Hypoglycaemia in adrenal insufficiency (2023)

Type of publication:Journal article

Author(s):*Lee, Shien Chen; Baranowski, Elizabeth S; *Sakremath, Rajesh; Saraff, Vrinda; Mohamed, Zainaba

Citation:Frontiers in Endocrinology. 2023. [epub ahead of print]

Abstract:Adrenal insufficiency encompasses a group of congenital and acquired disorders that lead to inadequate steroid production by the adrenal glands, mainly glucocorticoids, mineralocorticoids and androgens. These may be associated with other hormone deficiencies. Adrenal insufficiency may be primary, affecting the adrenal gland's ability to produce cortisol directly; secondary, affecting the pituitary gland's ability to produce adrenocorticotrophic hormone (ACTH); or tertiary, affecting corticotrophin-releasing hormone (CRH) production at the level of the hypothalamus. Congenital causes of adrenal insufficiency include the subtypes of Congenital Adrenal Hyperplasia, Adrenal Hypoplasia, genetic causes of Isolated ACTH deficiency or Combined Pituitary Hormone Deficiencies, usually caused by mutations in essential transcription factors. The most commonly inherited primary cause of adrenal insufficiency is Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency; with the classical form affecting 1 in 10,000 to 15,000 cases per year. Acquired causes of adrenal insufficiency can be subtyped into autoimmune (Addison's Disease), traumatic (including haemorrhage or infarction), infective (e.g. Tuberculosis), infiltrative (e.g. neuroblastoma) and iatrogenic. Iatrogenic acquired causes include the use of prolonged exogenous steroids and post-surgical causes, such as the excision of a hypothalamic-pituitary tumour or adrenalectomy. Clinical features of adrenal insufficiency vary with age and with aetiology. They are often non-specific and may sometimes become apparent only in times of illness. Features range from those related to hypoglycaemia such as drowsiness, collapse, jitteriness, hypothermia and seizures. Features may also include signs of hypotension such as significant electrolyte imbalances and shock. Recognition of hypoglycaemia as a symptom of adrenal insufficiency is important to prevent treatable causes of sudden deaths. Cortisol has a key role in glucose homeostasis, particularly in the counter-regulatory mechanisms to prevent hypoglycaemia in times of biological stress. Affected neonates particularly appear susceptible to the compromise of these counter-regulatory mechanisms but it is recognised that affected older children and adults remain at risk of hypoglycaemia. In this review, we summarise the pathogenesis of hypoglycaemia in the context of adrenal insufficiency. We further explore the clinical features of hypoglycaemia based on different age groups and the burden of the disease, focusing on hypoglycaemic-related events in the various aetiologies of adrenal insufficiency. Finally, we sum up strategies from published literature for improved recognition and early prevention of hypoglycaemia in adrenal insufficiency, such as the use of continuous glucose monitoring or modifying glucocorticoid replacement.

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The impact of community teaching sessions on onward referral to specialist diabetic foot services (2023)

Type of publication:Journal article

Author(s):Al-Saadi, Nina; *Beard, Nichola; Al-Hashimi, Khalid; Suttenwood, Helen; Wall, Michael; *Jones, Steven; Merriman, *Catherine

Citation:Primary care diabetes.2023 Nov 28. [epub ahead of print]

Abstract:INTRODUCTION: Prompt referral of patients with diabetic foot ulceration (DFU) to specialist services can lead to more timely assessment of these patients and subsequent improved rates of limb salvage and patient outcomes. In this study we wanted to determine the impact of education in the primary care setting on onward referrals to our specialist Diabetic Foot multi-disciplinary team (MDT) clinic. METHODS: As part of a Diabetic Foot Roadshow, four teaching sessions were delivered in primary care settings across Shropshire by our specialist team from 17th March to the 25th May 2022. Attendees included podiatrists, tissue viability nurses, district nurses and wound care practitioners. Hospital records were used to identify all onward referrals to our Diabetic Foot MDT clinic in the weeks before and after delivery of the roadshow education sessions. RESULTS: 184 referrals were made to the diabetic foot clinic from January to July 2022. There were 0.3 referrals per day in the months prior to the commencement of the education sessions, compared to 1.5 referrals per day following the commencement of the teaching sessions. This increase in referrals was statistically significant (p < 0.0001). CONCLUSION: Teaching sessions delivered to community specialist healthcare professionals significantly increase onward referral of patients to specialist services, facilitating more timely assessment and management of patients with DFUs.

Managing hypertension in type 2 diabetes – the basics (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(6)

Abstract:Brought to you by Diabetes & Primary Care, this interactive case study takes you through the basic considerations of managing hypertension in type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.

Fatty liver disease and type 2 diabetes (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(5)

Abstract:This interactive case study, presented by Diabetes & Primary Care, takes you through the necessary considerations in managing fatty liver disease in an individual with type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.

Steroid-induced hypoglycaemia (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(4)

Abstract:Brought to you by Diabetes & Primary Care, the three mini-case studies presented below take you through what it is necessary to consider in identifying and managing steroid-induced hyperglycaemia. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Hypoglycaemia and type 2 diabetes (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(4)

Abstract:Brought to you by Diabetes & Primary Care, the four mini-case studies presented below will help you to consider what constitutes hypoglycaemia, what its causes and risk factors are in type 2 diabetes, how to detect and manage it in primary care, and strategies for minimising the risk. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Making a diagnosis in type 2 diabetes (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(2)

Abstract:Brought to you by Diabetes & Primary Care, the three mini-case studies presented below take you through what it is necessary to consider in making an accurate diagnosis of type 2 diabetes. Each scenario provides a different set of circumstances that you could meet in your everyday practice. By actively engaging with them, you will feel more confident and empowered to manage effectively such problems in the future.

Diabetic nephropathy and type 2 diabetes (2021)

Type of publication:Interactive case study

Author(s):*Morris, David

Citation:Diabetes and Primary Care; 2021; 23(1)

Abstract:This interactive case study, presented by Diabetes & Primary Care, takes you through the necessary considerations in managing diabetic nephropathy in an individual with type 2 diabetes. The scenario is not unusual and is one that, as a primary healthcare worker, you could easily be confronted with. By actively engaging with this case history, you should feel more confident and empowered to manage effectively such a problem in the future.

Pancreatic enzyme replacement therapy in patients with pancreatic cancer: A national prospective study (2021)

Type of publication:Journal article

Author(s):Harvey P.R.; McKay S.C.; Wilkin R.J.W.; Layton G.R.; Powell-Brett S.; Okoth K.; Trudgill N.; Roberts K.J.; Baker G.; Brom M.K.; Brown Z.; Farrugia A.; Haldar D.; Kalisvaart M.; Marley A.; Pande R.; Patel R.; Stephenson B.T.F.; Baillie C.; Croitoru C.; Eddowes P.J.; Elshaer M.; Farhan-Alanie M.M.; Laing R.; Mann K.; Materacki L.; Nandi S.; Pericleous S.; Prasad P.; Rinkoff S.; Selvaraj E.; Shah J.; Sheel A.R.G.; Szatmary P.; Williams P.; Milburn J.; Bekheit M.; Ghazanfar M.; Curry H.; Persson P.; Rollo A.; Thomson R.; Harper S.; Varghese S.; Collins J.; Stupalkowska W.; Afzal Z.; Badran A.; Barker J.; Hakeem A.; Kader R.; Saji S.; Sheikh S.; Smith A.C.D.; Stasinos K.; Steinitz H.; Malik H.; Burston C.; Carrion-Alvarez L.; Shiwani M.; Ahmad G.; Allen T.; Darley E.; Patil S.; Brooks C.; Cresswell B.; Welsh F.; Cook C.; Smyth R.; Booth R.; West M.; King A.; Tucker O.; Phelan L.; Burahee A.; Devogel C.; Javed A.; Kay R.; Khan S.; Leet F.; Troth T.; Ward A.; Young J.; Murray E.; Gray T.; Johnson R.; Lockwood S.; Young R.; Zhou G.; Portal J.; Rees J.; Arnold B.; Scroggie D.; Abeysekera K.W.M.; Asif A.; Hay F.; Maccabe T.; Pathak S.; Robertson H.; Sandberg C.; Woodland H.; Charalabopoulos A.; Kordzadeh A.; Anderson J.; Napier D.; Hodges P.; Jones G.; Sheiybani G.; Archer T.; Khan A.; Kirk S.; Walker N.; Hassam U.; Wong I.; Silva M.; Jones K.; Allen J.; Abbas S.H.; Harborne M.; Majid Z.; Eardley N.; Reilly I.; Wadsworth P.; Bell C.; Holloway K.; Stockton W.; Thomas R.; Williams K.J.; Canelo R.; Tay Y.; Adnan M.; Aroori S.; Rajaretnam N.; Rekhraj S.; Wilkins A.; Nelapatia R.; Verebcean M.; Braithwaite S.; Apollos J.; Robertson N.; Belgaumkar A.; Brant A.; Shahdoost A.; French J.J.; Sen G.; Thakkar R.; Kanwar A.; Klaptocz J.; Rodham P.; O'Riordan B.; Maharaj G.; Davies M.; Higgs S.; Cutting J.; Joseph M.; Backhouse L.; Butler J.; Cooper J.; O'nions T.; Shaukat S.; Kumar A.; George V.; Ingmire J.; Saha A.; Coe P.; Noor R.; Lykoudis P.; Elshaer A.; Andreou A.; Clarke T.; Davies O.; Rimmer P.; Kanakala V.; Mitra V.; Akol G.; Burgess M.; Elzubier M.; Jones R.; Majumdar D.; Wescott H.; Bailey A.; Gomez M.; Herman O.; Deguara J.; Whitehead-Clarke T.; Gorard L.; Law R.; Leung L.Y.; Whitelaw D.; Adil M.; Krivan S.; Waters J.; Fernandes R.; Mealey L.; Merh R.; Okaro A.; Shepherd J.; O'Reilly D.; Pilkington J.; Hussain Z.; Ingram S.; Stott M.C.; Abbott S.; Bhamra N.; Hirri F.; Lee K.; Murrell J.; Resool S.; Taylor M.; King M.; Madhotra R.; Ayubi H.; Ali J.; Chander N.; Mckune G.; Wothers T.; Shingler G.; Mortimer M.; Dykes K.; Edwards H.; Menon S.; Gautham A.; Ali I.; Anjum R.; Brookes M.; Wilkinson B.; Tait I.; Noaman I.; Wilson M.; Mogan S.; Rushbrook S.; Hyde S.; Baker S.; Hall P.; Lucas H.; Pease J.; Millar A.; Tariq Z.; Blad W.; Cunningham M.; Hall M.; Luthra P.; Seymour K.; Aawsaj Y.; Jones M.; Elliott D.; Finch J.G.; Rajjoub Y.; Gupta A.; Molloy P.; Mykoniatis I.; Atallah E.; Albraba E.; Asimba V.; Baxter A.; Chin A.; Vojtekova K.; Ong L.; Modi H.N.; Muscara F.; Perry M.; Katz C.; Shaban N.; Dichmont L.; Dissanayake T.; Mostafa W.; Ghosh D.; Hwang S.; Bajomo O.; Lloyd T.; Wye J.; Holt A.; Pathanki A.; Townsend S.; Babar N.; Giovinazzo F.; Kennedy L.; Kandathil M.; King D.; Pillai M.; Glen P.; Holroyd D.; Drozdzik S.; Kourounis G.; Thompson J.; McNally S.; Thomas I.; Reddy Y.; Subar D.; Heywood N.; Khoo E.; Austin A.; Awan A.; Tan H.; Kasi M.; Prasad S.; Baqai M.; Abd Alkoddus M.; Al-Allaf O.; Mitchell K.; Mole S.; Yoong A.; Fusai G.; Brown S.; Bulathsinhala S.; Gilliland J.; Boyce T.; Al-Ardah M.; Matthews E.; Wakefield C.; Hou D.; Thomasset S.; Guest R.; Falconer S.; Hughes M.; Johnston C.; Kung J.W.C.; Lee E.; McNally E.; Sherif A.E.; Stutchfield B.; Baron R.D.; Dunne D.F.J.; Dickerson L.D.; Exarchou K.E.; Knight E.; Whelan P.; Hutchins R.; Wilson P.; Phillpotts S.; Badrulhisham F.; Dawes A.; Derwa Y.; Rajagopal S.; Ramoutar S.; Vaik T.; Bhogal R.H.; McLaren N.; Policastro T.; *Butterworth J.; *Riera M.; *Ismail A.; *Ahmed A.; *Alame R.; *Alford K.; *Banerjee S.; *Bull C.; *Kirby G.; Athwal T.; Hebbar S.; Ishtiaq J.; Kamran U.; Abbasi A.; Kamarul-bahrin M.; Banks A.; Khalil A.; Karanjia N.; Trivedi D.; Chakravaratty S.; Frampton A.; Gabriella J.; Pinn G.; Colleypriest B.; Betteridge F.; Murugiah D.; Rossiter A.; Yong K.; Sellahewa C.; Chui K.; Ehsan A.; Fisher N.; Iyer S.; McMurtry H.; Garbutt G.; Mahgoub S.; Alleyne L.; Harvey J.; Johnson K.; Richards E.; Palaniyappan N.; Bowler C.; Inumerable R.; Abu M.; Suhool A.; Talbot T.; Westwood J.; Zumbo G.; Osborne A.; Botes A.; Dyer S.; Thomas-Jones I.; Merker L.; Przemioslo R.; Roderick M.; Valverde J.; Zerafa A.; Barker S.; Wan A.; Lalani R.; Barrett C.; Kapirial N.; McCarthney K.; Ramamoorthy R.; Yalchin M.; Huggett M.; Macutkiewicz C.; Smith A.; Buchanan A.; Burke J.; Goodchild G.; Keane M.G.; Potts J.; Disney B.; McFarlane M.; Baker E.; Bullock S.; Coleman S.; Mcardle C.; Morgan J.; Mozdiak E.; Obisesan A.; O'Flynn L.; Mowbray N.; de Berker H.T.; Driscoll P.; Alberts J.C.; Sadien I.D.; Webb K.; Khalil H.; Parmar C.; Sadigh D.; Seyed-Safi P.; Shala L.; Somasundaram M.; Bryce G.; McCormack K.; Jamieson W.; Mitchell L.; Cheung D.; Hicken B.; Abbas N.; Kurian A.; Tahir I.; Spearman J.; Johnston T.; Jones C.

Citation:Pancreatology; Sep 2021; vol. 21 (no. 6); p. 1127-1134

Abstract:Objective: UK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates. Design(s): RICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing. Result(s): Rates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease. PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5-7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028). Conclusion(s): Despite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.

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