2024

Streamlining administrative processes by analysing how delayed benign histology results letters were done for 2-Weeks- Wait (2WW) gynaecology oncology patients (2024)

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Conference abstract

Author(s):

*Khanh Kieu X.M.; *Sahu B.; *Ghumaann M.K.

Citation:

BJOG: An International Journal of Obstetrics and Gynaecology. Conference: BGCS ASM 2024. Liverpool United Kingdom. 131(Supplement 4) (pp 34), 2024. Date of Publication: 01 Oct 2024.

Abstract:

Aims: A quality improvement project to identify bottlenecks to the delayed result letters to patients on the 2WW pathway and evaluate the use of a template letter that can be beneficial to both staff and patients. Background(s): The aim of the 2-week- wait pathway is to expedite the diagnosis and treatment of potential cancer cases. From the patient's point of view, the 2WW pathway would not officially end until the final histology result reached the patient. Method(s): We conducted two retrospective audits before and after the implementation of the benign histology template in a span of one month. The date of the primary care referral is day 0. The date and time for the 2WW patients' histology final report can be obtained from SATH's medical electronic platform called Portal. We can then calculate how many days it will take for the result letter to be ready from day 0 of the initial referral. Result(s): Roughly 80% of these patients have benign histology results. Yet, the average time for a 2WW benign histology result letter to be issued is 51 days, counting from their initial 2WW referral. After implementation of template letter, the average waiting time for result has decreased to 37 days. Conclusion(s): The implementation proposal depends greatly on the Trust budget, and further consideration for speech recognition technology training will need a thorough discussion. A benign histology result template would be a cost-effective solution to reduce the unnecessary typing delay.

DOI: 10.1111/1471-0528.17941

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Triple line stapled jejunojejunal anastomosis does not completely prevent post-operative bowel obstruction following laparoscopic Rouxen- Y gastric bypass (2025)

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Author(s):

*Gungadin P.; *Bhandari M.; *Riera M.;

Citation:

Obesity Surgery. Conference: BOMSS 2024 Congress. Harrogate . 34(Supplement 1) (pp S26), 2024. Date of Publication: 01 Jun 2024.

Abstract:

Introduction: Small bowel obstruction following jejunojejunal anastomosis (JJ) during a gastric bypass is a recognised complication. Common causes include strictures, intussusception, internal herniae and bowel kinking, thus preventing passage of bowel contents into the common limb (CL). Bidirectional jejunal stapled anastomosis, or triple line anastomosis is meant to decrease the risk of obstruction. However, this risk may not completely be avoided. Case presentation: A patient with history of gastroesophageal reflux, after a sleeve gastrectomy, underwent a conversion to laparoscopic Roux-en-Y gastric bypass. The JJ anastomosis was successfully tested intraoperatively for leak and patency with methylene blue. The patient still developed post-operative bilious vomiting after 24 hours. Abdominal CT confirmed obstruction at the JJ anastomosis. Subsequent laparoscopy demonstrated collapsed CL and dilated both alimentary (AL) and biliopancreatic (BP) limbs. There was no stricture or narrowing. Upon straightening the limbs, bowel contents successfully emptied into the common limb. However, the common limb would appear kinked again when the anastomosis was released, thus causing obstruction. A further stapled anastomosis was performed between CL and BP which straightened the kinked CL. This solved the obstruction. The patient was discharged home three days later. Discussion(s): Small bowel obstruction secondary to kinking despite a triple stapler approach is uncommon. Unfortunately, anastomotic leak and patency test may not completely preclude this complication. Awareness and careful intraoperative inspection of the anastomosis may help to detect probable obstruction.

DOI: 10.1007/s11695-024-07287-1

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Learning from Interventions Within Cancer Services (2024)

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Author(s):

*Flynn K.; *Poulsom R.; *Wilfred D.;* Lindsey K.; *Tibitendwa A.

Citation:

Journal of Oncology Pharmacy Practice. Conference: 26th Annual BOPA Symposium. Wales United Kingdom. 30(1 Supplement) (pp 74), 2024. Date of Publication: 01 Mar 2024.

Abstract:

Introduction / objectives: This Service Evaluation was carried out to assess interventions for oncology SACT prescriptions, identify trends and potential areas for improvement. The primary objective was to quantify and categorise the interventions of the Cancer Pharmacist team, encompassing IV and oral oncology SACT prescriptions in the inpatient and outpatient setting, over a 12-week period. The secondary objective was to look in more detail at the interventions logged under the high-risk categories of 'Regimen query/error', 'Dose query' and 'Dose error'. This would enable greater understanding of the issues contributing to prescription errors and will form the basis for future work to improve patient safety. Method(s): Cancer pharmacists completed a data collection form for each oncology SACT prescription query over a 12-week period. A support document defining each category ensured standardisation among pharmacists when classifying queries. The data was collated and analysed using Microsoft Excel. Each patient case in the specified high-risk categories was examined retrospectively to provide more detailed insight into the intervention and identify common themes. Result(s): In total, 124 interventions were logged (Fig.1), the highest number related to 'funding queries', 36%, with 'missing prescription' and 'dose query' both at 15%. The high-risk categories accounted for 31%, (n = 39). Of the 39 high-risk interventions, 9 related to intended dose changes that had not been actioned; 14 related to patient factors (bloods, DPYD, co-morbidities), of which 6 involved carboplatin; 5 prescriptions were missing a critical element. Discussion / conclusions: Funding queries were identified as the largest category of interventions; consultants were reminded to complete Blueteq forms when planning treatment to ensure the patient is eligible for the chosen regime. Prescriptions not available in advance mean that treatment cannot be ordered in time from third-party compounders. Pharmacy and oncology are working to find an efficient way of identifying patients scheduled for treatment that has not yet been prescribed to reduce delays to patients due to treatment not being available. From the in-depth analysis of high-risk categories, key areas for service development were identified. 1) Establishing a clear process for communicating changes to planned treatment. 2) Creating a policy and educating staff on carboplatin dosing to reduce unnecessary changes. 3) Improving blood test scheduling with the administration team. 4) Reviewing regimens requiring two prescriptions and considering combined prescriptions. This would reduce the number of prescriptions missing a critical element. Our Service Evaluation had limitations, mainly due to manual documentation. There was a noticeable drop in number of queries logged during extremely busy periods; it is likely that some interventions have been missed. Some duplication was identified when collating the data, particularly where more than one pharmacist was involved in following up a query. Of the 39 high-risk interventions, 4 were excluded from the data, 3 were duplicate entries and 1 had the incorrect patient number documented so further follow up was not possible. Future work will involve liaising with the oncology team to address the areas identified above with reference to improvement projects that have been successful in other hospitals.

DOI: 10.1177/10781552241228011

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Feasibility of same day discharge following total laparoscopic hysterectomy in District General Hospital (2024)

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Author(s):

*Malik N.; *Sahu B.; *Parry-Smith W.; *Elsheikh M.;

Citation:

BJOG: An International Journal of Obstetrics and Gynaecology. Conference: RCOG 2024. Muscat Oman. 131(Supplement 5) (pp 20), 2024. Date of Publication: 01 Oct 2024.

Abstract:

Introduction: Hysterectomy is one of the commonest gynecologic surgical procedures and an increasing number of hysterectomies are being completed minimally invasively. Previously, hysterectomies have been performed as in-patient operative procedures to manage post-operative pain and monitor post-operative complications such as symptomatic anemia or delayed return of bowel function. Studies have described same-day discharge after laparoscopic hysterectomy to be safe and acceptable and same-day discharge can reduce hospital costs and decrease iatrogenic complications associated with hospitalization such as venous thromboembolic complications due to delayed mobilization or infections. A quality improvement project to assess the feasibility of implementing same-day discharge protocols for patients undergoing total laparoscopic hysterectomy (TLH) in district general hospital in west midlands. <br/>Design(s): A quality improvement project was conducted to evaluate success rates of same-day discharge, adherence to pre and postoperative protocols, incidence of complications, readmission rates, and patient satisfaction levels. Material(s) and Method(s): The project involved analysing clinical records of patients who underwent TLH for benign and oncological indications over a six-month period (May2023 to October 2023) at shrewsbury and telford NHS Trust. Compliance with multimodal perioperative protocols, readmission rates, and patient satisfaction were assessed retrospectively. Result(s): Out of 40 cases of Total laparoscopic hystrectomies, 12 cases (30%) were successfully discharged on the same day. Further analysis revealed that oncological cases had a higher same-day discharge rate (40%) compared to benign cases (12%). Reasons for overnight stay were, anxiety (5 patients), Haematuria (2 patients), Surgeons decision (10 patients), drain insitu (3 patients) social reasons (5 patients) and no reason was documented in three patients. Two patients were readmitted in 24-48 h with pain and infection symptoms. Conclusion(s): In gynecology, laparoscopic hysterectomy has become increasingly prevalent due to its minimally invasive nature. This shift aims to enhance patient outcomes and reduce healthcare costs. The findings of this study indicate that same-day discharge following TLH is feasible without compromising patient safety. Key factors contributing to successful implementation include standardized techniques, collaboration with anesthestists and theatre teams, adequate postoperative nursing care, and comprehensive preoperative patient counseling. This study underscores the importance of a coordinated approach involving various healthcare professionals to ensure successful same-day discharge protocols for TLH patients. By optimizing perioperative care pathways and patient education, hospitals can effectively implement same-day discharge practices, thereby improving patient experience and resource utilization.

DOI: 10.1111/1471-0528.17946

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Analysing risk factors for diabetic non-traumatic major amputation in Shropshire and Telford: Early metabolic and risk factor management is the key to prevention (2024)

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Author(s):

*Basavaraju N.; *Al-Samaraaie E.; *Cane C.; *Beard N.; *Moulik P.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024

Abstract:

Aims: Shropshire and Telford have significantly higher minor and major non-traumatic diabetic lower-limb amputations. We analysed data on risk factors leading to major amputation. Method(s): Data on all 48 major non-traumatic lower-limb amputation in diabetes between April 2022 and March 2023 were analysed. Result(s): 90% type 2 diabetes with 32 (67%) diabetes duration >10 years, 11 (23%) <10 years, 1 was diagnosed at admission. 17 (35%) were female. 38 (80%) were between 50 and 80, 9 (18%) over 80 years age. 26 (54%) had below knee and 22 (46%) above knee amputation. Postcode-based assessment of deprivation indices revealed amputations were higher in patients from most deprived (29%) compared to deprived (25%), average (21%), affluent (20%) and very affluent (4%) areas. 20 (41%) were considered concordant, 18 (37%) non-concordant by the assessing clinician. 21 (42%) were overweight or obese. Half were current or ex-smokers, 58% hypertensive, 79% hyperlipidaemic or on statins, 83% on antiplatelet/anticoagulants. Sixteen (44%) had eGFR >60 mL/min, 17 (35%) 30-60 mL/min, 4 (8%) eGFR 15-30mL/min and none with eGFR <15mL/min. HbA1c was <48 mmol/mol in 10%, 48-68 mmol/mol in 35%, 69-99 mmol/mol in 37% and >100 mmol/mol in 17%. 37% had pre-proliferative/proliferative retinopathy or maculopathy. 80% had high risk feet, 28 (58%) previous foot ulcers and 19 (40%) previous amputation. 80% had neuropathy and peripheral arterial disease and 10% had Charcot. Final cause of amputation was critical ischaemia in 27 (56%), infection/osteomyelitis/sepsis in 7 (15%), spreading gangrene in 10 (21%) and Charcot in 4 (8%). Conclusion(s): Long-standing diabetes with multiple chronic complications and social deprivation were associated with major amputations. Cardiovascular risk factors were generally well managed. Preventive strategies must focus on improving metabolic and risk factor management early in disease.

DOI: 10.1111/dme.15295

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Magtrace Can Sustainably Improve Theatre Efficiency, Operative Capacity, and Patient Experience (2024)

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Conference abstract

Author(s):

*Lake B.; *Wilson M.; *Appleton D.

Citation:

Annals of Surgical Oncology. Conference: 25th American Society of Breast Surgeons Annual Meeting, ASBrS 2024. Orlando, FL United States. 31(Supplement 2) (pp S498), 2024. Date of Publication: 01 Jun 2024.

Abstract:

Background/Objective: Magtrace is an iron oxide liquid which has revolutionized sentinel lymph node biopsy treatment for breast cancer. It has a flexible injection window which allows patients to have the injection prior to the day of surgery at a convenient time for both the patient and the provider and removes the need for nuclear medicine completely. Magtrace was reviewed by the National Institute for Health and Care Excellence in October 2022 (MTG72) and they highlighted that Magtrace has the potential to reduce cost based on an expectation that its usage would enable hospitals to perform additional sentinel node biopsies due to improved operating room utilization. The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care in the UK. This guidance is the gold standard for advice for breast cancer treatment. Our team designed a study to investigate the "additive effect" of Magtrace in improving theatre efficiency, operative capacity, and patient experience (Presented at European Society of Surgical Oncology, to be published in European Journal of Surgical Oncology early 2025). The aim of this study was to assess if these previously described benefits of Magtrace by NICE are sustained in a hospital system. Method(s): All Magtrace cases for sentinel node biopsy at the Shrewsbury & Telford NHS Trust were prospectively recorded. The outcomes measured were operating room utilization, number of sentinel node biopsies performed per week, and patient satisfaction. Result(s): 150 patients undergoing a wide local excision or mastectomy received Magtrace as the sole technique for SLNB. Operating room utilization improved from 77% to 84% (with peak utilisation at 96%) due to a reduction in OR delays and improved OR flow. Previous delays were caused by patients waiting to have radioisotope injections. Significantly more sentinel node biopsies were performed per week, increasing from 6.48 per week (Pre Magtrace 2022) to 8.57 per week (Post Magtrace ) (t-value = 3.53057, p-value < 0.00041). This resulted in a net increase of 2 additional patients per week. The t-value is 3.53057. The p-value is .00041. The result is significant at p < 0.05. The study showed high patient satisfaction with 100% of patients finding injection more convenient on the day of surgery and 100% of patients would recommend Magtrace to a friend or relative. Conclusion(s): Utilising Magtrace for sentinel lymph node biopsy creates a sustained "additive effect" by improving operating room utilization, operating room capacity and demonstrates a high patient satisfaction.

DOI: 10.1245/s10434-024-15410-w

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Menopause training among obstetrics & gynaecology trainees in UK: Are we getting it right? (2024)

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Conference abstract

Author(s):

*Malik N.; *Sahu B.; *Wood M.; *Afzal M.

Citation:

BJOG: An International Journal of Obstetrics and Gynaecology. Conference: RCOG 2024. Muscat Oman. 131(Supplement 5) (pp 129-130), 2024. Date of Publication: 01 Oct 2024.

Abstract:

Background: The menopause has garnered significant media attention in recent times due to the rising number of working menopausal women, accounts of women being disregarded, and anxiety surrounding the prescription and usage of hormone replacement therapy (HRT) due to lack of training and knowledge gap among physicians. It is a normal, natural, and inevitable part of ageing. Yet for too long, too many people experiencing menopause have struggled with societal stigma, inadequate diagnosis and treatment, workplace detriment and discrimination. The management of menopausal symptoms requires a comprehensive understanding and specialized training, particularly among obstetrics and gynecology trainees in UK. The national survey was conducted among obstetrics and gynecology trainees to evaluate the depth of knowledge with regards to management of menopause and menopause services provided at their hospital and training opportunities. Participants and Methods: This online Menopause Training review surveyed 103 postgraduate obstetrics and gynecology trainees in the UK from September 2023 to October 2023. The national survey was distributed to all deaneries in the UK for circulation to all their trainees via social media, WhattsApp groups and emails. The survey comprised of questions regarding trainees' level of training, country of training, menopause clinics in their hospital, their clinic regularity, and any designated lead clinician for menopause clinics in their hospital, management of menopause, the trainees' confidence advising patients with menopausal symptoms, and any benefit from their patient care. Result(s): The majority of responders 70 (68.63%) belonged to England followed by 21 (20.59%) Wales and Ireland 11 (10.78%). About 56 (54.36%) had a menopause clinic in their hospital and 46 (45.10%) responders conducting regular clinics. Approximately 44 (42.72%) had a designated lead clinician present in their hospital. Specific trust guidelines on the management of menopause were applied in 30 (29.13%). About 21 (20.39%) respondents felt confident advising patients with menopausal symptoms and 99 (96.12%) participants thought that going through additional formal menopause training could benefit patient care.It is imperative to adopt a novel pedagogical strategy for teaching menopause in healthcare curriculum. Conclusion(s): The survey emphasized that the need for ongoing evaluation and enhancement of menopause training programs for obstetrics and gynaecology trainees in the UK to ensure optimal patient care during this critical life stage.

DOI: 10.1111/1471-0528.17946

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A young lady with diabetic mastopathy (DMP): A less well-known complication of diabetes (2024)

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Conference abstract

Author(s):

*Cane C.L.; *Jones A.M.; *Moulik P.K.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

A 26-year-old nulliparous female presented with a 2-week history of a right breast lump. She had type 1 diabetes for 17 years and polycystic ovaries. Her diabetes distress led to suboptimal glycaemic control. There was firm tissue under the right nipple-areola complex, and ultrasound (US) demonstrated a suspicious 43-mm mixed echogenic lesion with posterior shadowing (U4). Core biopsy revealed marked fibrosis with fibroblasts and entrapped benign breast ducts and adipose tissue. Breast ducts were highlighted by epithelial markers (AE1/3 and small P63), blood vessels by CD34, and fibroblasts and myoepithelial layers by smooth muscle actin (SMA). She was reassured; 2 years later she developed a left breast lump and 26-mm focal hypoechoic glandular lesion on US, right breast lesion unchanged. A diagnosis of DMP was made. DMP occurs in 20- to 40 year-old women with long duration of type 1 diabetes. It can occur in men rarely. It presents with a painless, hard, mobile breast lesions which are irregular. Bilateral lesions develop in 50% patients. Axillary lymphadenopathy is absent. Mammography reveals dense glandular tissue and US shows acoustic shadows behind the lesion. Core biopsy is recommended. DMP is a benign condition which may raise concerns of breast cancer. It may be associated with autoimmunity and occasionally seen in insulin treated type 2 diabetes, systemic lupus erythematosus and Hashimoto's. Microscopy shows periductal, perilobular and perivascular B-lymphocytic infiltrates with some T cells, fibroblast proliferation and collagen. Management is conservative unless a larger lesion requires excision. To date, only one case report has been published on breast cancer in a patient with DMP.

DOI: 10.1111/dme.15295

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Motivational techniques combined with unconventional medications and technology improving care in a disengaged patient with type 1 diabetes: A case study of a success story (2024)

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Conference abstract

Author(s):

*Jones A.M.; *Basavaraju N.; *Moulik P.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

A 42-year-old lady with complex diabetes was diagnosed age 19 years. She went on an insulin pump (Medtronic Minimed), Hba1c was 56 mmol/mol which crept up to 72 mmol/mol. She developed hypertension, nephropathy and laser treated retinopathy. Starting Freestyle Libre with Medtronic640 improved Hba1c down to 52 mmol/mol. Her social and financial circumstances, including being a single mum, deteriorated leading to diabetes distress and burnout. Healthcare and diabetes management became a burden. Ambulatory glucose profile (AGP) showed time in range (TIR) 28%, high (H) 23%, very high (VH) 42% and Hba1c71 mmol/mol. Counselling and motivational interviewing with regular support was provided. She had stopped all medications and insisted on a pump break. Hba1c increased to 118 mmol/mol, TIR14%, H5%, VH81%, mean glucose (MG) 23.3 mmol/L. She wanted to restart the pump and it was felt on previous pump therapy she had safer glucose levels and no ketoacidosis. AGP improved with TIR29%, H18%, VH52%, MG15.4 mmol/L in 2 weeks. After 3 months, TIR was 33%, H20% VH42%, Hba1c76 mmol/mol. Weight was increasing with associated diabulimia. Dulaglutide was started after counselling. TIR51%, H16%, VH9%, level 1 hypoglycaemia11%, level 2 hypoglycaemia13%. She started HCL (Medtronic 780G with Guardian G4) and Hba1c was 45 mmol/mol, TIR66%, H18%, VH15%, level 1 hypoglycaemia1%, level 2 hypoglycaemia0%. Her weight has come down from 99 to 82 kg with BMI 31.4 kg/m2. Renal function has improved (eGFR 33 to 42 mL/min). Quality of life (QOL) assessments show great improvement. This case highlights a life plan is as important as a health plan. A motivational and supportive approach, advanced technologies and some off-license medication reduced diabetes burden and improved patient engagement.

DOI: 10.1111/dme.15296

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Discrepancies of glycated haemoglobin (HbA1c) and actual glucose: A case series with clinical scenarios (2024)

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Conference abstract

Author(s):

*Basavaraju N.; *Al-Samaraaie E.; *Moulik P.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

Introduction: HbA1c is a useful measure of glycaemic control over the preceding 3 months with an emphasis on preceding 30 days. We present four clinical scenarios that affect its reliability. Case 1: Twenty-nine-year-old female started on Dapsone for hidradenitis suppurativa. Pre-dapsone HbA1c was 38 mmol/mol and 2 years post-dapsone HbA1c <18 mmol/mol, normal fructosamine 272 mumol/L (211-328), glucose-6-phosphate dehydrogenase (G6PD) activity 12.9 IU/gHb (8.8-12.8), methaemoglobin 8.6% (0-1.5) and reticulocyte 6.5% (0.5-2.5) indicating haemolysis. Case 2: Forty-nine-year-old female with type 1 diabetes and rheumatoid arthritis started on sulfasalazine. HbA1c dropped from 65 to 30 mmol/mol, fructosamine 415 mumol/L (211-328), mildly raised reticulocyte 2.6%, haemoglobin 128 g/L (115-165) indicating mild haemolysis. Case 3: Fifty-nine-year-old male with type 2 diabetes and genetic haemochromatosis (C282Y homozygous) started venesection. HbA1c prior was 63 mmol/mol reduced to 29 mmol/mol, fructosamine 262 mumol/L and c-peptide 2760 pmol/L indicate good beta cell reserve. Case 4: Seventy-year-old female with Graves' disease, post-radioiodine hypothyroidism, HbA1c <20 mmol/mol (was 41 mmol/mol 2 years ago) as part of annual hypertension screen. Fasting glucose 6.0 mmol/L, low haemoglobin 102 g/L, high reticulocytes 9.5%, direct antiglobulin Coombs test positive indicating low HbA1c due to autoimmune haemolytic anaemia. Discussion(s): HbA1c depends on glycation of red blood cells (RBC) and is proportional to ambient glucose concentrations. Conditions that affect RBC lifespan and turnover can alter HbA1c values. Dapsone causes oxidative haemolysis as can sulfasalazine. Venesection and haemolytic anaemia shorten life span of red blood cells and duration of haemoglobin exposed to glucose in the bloodstream resulting in falsely lower HbA1c. Conclusion(s): Clinicians must be aware of conditions affecting accuracy of HbA1c and consider alternate tests including venous glucose, fructosamine, capillary glucose or continuous glucose monitoring.

DOI: 10.1111/dme.15296

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