays in diagnosis and treatment. We herein present the diagnosis and management of the case of vulval EMC in a 42-year-old Caucasian female patient who presented in 2011 with a swelling on the right labium majus. The tumour was initially misdiagnosed as a Bartholin's cyst and managed conservatively. The tumour was ultimately diagnosed as EMC and treated by radical surgical excision and adjuvant radiotherapy. The aim of the present study was to report the results after a long-terms follow-up period and review the available relevant literature.

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A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy (2019)

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Type of publication:
Randomised controlled trial

Author(s):
A. Coomarasamy, A.J. Devall, V. Cheed, H. Harb, L.J. Middleton, I.D. Gallos, H. Williams, A.K. Eapen, T. Roberts, C.C. Ogwulu, I. Goranitis, J.P. Daniels, A. Ahmed, R. Bender‑Atik, K. Bhatia, C. Bottomley, J. Brewin, M. Choudhary, F. Crosfill, S. Deb, W.C. Duncan, A. Ewer, K. Hinshaw, T. Holland, F. Izzat, J. Johns, K. Kriedt, M.-A. Lumsden, P. Manda, J.E. Norman, N. Nunes, C.E. Overton, S. Quenby, S. Rao, J. Ross, A. Shahid, *M. Underwood , N. Vaithilingam, L. Watkins, C. Wykes, A. Horne, and D. Jurkovic

Citation:
New England Journal of Medicine 2019;380:p.1815-24.

Abstract:
BACKGROUND
Bleeding in early pregnancy is strongly associated with pregnancy loss. Progesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone therapy may improve pregnancy outcomes in women who have bleeding in early pregnancy.
METHODS
We conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. Women were randomly assigned to receive vaginal suppositories containing either 400 mg of progesterone or matching placebo twice daily, from the time at which they presented with bleeding through 16 weeks of gestation. The primary outcome was the birth of a live-born baby after at least 34 weeks of gestation. The primary analysis was performed in all participants for whom data on the primary outcome were available. A sensitivity analysis of the primary outcome that included all the participants was performed with the use of multiple imputation to account for missing data.
RESULTS
A total of 4153 women, recruited at 48 hospitals in the United Kingdom, were randomly assigned to receive progesterone (2079 women) or placebo (2074 women). The percentage of women with available data for the primary outcome was 97% (4038 of 4153 women). The incidence of live births after at least 34 weeks of gestation was 75% (1513 of 2025 women) in the progesterone group and 72% (1459 of 2013 women) in the placebo group (relative rate, 1.03; 95% confidence interval [CI], 1.00 to 1.07; P=0.08). The sensitivity analysis, in which missing primary outcome data were imputed, resulted in a similar finding (relative rate, 1.03; 95% CI, 1.00 to 1.07; P=0.08). The incidence of adverse events did not differ significantly between the groups.
CONCLUSIONS
Among women with bleeding in early pregnancy, progesterone therapy administered during the first trimester did not result in a significantly higher incidence of live births than placebo. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment program; PRISM Current Controlled Trials number, ISRCTN14163439.)

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Pre-transplant Nurse Led Education Clinic (2019)

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Type of publication:
Poster presentation

Author(s):
*Dean S, *Rogers C, *Chand S

Citation:
Joint British Transplant Society and NHS Blood and Transplant Annual Congress 6th – 8th March 2019, Harrogate Convention Centre

Abstract:
Introduction: Locally, there is a 40% pre-emptive renal transplant listing rate, between 2013-2016; and 22% for living donor pre-emptive 2014-2017. Thus we needed to revise our processes. After returning from the tertiary transplant centre, patient feedback including their shock of what was required and their follow-up arrangements, and they felt under-prepared from their local education.
Methods: By creating a separate renal pre-transplant education clinic, we aim to improve the education and experience of potential recipients and donors in order to improve or transplantation rates. This clinic was started in August 2016. It was also important to rationalise the time of the single transplant nurse more effectively.
Results: The nurse was able to stop time wasted travelling between individual consultant clinics, catching patients in an adhoc manner, and time wasted travelling between hospital sites. There was an increase of 20% over a 18 months period of patients transplant listed. Patients feedback has been qualitatively positive after their tertiary centre assessments, with noone reporting feeling under-prepared or shocked from the information and requirements if transplanted. Discussion: The nurse led clinic has been successful and we would like to share this model with other units. Other surprising benefits have included patients being better prepared for their transplantation clinic assessment at the tertiary assessment. Potential living donor assessments and any initial investigations have been identified and performed in a more timely manner. The clinic has also allowed to unmask and address unmet psychological and social needs prior to being assessed for transplantation and thus reducing the psychological burden post-transplantation.

Risk Prediction for Acute Kidney Injury in Acute Medical Admissions in the UK (2019)

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Type of publication:
Journal article

Author(s):
The RISK investigators [including *Chand, S ]

Citation:
QJM: An International Journal of Medicine, Volume 112, Issue 3, March 2019, Pages 197–205

Abstract:
Background
Acute Kidney Injury (AKI) is associated with adverse outcomes; therefore identifying patients who are at risk of developing AKI in hospital may lead to targeted prevention.

Aim
We undertook a UK-wide study in acute medical units (AMUs) to define those who develop hospital-acquired AKI (hAKI); to determine risk factors associated with hAKI and to assess the feasibility of developing a risk prediction score.

Design
Prospective multi-centre cohort study across 72 AMUs in the UK.

Methods
Data collected from all patients who presented over a 24-h period. Chronic dialysis, community-acquired AKI (cAKI) and those with fewer than two creatinine measurements were excluded. Primary outcome was the development of h-AKI.

Results
Two thousand four hundred and fourty-six individuals were admitted to the seventy-two participating centres. Three hundred and eighty-four patients (16%) sustained AKI of whom two hundred and eighty-seven (75%) were cAKI and ninety-seven (25%) were hAKI. After exclusions, chronic kidney disease [Odds Ratio (OR) 3.08, 95% Confidence Interval (CI) 1.96–4.83], diuretic prescription (OR 2.33, 95% CI 1.5–3.65), a lower haemoglobin concentration and elevated serum bilirubin were independently associated with development of hAKI. Multi-variable model discrimination was only moderate (c-statistic 0.75).

Conclusions
AKI in AMUs is common and associated with worse outcomes, with the majority of cases community acquired. Only a small proportion of patients develop hAKI. Prognostic risk factor modelling demonstrated only moderate discrimination implying that widespread adoption of such an AKI clinical risk score across all AMU admissions is not currently justified. More targeted risk assessment or automated methods of calculating individual risk may be more appropriate alternatives.

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A comparison of follow-up rates of women with gestational diabetes before and after the updated National Institute for Health and Care Excellence guidance advocating routine follow-up, and the association with neighbourhood deprivation (2019)

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Type of publication:
Journal article

Author(s):
Sebastian Walsh, Mahmoud Mahmoud, Htwe Htun, *Sheena Hodgett, *David Barton

Citation:
British Journal of Diabetes 2019;19:[epub ahead of publication]

Abstract:
Background: Gestational diabetes mellitus (GDM) occurs in one in every 23 UK pregnancies. GDM identifies the mother as high-risk for development of type 2 diabetes. The National Institute for Health and Care Excellence (NICE) published updated guidance in February 2015 recommending routine follow-up of women with GDM.

Aims: This cohort study compared follow-up rates of women with GDM before and after the updated guidance. We also investigated for an association between follow-up rates and deprivation.

Methods: Participants were identified from the database of the GDM service of two English hospitals and were organised into two cohorts: ‘pre-guidance’ (2012–2015) and ‘post-guidance’ (2015–2016). Using the recommendations of the NICE guidance as the follow-up standard, we used the hospitals’ computer system to compare follow-up rates of the two cohorts. The English Indices of Deprivation split the country into 32,844 small areas and rank them in order of deprivation such that 1 is the most deprived area and 32,844 is the least deprived. We compared the patients’ postcodes against the English Indices of Deprivation to investigate the relative levels of neighbourhood deprivation of those followed up compared with those not followed up. The Z statistic was used to test for statistical significance.

Results: 535 participants were included (pre-guidance n=306, post-guidance n=229). Baseline average age (pre-guidance 32.2 years, post-guidance 32.5 years), body mass index (30.7 kg/m2, 30.9 kg/m2) and fasting glucose (4.9 mmol/L, 4.8 mmol/L) were all comparable between cohorts. The follow-up rate improved from 60.5% in the pre-guidance group to 69.9% in the post-guidance group. The median deprivation rank of those followed up was 14,565 compared with 13,393 in those not followed up. This difference was not found to be significant.

Conclusion: A higher proportion of women with GDM were followed up with screening for type 2 diabetes after the updated NICE guidance in 2015 recommended routine follow-up. Across the study, over a third of women were not followed up. There was no statistically significant difference in the deprivation levels of those women followed up compared with those not followed up.