Hypoglycaemia Documented With Real-Time Continuous Glucose Sensing in A Case of Dead in Bed' Syndrome

DIABETICMedicine
Clinical care and other categories posters: audit
Refer to page 80, poster 162
P134
Vitamin B12 is lower in metformin treated
patients but haemoglobin is unaffected
RP Narayanan1, SG Anderson2, E Onyekwelu3 and AH Heald1,3
1
Vascular Research Group, University of Manchester, Manchester, UK,

Cardiovascular Sciences Group, University of Manchester, Manchester, UK,
3
Department of Medicine, Leighton Hospital, Crewe, UK
2
Introduction: Metformin treatment has recently been linked with

vitamin B12 deficiency. Given the widespread use of metformin in
treatment of Type 2 diabetes and the implications for haematological
health, we determined how long-term metformin treatment affects
vitamin B12 and haemoglobin (Hb) levels in primary care.
Methods: We used pseudo-anonymised data drawn from primary
care records in practices based in central and eastern Cheshire. We
compared vitamin B12 levels in 7,823 patients with Type 2 diabetes
taking metformin for more than 12 months, and 4,930 Type 2 diabetes
patients not taking metformin. The mean age was 63.6 years (range
1780 years). The study involved 7,456 men and 5,297 women.
Comparison between groups used t tests.
Results: Vitamin B12 levels when checked were significantly lower in
metformin treated patients (2,767 subjects, mean 355.1 ng/l, 95 per
cent CI 347.1363.1 ng/l) than non-metformin treated patients (1,567
subjects, mean 419.1 ng/l, 95 per cent CI 407.8430.3 ng/l), P < 0.001.
There was no difference in folate levels (P = 0.17). Interestingly MCV
was lower in metformin vs. non-metformin treated patients (90.1fL vs.
91.3fL) as was MCH (90.7pg vs. 90.3pg), P < 0.001. There was no
difference in Hb (136.1 vs. 135.6 g/l). Mean HbA1c was 7.47 per cent
(58 mmol/mol) and 6.88 per cent (52 mmol/mol) in the metformin and
non-metformin groups respectively (P < 0.001).
Conclusion: While vitamin B12 levels were lower in metformin
treated patients, there was no difference in circulating Hb. This has
implications for long-term monitoring requirements in metformin
treated patients.

P135
National Diabetes Audit (NDA): diabetes is
under-recorded on death certificates of
people with diabetes
B Young1, D Eayres2, J Barrett3, C Buttery3 and J Henderson3
1
Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford,
UK, 2Public Health Information, NHS Information Centre, Leeds, UK, 3Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK
Background: Diabetes is implicated in the cause of death for most

people with diabetes but death certificates may under-report diabetes as
a comorbidity.
Methods: The 20078 NDA included 1.42 million people with
diabetes, 65 per cent of the 2.19 million people diagnosed to have
diabetes in England. The NHS numbers of the people with diabetes
included in the 20078 NDA who were alive at 1 November 2008 were
matched by Office of National Statistics for deaths registered up to the
end of June 2010.
Results: During the 1 year follow-up period from 1 November 2008
to 31 October 2009 a total of 49,282 deaths were recorded.
Assuming that those included are representative of the general
diabetic population, then by extrapolation (multiplying by 2.1/1.41)
we can estimate that the total number of deaths of people with
diagnosed diabetes in England is of the order of 70,00075,000 per
year. This represents approximately 1516 per cent of all deaths
occurring annually in England. By comparison, in the calendar year
2009, only 30,894 (6.7 per cent) of the 460,000 deaths officially
registered in England included diabetes somewhere on the death
certificate, with 4,934 (1.1 per cent) having diabetes recorded as the
underlying cause of death. These figures suggest that less than half of
deaths of people with diabetes mention diabetes on the death
certificate.
Conclusions: Diabetes is related to almost one-sixth of deaths in
England and its impact on total mortality is significantly underestimated by reliance on death certificates.
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P136
National Diabetes Audit (NDA): comparison
between all-cause mortality in people with
diabetes and the general population in
England; more than 20,000 excess deaths in
people with diabetes and higher risks in
Type 1 diabetes
D Eayres1, J Barrett2, C Buttery2, J Henderson2 and B Young3
1
Public Health Information, NHS Information Centre, Leeds, UK, 2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK, 3Department of
Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
Background: The present impact of diabetes on overall mortality is

not known.
Methods: The 20078 NDA included 1.42 million people with
diabetes. Using NHS numbers the Office of National Statistics identified
49,282 deaths in this cohort during the year beginning 1 November
2008. The diabetes cohorts mortality experience is compared with the
general populations using directly age-standardised rates (DSRs) and
indirectly age-standardised mortality ratios (SMRs), with England
2009 as the standard population/rates.
Results: The crude death rate for all people with diabetes was 3,553
per 100,000 per year (background England rate 886). People with
Type 1 diabetes had the highest mortality with a DSR of 2,016
compared with 1,462 for people with Type 2 diabetes and 886 for the
background England population. The SMRs suggest that, compared
with the background mortality rates, there are approximately 2.5
times as many deaths in people with Type 1 diabetes and 1.5 times as
many in people with Type 2 diabetes. In total there were more than
16,000 more deaths of people with diabetes than would have occurred
if their mortality risk was equal to the general populations.
Extrapolating this to include people with diabetes not in the audit
suggests that there are about 21,000 excess deaths in people with
diabetes in England each year.
2012 The Authors.

Diabetic Medicine 2012 Diabetes UK. Diabetic Medicine, 29 (Supp. 1), 30177
Conclusions: The contemporary risk of death in people with diabetes

is substantially greater than in the general population and represents an
opportunity for improving national health outcomes. The risk in Type 1
is 1.7 times greater than in Type 2 diabetes.
P137
National Diabetes Audit (NDA):
investigation by age and sex of excess
deaths in people with diabetes in England;
greater effects in the young and in Type 1
females
DIABETICMedicine
P = 0.05) occurred. TC levels remained unchanged (T0 4.08 vs. T1

4.05, P 0.41). Creatinine and eGFR worsened (creatinine T0 141.53 vs.
T1 156.47, P = 0.043; D mean eGFR T0 to T1 of 2.46 ml/min/year,
P = 0.04). At T0, 76/186 (38 per cent) exhibited overt albuminuria
(ACR > 30); at T1 it was 7/172 (4 per cent). However, mean ACR did
not alter significantly (T1 60.23 vs. T0 50.23, P = 0.19). A total of 93/
174 (53 per cent) were on ACEi and 61/174 (35 per cent) on ARB.
Prescription of statins and aspirin at T0 and T1 were 74.1 per cent and
76.4 per cent and 59.8 per cent and 53.4 per cent respectively. Just 51/
186 (27 per cent) were referred to the low clearance clinic and 14/186
(7.5 per cent) died.
Conclusions: According to our AABC strategy, significant decreases
in blood pressure and triglycerides were observed during the audit
period with little change in HbA1c. A quarter of patients received
statins but prescription of aspirin remained comparatively low.
D Eayres1, J Barrett2, C Buttery2, J Henderson2 and B Young3

1
Public Health Information, NHS Information Centre, Leeds, UK, 2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK, 3Department of
Background: The effects of age and sex on excess mortality in

diabetes were investigated.
Methods: Using NHS numbers from the 20078 NDA the Office of
National Statistics identified 49,282 deaths during the year beginning 1
November 2008. The diabetes cohorts mortality was investigated
using age- and sex-specific mortality rates, directly age-standardised
rates (DSRs) and indirectly age-standardised mortality ratios (SMRs),
with England 2009 as the standard population.
Results: Compared with the background population males and
females with Type 1 diabetes are 2.5 times more likely to die and
with Type 2 diabetes 1.4 and 1.5 times respectively. In all instances this
excess mortality is inversely related to age: in the 1534 age group,
mortality in females with Type 1 diabetes is approximately 9 times the
female background rate, in males 4 times; for Type 2 diabetes the figures
are approximately 6 and 3.6 times respectively; in the 85+ age group all
of the ratios drop to less than 2. Compared to the general population
excess male mortality in Type 1 diabetes is less: no excess in the 1534
age group and a gradual increase to 1.3 times in the over 85s; for Type 2
diabetes excess male mortality is constant over all age groups at
approximately 1.2 times the female rate.
Conclusions: Compared with the general population the
contemporary risk of death in people with diabetes is greater at all
ages in both sexes but the relative risk is greatest in the young and in
females with Type 1 diabetes.
P138
Audit of a diabetic renal clinic: an appraisal
of the AABC treatment paradigm
K Al-Hourani1, T Mehrali2, A Murtaza2 and P De2
1
Merton College, University of Oxford, Oxford, UK, 2Diabetes and Endocrine
Unit, City Hospital, Birmingham, UK
Aim: To audit the outcome of our diabetic renal clinic using AABC
(HbA1c and aspirin, blood pressure, cholesterol/lipids) strategy.
Methods: Baseline data T0 in 2009 were compared with final data T1
end 2010 from clinic letters and electronic data of 186 patients
attending this clinic between 2009 and 2010.
Results: In all, 173/186 (93 per cent) had Type 2 diabetes (male 118);
53 per cent of patients were South Asian, 23 per cent Caucasian, 23 per
cent Afro-Caribbean. Mean HbA1c was T0 7.96 per cent vs. T1 8.23
per cent, P = 0.3. Significant improvements in blood pressure control
(mean SBP T0 141.5 vs. T1 136.8, P = 0.04; mean DBP T0 74.3 vs. T1
68.3, P = 0.0002) and triglycerides (mean TG T0 2.33 vs. T1 1.7,
2012 The Authors.

P139
Audit of the continuous subcutaneous
insulin infusion multidisciplinary service at
the University Hospitals Bristol NHS
Foundation Trust (UHB)
A Thomson-Moore, E Jones and N Thorogood
Diabetes and Endocrinology, University Hospitals Bristol NHS Foundation
Trust, Bristol, UK
Aim: To audit the UHB continuous subcutaneous insulin infusion

(CSII) service against 2008 NICE standards.
Method: This was a retrospective analysis of patient records
performed using the standard NICE 2008 audit proforma.
Results: On 25 August 2011 92 patients, 37 males and 55 females,
mean age at start of CSII 39.6 (range 964), were being actively
supported. Fifty (54 per cent) started after the 2008 NICE guidelines.
All UHB starts had received self-management education. Seven had
started too recently to assess outcome. For three the indication for CSII
was unknown, and data were incomplete for one patient. Of the
remaining 81 patients, 64/81 (79 per cent) were achieving NICE
specified treatment goals. Mean HbA1c pre-CSII was 8.4 per cent
(range 5.713.3 per cent) decreasing to 7.6 per cent (range 5.19.5 per
cent) at 1 year. An improvement in hypoglycaemia awareness and
frequency was reported by 95 per cent. Currently 17 are not achieving
treatment goals. Eleven (12 per cent) never have (nine started pre-2008).
The remainder, despite initial goal achievement, show subsequent drift
to HbA1c > 8.5 per cent. All but one are reluctant to consider
withdrawal of CSII.
Conclusion: In total, 79 per cent of the UHB cohort overall, and 90
per cent of patients who started post-2008 NICE guidelines, were
achieving treatment goals. There was no correlation with age or
socioeconomic class. Average HbA1c reduction at 1 year was 0.8 per
cent. Greater team experience, and 2008 NICE guidance, has led to
higher goal achievement through better patient selection. A written
contract enabling withdrawal of CSII if treatment objectives are not met
is essential, as patients are reluctant for it to be taken away. We do not
know the long-term effect of engagement with diabetes services if CSII is
withdrawn.
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DIABETICMedicine
P140
Safer administration of insulin: using an
audit to get the basics right and reduce risks
of patient harm
AC Reid, A Barridge, S Burmiston, C Hamilton and M Knapper
Department of Diabetes and Endocrinology, Guys and St Thomas NHS
Foundation Trust, London, UK
Aim: In 2010 the National Patient Safety Association highlighted

insulin errors, including the misuse of 1ml syringes, and a consensus
guideline on injection technique was published. In 2011
Maladministration of Insulin was added to the NHS never events
list. The aim is to identify the type of syringes and needles available and
how syringes are stored in all clinical areas of our trust, and to develop
trust recommendations to promote safety and good practice.
Methods: Matrons for all wards and departments completed an
audit, detailing types of insulin syringes and needles available, how they
are identified and stored and the estimated risk of syringe mis-selection.
Results: In all, 90 per cent (55/61) returned audits; three areas did not
stock insulin syringes. Of 52 responses analysed, 50 (96 per cent)
separated insulin syringes from 1ml syringes, 45 (93 per cent) reported
the storage area was labelled to identify content, 40 (90 per cent)
reported labelling included the word insulin, and 44 (92 per cent)
reported that the label reflected contents. One ward reported insulin
and 1ml syringes were mixed together. Twenty-nine (54 per cent)
stocked 50 unit syringes, 29 (44 per cent) 100 unit syringes and four (2
per cent) 30 unit syringes, with 49 (96 per cent) using BD syringes, 27
(62 per cent) had 8mm needles, 15 (34 per cent) 12.7mm needles and
two (4 per cent) other. Syringes were individually wrapped in 47 (90 per
cent) areas, unwrapped in six (11 per cent), sealed multipacks in two (4
per cent) and opened multipacks in three (8 per cent). The risk of syringe
mis-selection was estimated to be low by 78 per cent, moderate by 10
per cent, and significant by 12 per cent.
Summary: Eleven areas identified practice with moderate or
significant risk of harm. Fifteen areas used needle lengths with
potential for IM injections. We will implement trust-wide policy to
remove variation, improve practice and prevent potentially fatal errors.
P141
National Diabetes Audit (NDA): routine care
is less effective and outcomes are poorer in
younger people compared with older
people who have diabetes in England
B Young1, A Uddin2, J Barrett2 and J Henderson2
< 25 year, <15 per cent, age > 55 year, > 30 per cent; Type 2 diabetes, age
< 55 year, <50 per cent, age > 70 year, >70 per cent). The <55 year age
group accounts for 91 per cent of all age diabetic ketoacidosis; 62 per
cent of end stage kidney disease (ESKD) in Type 1 and 15 per cent of
ESKD in Type 2 diabetes; 15 per cent of all major amputations; and 12
per cent of all myocardial infarctions.
Conclusions: Measures of care quality in younger people with both
Type 1 and Type 2 diabetes are poorer than in older people. Perhaps
systems of care for younger people should be specifically targeted for
improvement.
P142
Improvements to diabetes services as a
result of participating in the NHS Diabetes
National Diabetes Inpatient Audit
LJ Richards, G Eyres, L Allan, G Johnson and G Sweeney
NHS Diabetes, Newcastle-Upon-Tyne, UK
Aim: The National Diabetes Inpatient Audit (NaDIA) was established

in 2009 by NHS Diabetes. The audit provides a national snapshot of
diabetes inpatient care, and enables local diabetes teams to identify areas
of care that require improvement. The aim was to explore the positive
impact of the NaDIA on diabetes services at participating trusts.
Methods: Changes to services as a result of taking part in the NaDIA
were captured during a workshop event attended by representatives
from 63 NHS Trusts. Qualitative thematic analysis of the data was used
to establish where improvements had been made. Semi-structured
interviews were conducted with selected participants to explore the
impact of these changes on patient care.
Results: Diabetes teams reported several advantages of participating
in the NaDIA, leading to numerous improvements to services. Thematic
analysis of the data revealed five main themes: raised profile of diabetes
and the diabetes team; reforms to systems and processes; investment in
additional diabetes staff and staff training; implementation of
ThinkGlucose; and improvements in the use of insulin. Further
investigation revealed that these improvements led to various benefits,
including one trust reporting a 0.61 day reduction in the average length
of stay in hospital for people with diabetes, saving the trust 477,000
over 7 months. Reductions (up to 75 per cent) in the number of insulin
errors and better management of hypoglycaemia were amongst the
other reported benefits.
Conclusions: Participating in the NaDIA has led to considerable
improvements in diabetes inpatient care in some trusts, including
improved quality of care and clinical outcomes, in addition to financial
savings.
1
Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK, 2Clinical
Audit Support Unit, NHS Information Centre, Leeds, UK
Background: The latest NDA data have been investigated to see

whether diabetes care and outcomes are age related.
Methods: In 200910 the NDA included 1.9 million people, 83 per
cent of those with diagnosed diabetes in England. The NDA uses
primary care, specialist care and hospital admission data collected
electronically with an approved data set comprising NICE
recommended care processes, treatment targets and diabetic
complications.
Results: Some 24 per cent of people with diabetes are less than
55 years old. These younger people less frequently received the nine
core processes of care (all care processes were completed in 20 per cent
aged 1624 years, 38 per cent aged 2554 years but 55 per cent aged
5584 years). Achieving the HbA1c < 7.5 per cent (58 mmol/mol)
treatment target was less likely in younger people (Type 1 diabetes, age
74
P143
An audit on referral for oral glucose
tolerance tests
M Sadeghi1, C Rai1, A Taylor2 and M Banerjee1,3
1
Department of Medicine, Furness General Hospital, Barrow-in-Furness, UK,

Department of Clinical Biochemistry, Furness General Hospital, Barrow-inFurness, UK, 3Cumbria Diabetes, Cumbria Partnership NHS Foundation Trust,
Barrow-in-Furness, UK
2
Introduction: The oral glucose tolerance test (OGTT) is one of the

dynamic tests to designate the dysglycaemic state of an individual. The
reproducibility of the OGTT has been poor, but with no other tests
being able to classify dysglycaemia as above, this has remained an
important investigation. For the same reason, strict patient selection for
OGTT is required.
2012 The Authors.

Methods: All the patients who had an OGTT requested between 1

January 2010 and 30 September 2010 were included in this audit. All
OGTTs requested in pregnancy were excluded. The data source was
the Pathology Laboratory in Furness General Hospital in Barrow-inFurness, which was checked for all plasma glucoses checked for the
patients in the preceding year. Early identification of people with
Type 2 diabetes Diabetes UK 2006 was used as the standard for this
audit.
Results: The total number of OGTTs requested was 354. After
excluding the OGTTs requested in pregnancy (n = 40), the total
number of patients selected for the audit was 314. The mean age of the
patients was 63.4 years and 54 per cent were female. There was poor
documentation of the indication for OGTT in 57.3 per cent of requests.
The OGTT was not indicated in 52.5 per cent of these individuals for
whom 29.7 per cent of fasting plasma glucose results were normal and
23.0 per cent were suggestive of Type 2 diabetes. In all, 37.2 per cent of
those deemed suitable and 61.8 per cent of those unsuitable for OGTT
had normal OGTT results.
Conclusion: The requests for OGTT need to be refined as this would
prevent unnecessary investigation and wastage of time both for the
patients and the healthcare staff.
P144
Audit of inpatient management of diabetes
in the elderly
A Mackett and KS Myint
Diabetes and Endocrinology, Norfolk and Norwich University Hospitals NHS
Foundation Trust, Norwich, UK
Aim: We evaluated elderly (> 70 years) inpatient diabetes care at

Norfolk and Norwich University Hospitals NHS Foundation Trust
over 6 months (October 2010 to April 2011).
Method: Patients were identified from clinical coding retrospectively.
The case notes of 30 emergency admissions (EAs) were randomly
selected and analysed.
Results: In total, 3,333 patients were identified (49 per cent EAs, 13
per cent elective, 38 per cent day admissions). Among EAs, 97 per cent
were Type 2 and 52 per cent were female, with a mean length of stay
(LOS) of 9.06 days (range 088) vs. a trust mean of 5 days; 20.7 per
cent were admitted 2 times. Among 30 patients analysed, 20 per cent
and 30 per cent admissions were diabetes and cardiovascular related
respectively. The triage specialties were elderly medicine (50 per cent),
cardiology (33 per cent) and endocrinology (6 per cent). 27 per cent
were on insulin, 17 per cent received intravenous insulin (40 per cent
were inappropriate). Ten (30 per cent) had hypoglycaemic episodes
(five had more than seven, one had >24, one required intravenous
dextrose four times). Only in 50 per cent were guidelines followed. Dose
adjustment was not done in 50 per cent with consecutive day hypos. 30
per cent experienced hyperglycaemia (consecutive days glucose
consistently >11.1 mmol/l) and all were acted upon. 96 per cent had
regular glucose monitoring. Eight (38 per cent) had prescribing errors
(four insulin, four oral agents). 24 per cent had feet examination
documented. All 10 per cent with active foot disease were reviewed by a
foot team. LOS was 16.5 days (insulin treated) and 6.5 days (without
insulin). 25 per cent had delayed discharges after being declared
medically fit (mean 9.8 additional days) and of these 40 per cent were
glycaemic control related. Five (17 per cent) died after discharge. 60 per
cent of them had unstable glycaemic control.
Conclusions: This audit highlighted issues of hypoglycaemia,
prescribing errors, high mortality and delay discharges in elderly
diabetes inpatients. More focused education for staff is recommended.
2012 The Authors.

DIABETICMedicine
P145
What proportion of patients fail NICE
criteria for continuing GLP-1 treatment
beyond 6 months and why
L Wessels, S Keigan, SV OBrien and KJ Hardy
Diabetes Centre, St Helens Hospital, St Helens, UK
Aims: Glucagon-like peptide 1 (GLP-1) agonist treatment in Type 2

diabetes is associated with improved glycated haemoglobin (HbA1c)
and weight loss. National Institute for Health and Clinical Excellence
(NICE) guidance exists for starting GLP-1 therapy and for its
continuation beyond 6 months. At 6 months, patients must have lost
at least 3 per cent body weight and improved HbA1c by at least 1.0 per
cent.
Methods: We assessed the impact of NICE continuation criteria in 61
patients, mean age (SD) 57 (10) years, diabetes duration 11 (6) years,
baseline median (range) weight 118kg (76192), body mass index
42 kg/m2 (3068) and HbA1c 9.6 (7.614) per cent, who met NICE
initiation criteria and had received at least 6 months treatment.
Results: Thirty-three patients (60 per cent) met continuation criteria.
After a median 8 (648) months follow-up, these patients had lost
7.2kg (2.926.3) and HbA1c had fallen by 1.4 (15.6) per cent. Of those
failing NICE continuation criteria, 23 per cent failed on weight alone,
55 per cent on HbA1c alone and 27 per cent on both. Baseline
characteristics could not predict treatment failure. Median weight loss
after 10 (639) months follow-up in those failing on HbA1c alone was
6.8kg (2.424.5) (similar to those who met NICE continuation criteria).
Conclusions: We conclude that in our clinic most patients can
continue GLP-1 treatment, but approximately 40 per cent fail to meet
NICE continuation criteria, most as a result of poor HbA1c response
despite marked weight loss.
P146
The impact of the diabetes outreach team
on long-term glycaemic control
H Siddique1, AA Tahrani2, W Leong2, K Crowley1, G Wheatley1
and C Holmes1
1
Diabetes, Dudley Group of Hospital NHS Trust, Dudley, UK, 2Diabetes,
University Hospital of Birmingham, Birmingham, UK
Aim: The aim of this audit was to assess the effectiveness of service
provided by the dedicated Diabetes Outreach Team at Russells Hall
Hospital, Dudley, UK.
Methods: We performed a retrospective audit of all inpatients who
were seen by our Diabetes Outreach Team between June 2007 and
December 2010. Blood samples including HbA1c at the initial visit and
subsequent follow-up (at our Diabetes Clinic) at 3 to 6 months were
collected.
Results: Over 3.5 years, baseline data were available for 2,490
patients, and 1,224 patients had follow-up data. Of these, 199 had
Type 1 diabetes and 990 Type 2 (16.7 vs. 83.3 per cent); 35 patients had
unspecified type. Thirty-two patients were referred for new onset Type
1 diabetes, 91 for Type 2 (2.6 vs. 7.4 per cent); 235 (19.2 per cent) were
referred because of hypoglycaemia. Mean age was 65.2 (+19.03) years.
Of the total sample, after excluding hypoglycaemia related admissions,
using paired t test the baseline HbA1c was 9.27 ( 2.57) and follow-up
HbA1c 8.32 ( 2.03) (P < 0.001). Patients with new onset Type 1
diabetes dropped their HbA1c from 12.55 per cent to 7.43 per cent and
new onset Type 2 from 10.7 per cent to 7.29 per cent, while patients
known to have diabetes also dropped their HbA1c from 8.99 per cent to
75
DIABETICMedicine
8.46 per cent (P < 0.001 for all comparisons). When the samples were
analysed based on their age (<50, 5074, >75), once again there was a
statistically significant drop in HbA1c.
Conclusion: By providing a comprehensive care, structured education
and appropriate intervention though our Diabetes Outreach Team, we
have shown a significant reduction in objective markers of long-term
glycaemic control for recently hospitalised patients.
P147
A clinical audit of the insulin pump service
in Lanarkshire
A White, H Innes, P Reid, K Gallagher, L Wilson, L Doran,
E McIntyre and T Sandeep
Department of Diabetes, Monklands Hospital, Airdrie, UK
Aim: This audit aimed to identify (1) indications for starting

subcutaneous insulin infusion (CSII) therapy, (2) the effectiveness of
structured education prior to pump start, (3) improvement in glycaemic
control and (4) improvement in hypoglycemia.
Method: A retrospective audit was carried out with data from 45
individuals identified as using the insulin pump service at the Diabetes
Clinical care and other categories posters: auto-immunity
Centre at Monklands Hospital. Audit standards were based on the

SIGN and NICE guidelines.
Results: The predominant reason for starting CSII therapy which
applied to 26 individuals was recurrent severe hypoglycaemia, followed
by HbA1c > 8.5 per cent despite structured education (DAFNE) which
applied to seven individuals. Prior to starting CSII therapy 27
individuals had completed DAFNE training. After 1 year of CSII,
HbA1c had improved from 8.8 per cent at baseline to an average of 7.8
per cent (n = 36). Baseline HbA1c in the DAFNE group was 8.80 per
cent (n = 26), improving to 7.76 per cent (n = 24); it was 8.79 per cent
in the non-DAFNE group (n = 15), improving to 7.88 per cent (n = 12).
Hypoglycaemia frequency was formally recorded as being less than one
per 6 months in six patients.
Conclusions: CSII is an effective treatment option for people with
Type 1 diabetes shown here to provide a 1 per cent improvement in
HbA1c. Recurrent hypoglycaemia was the most likely reason to start
CSII and most individuals had completed DAFNE. More robust
recording of hypoglycaemia frequency and patient satisfaction surveys
are needed and are being implemented.
Clinical care and other categories posters: auto-immunity

P148
The evaluation of the utility of islet cell
auto-antibody measurements in clinical
practice
SA Nathwani1, D Kariyawasam2 and S Thomas2
1
Medical School, Kings College London University, London, UK, 2Diabetes

and Endocrine Department, Guys and St Thomass Hospital, London, UK
Aim: The earlier onset of Type 2 diabetes and increasing atypical

presentations of diabetes, eg ketosis-prone diabetes, have led to an
increase in the number of auto-antibody tests being performed.
However, the role of testing in routine clinical practice remains
unclear. This study aimed to assess the clinical usefulness of autoantibody testing in an inner-city hospital serving a diverse ethnic
population.
Methods: The role of auto-antibody testing in affecting changes in
management, defined as treatment change, referral to a specific
education programme or change in diagnosis, were assessed. All
patients presenting from 2007 to 2009 were identified from the
Diabeta3 database. Of these, 201 patients with either diagnosis under
76
40 years of age (n = 176) or above 40 years of age with ketones

(n = 25) were identified.
Results: A total of 108 (54 per cent) had an auto-antibody test
ordered. Antibody testing predicted a change in management
(P = 0.003); 45 per cent (n = 49) of the tested population had one or
more changes in their diabetes management following the test. The
most common change was a change in treatment (55 per cent) in the
majority the withdrawal or addition of insulin. In all, 51 per cent of
auto-antibody positive individuals had a change in management in
comparison with 43.2 per cent auto-antibody negative (P < 0.001); 22
per cent of auto-antibody tested individuals had a change in diagnosis,
eg from Type 1 to Type 2 diabetes.
Conclusions: Auto-antibody testing did lead to changes in diagnosis
and or management whether positive or negative. As classical
presentations of diabetes change there may be a greater role for
testing and a need for awareness of the limitations of the test.
2012 The Authors.

Clinical care and other categories posters: beta cells, islets and stem cells
DIABETICMedicine
Clinical care and other categories posters: beta cells,

islets and stem cells
P149
Resolution of hypoglycaemia, improvement
in glycaemic control and assessment of
metabolic graft function in islet transplant
recipients in the UK islet transplant
consortium programme
AMS Brooks1, SA Amiel2, S Forbes3, P Johnson4, M Rosenthal5,
M Rutter6, R Smith7 and JAM Shaw1
1
Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne,
UK, 2Diabetes Research Group, Kings College London, London, UK,
3
Endocrinology Unit, University of Edinburgh, Edinburgh, UK, 4Oxford Centre
for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford,
UK, 5Department of Endocrinology, Royal Free Hospital, Royal Free
Hampstead NHS Trust, London, UK, 6Manchester Diabetes Centre, University
of Manchester, Manchester, UK, 7Academic Renal Unit, University of Bristol,
Bristol, UK
Refer to Oral number A15
Clinical care and other categories posters: cardiovascular

P150
Association of carotid plaque morphology
with cardiovascular disease and vascular
risk factors in older people with Type 2
diabetes: the Edinburgh Type 2 Diabetes
Study
CM Robertson1, MWJ Strachan2, L Nee3, J Morling1, S Masle1
and JF Price1
1
Centre for Population Health Sciences, University of Edinburgh, Edinburgh,

UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK, 3Department
of Radiology, Western General Hospital, Edinburgh, UK
P151
Socioeconomic status and cardiovascular
mortality in people with Type 2 diabetes in
Scotland
C Jackson1, J Walker2, C Fischbacher3 and S Wild2
1
Scottish Collaboration for Public Health Research and Policy, Medical
Research Council, Edinburgh, UK, 2Public Health Sciences, University of
Edinburgh, Edinburgh, UK, 3Information Services Division, NHS National
Services Scotland, Edinburgh, UK
2012 The Authors.

P152
Effect of exenatide on cardiovascular
parameters: evidence from a small cohort
study
I Ramracheya
Centre for Diabetes and Endocrinology, Royal Berkshire NHS Foundation
Trust, Reading, UK
Aim: The glucagon-like peptide 1 (GLP-1) analogue exenatide is

recommended by the National Institute for Health and Clinical
Excellence as an add-on therapy to optimise diabetes control and
weight reduction. This study examined the effects of exenatide on
cardiovascular parameters in a cohort of patients with diabetes.
Methods: Patients were identified at a general hospital. Data were
collected retrospectively from notes, a local diabetes database and
laboratory results. Follow-ups lasted up to 12 months. Data were
analysed using Excel 2010.
Results: Forty patients were identified (male-to-female ratio 26:14).
Age ranged between 35 and 75 years (average SEM: 59.1 1.7).
Diabetes duration varied between 1 and 19 years (9.2 0.7). Other
parameters were as follows: weight 124.8 4.0 kg; body mass index
41.3 7.7 kg/m2; HbA1c 9.6 0.2 per cent. Twenty-five patients
were identified for comparison between 0 and 6 months and 18 patients
for 012 months. Blood pressure recordings at baseline were (mm Hg)
systolic 142 2.9; diastolic 80 1.6. Systolic readings at 6 months
showed a modest drop of 3.2 mm Hg (baseline 143.3 3.8 vs.
140.1 3.9) and at 12 months there was a significant drop of 6 mm
Hg (baseline 146.6 6.2 vs. 140.5 5.5; P < 0.05). No change was
noted in diastolic blood pressure. Triglyceride levels dropped by 9 per
77
DIABETICMedicine
cent (P < 0.05) at 3 and 6 months and 10 per cent (P < 0.05) at
12 months. There was a small reduction in total cholesterol levels at
3 months. At 6 months and 12 months total cholesterol fell
significantly (P < 0.05) by 5 per cent (3.9 0.1 vs. 3.7 0.1) and 8
per cent (3.9 0.1 vs. 3.6 0.1) respectively. LDL levels were
unaffected in this cohort.
Conclusions: Exenatide treatment can significantly and timedependently improve cardiovascular risk factors. Further studies are
needed to assess the long-term cardiovascular benefits of exenetide.
P153
Frequency and characteristics of carotid
artery plaque in older people with Type 2
Study
CM Robertson1, MWJ Strachan2, L Nee3, J Morling1, S Masle1
and JF Price1
1
UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK, 3Department
of Radiology, Western General Hospital, Edinburgh, UK
Introduction: Carotid plaque presence and characteristics may be

important in cardiovascular risk prediction, in particular echolucent
and/or heterogeneous plaque. However, little is known about the
prevalence and characteristics of carotid plaque in people with Type 2
diabetes.
Methods: In total, 939 subjects aged 6176 years from the Edinburgh
Type 2 Diabetes Study underwent ultrasound assessment of their left
and right carotid arteries. Plaque presence, thickness, echolucency and/
or heterogeneity were assessed within 2cm of the bifurcation in the
common, internal and external carotid arteries. Measurements were
repeated in 830 subjects after 4 years.
Results: Plaque was most common at the right and left bifurcation
(90.4 vs. 92.4 per cent respectively) and in the internal carotid arteries
(59.6 vs. 61.7 per cent), and least common in the common (31.9 vs. 42.2
per cent) and external carotid arteries (28.8 vs. 26.1 per cent); mean
maximum plaque thickness (mMPT) was 2.47mm (95 per cent CI
2.412.54). Overall, 35.6 per cent of participants had echolucent
plaque and 43.0 per cent had heterogeneous plaque. Plaque distribution
at follow-up was similar to baseline; however, the percentage with
plaque present was increased and mMPT significantly increased to
2.82mm (95 per cent CI 2.742.89). Subjects with echolucent or
heterogeneous plaque had a greater mMPT compared with those with
predominantly echogenic plaque (2.7 vs. 2.3, 2.9 vs. 2.1 respectively,
P < 0.001).
Conclusions: Carotid plaque is highly prevalent in older people with
Type 2 diabetes, especially at the carotid bifurcation and internal
carotid arteries. Plaque presence and thickness increase with age and
those people with high risk plaques have higher plaque thickness. Given
the high prevalence of carotid plaque, investigation into its clinical
significance in people with Type 2 diabetes, including as a predictor of
subsequent events, is warranted.
P154
Sex differences in cardiovascular disease
risk factor profiles in those with Type 1
diabetes in Scotland
HM Colhoun
Population Health Sciences (PHS), University of Dundee, Dundee, UK
Aim: We previously reported that the relative risk for cardiovascular

disease (CVD) continues to be higher in women than men with Type 1
78
Clinical care and other categories posters: cardiovascular
diabetes in Scotland compared with the general population. To explore

reasons for this we examined whether CVD risk factor profiles and
achievement of treatment targets differ by sex in Type 1 diabetes.
Methods: We used clinical data and issued prescriptions data from
the Scottish Care Initiative Diabetes Collaboration (SCI-DC) which
captures data on the majority of patients with diabetes in Scotland.
Comparisons between sex were by logistic and linear regression with
age and diabetes duration adjustment. Analyses were restricted to those
aged 20 and over.
Results: Currentsmokingwasmorecommoninmenthanwomenatall
ages [31 vs. 26 per cent; odds ratio (OR) 0.81, 0.760.86, P < 0.001].
Below age 50 years only hypertension (SBP > 130mm Hg or
DBP > 80mm Hg) was more common in men than women (63 vs. 51
per cent; OR 0.6, P < 0.001) and non-HDL cholesterol was higher
(beta = + 0.11 mmol/l, P < 001). More women than men were obese
(26 vs. 20 per cent, OR 1.35, 1.31.4, P < 0.001) and had an
eGFR < 60 ml/min/1.73m2 (19 vs. 12 per cent, OR 1.8, 1.72.0,
P < 0.001). Above age 50 years only fewer women (21 per cent) than
men (25 per cent) met a target HbA1c < 7.5 per cent (OR 0.76, 0.60.9,
P = 0.013).
Conclusions: The worse risk factor profile for obesity, glycaemic
control and renal function in women than men with Type 1 diabetes
may contribute to their greater elevation in CVD risk.
Acknowledgement: On behalf of the Scottish Diabetes Research
Network.
P155
New onset hyperglycaemia in a multi-ethnic
cohort presenting with acute coronary
syndrome
A Mathew and P De
Diabetes and Endocrine Unit, City Hospital, Birmingham, UK
Aim: Disturbances of glucose metabolism are widely prevalent in acute

coronary syndrome (ACS) and relate to adverse outcome, irrespective of
presence or absence of previously diagnosed diabetes. The aim of this
study was to find degrees of glucose intolerance amongst patients
without diabetes admitted to the coronary care unit with ACS in our
hospital population.
Methods: All patients admitted to the coronary care unit with ACS
(between May 2009 and October 2010) underwent fasting plasma
glucose, HbA1c and oral glucose tolerance test (OGTT) on day 3 of
admission and had a repeat OGTT 2 weeks later following discharge.
Results: Forty-two of 52 patients admitted had an inpatient OGTT.
49 per cent of patients were Caucasian, 45 per cent South Asians and 6
per cent Afro-Caribbean. 52 per cent and 38 per cent were found to have
impaired glucose tolerance (IGT) and diabetes, respectively. Repeat
OGTT 2 weeks later showed 48 per cent now had normal glucose
tolerance while 27 per cent and 25 per cent were found to have IGT/IFG
and diabetes respectively. 75 per cent of those who developed diabetes
were South Asians, and 25 per cent were Caucasian (no family history of
diabetes in 62 per cent). Fifteen of 53 patients (28 per cent) with either
IGT or diabetes normalised on repeat OGTT. Using a cut-off HbA1c
of > 6.5 per cent for diabetes diagnosis, 12/46 (26 per cent) patients
would be diabetic.
Conclusion: There is a high incidence of undiagnosed diabetes and
IGT among patients admitted with ACS in our multi-ethnic population,
particularly South Asians. Every effort must be made to identify these
patients early, inculcate lifestyle measures appropriately and
aggressively target and treat cardiovascular risk factors.
2012 The Authors.

Clinical care and other categories posters: case reports
P156
Relieving the stress: the effect of primary
percutaneous coronary intervention on
blood glucose levels in ST elevation
myocardial infarction
1
AK McGregor , R Edwards , H Thomas , IF Purcell and

NJ Leech2
1
Cardiothoracic Services, Newcastle-upon-Tyne Hospitals NHS Foundation

Trust, Newcastle-upon-Tyne, UK, 2Diabetes and Endocrinology, Newcastleupon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
Aim: Studies demonstrating the benefit of insulin/dextrose infusion in

patients with hyperglycaemia and ST elevation myocardial infarction
(STEMI) precede the widespread use of primary percutaneous coronary
intervention (PCI). The effect of immediate reperfusion on blood
glucose is not known. We propose that immediate PCI for STEMI may
lower blood glucose and reduce the requirement for insulin/dextrose
infusion.
Methods: We measured capillary blood glucose on admission and 1 h
after PCI balloon inflation in consecutive patients presenting with
STEMI. Pre and post PCI blood glucose were compared by paired t test.
Insulin/dextrose infusion was only initiated if the post PCI blood
glucose was greater than 10 mmol/l.
Results: Paired blood glucose values were available for 98 patients.
Eight patients had a history of diabetes of which four had admission
blood glucose greater than 10 mmol/l. Overall, blood glucose fell from
8.7 2.87 mmol/l (mean SD, range 4.520.3 mmol/l) to 8.1
2.61 mmol/l (mean SD, range 5.024.4 mmol/l, P = 0.002). In
the 19 patients with admission glucose greater than 10 mmol/l,
blood glucose fell from 13.3 3.1 mmol/L (mean SD, range
10.420.0 mmol/l) to 10.8 4.6 mmol/l (mean SD, range
5.324.4 mmol/l, P = 0.0008). In 11 of these patients (58 per cent)
post PCI glucose fell to less than 10 mmol/l.
Conclusions: In patients admitted with STEMI undergoing PCI,
blood glucose falls significantly immediately post reperfusion even in
those hyperglycaemic on admission. We propose that reperfusion
reduces stress hyperglycaemia and allows blood glucose to fall in the
majority of patients. The benefits of insulin/dextrose infusions before
and after PCI therefore need further study.
DIABETICMedicine
P157
Estimating absolute cardiovascular risk
reduction in young South Asians with newly
diagnosed glucose disorders
DR Webb1, LJ Gray2, K Khunti2, A Farooqi2 and MJ Davies1
1
Cardiovascular Sciences, University of Leicester, Leicester, UK, 2Health
Sciences, University of Leicester, Leicester, UK
Aims: Screening is recommended within groups at high risk of Type 2

diabetes as earlier intervention theoretically improves outcomes.
Despite a significant burden of metabolic disease, research exploring
these effects in young ethnic minority groups is lacking. We modelled
estimated absolute 10 year cardiovascular risk reduction (CVRR)
associated with pharmacological interventions in 2540-year-old South
Asians identified with impaired glucose regulation (IGR) or diabetes
through screening.
Methods: Effect estimates were derived from outcome trials of
individual risk factors in established diabetes (additive model) and a
published randomised trial of multi-factorial intervention in screendetected cases (cumulative model). Baseline biomedical characteristics
required to calculate CVRR via the Framingham CVD-ethrisk equation
were obtained from participants of a systematic screening programme
(ADDITION Leicester). IDF diagnostic criteria were applied with an
HbA1c of 6.06.5 per cent representing IGR and >6.5 per cent diabetes.
Results: Population-based random sampling produced a screened
cohort of 359 with undiagnosed diabetes and IGR frequencies of 3.1
per cent (n = 11) and 12 per cent (n = 42) respectively. Calculated
baseline 10 year cardiovascular risk was 4.91 per cent (SD 3.91) for
diabetes and 4.44 per cent (SD 4.14) for IGR. The additive effects model
of lipid, blood pressure, glucose lowering and aspirin resulted in a CVRR
of 2.7 per cent (range 2.03.2) for diabetes and 1.1 per cent (range 0.1
1.7) for IGR. The cumulative effects model reflecting 5-year intensive
multi-factorial intervention resulted in a CVRR of 0.7 per cent (range
0.2 to 1.4) for diabetes and 0.5 per cent (range 0.1 to 1.0) for IGR.
Conclusion: Assuming extrapolation of intervention efficacy across
populations is valid, clinically significant reductions in absolute
cardiovascular risk are likely within this group using existing
treatments. The number needed to treat ranges from 37 to 143 for
diabetes and from 91 to 200 for IGR.

P158
The first case of fetal genetic testing to
guide insulin treatment in gestational
diabetes
AJ Chakera1,2, BA Knight1,2, RH Sturley3, S Ellard4 and
AT Hattersley1,2
1
Peninsula National Institute for Health Research (NIHR) Clinical Research
Facility, Peninsula College of Medicine and Dentistry, University of Exeter,
Exeter, UK, 2Research and Development Directorate, Royal Devon and Exeter
NHS Foundation Trust, Exeter, UK, 3Department of Obstetrics and
Gynaecology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK,
4
Department of Molecular Genetics, Royal Devon and Exeter NHS Foundation
Trust, Exeter, UK
P159
Important lessons from a rare case of
Charcot osteoarthropathy of the wrist in
diabetes
ME Edmonds1, V Kavarthapu2, J Compson2, G Vivian3, D Elias4
and NL Petrova1
1
Diabetic Foot Clinic, Kings College Hospital, London, UK, 2Department of

Orthopaedics, Kings College Hospital, London, UK, 3Department of Nuclear
Medicine, Kings College Hospital, London, UK, 4Department of Radiology,
Kings College Hospital, London, UK
2012 The Authors.

79
DIABETICMedicine
P160
Improved metabolic response to exercise on
sulfonylurea drugs compared with insulin in
HNF1A-MODY
AN Lumb1, G Thanabalasingham2,3, IW Gallen1 and
KR Owen2,3
1
Diabetes Centre, Wycombe Hospital, Buckinghamshire Healthcare NHS

Trust, High Wycombe, UK, 2Oxford Centre for Diabetes, Endocrinology and
Metabolism (OCDEM), University of Oxford, Oxford, UK, 3Oxford National
Institute for Health Research (NIHR) Biomedical Research Centre, Churchill
Hospital, Oxford, UK
P161
6q24 transient neonatal diabetes, due to
hypomethylation of the maternal TND locus,
is characterised by impaired insulin
sensitivity and secretion
YS Cheah1,2, T Evans3, L Docherty4, DJG Mackay4, IK Temple4
and SA Amiel1,2
1
Diabetes Research Group, Kings College London, London, UK, 2Department
of Diabetes, Kings College Hospital NHS Foundation Trust, London, UK,
3
Paxton Green Group Practice, Lambeth Primary Care Trust, London, UK,
4
Faculty of Medicine, University of Southampton, Southampton, UK
P162
Hypoglycaemia documented with
continuous glucose sensing in a case of
dead in bed
N Waheed, MI Butt, E Jones, A Newton, S Wong and C Dayan
P163
Managing insulin and carbohydrate
requirements for an athlete with Type 1
diabetes: cycling from John OGroats to
Lands End
R Ritchie1, J Hadley2, S Woodman1 and R Holt3
1
Nutrition and Dietetics, University Hospital Southampton NHS Foundation
Trust, Southampton, UK, 2Community Diabetes Service Solent NHS Trust,
Solent, Southampton, UK, 3Institute of Developmental Sciences, University of
Southampton, Southampton, UK
Background: The management of Type 1 diabetes whilst performing

high intensity and long duration exercise, in particular preventing
hypoglycaemia and hyperglycaemia to optimise performance, is
challenging. To achieve this, a fine balance between carbohydrate
intake and basal/bolus insulin is required.
Case report: A 28-year-old man with Type 1 diabetes was referred
with fluctuating blood glucose levels (BGL) (<4 to > 20 mmol/l,
HbA1c 8.8 per cent, 73 mmol/l) during intensive prolonged exercise.
He planned to cycle 900 miles over nine consecutive days. Guided by
self-monitored blood glucose results collected during practice cycles,
on race days he reduced the basal insulin by approximately 1720 per
cent and bolus doses by 60 per cent (breakfast), 50 per cent (lunch)
and 10 per cent (evening meal). The target BGL range prior to the
race was 12 mmol/l and finish 59 mmol/l. The blood glucose target
was 58 mmol/l. To prevent hypoglycaemia he was consuming
numerous large quantities of fast acting glucose (> 80 g) throughout
the day. To maintain the BGL within target range and avoid
hypoglycaemia and hyperglycaemia he was advised to consume 20 g
fast acting carbohydrate every 20 min in the form of liquid, gels or
glucose tablets. He was also advised to consume complex
carbohydrate-dense meals in order to help provide a steady energy
release through the day.
Conclusion: This case illustrates that reductions of up to 60 per cent of
rapid insulin and 1720 per cent of basal insulin may be required to
reduce the risk of hypoglycaemia during and post intensive exercise.
The findings suggest that a regular intake of 20 g fast acting
carbohydrate intake may help stabilise blood glucose level
concentration during intensive exercise.
Diabetes Department, United Bristol Healthcare NHS Trust, Bristol, UK
We report a 41-year-old man who was found dead in his bed with a
continuous glucose monitoring device in situ. He had Type 1 diabetes
diagnosed at age 14 years. He had poor glycaemic control during his
teenage years and suffered from severe hypoglycaemic episodes and
reduced hypoglycaemic awareness resulting in three road traffic
accidents. His diabetes was complicated by retinopathy, nephropathy
and neuropathy. He began continuous subcutaneous insulin pump
therapy in 2005 and linked continuous real-time glucose monitoring in
June 2009. He lived alone and was last seen alive and well by his
family 7 days prior to being found dead in bed with no signs of any
violent injury. The post-mortem download of his glucose monitoring
device and insulin pump showed frequent hypoglycaemic episodes
over the preceding few days. On the last day of pump and sensor
interaction, he was noted to be hypoglycaemic around 16:00 h and he
temporarily stopped and then restarted his pump. Despite the evidence
of alarms from the continuous glucose monitor, he remained
persistently hypoglycaemic. At 17:00 h, he administered 10 units of
insulin bolus on two occasions while still hypoglycaemic. This was the
last recorded interaction between the patient and the pump/sensor
system. He was found dead in bed 7 days later. Post-mortem
examination was consistent with death several days before and
showed no specific cause of death. Hypoglycaemia is known to
precipitate sudden cardiac arrhythmias which in our patient may have
been the cause of death.
80
P164
Use of insulin pump therapy in patients with
cystic fibrosis related diabetes: a case series
S Gupta and R Canavan
Endocrinology and Diabetes Centre, St Vincents University Hospital, Dublin,
Ireland
Cystic fibrosis related diabetes (CFRD) is associated with 6-fold

increase in morbidity and mortality. Numerous case reports have
shown improvement of glycaemic control and quality of life using
continuous subcutaneous insulin infusion (CSII). We report our
experience of a 3-year follow-up with CSII use in a series of CFRD
patients at our institute. The first patient, female 18 years old,
diagnosed with CFRD at age 15, was commenced on multiple daily
insulin injections (MDI) in view of her catabolic state [body mass
index (BMI) 19 kg/m2] and poor glycaemic control (HbA1c 9.3 per
cent). Her nutritional status continued to decline and within a year
CSII was commenced. During a 2-year follow-up, BMI improved to
24 kg/m2, HbA1c failed to improve and FEV1 (69 per cent of
predicted) remained stable. The second patient, male 18 years old,
diagnosed with CFRD at an early age, was commenced on CSII at a
time of declining lung function (FEV1, 50 per cent of predicted) and
malnutrition (BMI 18.2 kg/m2). Multiple hospital admissions were
2012 The Authors.

required to manage complications of decompensated liver disease.

BMI improved minimally (19 kg/m2) and HbA1c fell (7.4 to 5.5 per
cent). He subsequently underwent successful liver transplantation.
Another patient passed away within 2 years of commencing CSII of
end-stage respiratory disease. Use of CSII in patients with CFRD has
potential benefits in this highly complicated group. The indications
for CSII to date have not been widely defined but should be both
disease and patient centred. Our experience shows that CSII may be a
safe and effective therapeutic alternative to MDI treatment in CFRD
patients.
P165
MODY: its not always what it says on the
tin
JT Cameron1, M Shepherd2, S Ellard2 and E Pearson1
DIABETICMedicine
lesion on sectioning. Microscopy of this showed a nodular lesion

composed of amorphous eosinophilic material within fat, with a minor
patchy lymphocytic infiltrate around the periphery. This material
stained positively with Congo Red and under high intensity polarised
light showed the apple-green birefringence characteristic of amyloid.
Immunohistochemistry was performed with serum amyloid A protein
(SAA) and anti-insulin monoclonal antibodies, both of which were
positive, indicating amyloidosis of the insulin type. His serum amyloid P
component (SAP) scintigraphy scan showed no visceral amyloid
deposits. There was no evidence of systemic amyloidosis and plasma
cell dyscrasia. His electrocardiogram and echocardiogram showed no
evidence of cardiac amyloid. This man had insulin-type cutaneous
amyloid which is a localised form of amyloid. There are few reports in
the literature of the association of cutaneous amyloidosis with porcine
and human recombinant insulin. Although uncommon, it is important
to be aware of this complication when assessing patients insulin
injection sites so that this diagnosis is not missed and the patient can
then be investigated accordingly.
Diabetes, NHS Tayside, Perth, UK, 2Diabetes Genetics, Peninsular Medical

School, Exeter, UK
Background: Maturity-onset diabetes of the young (MODY) is often

mis-diagnosed as Type 1 diabetes (T1D). The discovery of an HNF1A
mutation can result in successful transfer from insulin to sulfonylureas.
Yet sometimes the diagnosis of MODY is not clear cut, and treatment
change is not always successful. We report a MODY pedigree with
four different presentations of diabetes.
Case reports: The proband was diagnosed with T1D aged 18 years.
Persistent insulin secretion prompted MODY testing resulting in
discovery of an HNF1A mutation. He transferred off insulin and is well
controlled on gliclazide. His cousin had insulin-treated diabetes and the
same mutation. She stopped insulin treatment but was not sensitive to
sulfonylureas with deteriorating glycaemic control on maximum dose.
Surprisingly her GAD antibodies, which had been negative at diagnosis,
were now positive, indicating that she has both HNF1A MODY (like
her father) and T1D (like her mother). Their aunt was diagnosed at
46 years with Type 2 diabetes but has the HNF1A mutation. Despite
her age (64 years), she was extremely sulfonylurea sensitive. Another
cousin had transient neonatal diabetes diagnosed at 6 weeks, which
remitted at 8 weeks but relapsed at 11 years. He is heterozygous for
both the HNF1A mutation and an activating ABCC8 mutation. He is
awaiting transfer off insulin.
Conclusion: This family demonstrates the importance of offering
genetic testing to all family members with diabetes. Dual diagnoses are
possible and a thorough assessment of each individual is required to
ensure an accurate diagnosis is made which will also influence treatment
choices.
P166
Insulin-type cutaneous amyloid from insulin
injections
IW Seetho1, A Coup2 and SA Olczak3
1
Department of Diabetes and Endocrinology, Derby Hospitals NHS
Foundation Trust, Royal Derby Hospital, Derby, UK, 2Department of Cellular
Pathology, Pilgrim Hospital, Boston, UK, 3Department of Diabetes and
Endocrinology, Pilgrim Hospital, Boston, UK
P167
GLIS3 mutations: a rare cause of neonatal
diabetes
O Ajala1, J Jones2, S Ellard3, C Shaw-Smith3 and BA Millward1
1
Diabetes Clinical Research Centre, Peninsula College of Medicine and
Dentistry, Plymouth, UK, , 2Primary Care Trust, Cornwall and Isles of Scilly,
UK, 3Peninsula College of Medicine and Dentistry, University of Exeter, Exeter,
UK
Background: Permanent neonatal diabetes (PNDM) caused by

recessive GLIS gene mutations (which encode a zinc finger
transcription factor) is rare; five families have been reported to date.
Cardinal features are neonatal diabetes and congenital hypothyroidism;
additional features include congenital glaucoma, hepatic fibrosis,
polycystic kidneys, developmental delay and facial dysmorphism. We
report an unusual case with neonatal diabetes without thyroid
abnormalities.
Case history: SM, now 33 years, weighed 2,750 g at birth. She was
diagnosed with diabetes at 1 week and treated with insulin. Choanal
atresia was noted at 9 days and surgically corrected. By 4 years, she
failed to meet developmental milestones. Genetic screening of the
KCNJ11, ABCC8, INS, GCK and IPF1 genes in 20062008 revealed no
abnormalities. DNA was retested in 2011 by array CGH revealing a
paternally derived 4Mb deletion of chromosome 9p, encompassing
GLIS. Sequence analysis identified a novel R589W missense mutation
inherited from her unaffected mother. Her (unaffected) father died an
unrelated death; hence samples were unavailable for testing. Thyroid
ultrasound, function and autoantibodies were normal; she had no other
abnormalities and normal menstrual function.
Discussion: Genetic testing for PNDM is routine practice since
identification of a mutation in the KCNJ11 or ABCC8 genes (which
account for G50 per cent of cases) allowed better treatment with
sulfonylureas rather than insulin. There are multiple other causes of
PNDM, many syndromic. Our patient has biallelic GLIS3 mutations,
usually associated with the very rare syndrome of neonatal diabetes and
congenital hypothyroidism. This patients normal thyroid function
illustrates further phenotypic heterogeneity of this syndrome.
A 54-year-old man with Type 2 diabetes had been on insulin aspart

(810 units at meal times) and detemir 26 units daily for about 5 years.
HbA1c was 8.0 per cent (IFCC 64 mmol/mol). A soft tissue swelling
was noticed in the region of the left iliac fossa where he administered his
insulin injections. The excised specimen consisted of fatty tissue 52mm
in maximum dimension, which contained a firm, yellowish central
2012 The Authors.

81
DIABETICMedicine
P168
Ketoacidosis is not always due to diabetes
O Ajala and DE Flanagan
Department of Diabetes and Endocrinology, Plymouth Hospitals NHS Trust,
Plymouth, UK
Background: Diabetic ketoacidosis (DKA) is an acute life-threatening

complication of diabetes. In some situations an alternative diagnosis
needs to be considered. Alcohol related ketoacidosis may be seen
following an alcoholic binge in an otherwise under-nourished
individual. The presenting history should differentiate these two
conditions but this is not always available. We report a case of
ketoacidosis inappropriately labelled as resulting from new onset of
diabetes.
Case history: A 29-year-old female was admitted after being found
unconscious in the street. The paramedics found evidence suggestive of
alcohol intoxication. Initial investigations were metabolic acidosis
(arterial pH 7.1, bicarbonate 3 mmol/l), hyperglycaemia (capillary
glucose 12 mmol/l, venous glucose 14.8 mmol/l), ketonuria (ketones
4+) and deranged liver function (GGT > 2000iu/l, ALT 175iu/l, AST
197iu/l, ALP 174u/l). A diagnosis of diabetic ketoacidosis was made
and she was managed with intravenous fluids and insulin. Diabetology
review felt the diagnosis of new onset diabetes was not secure (although
there was no documentation of initial hypoglycaemia or dextrose
administration). Insulin was discontinued with very close monitoring of
capillary glucose. Diabetes was excluded following normal capillary
glucose readings over a 24 h period ( 5 mmol/l), normal fasting
glucose (4.9 mmol/l), normal HbA1c (4.8 per cent), Cpeptide > 500pmol/l and negative diabetes auto-antibodies (GAD
and islet cells).
Discussion: A possible explanation for initial hyperglycaemia might
be the administration of intravenous dextrose prior to admission to
medical assessment (although this was not documented in the medical
notes). It is important to consider other causes of ketoacidosis
including alcohol and starvation, both of which were likely triggers in
this patient.
P169
Glycogenic hepatopathy: a rare and
potentially reversible complication of
poorly controlled diabetes
B Paranandi1, J Hannah2, S Ashton-Cleary2, R Rea2 and
A Austin1
of hepatocyte cytoplasm and glycogenation of nuclei. There was no

evidence of fatty change, inflammation or fibrosis. A diagnosis of
glycogenic hepatopathy was made. Medical management was targeted
predominantly towards improving glycaemic control. Following
limited progress with various standard insulin regimes, a continuous
subcutaneous insulin infusion pump was commenced. Six months later,
her blood sugars had stabilised and she was demonstrating significantly
improved glycaemic control with an absence of urinary ketones. Her
LFTs had normalised, there was radiological resolution of her
hepatomegaly with bedside examination revealing an impalpable
liver and no other hepatic sequelae.
P170
Autoimmune pancreatitis and diabetes
N Kaimal, A Kyriacou, C Babbs, S Taggart and B Young
Case history: A 68-year-old South Asian gentleman presented with

reduced appetite, 10kg weight loss and a recent diagnosis of diabetes
(pre-meal blood sugars in the range of 78 mmol/l). He had never been
overweight and there was no family history of diabetes. He had a past
history of tuberculous adenitis in his right supraclavicular fossa 3 years
ago, for which he had a full course of anti-tuberculous therapy. He also
had a past history of idiopathic thrombocytopenic purpura. Presenting
chest X-ray showed mediastinal lymphadenopathy, which was
confirmed on CT.
Investigations: CT showed mediastinal and hilar lymphadenopathy
but also showed bulky pancreas with peripancreatic oedema. Lymph
node aspirate was negative for tuberculosis but positive for silica. ESR
was elevated at 75, amylase was normal and globulins were raised at
48 g/l. Electrophoresis confirmed a polyclonal IgG increase. IgG
subclass 4 was grossly elevated at 27.1 g/l (0.002.91 g/l).
Treatment and progress: The grossly elevated IgG subclass 4 in the
context of his clinical presentation with diffuse pancreatic swelling was
highly suggestive of a diagnosis of autoimmune pancreatitis. He was
commenced on high dose prednisolone (40mg/day) and also started on
insulin whilst on steroids. Repeat CT done 3 months later showed clear
improvement in the inflammatory changes of the pancreas as well as the
hilar and mediastinal lymphadenopathy.
Conclusions: Pancreatic endocrine deficiency may rarely be
secondary to autoimmune pancreatitis. Although uncommon, this
disorder is usually treatable and hence merits consideration when the
presentation of diabetes is unusual.
1
Hepatology, Royal Derby Hospital, Derby, UK, 2Diabetes and Endocrinology,
Royal Derby Hospital, Derby, UK
Glycogenic hepatopathy is a rare and under-recognised complication of

poorly controlled diabetes which is characterised by a pathological
overloading of hepatocytes with glycogen. It is radiologically and
clinically difficult to distinguish from fatty liver but there are unique
histological features on liver biopsy that are distinct from
steatohepatitis. It can resolve following optimal glycaemic control
and this is demonstrated below. LN is a 29-year-old Caucasian female
with known coeliac disease and poorly controlled Type 1 diabetes who
presented with abdominal swelling and discomfort, significantly
deranged liver function tests in a predominantly hepatitic pattern,
persistently erratic blood sugars and ketonuria. Non-invasive liver
screening for viral, autoimmune and other well-recognised causes of
liver disease was unremarkable. Clinical examination revealed smooth
hepatomegaly (10cm below the costal margin). Abdominal ultrasound
revealed marked hepatomegaly with diffuse echogenicity, mild
splenomegaly and patency of the portal and hepatic veins. Liver
biopsy showed a patchy lobular neutrophil infiltrate, extensive clearing
82
P171
Acromegaly: a rare but important cause of
insulin resistance in Type 1 diabetes
J Prague1, MSB Huda2, A McGregor1 and D Hopkins2
1
2
Department of Endocrinology, Kings College Hospital, London, UK,

Department of Diabetes, Kings College Hospital, London, UK
Although insulin resistance is a typical feature of acromegaly,

deterioration in metabolic control in established Type 1 diabetes
due to this can easily be missed. We report a 27-year-old female with
Type 1 diabetes of 18 years duration, who was referred for tertiary
opinion and consideration of pump treatment due to deterioration
of glycaemic control (HbA1c 10.2 per cent) and with increasing
insulin requirements. Inpatient investigation confirmed high insulin
requirements; intravenous insulin at 3 units/h was required to
maintain fasting euglycaemia. Following basal insulin optimisation,
2012 The Authors.

continuous glucose monitoring revealed persistently raised

postprandial glucose, despite progressive increase in prandial insulin
(3 units: 10 g carbohydrate). On examination, the patient was normal
weight (body mass index 22 kg/m2) and blood pressure was 103/
62mm Hg. Subtle coarsening of facial features were noted together
with soft tissue thickening of the hands, previously attributed to
cheiroarthropathy. Subsequent investigation confirmed acromegaly.
Serum IGF-1 was elevated at 697 mcg/l (94252 mcg/l) and serum
GH paradoxically rose from 75 mcg/l to 85 mcg/l during a 75 g oral
glucose tolerance test. MRI identified a 17mm 18mm sella mass.
Following successful trans-sphenoidal surgery, GH and IGF-1
normalised and there was an immediate fall in insulin
requirements, basal insulin falling from 109 to 23 units/24 h and
prandial insulin ratio falling to 1 unit/10 g carbohydrate. HbA1c fell
to 7.6 per cent within 3 months. Histology confirmed an adenoma
staining positive for GH on immunohistochemistry. This case
highlights the importance of identifying the underlying cause of
insulin resistance in patients with decline in control and changing
insulin requirements; initial clinical signs of acromegaly may be subtle
but this should be considered.
P172
Boerhaaves syndrome and diabetes
S Zhyzhneuskaya, R Sinha, J Chapman and R Nayar
Diabetes and Endocrinology, City Hospitals Sunderland NHS Foundation
Trust, Sunderland, UK
Introduction: We present a rare but important complication of

diabetic ketoacidosis (DKA), which should be considered and sought
for in acute presentations of DKA associated with vomiting.
Case history: A 20-year-old man with known Type 1 diabetes
presented with DKA. He reported severe vomiting for 3 days followed
by chest discomfort prior to presentation. On examination he was
tachypneoic with Kussmauls type of breathing pattern. Investigations
confirmed DKA with a high C-reactive protein and leucocytosis. No
reference to supraclavicular subcutaneous emphysema or Hammans
crunch sign was made on admission. Chest radiography revealed a rim
of air along the lateral border of the heart.
Management: Our patient was kept nil by mouth and continued on
intravenous broad spectrum antibiotics. Water soluble contrast studies
on the following day did not reveal an oesophageal leak. Subsequent
chest radiographs revealed resolution of the pneumomediastinum with
clinical and symptomatic improvement.
Discussion: The source of air in the mediastinum or
pneumomediastinum can be lungs, bronchial tree or oesophagus.
Spontaneous pneumomediastinum is uncommon; it results from
alveolar rupture, otherwise known as the Macklin phenomenon. Air
may track into subcutaneous tissue leading to cervical or
supraclavicular emphysema, or pericardium, peritoneal cavity and/or
epidural space.
Summary: Nearly 70 years ago, Hamman described a patient in
whom pneumomediastinum was associated with DKA. These two
entities may coexist more frequently than previously thought. Hence a
high index of suspicion should exist in all patients presenting with DKA
with vomiting and chest discomfort.
2012 The Authors.

DIABETICMedicine
P173
Person with Type 1 diabetes and
hypoglycaemia unawareness who regained
hypoglycaemia awareness and improved
glycaemic control post DAFNE course: a case
report
KE Jones, S Fleming and J Morgan
Diabetes Resource Centre, Northumbria Healthcare NHS Foundation Trust,
North Tyneside, UK
JM is a 57-year-old White male who was diagnosed with Type 1

diabetes in 1977. He had his insulin changed from porcine to analogues
in 2007 and started to experience hypoglycaemia unawareness in 2008;
his driving licence was revoked in June 2010. At his request he
was converted back to porcine neutral in 2010 with no resulting
improvement in his hypoglycaemia awareness. JM attended a DAFNE
(Dose Adjustment for Normal Eating) education course in July 2010
where he was advised to aim for a pre-meal blood glucose level target of
7.5 mmol/l and to avoid his blood glucose level falling below 4.5 mmol/
l. On the first day of the course he converted back to rapid acting
analogue insulin. Prior to the course his HbA1c was 66 mmol/mol (8.2
per cent) and in the preceding year he had required paramedic assistance
for hypoglycaemia episodes three times. One year post course his
hypoglycaemia warning signs have fully returned, he has had no
episodes of hypoglycaemia requiring paramedic assistance and his
driving licence had been reinstated. JMs HbA1c is within target and
lower than prior to the course at 53 mmol/mol (7.0 per cent) and his
PAID score has improved from 40.0 prior to the course to 17.5 1 year
post course.
Conclusion: Undertaking the DAFNE course and following the
principles has improved JMs diabetes control, improved his
hypoglycaemia awareness, improved his quality of life and enabled
him to resume driving.
P174
Ketoacidosis in non-diabetic pregnancy
F Le Neveu1, B Hywel2 and J Harvey1
1
Department of Endocrinology and Diabetes, Wrexham Maelor Hospital, Betsi
Cadwaladr University Health Board, Wrexham, UK, 2Department of Medicine,
Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board,
Wrexham, UK
Introduction: Euglycaemic diabetic ketoacidosis has been a topic of

discussion for over 30 years. Historically it was suggested to occur at a
blood glucose less than 16.6 mmol/l. More recently definitions of
glucose less than 13.9 mmol/l or less than 11.1 mmol/l have been
suggested. Cases has been reported with various causes and
contributing factors. A number of these cases have occurred during
pregnancy.
Case report: A healthy 33-year-old who was 30 weeks pregnant with
her second child presented with a week-long history of flu-like
symptoms, productive cough and rigors. On examination she had
blood pressure 103/53, respiratory rate 30 and temperature 39.1C
(102F), with lobar pneumonia and subsequent empyema. She required
inotropic support on ITU. She had urinary ketones since admission and
her plasma beta-hydroxy butyrate was 5.3 mmol/l. Glucose levels were
normal throughout; arterial pH 7.32; BE-12 with a compensated
metabolic acidosis; lactate 0.8; eGFR > 60. Her non-diabetic
ketoacidosis was successfully treated with intravenous insulin 6 unit/
h, 10 per cent dextrose with potassium. On day 9 of admission a
31-week gestation infant was successfully delivered.
Conclusions: Ketoacidosis occurs in periods of stress when counterregulatory hormone levels rise causing free fatty acid release and ketone
83
DIABETICMedicine
production by the liver. With fasting, insulin levels are suppressed.

Euglycaemic ketoacidosis is more common in pregnancy probably
because of the insulin resistant state and the events of relative starvation.
The metabolic acidosis needs to be recognised and differentiated from
other causes. Guidelines on ketoacidosis do not always recognise that it
can occur with euglycaemia.
P176
Previously unrecognised HNF1B in a
diabetes clinic: the value of systematic
testing in patients with young-onset
diabetes
S Tiley1,2, M Shepherd1,2, UNITED Research Team1,2,
TM McDonald3, S Ellard4 and AT Hattersley1,2
P175
Eruptive xanthoma preceding acute
presentation of severe
hypertriglyceridaemia with new onset
diabetes complicated by pancreatitis: a case
report
R Ahluwalia1 and L Overend2
1
Diabetes and Endocrinology, Royal Liverpool and Broadgreen University
Hospital, Liverpool, UK, 2Diabetes and Endocrinology, St Helens and
Knowsley Teaching Hospitals NHS Trust, Prescot, UK
Diabetes is a well-recognised cause of secondary hyperlipidaemia

including hypertriglyceridaemia mainly as a result of altered
activity of insulin dependent enzymes such as lipoprotein lipase.
Hypertriglyceridaemia is an uncommon cause of pancreatitis
accounting for 14 per cent of cases especially with triglyceride levels
> 55 mmol/l (normal < 2.3). Poorly controlled diabetes with type 4
hyperlipidaemia is a risk factor for hypertriglyceridaemia induced
pancreatitis. In addition the possibility of normal amylase levels on
presentation of hypertriglyceridaemia-induced pancreatitis makes
diagnosis challenging. We report a case of a 40-year-old Caucasian
male presenting with hypertriglyceridaemia-induced pancreatitis with
new onset diabetes. He presented to the emergency department with
severe abdominal pain and projectile vomiting. He was hyperglycaemic
and had raised amylase levels. Corroborating abdominal imaging
established the diagnosis of acute pancreatitis which was managed
conservatively. Given a paired triglyceride level of 39.2 mmol/l,
hypertryglyceridaemia was presumed to be the likely cause. He had a
baseline glycosylated haemoglobin of 13.2 per cent (121 mmol/mol
IFCC value) alluding to undiagnosed diabetes prior to current
admission. He also reported a widespread rash consistent with
eruptive xanthoma, appearing months before his acute presentation.
He received a short course of insulin therapy followed by oral agents for
diabetes. His dyslipidaemia and the rash improved with lipid lowering
agents. Cutaneous manifestations such as eruptive xanthoma
associated with dyslipidaemia may precede the diagnosis of the
underlying lipid disorder. Given the association with diabetes as well
as the risk of potentially life threatening pancreatitis if left untreated,
xanthomas warrant a detailed metabolic evaluation following
diagnosis. They also offer an excellent opportunity for early diagnosis
and intervention, to avert future complications.
1
Exeter, UK, 2Research and Development, Royal Devon and Exeter Foundation
Trust, Exeter, UK, 3Department of Clinical Chemistry, Royal Devon and Exeter
Foundation Trust, Exeter, UK, 4Molecular Genetics, Royal Devon and Exeter
Foundation Trust, Exeter, UK
Background: HNF1B accounts for G1 per cent of maturity-onset

diabetes of the young (MODY) and is typically characterised by renal
cysts and diabetes, although the renal disease is highly variable. The
UNITED project aims to improve diagnosis by offering a systematic
series of tests for those diagnosed < 30 years and selecting patients to
proceed to genetic testing.
Case study: A 29-year-old man presented with a 6 months history of
polyuria, polydipsia and loss of appetite; RBG 20.1 mmol/l, Hba1c
16.2 per cent (157 mmol/l), urinalysis 4 + glucose, 1 + ketones, body
mass index 23.4 kg/m2, GAD negative. There was no family history of
diabetes. A diagnosis of Type 1 diabetes made and insulin was
commenced.
UNITED study involvement: He was recruited to UNITED and
provided 2 h postprandial urine for urinary C-peptide creatinine ratio
which indicated significant insulin production, 2.24 nmol/mmol,
3 years post diagnosis. GAD65 and IA2 were both negative. As he
was making endogenous insulin and was antibody negative, DNA was
tested for mutations in the commonest MODY genes. A deletion of
exons 19 of HNF1B was identified.
Follow-up: Renal ultrasound showed multiple renal cysts in the left
kidney; the right kidney appeared entirely normal, renal function was
normal, creatinine 87 lmol/l. Faecal elastase 106 mcg/g indicated
moderate pancreatic insufficiency. Both parents tested negative for the
deletion indicating that this was a de novo mutation.
Conclusion: Use of a systematic series of tests in those with youngonset diabetes can indicate individuals who may benefit from genetic
testing and identify previously unrecognised cases of monogenic
diabetes. Recognising HNF1B is important as this allows
appropriate screening, follow-up and discussion of risk to other
family members.
P177
Dual onset of autoimmune hepatitis and
diabetes in an 18 year old patient
M Reddy, C Feeney and D Gable
Department of Diabetes, Endocrinology and Metabolic Medicine, St Marys
Hospital, Imperial College Healthcare NHS Trust, London, UK
An 18-year-old Afro-Caribbean man, with a body mass index of 19,

presented with a 2-week history of jaundice, pale stools, weight loss
and abdominal pain. Initial blood results revealed deranged liver
function tests as follows: ALT 1739iu/l (normal range 040),
bilirubin 242 lmol/l (017), albumin 30 g/l (3551), ALP 126u/l
(30130) and INR 1.4. An autoimmune liver screen revealed positive
smooth muscle antibodies and hence a working diagnosis of
autoimmune hepatitis was made. An ultrasound and CT liver were
normal and he underwent a liver biopsy which confirmed severe
acute lobular hepatitis with areas of collapse. Prednisolone 40mg
daily was commenced and 2 days later it was noted that his capillary
84
2012 The Authors.

blood glucose measurements were elevated to above 20 mmol/l.

Diabetic ketoacidosis was ruled out and subcutaneous insulin was
commenced. Of note, he had positive GAD antibodies of > 250u/ml
but islet cell antibodies were negative. On further autoimmune
screening, parietal cell antibodies were positive but intrinsic factor
and tissue-transglutaminase antibodies were negative. B12 and
thyroid function were within the normal range. His diabetes is
most likely Type 1 diabetes in view of the positive GAD antibodies,
body habitus and the well-established association between
autoimmune conditions.
Conclusion: Although Type 1 diabetes is commonly associated with
autoimmune conditions such as Graves, Addisons and coeliac disease,
it is less commonly seen in association with autoimmune hepatitis. This
case highlights the importance of being alert to, and screening if
necessary for, other potential coexisting autoimmune conditions.
P178
Does exercise preserve the honeymoon
period in Type 1 diabetes? A presentation of
three clinical cases
A Kennedy and P Narendran
School of Clinical and Experimental Medicine, University of Birmingham,
Birmingham, UK
The honeymoon period in Type 1 diabetes (T1D) is a period of partial

remission of diabetes with near normal blood glucose and low insulin
requirements (<0.5U/kg/day). It has been documented to last from a few
months to years. The reduction in insulin requirements is believed to be
due to a combination of improved insulin sensitivity and beta cell
function, due to improved metabolic health following correction of
prolonged hyperglycaemia. Exercise has a proven insulin sensitising
effect in T1D. Whilst the effect of exercise on beta cell function in T1D is
unknown, it preserves function in obese subjects and in subjects with
Type 2 diabetes. We were therefore interested in whether exercise can
improve the duration of the honeymoon in patients newly diagnosed
with T1D. We present the cases of three T1D patients attending our
adult diabetes clinic who experienced a prolonged honeymoon period.
All three patients undertook significant levels of exercise prior to and
around the time of diagnosis and continued to do so after diagnosis. The
three patients, aged 16, 26 and 30 years at diagnosis of T1D, were all
initially commenced on multiple daily injections (MDI) of insulin. The
first two patients, who train regularly (athletics and running/climbing),
have been reduced to basal insulin only; the third does not train formally
but is very active. Their weights are 70, 93.2 and 73.7kg. They continue
to experience the benefits of honeymoon with insulin requirements of
0.10.2u/kg/day, 0.04u/kg/day and 0.30.4u/kg/day at 9, 15 and
12 months following diagnosis. They all have a current HbA1c 7.2
per cent.
2012 The Authors.

DIABETICMedicine
P179
Recurrent spontaneous nocturnal
hypoglycaemia during enteral feeding
in cystic fibrosis related diabetes
K-L Bluett1, G Noble-Bell2, C Elston3, P Choudhary2 and
D Hopkins2
1
Nutrition and Dietetics, Kings College Hospital NHS Foundation Trust,
London, UK, 2Diabetic Medicine, Kings College Hospital NHS Foundation
Trust, London, UK, 3Respiratory Medicine, Kings College Hospital NHS
Optimising insulin management of supplemental enteral feeding is a

particular management challenge in cystic fibrosis related diabetes
(CFRD). Many patients experience large glucose excursions but
conversely we have
observed paradoxical spontaneous
hypoglycaemia related to endogenous insulin secretion. The patient, a
25-year-old female, was first diagnosed with CFRD at the age of 15 with
persistent poor control (HbA1c 9.9 per cent). Maintaining adequate
nutrition has been limited by pancreatic insufficiency and poor intake
with a fall in body mass index to 16.5 kg/m2 necessitating overnight
gastrostomy feeding, providing 2,000kcal and 210 g carbohydrate over
6 h. Diabetes management, comprising morning basal isophane and
prandial insulin aspart, has been complicated by marked diurnal
variation in insulin requirements. Nocturnal hypoglycaemia with
complete unawareness has been a recurrent phenomenon. This
appears to be exacerbated by gastrostomy feeding with a rapid fall to
a glucose nadir below 2.2 mmol/l observed on a continuous glucose
monitoring system following feed initiation. This persisted despite
limiting basal insulin replacement to morning and avoiding prandial
insulin after 6 pm. We hypothesised that exaggerated endogenous
insulin secretion in response to a high intragastric glucose load caused
hypoglycaemia; this was supported by an observed rise in C-peptide
from 172 to 745pmol/l during a test feed, although C-peptide remained
consistently < 200pmol/l after regular meals. We hypothesise that this
reflects preserved islet incretin responsiveness following a rapid rise in
intragastric glucose, despite poor islet response to elevated blood
glucose. Improvement in hypoglycaemia frequency has been achieved
by slower feed administration but spontaneous hypoglycaemia remains
a limiting factor in her management.
P180
Furosemide as a treatment of diabetic
macular oedema in pregnancy
MH Charlton and PM Dodson
Department of Diabetes, Heart of England Foundation Trust, Birmingham, UK
Introduction: Two cases of diabetic macular oedema arising in

pregnancy responded favourably to oral furosemide.
Case 1: A 35-year-old primagravida with 19 years Type 1 diabetes
conceived with HbA1c 8.8 per cent which dropped to 6.7 per cent in
pregnancy. She developed no hypertension, peripheral oedema or
proteinuria. Pre-pregnancy she had laser for maculopathy and
proliferative retinopathy and in the first trimester required further
panretinal photocoagulation but maculae were dry. During the second
trimester visual acuity (VA) dropped from 6/5, 6/9 to 6/7.5, 6/12 and
optical coherence tomography (OCT) confirmed bilateral cystoid
macular oedema. Treatment with furosemide 40mg once daily was
instituted. VA improved to 6/6 on the right and 6/9 on the left and OCT
showed less oedema on the left.
85
DIABETICMedicine
Clinical care and other categories posters: children, adolescents and young adults
Case 2: A 28-year-old primagravida with well-controlled Type 1

diabetes of 18 years duration, microalbuminuria and previous
treatment of right-sided maculopathy presented with maculopathy at
20 weeks gestation. VA was 6/6, 6/6 with bilateral macular
microaneurysms. No oedema was evident on slit-lamp examination
but OCT revealed early fluid accumulation. At 29 weeks she reported a
sudden deterioration in vision with a drop in VA to 6/9, 6/15. OCT
showed diffuse macular oedema. Treatment with oral furosemide 40mg
daily was instituted. By 34 weeks VA had improved to 6/6, 6/7.5
although OCT indicated progression of macular oedema.
Discussion: Macular oedema may arise or worsen in pregnancy. The
benefit of grid laser treatment during pregnancy is disputed. A medical
approach is therefore attractive. A fall in maternal plasma volume may
retard fetal growth but both our women had babies of normal birth
weight.
P181
An insulin gene mutation presenting as
maturity-onset diabetes of the young
SA Mughal1,2, A Webster3, S Ellard4 and KR Owen1,2
1
Oxford Centre for Diabetes Endocrinology and Metabolism, University of
Oxford, Oxford, UK, , 2Oxford National Institute for Health Research (NIHR)
Biomedical Centre, Churchill Hospital, Oxford, UK, 3Oxford Radcliffe Hospitals
(NHS Trust), Oxford, UK, 4Institute of Biomedical and Clinical Science,
Peninsula Medical School, Exeter, UK
Most patients with insulin gene (INS) mutations have neonatal diabetes.
However, a few patients present with clinical characteristics similar to
maturity-onset diabetes of the young (MODY). We present a family
clinically diagnosed as MODY who on further investigation were found
to have a novel INS mutation. A 20-year-old lean woman was referred
to our monogenic diabetes clinic with symptoms of postprandial
reactive hypoglycaemia. She was concerned because her father and
sister had similar symptoms before developing diabetes. Her sister was
diagnosed with non-insulin requiring diabetes at age 15. Their father
was diagnosed with Type 2 diabetes at 35 years and was wellcontrolled on metformin. MODY was suspected, but mutations in
common MODY genes were not found. Further genetic investigation
revealed that both her sister and father had the H29Q INS mutation.
Our patient underwent an extended oral glucose tolerance test. Fasting
glucose was 5.5 mmol/l, 17 mmol/l at 2 h and 6.6 mmol/l at 4 h.
Insulin and C-peptide levels were 20pmol/l and 0.29nmol/l fasting
rising to a maximum of 206pmol/l and 1.74nmol/l respectively at 2 h.
HbA1c was 6.3 per cent. No symptoms or biochemical confirmation of
hypoglycaemia was made. Diagnostic genetic testing confirmed the
same INS mutation in our patient. INS mutations account for G1 per
cent of MODY and are treated with insulin sensitisers or exogenous
insulin. Unlike HNF1A/4A-MODY, sulfonylureas are contraindicated
as they are thought to increase beta cell decline. This family illustrates
the importance of establishing the exact genetic aetiology in patients
presenting with a MODY-like phenotype to ensure appropriate
treatment.
Clinical care and other categories posters: children,

adolescents and young adults
P182
A network-delivered out of hours
specialist telephone support service for
young people and families with Type 1
diabetes
N Abdullah1, B VanMeijgaarden2, C Acerini1, K Wilson6,
N Cackett3, S Lim4, B Anand5, L Raman5, R Williams1,
C Pesterfield1, S Arun4 and C Bound2
1
Paediatrics, Cambridge University Hospitals NHS Trust, Cambridge, UK,

Paediatrics, Basildon University Hospitals NHS Trust, Basildon, UK,
Paediatrics, Colchester Hospital University NHS Trust, Colchester, UK,
4
Paediatrics, Mid Essex Hospitals Services NHS Trust, Chelmsford, UK,
5
Paediatrics, West Suffolk Hospital, Bury St Edmunds, UK, 6Paediatrics, NHS
Diabetes, UK
2
P183
How many paediatric patients are making
endogenous insulin?
S Hamersley1,2, M Shepherd1,2, REJ Besser1,2, The United
Research Team1,2, TJ McDonald3 and AT Hattersley1,2
1
Facility, PCMD University of Exeter, Exeter, UK, 2Research and Development,
Royal Devon and Exeter NHS Foundation Trust, Exeter, UK, 3Department of
Clinical Chemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
86
2012 The Authors.

P184
Diabetes Patient Experience Project with
Children, Young People and Parents:
developing a standard toolkit to guide
regional paediatric diabetes networks in the
ongoing collection of quantitative and
qualitative patient experience feedback
from children and young people as well as
parental opinion
P Hindmarsh1,3 and A Wright2,3
1
Developmental Endocrinology Research Unit, University College London,
London, UK, 2Social Research, Ci Research Ltd, Wilmslow, UK, 3Diabetes
Information, NHS Diabetes, Newcastle-Upon-Tyne, UK
Aims: The aims of this research, funded by NHS Diabetes and

supported by Diabetes UK, were to develop standard quantitative and
qualitative methodologies to measure patient experience of the diabetes
care they received and provide a toolkit to support regional networks in
the ongoing collection and analysis of patient experience insight.
Methods: Twenty-five hospital trusts in London, the South East and
Yorkshire and Humber participated in the research. The study methods
for each trust included (i) a full census of patients aged 09 and 1016 (a
total of approximately 3,218 patients), using parent/carer consultation
as a proxy for those aged 09; (ii) a trial of postal and online surveys to
test response rates, with options to complete in other formats if
required; (iii) testing a number of qualitative methodologies with a mix
of 12 families from both regions.
Results: Findings highlighted positive perceptions of services,
particularly concerning time and attention afforded, effectiveness of
communication, genuine care for patients and treatment options
offered. Despite this, a minority had changed diabetes team due to
perceived poor quality of service, or had come away from an
appointment over the last 12 months having not discussed or
resolved an issue they had wanted to.
Conclusions: This study facilitates the development of a standard and
regular way for patient diabetes experience to be measured in the future,
allowing for identification of potential issues and thus helping to
improve service provision. It also provides a benchmark for the
participating trusts to assess future performance.
P185
Standards for inpatient care for children
and young people with diabetes: are they
being achieved?
JA Edge1, F Ackland2, S Payne3, A McAuley3, C Burren4,
E Hind5, J Burditt2 and D Sims6
1
Paediatric Endocrinology, Oxford Childrens Hospital, Oxford, UK,

Paediatrics, Northampton General Hospital, Northampton, UK, 3Paediatrics,
Poole Hospital, Poole, UK, 4Paediatric Endocrinology, Bristol Royal Hospital for
Children, Bristol, UK, 5Paediatrics, Basingstoke Hospital, Basingstoke, UK,
6
Paediatrics, Hampshire County Hospital, Dorchester, UK
2
DIABETICMedicine
England and was funded by the Healthcare Quality Improvement

Partnership.
Results: All 27 services completed the questionnaire. Protocols for
diabetic ketoacidosis (DKA), surgery, new diagnosis and
hypoglycaemia were generally available on wards (70 per cent had all
four protocols) but less available in A&E (52 per cent). Childrentrained nurses worked on every shift in childrens wards (100 per cent)
but not necessarily in A&E (33 per cent). Diabetes link nurses were
identified on 74 per cent of wards and 61 per cent of HDUs, and diabetes
specialist nurses have inpatient liaison in job description (89 per cent)
and working role (93 per cent). Standards achieved less often were
access to dietetic advice on wards (37 per cent), education sessions for
A&E and ward staff, and informing the diabetes team (only 26 per cent
within 2 h of admission during the day, and only 11 per cent would
contact the diabetes consultant overnight for a child admitted to PICU/
HDU). Most centres reported insulin errors.
Conclusions: This first audit of childrens diabetes inpatient care
organisation demonstrates that some standards can be achieved but
others may not be possible. Further planned audit outcomes are to
produce patient and parent literature for children admitted to hospital
and to further refine the standards.
P187
Guidelines for the management of diabetic
ketoacidosis in adults and children
administer significant differences in fluid
volumes: does this place young adults at
risk of cerebral oedema?
KJ Cox2, SA Greene1 and V Alexander1
1
Child Health, Ninewells Hospital, Dundee, UK, 2Paediatrics, Royal Hospital

for Sick Children, Edinburgh, UK
Aims: Cerebral oedema is a rare life-threatening complication of

diabetic ketoacidosis (DKA) in young people with Type 1 diabetes. The
risk of cerebral oedema is associated with increased fluid administration
early in treatment. Current DKA treatment guidelines for adults and
paediatric patients differ significantly in the volumes of fluid
administered in the first 24 h. We audited fluid administration in the
management of DKA in young people.
Methods: Thiswasaretrospectivecasenoteanalysisinvolvingpatients
< 19 years of age admitted with DKA in a regional teaching hospital
(April 2009 to March 2010). Twenty-six episodes were identified (23
patients), and data were available for 20 episodes (17 patients).
Results: Adult and paediatric guidelines for management of DKA
were largely followed correctly. Administered fluid volumes were
significantly higher in patients managed according to adult guidelines
than those using paediatric guidelines: first hour, adults 1,000ml vs.
paediatrics 402ml; first 24 h, adults 7,000ml vs. 2,825ml. These greater
fluid volumes could not be accounted for by weight alone. As an
example, a 55kg 17-year-old treated according to adult guidelines
Aim: Hospital inpatient care is frequently mentioned by parents as

unsatisfactory for children with diabetes. Ward staff are now less
familiar with diabetes, as admissions are less common and diabetes
management more intensive. Our aim was to compare current practice
with Department of Health Childrens Diabetes Working Group care
standards.
Methods: This audit surveyed the organisation of inpatient care
for children with diabetes in three regional networks in southern
2012 The Authors.

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DIABETICMedicine
receives 3,000ml in the first 4 h vs. 780ml maximum according to

paediatric guidelines. No serious complications were identified.
Conclusion: The separate guidelines for adults and children led to
administration of different volumes of intravenous fluid. Healthcare
professionals managing young people with DKA should be aware of the
different guidelines in order to minimise the risk of cerebral oedema in
adolescents. The management of DKA should be according to the age of
the patient, not the location of treatment.
P188
Preserved endogenous insulin secretion as
measured by urinary C-peptide creatinine
ratio is associated with improved HbA1c and
less glycaemic variability in paediatric Type
1 diabetes
REJ Besser1, P Choudhary2, BM Shields1, TJ McDonald1,3,
AG Jones1, BA Knight1 and AT Hattersley1
1
Exeter,UK, 2Diabetes Research Group, Weston Education Centre, Kings
College London, London, UK, 3Department of Clinical Biochemistry, Royal
Devon and Exeter NHS Foundation Trust, Exeter, UK
Objectives: Preserving endogenous insulin secretion in Type 1

diabetes is important, with a stimulated serum C-peptide (sCP)
0.2nmol/l shown to be protective against severe hypoglycaemia and
microvascular complications. The urine C-peptide creatinine ratio
(UCPCR) is an alternative non-invasive measure of endogenous insulin
secretion (UCPCR 0.4 nmol/mmol being equivalent to stimulated
sCP 0.2nmol/l). We aimed to determine whether postprandial
UCPCR was associated with HbA1c, hypoglycaemia and glycaemic
variability in children and young people with Type 1 diabetes.
Methods: A 2 h postprandial UCPCR was collected at home from
135 paediatric patients with Type 1 diabetes aged [median
(interquartile range)] 13.2 (10.615.6) years with diabetes duration
of 3.9 (1.27.5) years. Self-monitoring blood glucose (BG) records
(mean 28 days, five tests/day) were collected from 19 patients covering
the period within 1 month of UCPCR collection. HbA1c, rate of
hypoglycaemia (BG < 3 mmol/l) and BG variability [standard deviation
(SD) of BG] were compared in patients with UCPCR 0.4 nmol/mmol
(n = 8) and UCPCR < 0.4 nmol/mmol (n = 11).
Results: Forty-one of the 135 patients (30 per cent) had detectable
UCPCR 0.4 nmol/mmol. Detectable UCPCR 0.4 nmol/mmol was
associated with lower HbA1c (8.0 vs. 9.2 per cent, P = 0.02) and lower
BG variability (SD 3.9 vs. 5.2, P = 0.01). Despite lower HbA1c seen in
patients with UCPCR 0.4 nmol/mmol, there was no increased rate of
hypoglycaemia < 3 mmol/l (1.2 vs. 3.0 per cent of BG, P = 0.2).
88
Conclusions: Postprandial UCPCR collected at home can be used to

non-invasively detect children with Type 1 diabetes who have persistent
endogenous insulin secretion. Patients with a detectable postprandial
UCPCR 0.4 nmol/mmol have lower HbA1c without increased
hypoglycaemia, and more stable BG.
P189
Audit of care of young adults with Type 1
diabetes in Tayside
CY Allan1, A Bell2, R McCalpine3, S Ogston2, D Voigt4 and
ADR Mackie4
1
Undergraduate Medicine, Dundee University, Dundee, UK, 2Health
Informatics Centre, NHS Tayside, Dundee, UK, 3Clinical Technology Centre,
NHS Tayside, Dundee, UK, 4Diabetes, NHS Tayside, Dundee, UK
Background: Transition from paediatric to adult diabetes services is

associated with worsening glycaemic control and reduced engagement
with healthcare teams. In this retrospective audit prevailing levels of
glycaemia, admissions with diabetic ketoacidosis (DKA) and screening
in young adults in Tayside over the 2 years from 2009 to 2010 were
examined.
Methods: All young adults aged 1625 years resident in Tayside were
included. Data on glycaemic control, lipids, blood pressure, presence of
complications and screening for microvascular complications were
extracted from the regional SCI-DC database and anonymised. Data on
admission to hospital with DKA were collected prospectively during the
same time period.
Results: In all, 305 (166 male) records were examined. Of these, data
on HbA1c were available for 266 (87.1 per cent). The mean HbA1c for
the group was 10.4 per cent (90 mmol/mol) with only 8.3 per cent of
subjects having an HbA1c of 7 per cent (53 mmol/mol) or less. Blood
pressure and lipid measurements were recorded for 83.6 per cent and
30.5 per cent of subjects respectively. Screening for retinopathy,
microalbuminuria and foot risk within 15 months of clinic attendance
occurred in 71.8 per cent, 51.1 per cent and 46.3 per cent respectively.
Evidence of microalbuminuria and any retinopathy were recorded for
5.6 per cent and 41.4 per cent respectively in those screened. Admission
rates for DKA were comparable in both years with 56 per cent of all
known admissions over age 16 years with DKA occurring within this
age group.
Conclusion: These data confirm ongoing poor glycaemic control and
microvascular sequelae in young adults with Type 1 diabetes. Service
design that addresses the specific needs of and maximises engagement
with this group appears paramount.
2012 The Authors.

Clinical care and other categories posters: diabetes specialist nurse
DIABETICMedicine
Clinical care and other categories posters: diabetes

specialist nurse
P190
Sustained reduction in cardiovascular risk
factors over 2 years in people with Type 2
diabetes and renal impairment managed in
a nurse led clinic
P192
Lead Diabetes Midwives Network: a
valuable network?
S Winship1, M Bilous1, I Tullo1, J Ellis1, A Phillips1, R Mukhtar1,

V Arutchelvam1, S Jones1, S Nag1 and RW Bilous1,2
Aim: NHS Diabetes established a Lead Diabetes Midwives Network

in 2009 (now hosted on NHS Networks) to enable often isolated
individuals to share good practice and experiences. Our aim was to
assess network usage, perceived benefits and barriers, and suggestions
for improving the network.
Methods: A series of validated quantitative and qualitative questions
were used to survey all members of the network (n = 174) via
SurveyMonkey.
Results: Data were received from 30 per cent (n = 53) of network
members. Of those responding 78 per cent (n = 41) had accessed the
network within the past 6 months, and of those 54 per cent (n = 22)
had accessed it more than four times during that period. Reasons for
accessing the network included accessing documents/guidelines (53 per
cent; n = 21); and looking for events (25 per cent; n = 10). Perceived
benefits of membership were reported by 74 per cent (n = 39) including
accessing and sharing ideas, guidelines and best practice; and
networking with colleagues and peers. Ten respondents provided
details of changes in working practice as a result of network
membership, including introducing expressing of breast milk for
women with diabetes, changes to the pre-pregnancy service, and
introducing managing steroids without a sliding scale. Of those not
accessing the network within the past 6 months (21 per cent; n = 11),
55 per cent (n = 6) identified barriers including lack of time and access
to computers. Suggestions for improvement were reported by 8 per cent
(n = 4) including providing an easy to follow guide to using the network
and providing reminder emails to members to prompt use.
Conclusions: The Lead Diabetes Midwives Network is a valuable
resource, with clear perceived user benefits. Identified barriers and
suggestions for improvement will enable further network development.
1
Diabetes, James Cook University Hospital, South Tees NHS Trust,
Middlesbrough, UK, 2Institute of Cell Science, Newcastle University,
Newcastle-Upon-Tyne, UK
P191
Evaluation of consultant nurse led
intermediate diabetes care services in
England
J James1, D Hicks2, J Hill3 and G Vanterpool4
1
Diabetes and Endocrinology, University Hospitals of Leicester, Leicester, UK,

Diabetes Specialist Nurse Team, Enfield Community Services, Enfield,
London, UK, 3Diabetes Specialist Nurse Team, Birmingham Community
Healthcare Trust, Birmingham, UK, 4Diabetes Specialist Nurse Team, Imperial
and Central London Community Trust, London, UK
2
Aim: NHS reforms demand that resources used are clinically and cost
effective. Specialist nurse led intermediate care costs are half those of
hospital care. Lack of evidence in intermediate care effectiveness led to a
TREND-UK audit of existing services. The aim was to assess clinical
effectiveness and patient satisfaction in consultant nurse and diabetes
specialist nurse led intermediate care clinics.
Method: Retrospective randomised data collected from 52 case
notes (two from each letter of the alphabet) in nine English centres
included HbA1c, total cholesterol and blood pressure (BP) at referral
and 6 months. Statistical significance was calculated using Students
paired t test. A Diabetes UK one-page questionnaire was sent to
participants and assessed number of consultations, input, patient
participation and changes in practice post-intervention. Individuals
self-rated their ability to manage pre- and post-intervention using a
Likert scale.
Results: The cohort was 424 subjects, mean age 59, 52 per cent men
(n = 219). The average number of appointments was 3.8, median 3.
HbA1c reduced by a mean of 1.14 per cent (9.53 vs. 8.39, P < 0.0001;
n = 381). Total cholesterol reduced by a mean of 6.84 per cent (4.53 vs.
4.22 mmol/l, P < 0.0001; n = 269); systolic BP, mean 136.63 vs.
135.49mm Hg, P = 0.3547; diastolic BP, mean 78.71 vs. 78.27mm Hg,
P = 0.5773 (n = 269). Patient satisfaction questionnaires returned
(n = 123, 29 per cent) showed that 88 per cent were very satisfied that
concerns were met, 97 per cent (n = 115) felt included in consultations,
and 80 per cent made positive changes. A three-point rise was seen in the
Likert scale and average self-rating doubled in patients perceived ability
to self-manage post-intervention.
Conclusion: Patients achieved significant positive clinical outcomes in
Hba1c and cholesterol reduction in the direction of NICE targets.
Feedback showed high patient satisfaction and increased confidence in
ability self-manage.
2012 The Authors.

G Eyres, LJ Richards, H Stephens, A Morton and G Sweeney

Research and Evaluation, NHS Diabetes, Newcastle-Upon-Tyne, UK
P193
Quality improvement from a nurse led
intermediate care diabetes service in a
multi-ethnic population: implementation
and evaluation one year on
J James, J Fairfield, J Spiers, J Ferns, O Sudar, M Trown,
M Roshan, S Jackson and R Gregory
Department of Diabetes and Endocrinology, University Hospitals of Leicester,
NHS Trust Leicester, UK
Background: Diabetes intermediate care is promoted as a way of

bringing specialist care closer to home. There is little documented
evidence relating to clinical outcomes or patient satisfaction after
implementation of these services. The Hospital Trust was
commissioned to deliver clinics in 10 community locations. Referred
Type 1 and Type 2 patients self-selected venue and appointment times;
diabetes specialist nurses and dietitians delivered clinics. Sessions
promoted self-management with patients attending for on average four
contacts with referral back to GPs for ongoing care. Our aim here was to
89
DIABETICMedicine
Clinical care and other categories posters: diet, lifestyle, obesity and inflammation
evaluate clinical outcomes and patient satisfaction in intermediate care

clinics 1 year after implementation.
Method: One-year retrospective data pre- and post-intervention
included patient demographics, HbA1c, total cholesterol and blood
pressure. Statistical significance was calculated using Students paired t
test. A patient satisfaction questionnaire piloted in 20 patients assessed
changes in practice and patients ability to self-manage their diabetes
pre- and post-intervention using a Likert scale.
Results: The cohort included 556 subjects, mean age 60 years, male
55 per cent (n = 308), English speakers 76 per cent (n = 426),
community referrals 51 per cent (n = 285), hospital 38 per cent
(n = 216), existing patients 11 per cent (n = 52). HbA1c reduction was
0.77 per cent (9.17 vs. 8.40, P < 0.0001; n = 246), total cholesterol
reduction 0.36 mmol/l (4.43 vs. 4.07mmol, P = 0.0056; n = 65), blood
pressure (systolic), mean 144.4 vs. 143.7mm Hg, P = 0.8939; blood
pressure (diastolic) 78.8 vs. 73.0mm Hg, P = 0.0592. In all, 95 per cent
of patients changed practice; individuals reported a Likert scale increase
of 3.8 per cent in their ability to self-manage diabetes post-intervention.
Conclusion: One-year data showed intermediate nurse led clinics
delivered in a community setting improved HbA1c, cholesterol and
patient satisfaction scores.
Clatterbridge Hospital, a list of patients to be contacted is generated

on a weekly basis. Our aim was to audit the workload generated by
DSN patient calls. These calls were to support patients from three
weekly consultant led clinics.
Method: All planned calls from the DSN to patients over a month
were retrospectively reviewed and classified according to reason for
contact. Only successful calls were included. Calls from patients and
unplanned calls were excluded.
Result: The DSNs (0.67 whole time equivalent) made 262 patient calls
(108 males, 153 females; average age 60.4 years, range 2390 years).
Of these, 123 calls (48.3 per cent) were for general support following
clinics, 85 (32.5 per cent) for insulin titrations, 23 (8.8 per cent) for
follow up following hypoglycaemia, three (1.1 per cent) for post
diabetic ketoacidosis, 11 (4.21 per cent) to patients recently commenced
on exenatide, three (1.1 per cent) for post inpatient discharge support,
one (0.4 per cent) for illness and two for carb counting. The time taken
for these calls was not recorded but the DSNs estimated 515 min per
call. Calls for post discharge patients were low as most wards are based
on a separate site with separate DSN cover.
Conclusion: A significant amount of DSN time is taken up to support
patients outside clinics. These calls are invaluable and may help with
admission avoidance (such as those for hypoglycaemia and illness) and
need to be adequately recognised and resourced.
P194
Diabetes specialist nurse calling: an audit of
diabetes specialist nurse workload
generated by patient phone contacts
K Leong1, P Joseph1, I Fenna1 and KS Leong1,2
1
Diabetes Department, Clatterbridge Hospital, Wirral, UK, 2Diabetes
Department, Arrowe Park Hospital, Wirral, UK
Aim: Telephone support to patients is an integral part of the diabetes

specialist nurse (DSN) workload and helps patients manage their
diabetes. However, this activity is often under-recognised. At
Clinical care and other categories posters: diet, lifestyle,

obesity and inflammation
P195
Reversal of Type 2 diabetes following
bariatric surgery is not limited by duration
of diabetes
P196
Effect of Mediterranean diet on fasting
glucose compared with other dietary
interventions: a network meta-analysis
S Steven1, JA Coates2, P Ogilvie2, PE Carey2, PK Small3 and

R Taylor1
MJ Davies2, FA Achana1, P Carter2, J Troughton3, LJ Gray1 and

K Khunti1
1
Magnetic Resonance Centre, Newcastle University, Newcastle-Upon-Tyne,
UK, 2Metabolic Medicine Unit, Sunderland Royal Hospital, Sunderland, UK,
3
Department of Surgery, Sunderland Royal Hospital, Sunderland, UK
Department of Health Sciences, University of Leicester, Leicester, UK,

Department of Cardiovascular Sciences, University of Leicester, Leicester,
UK, 3Diabetes Research Department, University Hospitals of Leicester, NHS
Trust, Leicester, UK
2
Aim: To investigate the effects of Mediterranean diets (MDs) on

glycaemic control compared with other dietary interventions.
Methods: Electronic databases were searched for randomised
controlled trials which included an MD intervention. Data on fasting
glucose, fasting insulin and HbA1c levels at follow-up were extracted.
The network meta-analysis method adjusting for length of follow-up
was used to compare interventions while maintaining randomisation.
All analyses were conducted in WinBUGS using Markov chain Monte
Carlo simulation.
90
2012 The Authors.

Clinical care and other categories posters: diet, lifestyle, obesity and inflammation
Results: Ten studies met the inclusion criteria, nine examined fasting
glucose levels (n = 1399), seven fasting insulin levels (n = 1362) and
four HbA1c levels (n = 516). Length of follow-up had no significant
effect on relative effectiveness of interventions. None of the
interventions were significantly better than the others in lowering
fasting glucose, fasting insulin or HbA1c. Compared to a healthy diet
with advice, a Palaeolithic diet with advice reduced fasting blood
glucose (FBG) by about 0.73 mmol/l (95%CI: )1.572 to 0.07), yet low
fat diet with advice increased FBG by 0.43 mmol l (95%CI: )0.21 to
1.10), MD with advice by 0.05 mmol l (95%CI: )0.35 to 0.46) and
MD only by 0.10 mmol l (95%CI: )0.39 to 0.59). Similar trends were
obtained for fasting insulin and HbA1c levels. Results for HbA1c levels
were largely imprecise because fewer studies reported on this outcome.
Overall, a Palaeolithic diet with Advice had an 96% probability of
being the best intervention for improving fasting blood glucose levels.
P197
The incidence of undiagnosed prediabetes
in the population requesting bariatric
surgery
LL Chuah, S Jackson and C Le Roux
Imperial Weight Centre, Imperial College Healthcare NHS Trust, London, UK
Aim: In some areas of the UK, funding for bariatric surgery is restricted
to morbidly obese patients with comorbidities such as diabetes. We
aimed to test for the presence of undiagnosed diabetes or prediabetes in
patients referred for bariatric surgery with no known diabetes, who
would otherwise be denied bariatric surgery.
Methods: Twenty-eight patients who were not known to have
diabetes had an HbA1c and oral glucose tolerance test (OGTT).
ADA criteria for diagnosis of diabetes [HbA1c 6.5 per cent, fasting
blood glucose (FBG) 7 mmol/l, 2 h OGTT 11.1 mmol/l] and
prediabetes (HbA1c 5.76.4 per cent, FBG 5.66.9 mmol/l, 2 h OGTT
7.811.0 mmol/l) were used.
Results: The group of 28 patients (10 male) were 44.5 2.3 years old
with a mean body mass index of 44.5 1.4 kg/m2. Of these, 18
patients (64 per cent) had prediabetes and four patients (14 per cent)
had diabetes. In the prediabetes cohort, six patients were diagnosed on
one positive parameter, nine patients were diagnosed on two
parameters being positive, and three patients had all parameters
positive (FBG, 2 h OGTT and HbA1c). In the diabetes cohort, three
patients were diagnosed on one positive parameter whereas one was
diagnosed on two parameters (FBG +HbA1c).
Conclusion: A total of 78 per cent of our morbidly obese population
has undiagnosed prediabetes and diabetes. The number needed to treat
to prevent diabetes after bariatric surgery is two. Given the preventative
benefit of bariatric surgery, we would suggest that all patients referred
for bariatric surgery should be screened for prediabetes. More studies
are required to convince commissioners of the beneficial effect of
bariatric surgery for patients with prediabetes.
2012 The Authors.

DIABETICMedicine
P198
Results of bariatric surgery and
conservative management in all subjects
referred to South Devon Healthcare obesity
service, 2006 to 2011
K Williams1, E Potter1, F Robertson2, R Dyer3 and RB Paisey3
1
Nutrition and Dietetics, South Devon Healthcare, Torquay, UK, 2Year 13,
Ivybridge College, Ivybridge, UK, 3Diabetes and Endocrinology, South Devon
Healthcare, Torquay, UK
Introduction: A multidisciplinary obesity service has been in

operation in Torbay since 2006. Withdrawal of funding for surgery
in 2009 for new patients has allowed comparison of outcomes for
surgical and non-surgical treatments in 243 subjects. The aims were to
compare weight loss 636 months after surgery (91 bypass, 16 gastric
banding) with that in conservatively managed subjects. Effects on
glycaemia and medication were also studied in those with diabetes.
Results: Seventy-one (29 per cent) had Type 2 diabetes (mean age
53 years). Thirty-five of these lost 36.8kg with a fall in HbA1c from 7.9
to 6.6 per cent after surgery (P < 0.001 for both), and all except three
stopped diabetic medication. Thirty-six diabetic subjects treated
conservatively lost 6.8kg with a fall in HbA1c from 7.2 to 6.9 per
cent (P = 0.011 and P = 0.079 respectively; unpaired t test P = 0.02 for
greater weight loss after surgery and P < 0.01 for a greater fall in
HbA1c). Thirty-nine subjects without diabetes (mean age 49 years)
underwent surgery and lost 42kg, P < 0.001, whilst 75 (mean age
48 years) without surgery lost 5.8kg, P < 0.03.
Conclusions: Only a minority of all patients referred for bariatric
surgery in this district have diabetes. Results of surgery are superior to
conservative management in both groups and similar for bariatric
surgery for those with and without diabetes. Substantial reductions in
antidiabetic medications occurred only after surgery.
P199
The effect of weight change on glycated
albumin concentrations following bariatric
surgery in obese Type 2 diabetes patients
MM Aye1, JM Ng1, N Lewis2, J Varghese3, H Kahal1, J Konya1,
SL Atkin1 and ES Kilpatrick2
1
Department of Diabetes, Endocrinology and Metabolism, University of Hull,
Kingston-upon-Hull, UK, 2Department of Biochemistry and Blood Sciences,
Hull and East Yorkshire Hospital NHS Trust, Kingston-upon-Hull, UK,
3
Department of Diabetes, Endocrinology and Metabolism, Hull and East
Yorkshire Hospital NHS Trust, Kingston-upon-Hull, UK
Aims: Glycated albumin (GA) is a marker of glycaemia over

13 weeks prior to sampling. While cross-sectional studies suggest
that obese diabetes patients have GA values lower than expected
compared with lean individuals, no study has established if this is also
the case when the same patients undergo marked weight change. We
therefore sought to establish if the improvement in GA following
bariatric surgery might be discordant with that of haemoglobin A1c
(HbA1c) and mean blood glucose (MBG).
Methods: We prospectively studied 12 patients with Type 2 diabetes
[six female, six male, age 52 (4464) years] undergoing Roux-en-Y
bariatric surgery. Fasting samples were taken at baseline and 2, 4 and
6 months following surgery. Glycaemia was monitored using
continuous glucose monitoring and seven-point daily glucose
measurements. The Wilcoxon signed rank test was used to assess
significance.
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DIABETICMedicine
Clinical care and other categories posters: early detection and prevention
Results: At baseline, GA was positively correlated with HbA1c

(r = 0.53, P = 0.04), not significantly with MBG (r = 0.47, P = 0.06)
and negatively with body mass index (BMI) (r = 0.49, P = 0.05).
Following surgery, BMI (median, IQR) [51.4 kg/m2 (48.0, 54.4) to
37.4 kg/m2 (31.2, 40.3), P = 0.002], HbA1c [8.8 per cent (7.7, 11.3) to
5.9 per cent (5.6, 7.1), P = 0.002], MBG [12.5 mmol/l (9.4, 15.2)
to 7.1 mmol/l (6.5, 8.2), P = 0.003] and GA [16.7 per cent (15.4,
23.50) to 11.9 per cent (10.2, 14.0), P = 0.06] all fell. However, the
proportionate fall in GA (mean SE) 27.9 8.5 per cent was not
significantly different to HbA1c 32.4 4.8 per cent or MBG
36.7 6.2 per cent (P > 0.05).
Conclusions: While this study confirmed a cross-sectional
relationship between high BMI and low GA, we could not
demonstrate that marked weight change in the same individual
influenced a change in GA that was discordant with that of HbA1c or
MBG. This suggests there may be other non-glycaemic factors
influencing the association of weight with GA concentration.
P200
Diabetes as a screening tool in referral for
bariatric surgery?
C Prener, LL Chuah and C Le Roux
Study has suggested that bariatric surgery has the highest mortality
benefit in patients with raised fasting insulin levels. We therefore aimed
to assess (1) any positive association between BMI > 50 kg/m2 and
comorbidities; (2) the impact on other comorbidities if diabetes is used
as the only referral criterion.
Methods: Seventy-eight patients were scored using the modified
Kings Obesity Staging Criteria, which assessed airways, BMI,
cardiovascular, diabetes, gonadal, health status and body image.
Each domain was classified as 0 (normal health), 1 (at risk), 2
(established disease) or 3 (advanced disease).
Results: Of 78 patients, 54 had BMI > 50 kg/m2 (mean BMI
56.0 0.9) and 24 had BMI 50 kg/m2 (mean BMI 46.0 0.9).
No significant differences were found between these two groups in
airways (1.5 0.1 vs. 1.3 0.1), cardiovascular (1.1 0.1 vs.
1.3 0.2), diabetes (1.3 0.1 vs. 1.3 0.1) or gonadal (0.8 0.1
vs. 0.8 0.3). The only significant difference was in body image, with
BMI 50 kg/m2 having a higher score (2.0 0.2 vs. 1.6 0.1,
P = 0.04). There were 38 (48.7 per cent) patients with diabetes (mean
BMI = 53.9 1.2) compared with 40 without (mean BMI =
54.4 1.4). The diabetes cohort had more comorbidities with regard
to airways (1.6 0.1 vs. 1.3 0.1, P = 0.02) and gonadal (1.1 0.2
vs. 0.5 0.1, P = 0.007).
Conclusion: Diabetes rather than BMI would be a better prioritising
criterion for bariatric surgery, because its predictive value for other
comorbidities sensitive to weight loss is higher and the potential
mortality benefit is more pronounced.
Objective: One of the National Institute for Health and Clinical

Excellence recommendations for direct referral for bariatric surgery is
body mass index (BMI) > 50 kg/m2. This has been used as the only
referring criterion for bariatric surgery by some primary care trusts.
Clinical care and other categories posters: early detection

and prevention
P201
The role and benefits of a centralised
approach to cardiometabolic risk reduction
in patients with impaired glucose tolerance
LS Cozma and S Rees
Diabetes Centre, Princess of Wales Hospital, ABMU Health Board, Bridgend,
UK
P202
Racial disparities in risk of diabetes and
cardiovascular risk in a Southeast Asian
population: initial results of the Eastern
Community Health Outreach (ECHO)
programme
RS Shekhawat1, SK Sonu1, F Kwong Ming2, J Khoo1 and B Ng1
1
2
Department of General Medicine, Changi General Hospital, Singapore,

Department of Gastroenterology, Changi General Hospital, Singapore
Introduction: The early detection of cardiovascular risk factors

including diabetes has been shown to be beneficial in the prevention
92
of future disease complications. Community screening programmes

have attempted to unify the method of identifying these conditions in
the population. However, previous studies have suggested a racial
disparity to the risk of future diabetes and cardiovascular risk. The
present study sought to evaluate differences in the prevalence of glucose
intolerance and cardiovascular risk between the three main races
(Chinese, Indians and Malays) of a population in eastern Singapore.
Method: All participants in the East Coast Health Outreach (ECHO)
programme held in Singapore in early 2011 were included in the study.
All participants who agreed to take part had bloods sampled for
cardiovascular risk assessment and baseline characteristics measured.
Results: There were 196 males and 282 females, comprising a total of
478 subjects, median age 50 (IQR 4264), included in the study. Of 478
subjects 75 per cent of men and 58.9 per cent of women were
overweight. The incidence of metabolic syndrome was observed most in
the Indian male population (P < 0.05). Some 16 per cent of Indians
have impaired fasting glucose followed by Malay (13.8 per cent) and
Chinese (13.8 per cent). Participants of Indian descent had significantly
higher body mass index, triglycerides and diastolic blood pressure and
lower HDL despite being younger than the other races (P < 0.05).
Conclusion: Patients of Indian descent were at significantly greater
risk of developing diabetes and cardiovascular disease. Physicians need
to be aware of racial disparities in the assessment and management of
such patients.
2012 The Authors.

Clinical care and other categories posters: education and self-management
DIABETICMedicine
Clinical care and other categories posters: education and

self-management
P203
Problems are the price you pay for progress:
the effect of an educational initiative on
inpatient glycaemic control
LM Gibson, J Brown, G McRobert, S Delaney, S Ritchie and
J McKnight
Metabolic Unit, Western General Hospital, Edinburgh, UK
Aims: Foundation doctors lack confidence in the management of

inpatients with hypoglycaemia and suboptimal glycaemic control.
Newly qualified doctors start work in August each year. We aimed first
to determine whether there is a difference in the proportions of
hypoglycaemic capillary blood glucose (CBG) measurements
(4 mmol/l) or severely hyperglycaemic CBG measurements (
20 mmol/l) in August compared with July. Second, we aimed to
compare the proportions of CBG readings 4 mmol/l or 20 mmol/l
before and after the introduction of an educational initiative designed to
reduce the incidence of hypoglycaemia.
Methods: We downloaded CBG data from 20 wards from a large
general hospital from July and August 2008 to 2011. We used chisquared with Yatess correction to test for significant differences
between the number of measurements4 mmol/l and 20 mmol/l in
July 20082011 compared with August 20082011 and the number of
measurements 4 mmol/l and 20 mmol/l in 20102011 compared
with 20082009.
Results: In total, 52,420 CBG measurements were downloaded with
1,645 (3.1 per cent) 4 mmol/l and 2,769 (5.3 per cent) 20 mmol/l.
There were no significant differences between July 20082011
and August 20082011 in the number of CBG measurements either
4 mmol/l (P = 0.069) or 20 mmol/l (P = 0.054). In 20102011
compared with 20082009 there were significantly fewer
measurements 4 mmol/l (P = 0.0137) and significantly more
measurements 20 mmol/l (P < 0.0001).
Conclusions: The new intake of doctors does not adversely affect
inpatients glycaemic control. The educational initiative has reduced
the incidence of hypoglycaemia but the incidence of severe
hyperglycaemia has increased. These data may be useful indicators
of quality of care.
P204
A pilot study examining group and 1:1
education for obesity in the primary and
secondary care settings
E Jones1, F Palmer2, K John1, J Nedin1, R Tristham3 and
JW Stephens2,4
1
Department of Dietetics, Morriston Hospital, ABM University Health Board,
Swansea, UK, 2Diabetes Research Group, College of Medicine, Swansea
University, Swansea, UK, 3Clydach Primary Care Centre, ABM University
Health Board, Swansea, UK, 4Department of Diabetes and Endocrinology,
Morriston Hospital, ABM University Health Board, Swansea, UK
Aims: Weight loss education in obese patients has been successful in

large trials. However, this is rarely replicated in clinical practice. We
chose to examine the effectiveness of 1:1 and group education in the
management of obesity in primary and secondary care.
2012 The Authors.

Methods: We set out to deliver two courses of 1:1 and group

education sessions in primary and secondary care. Patients with a body
mass index (BMI) between 30 and 49.9 kg/m2 were invited to
participate. Groups had 2 h, 2-weekly sessions (maximum of 10
patients). The 1:1 sessions were 2-weekly, 20 min (maximum of seven
patients).
Results: Course 1 Primary Care: Nineteen patients prescribed
weight-reducing medication were invited via person or phone. Only
two patients accepted and then failed to attend. Subsequently 70
patients not prescribed medication were invited to attend. Of these 36
declined and 15 were not contactable. Of the remaining 19 (29 per
cent), 14 chose group (six completing) and five chose 1:1 sessions (two
completing). Weight change at 22 weeks was 4 to 10.7kg. Course
2 Primary Care: Failed to recruit patients. Course 1 Secondary Care:
Sixteen patients were referred and three declined. Of the remaining 12
(81 per cent), seven chose group (three completing) and six chose 1:1
(three completing). Weight change at 22 weeks was +1 to 5kg. Course
2 Secondary Care: Eleven attended a group session with six (55 per
cent) attending all.
Conclusions: Despite a well-planned pilot, recruitment was poor
especially in those prescribed weight loss medication. The best results
were in response to an advertisement. Group sessions were preferred.
P205
Impact of community pharmacy diabetes
monitoring and education programme on
diabetes management: a randomised
controlled study
M Ali1, F Schifano1, P Robinson2, G Phillips3, A Sinclair4 and
S Dhillon1
1
School of Pharmacy, University of Hertfordshire, Hatfield, UK, 2Research,
Merck Sharp and Dohme Ltd, Hoddesdon, UK, 3Manor Pharmacy Group, St
Albans, UK, 4Bedfordshire and Hertfordshire Postgraduate Medical School,
University of Bedfordshire, UK
Aim: To evaluate the impact of a pharmacist-led patient education and

diabetes monitoring programme on HbA1c and other cardiovascular
risk factors in the community setting.
Methods: Patients with Type 2 diabetes (n = 46) attending two
community pharmacies in Hertfordshire, UK, were randomised to
one of two groups. The intervention group (n = 23) received a
programme of education about diabetes, its treatment and associated
cardiovascular risk factors. They were seen for monitoring/counselling
by the community pharmacist on six occasions over a 12-month period.
Measures included HbA1c, body mass index (BMI), bold pressure (BP),
blood glucose and lipid profile. The control group (n = 23) underwent
these measurements at baseline and at 12 months only, without specific
counselling or education over and above usual care.
Results: HbA1c fell from 8.2 (65.55 mmol/mol) to 6.6 per cent
(48.73 mmol/mol) (P < 0.001) in the intervention group, compared
with a fall from 8.1 (64.54 mmol/mol) to 7.5 per cent (58.76 mmol/
mol) in the control group (P = 0.03). BP fell from 146/87 to 126/81mm
Hg in the intervention group (P = 0.01) compared with no significant
change in the control group (136/86 to 139/82mm Hg). Significant
93
DIABETICMedicine
reductions in BMI (30.8 to 27 kg/m2, P < 0.001) and blood glucose

(8.8 to 6.9 mmol/l, P < 0.001) were also observed in the intervention
group compared with no significant changes in the control group. Lipid
profile changes were mixed. In the intervention group, improvements
were seen in diabetes-related quality of life (P = 0.001), diabetes
knowledge (P = 0.018), belief about the need for medication
(P = 0.004) and a reduced concern regarding their medication
(P < 0.001).
Conclusions: Education and counselling by community pharmacists
can result in favourable improvements to the cardiovascular risk profile
of patients with Type 2 diabetes.
P206
Successful patient education following the
withdrawal of Mixtard 30 in southern
Derbyshire
J Simpson, L Langeland, J Ortega, W White and R Rea
Diabetes and Endocrinology, Royal Derby Hospital, Derby, UK
Background: The withdrawal of Mixtard 30 in June 2010 presented a

significant problem to a large number of patients in southern
Derbyshire. It also presented an opportunity to provide structured
education for these patients.
Methods: An education course for all patients on Mixtard 30 was
offered to all GP practices in southern Derbyshire. The course aimed to
give patients the knowledge needed to choose which diabetes treatment
to change to and improve their quality of care.
Results: A total of 123 patients across 21 GP practices underwent
group education delivered by a diabetes nurse specialist and a diabetes
dietitian. A further 38 patients received one to one education. Median
HbA1c before education was 8.0 per cent with a median dose of
insulin of 50 Units and median weight of 84kg. After 36 months the
median dose of insulin had fallen to 42 Units. Fifteen patients were on
more than 100 units of Mixtard 30 prior to the education and after
3 months this fell to one patient. Seven patients were having severe or
frequent hypoglycaemic attacks and this was reduced to none. Four
patients were able to stop insulin completely due to weight loss and
avoidance of hypoglycaemic attacks. In all, 71 per cent of patients felt
that the education was useful with no patients finding it of no use at
all.
Summary: The withdrawal of Mixtard 30 in southern Derbyshire was
used as an opportunity to re-educate patients. The education
programme was highly successful in improving the quality of care
and quality of life of these patients.
P207
First diabetes: a successful integrated
healthcare partnership for diabetes patients
in Derby
R Rea1,2, J Lindsay2,3, S Gregory2,3, D Prescott2,4, T Gray2,
A Warren2,3, J Hannah1,2, L Langeland1,2, P Dhindsa1,2 and
G Tan1,2
1
Department of Diabetes and Endocrinology, Royal Derby Hopsital, Derby,
UK, 2First Diabetes, Derby, UK, 3Overdale Medical Practice, Derby, UK,
4
Department of Engagement and Strategy, Royal Derby Hospital, Derby, UK
Background: Integrated working across primary and secondary care

is recognised as the solution to improving outcomes for patients with
diabetes and reducing expenditure on patients with long-term
conditions.
94
Methods: First Diabetes, a joint venture partnership between First

Provider Group (GP consortia) and Derby Hospitals NHS Foundation
Trust, was commissioned in June 2009 to provide NHS services for
2,300 patients with diabetes within Derby City PCT.
Results: Over 450 patients have been referred into the new service,
with 23 per cent of patients transferring from the hospital and 77 per
cent of patients being referred from GP practices. In all, 118 patients
have been discharged from the new service having achieved their
diabetes targets. Of these, 85 have maintained their HbA1c below 7.5
per cent 6 months after discharge with a further seven patients
maintaining their own targets above 7.5 per cent. The GP practices
have seen a 38 per cent and 26 per cent increase in the percentage of
patients achieving an HbA1c of < 7.0 per cent and < 8.0 per cent
respectively. A total of 187 patients have attended education courses
including newly diagnosed Type 2 diabetes, raised HbA1c prior to
insulin and on a basal bolus insulin regime and a course for patients
starting GLP-1 agonists. Over 1,000 patients have been screened for
diabetes and over 600 patients receive their retinal screening locally.
Unplanned admissions for diabetes have fallen by 21 per cent, together
with a reduction in new and follow-up outpatient appointments.
Discussion: Integrated partnership working between clinicians in
primary and secondary care provides significant clinical benefit to
patients with diabetes together with a reduction in hospital admissions
and outpatient appointments.
P208
Supporting a new culture of innovative
collaboration for diabetes services redesign
through a bespoke professional education
programme for primary care practitioners
PW Holdich1, M Freeman2, W Gillibrand1, V Newton1 and
J Oldroyd2
1
2
Human and Health Sciences, University of Huddersfield, Huddersfield, UK,

Well Being and Integration, NHS Kirklees, Huddersfield, UK
Aim: Professional education is one of the key requirements of a new

diabetes service. To facilitate this, a bespoke university work-based
learning programme was developed following a primary care training
needs analysis.
Methods: Four teaching modules injectable therapy initiation,
injectable therapy management, foot screening and caring for people
with Type 2 diabetes were developed by the University of
Huddersfield in collaboration with local specialist diabetes teams.
The University hosts the training and provides the infrastructure. A
work-based learning approach to facilitate education in practice is
supported by mentors from specialist services. Assessment of
competence is measured against a validated tool and clinical
management plans.
Results: Nine practitioners attended the initial Assessing for and
Initiating Injectable Therapies Module six have completed. Nineteen
practitioners attended the first Managing Type 2 Diabetes Programme
and 22 practitioners have attended a Managing Injectable Therapies
Module nine have completed. Ninety practitioners applied for the
foot care programme. Thirty-eight practitioners attended two courses
and are undergoing podiatry mentorship assessment.
Conclusions: Collaborative working to develop bespoke courses
ensures a consistent approach which is sensitive to local needs and
supports local pathways. Student evaluations of the training
programme are positive, particularly mentorship by specialist staff in
practice which has fostered a climate of closer collaborative working.
Joint working with pharmaceutical partners has assisted in course
promotion and post course support. The University has strengthened
2012 The Authors.

links with local diabetes services in primary and secondary care,

enhancing the opportunity for further collaborative education and
research.
P209
Implementing ThinkGlucose in practice:
evaluation of ward based diabetes
education for nurses
LC Kelly
Department of Diabetes, Hinchingbrooke Hospital NHS Trust, Huntingdon,
UK
Aim: The staff survey aimed to identify gaps in knowledge and areas
for training, to provide appropriate, streamlined education and to
reduce potential harm, while improving the patient experience.
Method: The diabetes ward was selected to pilot a pre-ThinkGlucose
survey and trial an education package. A questionnaire consisting of 12
questions was developed in relation to diabetes treatment and
management. Some questions were open in order not to lead the
responses. Responses were assessed against strict criteria for consistent
interpretation. Responders were anonymous. Education sessions were
delivered on the ward for up to 15 min, four times a week for 3 months.
Aide memoires were used to embed teaching.
Results: Findings demonstrated no significant increase in knowledge.
Unqualified staff demonstrated a better understanding of
hypoglycaemia. Open questions suggested that symptoms of blood
glucose imbalance were known but there was confusion concerning
hypoglycaemia and hyperglycaemia. Treatment answers mostly related
to moderate and severe hypoglycaemia rather than mild
hypoglycaemia. Less willingness to complete the post-questionnaire
than the pre-questionnaire was apparent.
Conclusion: It was disappointing that the ThinkGlucose survey did
not confirm that there had been an increase in knowledge. Alternative
strategies for teaching methods, times and venues need to be considered
for delivering and embedding education to comply with the NHS
Diabetes recommendation that staff are appropriately trained to
deliver safe care to people with diabetes. The value of a pilot exercise
was demonstrated.
P210
Ward based, small group teaching on
management of diabetes to new junior
doctors
NMW De Alwis, R Wright, J Wier, K Dukhan and S Wahid
South Tyneside District Hospital, Harton Lane, South Shields, UK
Aim: It is important for hospital diabetes educators to deliver effective

teaching to new junior doctors on inpatient diabetes management.
Historically, our Trust has arranged group based induction lectures on
this topic. We evaluated the benefit of (a) additional lectures and (b)
ward based, small group teaching allowing junior doctors to discuss
individual concerns with a diabetes educator.
Methods: Groups of junior doctors from 2009 and 2010 were
randomly selected. Group 1 (n = 15) had only induction lectures on
diabetes. Group 2 (n = 17) had additional department of medicine
(DOM) and acute medical forum (AMF) lectures. The latter also had
ward based small group teaching by a diabetes educator (StR).
Confidence at inpatient diabetes management was assessed after each
of the three stages. Seven broad areas (types of diabetes, insulin infusion,
2012 The Authors.

DIABETICMedicine
sub-cut insulin and oral agent therapy, hypoglycaemia, diabetic

ketoacidosis and hyperosmolar non-ketotic coma) were assessed on a
numerical score of 0 to 5.
Results: The mean confidence level in group 1 was 2.9 (SD 0.7),
median 3 (range 15). No improvement was seen following the
additional DOM and AMF lectures: mean 2.6 (SD 0.99), median 2.6
(range 25), P > 0.05 in all areas. However, after the extra small group
session (StR lead), group 2 had a mean confidence of 3.9 (SD 0.65),
median 3.9 (range 25), P < 0.05 in all areas. Foundation Year 1
doctors were least confident at all stages.
Conclusion: Teaching junior doctors the management of inpatient
diabetes by way of face to face small group teaching is very effective at
improving their confidence level compared with traditional lecture
based teaching. This is an important educational tool for hospital
diabetes educators.
P211
The NHS Diabetes safe use of insulin
e-learning course: is it making a difference
for healthcare professionals in the UK?
G Eyres1, LJ Richards1, A Morton1, H Wilkinson1, J James2 and
G Sweeney1
1
Research and Evaluation, NHS Diabetes, Newcastle-Upon-Tyne, UK,

Department of Diabetes and Endocrinology, University Hospitals of Leicester
NHS Trust, Leicester, UK
2
Aim: The National Patient Safety Agency issued an alert in 2010

requiring training to be put in place for all healthcare staff that
prescribe, handle or administer insulin. To meet this need, NHS
Diabetes and clinical colleagues developed a Safe Use of Insulin
e-learning course, training 31,627 individuals within 12 months of its
launch. Our aim was to evaluate the effectiveness of the Safe Use of
Insulin e-learning course, and identify changes in working practice and
trust policies/procedures following course completion. Methods: Those
completing the course from 1 June to 31 August 2011 were invited to
complete a 3-month follow-up questionnaire via SurveyMonkey. A
qualitative thematic analysis of the data was carried out to establish
changes in working practice and trust policies/procedures following
course completion.
Results: Initial data from June (n = 640; 18 per cent) revealed that 52
per cent (n = 325) reported increased confidence in prescribing/
preparing/administering insulin. Changes in working practice were
reported by 33 per cent (n = 211), with writing units in full and no
longer storing open insulin pens in fridges the changes most commonly
reported. Alterations in trust policies/procedures were reported by 14
per cent (n = 89), with the introduction of new insulin charts and new
care protocols the most commonly reported. The majority (87 per cent;
n = 533) would recommend the course to colleagues.
Conclusion: The e-learning course has resulted in increased
healthcare professional confidence in prescribing/handling/
administering insulin, and has led to a series of changes in working
practice and trust policies/procedures. This success has resulted in NHS
Diabetes developing further insulin related e-learning courses.
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P212
Inpatient diabetes: a novel APPortunity
M Patel1 and S Gupta2
Conclusion: The FoB form significantly increased assessments by

ward staff and identified all found to be neuropathic by the diabetes
specialist nurses. In total 36.6 per cent of inpatients with diabetes were
found to be at high risk of heel/foot ulceration.
1
Diabetes, Southampton General Hospital, Southampton, UK, 2General
Intensive Care, Southampton General Hospital, Southampton, UK
At least 15 per cent of adult inpatients in UK hospitals have diabetes.

The vast majority of these patients are managed by non-diabetes teams.
There are often gaps in the knowledge around issues that are common in
diabetes, such as managing hypoglycaemia, prescribing insulin safely
and adjusting insulin doses. Access to appropriate diabetes guidance or
to a specialist diabetes team is not always readily available. An
increasing number of healthcare professionals now use smartphones,
which carry applications (APPs) to provide guidance and help with
everyday activities. Following first-hand experience and surveys of gaps
in the knowledge of junior doctors around diabetes at our trust, we have
created a smartphone application to support inpatient diabetes care. We
believe that diAPPbetes is the first smartphone application available to
support inpatient diabetes care, by providing rapid bedside access to
common diabetes related information. Amongst the information
provided is guidance on the safe use and prescribing of insulin, which
patients to refer to the inpatient diabetes team, the means to establish
which insulin regimen patients use, and a summary of all available noninsulin based treatments for diabetes. In addition, there are decision
support tools to provide help with managing hypoglycaemia, adjusting
insulin doses and insulin dose calculation. It is hoped that widespread
uptake and use of this novel smartphone application will be a means of
improving inpatient diabetes care. Non-diabetes teams will be provided
with rapid access to concise information, essential in managing the
needs of their patients with diabetes more effectively.
P213
The Ipswich Touch Test and Foot of the Bed
form identify inpatients at risk of hospital
acquired foot ulceration
C Kerry, PRJ Vas, AC Scott, N Baker, D Fowler and G Rayman
Ipswich Diabetes and Endocrinology Centre, Ipswich Hospital NHS Trust,
Ipswich, UK
Aims: Only 27 per cent of inpatients with diabetes at Ipswich Hospital

had a foot assessment in NaDIA 2009. To improve, we developed the
Foot of the Bed (FoB) form which includes a risk list, daily heel check
and simple neuropathy test [the Ipswich Touch Test (IpTT), involving
touching six toes with two or more insensate indicating neuropathy].
We aimed (1) to determine whether the FoB form increases foot
assessments and (2) to validate the IpTT in inpatients (previously
validated in outpatients).
Methods: Over 2 weeks 167 nurses/healthcare assistants were each
trained for 1 h and thereafter cascaded training to other staff. The FoB
form uptake was assessed in snapshot audits by diabetes specialist
nurses who also validated the IpTT by repeating testing and comparing
it with monofilament tests.
Results: After 2 weeks 35 per cent of all diabetes inpatients had an
FoB form, 55 per cent, 75 per cent, 80 per cent and 79 per cent at 3, 4, 5
and 10 months. Overall, 226 of 315 (72 per cent) had an FoB form.
Using the risk list, 39 (17.3 per cent) were at risk (eg previous
amputation) so did not require an IpTT. Of the remaining 187, diabetes
specialist nurses found neuropathy in 36 using monofilaments and 35
(19.3 per cent) using the IpTT (one false negative). In comparison,
nurses/healthcare assistants found neuropathy in 37 using the IpTT (one
false positive cf 10 g and two false positives cf IpTT).
96
P214
See one, do one, teach one: perhaps not
when it comes to diabetes care
PL Wong1, J Murray2, A Jones2 and R Nayar1
1
Department of Diabetes and Endocrinology, City Hospitals Sunderland NHS
Foundation Trust, Sunderland, UK, 2Department of Medicine, University of
Newcastle, Newcastle-Upon-Tyne, UK
Aims: Inpatient diabetes care is multifaceted. Appropriate and

continued training for foundation doctors is vital to reduce errors and
length of stay. Our aims were (i) to evaluate foundation doctors
confidence and knowledge in diabetes care (insulin prescribing,
adjustment, perioperative care, emergencies), and (ii) to develop an
education programme addressing areas of suboptimal confidence and
ability.
Methods: An education programme covering practical aspects of
inpatient diabetes management incorporating an e-learning package via
NHS Diabetes was developed. Evaluation was via a self-assessment
confidence tool (1 = not confident to 5 = very confident), formative
assessment and prescribing audit. Baseline data were collected during
induction, following educational tutorials, the e-learning package and
feedback; reassessment occurred at 1 and 12 months.
Results: At baseline doctors rated their ability to perform urinalysis,
measure finger prick glucose and venepuncture the highest (mean 4.53,
4.47, 4.44 respectively). They were least confident in adjusting insulin,
knowledge of regimens and insulin prescribing (mean 2.14, 2.22, 2.47
respectively). At 1 month the largest mean increases in confidence were
in adjusting insulin (1.66), knowledge of insulin regimens (1.48) and
safe insulin prescribing (1.33). Confidence in these domains increased
further at 12 months (mean 4.0, 4.0, 4.6 respectively). At baseline, 11
per cent passed the formative assessment, 75 per cent were borderline
and 14 per cent failed. In the reassessment at 12 months no doctors
failed; 73 per cent passed and 27 per cent were borderline. Insulin
prescribing audit at 12 months confirmed that 90 per cent of
prescriptions had the correct documentation, regimen and doses
adjustment.
Conclusions: A structured education programme can improve selfconfidence in diabetes management. Enhanced confidence was
associated with an improvement in ability, which was maintained
throughout the year.
P215
Insulin safety programme at the Royal
Surrey County Hospital
C Pengilley, H Hopkins, B Tuthill, V Watts and D Russell-Jones
Cedar Centre, Royal Surrey County Hospital, Guildford, UK
Aim: Insulin related drug errors are a significant source of adverse

incidents in the inpatient setting [National Patient Safety Agency
(NPSA) 2010]. With the introduction of several new initiatives we
hoped to demonstrate savings in insulin costs, reductions in waste and
substantial improvements in safety.
Method: There are three initiatives. Enhanced training: Insulin
e-learning mandatory for all qualified nurses and an essential
requirement for completion of drug competencies. Compulsory
2012 The Authors.

insulin training introduced for Foundation Year 1 doctors. An insulin

guide introduced for use in all clinical areas. Savings and waste:
Removal of ward insulin stock. Single insulin devices dispensed. Safety:
Introduction of pre-prepared intravenous insulin infusions. Changes to
insulin prescribing. The word insulin must be written after the name,
eg determir insulin. Insulin dose must be written in words and figures.
All doses must say Units not U and IU. Insulin device should be stated, eg
flexpen.
Results: Training 220 trained nurses (40 per cent) have completed
the insulin e-learning module. Savings removal of ward stock and
dispensing of single devices has produced a cost saving of 17 per cent
over 1 year. Safety insulin prescribing errors have fallen. Nine insulin
errors were reported between July and September 2010. In the same
period in 2011, there have been none.
Conclusion: We have worked relentlessly to ensure that the Royal
Surrey County Hospital is a safer place for our patients with diabetes.
We have managed to improve ward safety and produce a significant cost
savings. We now hope to implement a self-administration policy and
introduce a passport for our patients as per the NPSA alert (2011).
P216
Self-assessed confidence in qualified wardbased nurses managing diabetes care
within the hospital environment: audit
results before and after attendance at a
formal education programme
DIABETICMedicine
P217
Understanding and knowledge towards
current UK driving advice in patients with
diabetes treated with insulin
DS Bohania1, A Mulla1 and J Shakher2
1
Birmingham Medical School, University of Birmingham, Birmingham, UK,

Department of Diabetes and Endocrinology, Heart of England NHS
Foundation Trust, Birmingham, UK
2
P218
Diabetes self-management strategies after
DAFNE structured education
P Mansell1, L Grant2, D Cooke2, R Rea3, C Taylor4, J Speight5
and S Heller6
1
Department of Diabetes and Endocrinology, Nottingham University Hospitals
NHS Trust, Nottingham, UK, 2Department of Epidemiology and Public Health,
University College, London, UK, 3Department of Diabetes and Endocrinology,
Derby Hospitals NHSFT, Derby, UK, 4Department of Diabetes and
Endocrinology, Sheffield Teaching Hospitals NHSFT, Sheffield, UK, 5School of
Psychology, Deakin University, Melbourne, Australia, 6School of Medicine and
Biomedical Sciences, University of Sheffield, Sheffield, UK
AK Potts and N Robinson

Medicine and Diabetes, Brighton and Sussex University NHS Trust, Brighton,
UK
Aim: A bespoke educational programme of four 2 h sessions was

designed by diabetes inpatient specialist nurses to improve patient care.
Sessions focused on management of frequently observed clinical
situations, such as hypoglycaemia and hyperglycaemia. The principal
aim was to assess changes in qualified nurses confidence in managing
basic diabetes inpatient care.
Methods: Qualified nurses were invited to attend evening educational
sessions. A Likert score was completed at the beginning and end of
sessions to indicate how confident they felt managing diabetes in
relation to the topic being covered (1 = not at all confident, 2 = lacking
confidence, 3 = confident in some cases, 4 = fully confident).
Results: Of the109 attendees 55 per cent were band five nurses and 62
per cent had been qualified for more than 8 years. There were
significant improvements across all domains post-attendance. Key
findings include the following. Only 9 per cent felt confident with their
understanding of basic pathophysiology pre-attendance, compared
with 53 per cent post-attendance. Some 40 per cent lacked confidence
dealing with severe hypoglycaemia, compared with 95 per cent who
were confident in some cases or fully confident after attendance. Only
15 per cent initially reported full confidence managing mild
hypoglycaemia, vs. 72.5 per cent post session. In relation to insulin,
56.5 per cent were not confident or lacked confidence in their
understanding about insulin compared with 100 per cent who were
confident in some cases or fully confident after attending.
Conclusion: Despite the experience of the nurses, a significant
number indicated low levels of confidence managing even basic
elements of diabetes inpatient care. This educational programme
improved self-reported confidence, which should enhance future
inpatient care.
2012 The Authors.

P219
Effectiveness of lifestyle education for
reducing diabetes and cardiovascular risk in
people with metabolic syndrome
AJ Dunkley1, MJ Davies2, MA Stone1, NA Taub1, J Troughton3,
T Yates2 and K Khunti1
1

Department of Cardiovascular Sciences, University of Leicester, Leicester,
UK, 3Diabetes Research, University Hospitals of Leicester NHS Trust, Leicester,
UK
2
P220
Alcohol and diabetes: what is the patients
perspective?
G Morrison1, T Coleman2, CL Morrison3, TS Purewal1 and
PJ Weston1
1
Diabetes Centre, Royal Liverpool University Hospital, Liverpool, UK, 2School
of Medicine, University of Liverpool, Liverpool, UK, 3Pendyffryn Medical
Group, Prestatyn, UK
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DIABETICMedicine
P225
P221
X-PERT Diabetes structured education
improves health and cuts costs
TA Deakin, CA Finch and SR Seed
Structured Education, X-PERT Health, Hebden Bridge, UK
P222
Improving the outcomes of pump therapy
E Jenkins, J Knott, J Ryder, M Weiss, C Shaban, J Charman,
D Kerr and D Cavan
Bournemouth Diabetes and Endocrine Centre (BDEC), Royal Bournemouth
Hospital, Bournemouth, UK
The DESMOND Lay Educator study: testing a

training programme for lay educators to
deliver the DESMOND (Diabetes Education
and Self-Management for Ongoing and
Newly Diagnosed) programme in
partnership with healthcare professional
educators
ME Carey1, P Mandalia1, S Cradock2, H Daly1, Y Doherty1,
LI Gray2, R Hale3, S Heller4, K Khunti2, G Kilgallen1, L Martin
Stacey1, J Phillips5, TC Skinner6, MA Stone2, NA Taub2,
C Taylor1 and MJ Davies7
1
Diabetes Research Group, University Hospitals of Leicester, Leicester, UK,

3
Fareham Voluntary Group, Diabetes UK, 4Academic Unit of Diabetes,
Endocrinology and Metabolism, University of Sheffield, Sheffield, UK, 5Expert
Patient Programme CIC, London, UK, 6Rural Clinical School, University of
Tasmania, Burnie, Tasmania, 7Department of Cardiovascular Sciences,
University of Leicester, Leicester, UK
2
P223
Does duration of Type 1 diabetes affect the
outcomes of structured education?
1
J Elliott , S Heller , H Hopkinson and P Mansell
1
Academic Unit of Diabetes, Endocrinology and Metabolism, University of
Sheffield, Sheffield, UK, 2Department of Diabetes and Endocrinology, Victoria
Infirmary, Glasgow, UK, 3Department of Diabetes and Endocrinology,
Nottingham University Hospitals, Nottingham, UK
P224
Can online structured education for people
with Type 1 diabetes improve glycaemic
control and quality of life?
SL Fearnley1,2, M Joyce2, C Jairam2, N Oliver2 and A Dornhorst2
1
Department of Nutrition and Dietetics, Imperial College Healthcare NHS
Trust, London, UK, 2Department of Diabetes, Imperial College Healthcare
NHS Trust, London, UK
P226
The Ipswich Touch Test (IpTT): screening for
diabetic neuropathy at home
S Sharma, C Kerry, J Rosier, H Atkins and G Rayman
Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
P227
My diabetes My Way: empowering people
with diabetes through electronic record
access
SG Cunningham1, M Brillante2, RR McAlpine1, D Wake3,
A Waller4, J Walker5, A Emslie-Smith6 and A Morris3
1
Clinical Technology Centre, University of Dundee, Dundee, UK, 2Health
Informatics Centre, University of Dundee, Dundee, UK, 3Clinical Research
Centre, University of Dundee, Dundee, UK, 4School of Computing, University
of Dundee, Dundee, UK, 5St Johns Hospital, Livingston, UK, 6Tayside
Diabetes Managed Clinical Network, Dundee, UK
P228
A 12-year audit of BERTIE: successful
outcomes for at least 5 years
J Knott, J Ryder, E Jenkins, J Charman, C Shaban, C Cross,
M Weiss and D Cavan
Hospital, Bournemouth, UK
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2012 The Authors.

P229
Developing a computer-based selfmanagement programme for people with
Type 2 diabetes: user perspectives
E Gubert, K Pal, C Dack and E Murray
Department of Primary Care and Population Health, University College
London, London, UK
Aims: It is NHS policy that patients with Type 2 diabetes receive a

structured educational intervention at diagnosis with annual
reinforcement. The evidence suggests this only occurs in a minority of
patients. An online self-management programme (SMP) could provide
a cost-effective way of improving self-management and thereby
improving clinical outcomes. We aimed to determine user
perspectives of essential and desirable features of a computer-based
intervention to assist us in developing such a service.
Methods: Individuals with Type 2 diabetes and relevant
multidisciplinary health professionals were recruited nationally and
interviewed either individually or within patient or clinician focus
groups. The interviews and focus groups were taped and transcribed
verbatim. Data from patients and health professionals were analysed
separately using a thematic approach. An initial coding framework was
reviewed in a multidisciplinary data clinic including a sociologist, a
psychologist and three academic general practitioners.
Results: Twenty patients and 17 health professionals were
interviewed via eight focus groups and seven interviews. We sampled
to saturation. Patients wanted an interactive intervention with multiple
self-management tools to assist with learning, self-assessment,
monitoring, emotional support and practical advice and to enhance
patienthealth professional communication. Clinicians were concerned
that the intervention should not add to their workload but should
ideally save time.
Conclusions: The user preferences reported in our study should help
our team as well as other developers and purchasers provide effective
internet interventions for Type 2 diabetes.
P230
Who still follows DAFNE and can baseline
characteristics help us to understand the
extent to which people continue to follow
DAFNE principles?
D Cooke2, C McWhinnie1 and L Kamps1
1
Department of Diabetes and Endocrinology, University College London
Hospitals, London, UK, 2Department of Epidemiology and Public Health,
University College London, London, UK
Objectives: It is not known how well people manage to weave the

content of structured education courses for diabetes into their everyday
management. The study aim was to assess the extent to which graduates
from Dose Adjustment for Normal Eating (DAFNE) courses follow the
principles they have been taught.
Methods: A questionnaire survey of DAFNE graduates (n = 211) was
conducted in one outpatients clinic. Questionnaires were distributed by
post, electronically and at a party for staff and graduates to celebrate the
200th DAFNE graduate.
Results: Seventy-two people (40 per cent) returned questionnaires.
Time since completing the course ranged from 3 months to 5 years. The
majority were still carbohydrate counting (92 per cent), correcting high
pre-meal glucoses with extra insulin (96 per cent) and testing glucose
four to five times per day (65 per cent). Adjusting ratios of quick and
long-acting insulin was less commonly reported. Only 40 per cent of
2012 The Authors.

DIABETICMedicine
respondents were still dose adjusting. About 31 per cent no longer kept a
DAFNE diary mainly due to lack of time. Those with longer diabetes
duration were more likely to fill in their DAFNE diary (t = 2.1, df = 67,
P = 0.04). Those with higher baseline HbA1c values were less likely to
report adjusting long-acting insulin (t = 2.0, df = 68, P = 0.05).
Women were significantly more likely to still use a DAFNE diary
(chi-squared 5.2, P = 0.023).
Conclusions: Whilst this is only a small-scale survey, it suggests that
dose adjustment, recording and responding to blood glucose are the
behaviours for which people need help and support in incorporating
into their day-to-day diabetes management.
P231
A diet of 140 characters: the role of Twitter
networks in the diabetes information
horizon
EM Cerri, AR Fisher and S Taheri
Collaborations for Leadership in Applied Health Research and Care (CLAHRC),
University of Birmingham, Birmingham, UK
Background: Patients are increasingly using digital media to access

health information independently of healthcare professionals. This is
particularly the case for chronic conditions such as diabetes as the
always on nature of the internet allows patients to seek information
online at the moment of concern. Given the potential impact which
online information can have on health behaviours, understanding the
information that patients access and identifying areas of greatest risk or
benefit to patients is a key challenge for 21st century medicine. Type 2
diabetes is associated with excess body weight and patients are likely to
be interested in weight loss. The search terms used will define the
information available which has implications for patients with diabetes
searching for weight management advice as some diets may be
unsuitable and potentially harmful. We assessed whether different
diet-related search terms would produce similar information.
Methods: From the Twitter digital media platform tweets using
#diabetes, #weight loss, #diet, #obesity, #health and #fit tags were
archived. The information structure, high content producers, their
followers and tweet content were analysed for 10,000 tweets per #tag.
Results: The text in the majority of #tags is dissimilar from the other
#tags examined. Across the six #tags, the term diabetes appeared
collectively 30,827 times in the tweets with 85 per cent of appearances
in #diabetes and 2 per cent in #weight loss.
Conclusions: The search terms used returned largely different
content. The low appearance of diabetes suggests that most weight
management information in this network will not be specific to patients
with diabetes.
P232
Transforming our insulin pump service
S Kay, C Soar and RCL Page
Diabetes Unit City Campus, Nottingham University Hospitals NHS Trust,
Nottingham, UK
Aim: Frustrated by the traditional clinic setting for pump patients and
finding they had similar concerns and problems, we reorganised the
service.
Method: Our new look service offers each patient an annual one to
one appointment to discuss their aspirations for the following year using
the Year of Care model. In addition 90 min monthly group clinics were
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established. These are facilitated by the diabetologist, diabetes specialist

dietitian and nurse. A minimum attendance of two sessions a year is
suggested, but many come more frequently, depending on their needs
and goals. Each session has a starting topic to initiate discussions. After
the session patients can see any of the healthcare professionals (HCPs)
on an individual basis, or can discuss practical issues about their
equipment. Each group has generated a Top Tips leaflet that is then
distributed.
Results: Feedback from the group sessions has been collated using
evaluation forms. The sessions have scored highly on a scale of
usefulness, with patients commenting fantastic support, great, really
find it useful, especially hearing of others experiences and the
opportunity to give our own experiences. As HCPs we have
increased our practical knowledge of pump therapy and have greater
enjoyment of our role. Looking at clinical outcomes HbA1c pre-groups
was 66 mmol/mol and 9 months later was 63 mmol/mol. Most
patients report a significant improvement in frequency and degree of
hypoglycaemia.
Summary: Giving patients the opportunity to determine and be
involved in their care has improved their clinical outcomes, as well as
patient and HCP satisfaction.
P233
Why should people with Type 1 diabetes
miss out? Establishing Year of Care in the
hospital setting
RCL Page, A Archer and S Kay
Diabetes Unit City Campus, Nottingham University Hospitals NHS Trust,
Nottingham, UK
Aim: The traditional medical model is not suited to enabling people

with long-term conditions live their everyday life. We applied the Year
of Care (YOC) model to secondary care whilst it was introduced to the
community. Barriers to establishing this patient centred care included
outpatient staff for pre-clinic assessment, setting up IT systems, the
concept of patients setting their own goals, engagement of colleagues,
clinic codes and payment pathways.
Methods: Three healthcare professionals (HCPs) attended Train the
Trainers Training. YOC courses ran for HCPs from both community
and secondary care. Further training for clinical support nurses
overcame barriers allowing greater understanding of YOC and care
planning. Identifying enthusiastic members of our administration team
enabled us to modify the YOC templates to become part of our diabetes
database, allowing automated letter generation.
Outcomes: Pre-clinic assessments by the clinical support nurse occur
1 month prior to the clinic. This change is cost neutral and enhanced
their role providing greater job satisfaction. Results with explanation
and things to think about prompt are sent out 2 weeks before their
appointment allowing time for reflection. The patients clinic
appointment allows for a true conversation, with the patient setting
their own goals. The HCP remains important in helping ensure the goals
are SMART and local services are supportive. Patient feedback is
favourable.
Summary: Introducing YOC allows patients with Type 1 diabetes
who mainly attend the hospital to benefit from this new model of care. It
is too early to report formal clinical outcomes.
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P234
Needle use and disposal in patients with
diabetes
NMW De Alwis, D Basham, A Stewart, J Wier, B Marron and
K Dukhan
Department of Diabetes and Endocrinology, South Tyneside District Hospital,
Harton Lane, South Shields, UK
Introduction: Complications of improper insulin needle use among

individuals with diabetes include inadequate glycaemic control and
local side-effects. Failure to dispose of used needles in a safe manner may
lead to accidental injury. Whilst in hospital, needle disposal is regulated;
individuals must have good insulin use and disposal practices in their
homes.
Method: Ninety consecutive patients with diabetes on insulin
contacting specialist nurses in December 2010 were selected. A
telephone questionnaire regarding insulin injection and needle
disposal was administered.
Results: In this group, 24 had Type 1 diabetes and 70 had Type 2 with
an average duration of diabetes of 12.48 years and were on insulin for
an average of 8.5 years (1 month 33 years).The number of times an
insulin needle was used before disposal was as follows: 62 per cent used
a needle only once, 20 per cent twice, 4 per cent three times and 14 per
cent used a needle four times or more before disposal. In all, 15.9 per
cent (n = 15) did not have a sharps bin or BD safeclip device for this
purpose and resorted to the general waste bin. Nine patients said they
had not had any education regarding insulin needle disposal (9.6 per
cent). Of those who had some teaching/training, 36.2 per cent had some
within the last 6 months while 28.7 per cent had some more than 1 year
ago.
Conclusion: Periodic questioning on insulin needle use and disposal is
important. This should be combined with regular patient education.
P235
Development of a behavioural intervention
targeting free-living physical activity in
adults with Type 2 diabetes in primary care:
Movement as Medicine
L Avery1, L Taylor2, M Lievesley2, K Mosely3,6, J Speight3,4,
FF Sniehotta5 and MI Trenell1,7,8
1
Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne,
UK, 2Centre for Design Research, Northumbria University, Newcastle-UponTyne, UK, 3Applied Health Psychology Research, Uxbridge, UK, 4Australian
Centre for Behavioural Research in Diabetes, Deakin University, Melbourne,
Australia, 5Institute of Health and Society, Newcastle University, NewcastleUpon-Tyne, UK, 6Faculty of Arts & Sciences, Australian Catholic University,
Sydney, Australia, 7National Institute for Health Research (NIHR) Biomedical
Research Centre for Ageing, Age-related Disease, Newcastle University,
Newcastle-Upon-Tyne, UK, 8MRC Centre for Brain Ageing, Vitality, Newcastle
University, Newcastle-Upon-Tyne, UK
Aim: To design an evidence-based behavioural intervention for use by

primary care clinicians to support adults with Type 2 diabetes to
increase their levels of free-living physical activity (PA).
Methods: An experience-based design approach was applied to
develop a professional and patient toolkit for PA consisting of the
following: (1) patient and clinician focus groups and semi-structured
interviews undertaken to identify information needs, and knowledge
and skills related to initiating and maintaining a physically active
2012 The Authors.

lifestyle; (2) a systematic review of behavioural interventions targeting

PA and HbA1c in adults with Type 2 diabetes conducted to identify
practical behaviour change strategies for increasing free-living PA; (3)
an iterative design process, including carers, patients and professionals,
to design the intervention materials.
Results: Patients reported the need for more information on the
benefits of PA for management of Type 2 diabetes and practical support/
guidance on initiating (or increasing) PA in their daily lives. They also
reported the need for improved support from their clinicians. Clinicians
reported the need for accredited online support and training on practical
strategies to initiate a physically active lifestyle in their patients during
routine diabetes consultations. The systematic review identified 16 key
strategies associated with improved levels of PA and HbA1c (eg goal
setting, self-monitoring).
Summary: Movement as Medicine is the UKs first evidence-based,
professional and patient development pathway targeting physical
activity in adults with Type 2 diabetes in the primary care setting.
P236
A systematic review of behaviour change
interventions targeting physical activity,
exercise and HbA1c in adults with Type 2
diabetes
L Avery1,2, D Flynn2,3, A van Wersch4, FF Sniehotta2,3 and
MI Trenell1,5,6
1
Institute of Cellular Medicine, Newcastle University, Newcastle-Upon Tyne,
UK, 2Newcastle Health Psychology Group, Newcastle University, NewcastleUpon Tyne, UK, 3Institute of Health and Society, Newcastle University,
Newcastle-Upon Tyne, UK, 4School of Social Sciences and Law, Teesside
University, Middlesbrough, UK, 5National Institute for Health Research (NIHR)
Biomedical Research Centre for Brain Ageing and Age-related Disease,
Newcastle University, Newcastle-Upon Tyne, UK, 6Medical Research Council
Centre for Brain Ageing and Vitality, Newcastle University, Newcastle-Upon
Tyne, UK
Aim: To systematically define effective behavioural interventions for

improving free-living physical activity and HbA1c in adults with Type 2
diabetes.
Methods: Five electronic databases were searched up to October
2010. Two reviewers independently extracted data using a structured
data extraction form to capture details of study characteristics;
methodological quality; practical strategies for increasing levels of
free-living physical activity using a taxonomy of theory-linked
behaviour change techniques; and treatment fidelity strategies
important for internal and external validity.
Results: Out of 8,457 titles and abstracts identified by the search
strategy, 15 randomised controlled trials fulfilled the review criteria
(1,152 adults with Type 2 diabetes). Out of these 15 studies, seven and
four reported a statistically significant improvement in physical activity
and HbA1c respectively. Sixteen behaviour change techniques were
associated with statistically significant improvements in both physical
activity and HbA1c. The three most commonly reported behaviour
change techniques were goal setting, self-monitoring and use of followup prompts. Few studies provided details of treatment fidelity strategies
to monitor/improve training of care providers (n = 3) or delivery of
interventions (n = 1).
Conclusions: Behaviour change interventions result in improved
levels of physical activity and consequently reduce HbA1c in adults with
Type 2 diabetes. Behavioural interventions of greater intensity (utilising
a greater range of behaviour change techniques) have potential for
yielding improved outcomes in routine diabetes care. These findings
suggest that future studies should be multi-faceted and include
2012 The Authors.

DIABETICMedicine
structured training for diabetes care providers on the delivery of

behavioural interventions.
P237
How to reduce the risk of failing to reach
recruitment targets: lessons learnt from a
pump pilot trial
KD Barnard1, MJ Campbell2, C Emery3, AJ Young1 and
S Heller4
1
Faculty of Medicine, University of Southampton, Southampton, UK, 2School
of Health and Related Research (SCHARR), University of Sheffield, Sheffield,
UK, 3DAFNE National Institute for Health Research (NIHR) Project Office, Royal
Hallamshire Hospital, Sheffield, UK, 4Academic Unit of Diabetes,
Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
Aim: To explore individuals understanding of insulin pump therapy

and their reasons for declining to participate in a pilot trial of insulin
pumps with a view to informing recruitment processes in the Relative
Effectiveness of Pumps over Structured Education (REPOSE) trial.
Method: This was a qualitative study using semi-structured telephone
interviews. All interviews were transcribed and responses were
thematically coded and analysed by two researchers independently.
Results: Eight participants were interviewed out of a possible 18
which was sufficient to reach the saturation point of new data. Reported
reasons for non-participation included lack of time, inconvenience,
disinterest in insulin pump therapy and satisfaction with current
treatment. Understanding of insulin pump therapy was generally poor,
with six participants reporting little knowledge of how the pump works,
its functions or what it looks like, eg size and method of attachment. The
level of ignorance was a major deterrent to participation. There was also
a high level of satisfaction with current therapy.
Conclusions: Despite the increasing use of insulin pump therapy,
there is limited understanding of the its nature and potential. The
apparent satisfaction with current therapy may reflect current practice,
where only a small percentage of individuals actively seek out insulin
pump therapy. These findings emphasise the wider finding that myths
and misunderstandings are important barriers to participation in
clinical trials. Targeted education providing clear explanations of the
technology and potential advantages/disadvantages is an important
part of recruitment in large trials involving pumps and probably other
technologies.
Acknowledgement: Submitted on behalf of the DAFNE
collaborative.
P238
Acceptability of lifestyle education for
people with metabolic syndrome: a
qualitative evaluation
AJ Dunkley1, MA Stone1, H Fisher1, MJ Davies2 and K Khunti1
1
Health Sciences, University of Leicester, Leicester, UK, 2Cardiovascular

Aims: The Reversal Intervention for Metabolic Syndrome (TRIMS)

study is a 12-month randomised controlled trial, to compare the
effectiveness of structured group lifestyle education (intervention) with
usual care (control) for improving management of cardiovascular and
diabetes risk factors in people with metabolic syndrome (MetS). As part
of the evaluation of the trial, we aimed to assess the acceptability of the
TRIMS education programme.
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Method: Qualitative semi-structured interviews were conducted via

the telephone with a convenience sample of subjects who had attended
the TRIMS programme. Topics explored included ease of
understanding; views about the content of the programme and style
of delivery; and usefulness and relevance (including cultural relevance).
Transcripts were analysed using a thematic approach including the use
of charting to collate data.
Results: Thirteen people (nine men) were interviewed; average time
since completion of the TRIMS programme was 4.3 weeks (IQR 2.9
5.1). Key findings from the interviews suggested that, after attending the
course, peoples knowledge of MetS improved, including awareness of
possible health risks. In addition, people generally perceived that they
could make beneficial changes to their lifestyle and so improve their
future health. Commonly reported behaviour changes included
increasing physical activity; trying to lose weight/reduce waist size;
making changes to the types of foods bought and eaten; and reducing
portion size.
Conclusion: The qualitative evaluation indicates that, overall, the
TRIMS programme was well received and there were improvements in
participants knowledge about the risks associated with MetS and the
benefits of lifestyle interventions to reduce these risks.
P239
Structured education: increasing referrals
and maximising attendance at the X-PERT
programme for people with Type 2 diabetes
S Lucas, CA Winter, N Collett, A Goodchild and J Grummit
Bexley Community Diabetes Team, Bexley Care Trust NHS SE London,
Bexleyheath, UK
Aim: Eighty people attended the X-PERT programme in 2009. The

aim was to increase referrals and attendance.
Methods: X-PERT was extensively reviewed and changes were made.
People were able to experience a taster week, as well as enrolling for
the full course. A dedicated administrator and new trainers were
appointed. X-PERT was marketed to GP practices, pharmacists and
opticians and self-referral was promoted. Referral from primary care
was simplified, using an electronic referral form. The original two
venues and times were extended to eight venues and 13 session times
including evenings and weekends. People are contacted with a choice of
venues and are reminded a week before the course with a letter or text.
All trainers, both lay and healthcare professional, are mentored and
attend regular team meetings to increase competence. Patient support
group members and practice nurses were contracted as trainers to
encourage referral rates. A league table of referral and outcome data
encouraged practices to increase referral rates.
Results: Referrals increased from 742 in 2010, with 1,659 between
January and August 2011. In the same period in 2011, 1,031 people
completed courses, with 300 booked to the end of the year. HbA1c
dropped by 15.5 per cent to 7.1 per cent on average, the best 6 months
follow-up results in the national X-PERT audit. Positive participant
feedback has also increased primary cares confidence in referring to
X-PERT.
Conclusions: By developing a systematic pathway, good
administrative processes, flexibility and choice for people and
confident, competent trainers we have achieved excellent outcomes
and high referral and attendance rates to X-PERT.
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P240
Cardiovascular risk related to gestational
diabetes and polycystic ovary syndrome:
are women aware?
J Wylie1, J Tomlinson2, J Pinkney2, G Letherby3 and
E Stenhouse4
1
Peninsula Local Diabetes Research Network, Peninsula College of Medicine
and Dentistry, Plymouth, UK, 2University Medicine, Derriford Hospital,
Peninsula College of Medicine and Dentistry, Plymouth, UK, 3School of Social
Science and Social Work, Faculty of Health, Education and Society, Plymouth
University, Plymouth, UK, 4School of Nursing and Midwifery, Faculty of
Health, Education and Society, Plymouth University, Plymouth, UK
Aim: Research is emerging suggesting that women with gestational

diabetes (GDM) and polycystic ovary syndrome (PCOS) are at
increased risk of cardiovascular disease due to Type 2 diabetes
(T2DM) as a consequence of impaired glucose tolerance. Our aim
was to explore womens understanding of cardiovascular risk (CVR)
following diagnosis of GDM and PCOS.
Method: Individual interviews with12 women with GDM and three
focus groups of three to five individuals with women with PCOS were
conducted. Using qualitative methodologies interviews and groups
were recorded and transcribed verbatim. Analysis was undertaken
using the grounded theory approach.
Results: Three themes were identified. Non-connection: Neither
group made any connection of the effect of the diagnosis of GDM
or PCOS on their long-term health. Cardiovascular risk what
risk?: In both groups women were aware of the impact of impaired
glucose tolerance but as expected this was greater in women with
GDM. Women with PCOS had very little knowledge of the CVR
associated with their condition. No one told me: All the women
stated they had to some degree been told of the risk of developing
T2DM in later life but none recalled being informed of CVR. The
majority of women with PCOS stated that they had a vague idea
that they could develop T2DM but not of the development of CVD
in later life.
Conclusion: Women with either GDM or PCOS should be informed
of their predisposition to CVD and nurses and midwives should
endeavour to inform women of preventative measures they could
employ to reduce this.
P241
Auditing structured education in a national
Type 1 diabetes programme: does it make a
difference?
G Thompson1 and CD Taylor2
1
National DAFNE Programme, Northumbria Healthcare Foundation NHS
Trust, North Shields, UK, 2Diabetes Service, Sheffield Teaching Hospitals NHS
Foundation Trust, Sheffield, UK
Aim: Each centre delivering Dose Adjustment for Normal Eating

(DAFNE) courses must demonstrate that their patients with Type 1
diabetes continue to receive a programme that fulfils NICE criteria.
Methods: Centres undergo a 3-yearly audit comprising selfcompleted questionnaires and external assessment against NICE
criteria, ie philosophy (one criterion), curriculum (two), trained
educators (five), quality assurance (QA) (nine), audit (four), plus user
input (one). Each of the 22 criteria is scored green (fully achieved),
amber (partial) or red (not achieved). Central DAFNE issues each centre
with a full report with recommendations for meeting criteria over the
subsequent 3 years.
2012 The Authors.

Results: Ten centres were audited in both 2007 and 2010, enabling
comparison of results. Due to database redevelopment, three criteria
covering data collection could not be scored in 2010; therefore only 19
items were compared. Mean (SD) scores were green 2007, 8.6 (1.8);
2010, 12.9 (3.1); amber 2007, 6.0 (2.6); 2010, 4.8 (2.1); red 2007, 4.4
(3.1); 2010, 1.3 (1.3). Criteria most commonly scored red in 2007
related to ongoing educator QA: core skills forms (six centres); session
learning outcomes forms (five); development objectives (five); plan for
QA (seven). In 2010 these red scores reduced to core skills (three
centres); learning outcomes (zero); development objectives (three); QA
plan (three).
Conclusions: DAFNE centres that have undergone consecutive audits
demonstrated improvement in meeting structured education standards
recommended by NICE. Fully achieving all standards is a challenge for
busy clinicians and requires local planning and leadership as well as
centralised organisation and administration.
P242
Eat study: exploring the patient experience
of changes in appetite and diet with incretin
analogue therapy in Type 2 diabetes
RM Paisey1, G Letherby2, M Smith2, S Estcort3 and
E Stenhouse2
1
Diabetes Research Department, Torbay Hospital South Devon Healthcare
NHS Foundation Trust, Torquay, UK, 2Faculty of Health, Education and
Society, Plymouth University, Plymouth, UK, 3Diabetes Research Network
Clinical Trials, Royal Devon and Exeter NHS Foundation Trust Hospital,
Exeter, UK
Aims: The variability in response to incretin analogue therapy in

subjects with Type 2 diabetes remains unexplained and there is a lack of
evidence to enable recommendations for dietary adaptations when
starting these therapies to gain optimum outcome. Our aims were to
explore the lived experience of patients who have been successful in
their response to incretin analogue therapy; to identify satiety influences
on dietary choices and eating behaviour; to investigate strategies
developed by patients to minimise side-effects.
Methods: Three focus groups each of four to six NICE compliant
participants (duration of therapy 652 months) were undertaken.
Using qualitative research methodologies the groups were audio and
visually recorded. Data were transcribed verbatim. Analysis was
undertaken based on grounded theory with key themes identified and
similarities and differences explored.
Results: Three themes emerged: (1) medical experience including
managing the process, reducing side-effects including hypoglycaemia,
reducing or discontinuing other diabetes medication, weight loss and
improvements in overall diabetes control, improved cognition in some;
(2) changing behaviour portion size and choices of food, speed and
timing of eating, reduction in grazing; (3) social and cultural differences
not least with reference to gender, social class, working patterns.
Conclusions: More evidence is needed for healthcare professionals
and patients on management of dietary changes or side-effects when
initiating incretin analogue therapy. The 40 years cumulative patient
experience of incretin analogue therapy in this study may inform future
practice. Further studies testing the findings amongst a broader cohort
including those who have not tolerated/achieved success with incretin
analogue therapy is planned.
2012 The Authors.

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P243
Resilience and its association with
personality, self-efficacy, self-care,
everyday worries and low moods in Type 2
diabetes patients and a community sample
M Grivnova1 and JW Huber2
1
Life Sciences, Roehampton University, London, UK, 2Centre for Health &
Wellbeing Research, The University of Northampton, Northampton, UK
Aims: Resilience refers to successful adaptation in the face of adversity

such as Type 2 diabetes. The aim was to investigate the relationship
between resilience, personality, self-efficacy, anxiety and depression
and diabetes self-care. Additionally, the psychometric properties of the
25 item ConnorDavidson CD-RISC resilience scale were explored in
patients and a community sample.
Methods: This cross-sectional study recruited 38 Type 2 diabetes
patients (26 males; mean age 72 years; mean HbA1c 7.7 per cent) from
the south of England and 98 participants from the community without
diabetes (29 males; mean age 37 years). Questionnaires were identical
except for self-care activities. Ethical approval was granted.
Results: Resilience was positively associated with extraversion,
conscientiousness and self-efficacy, but negatively with neuroticism,
anxiety and depression (all P values < 0.05). Resilience did not
correlate with HbA1c levels and only weakly with self-care;
personality characteristics were weakly associated with HbA1c.
Extraversion, conscientiousness and self-efficacy correlated positively
with self-care. Type 2 diabetes self-care was predicted by extraversion
over and above resilience and both resilience and extraversion predicted
depression. In the community sample, resilience predicted emotional
wellbeing (anxiety and depression). Principal components analysis
could not replicate the factor structure suggested by the authors of the
resilience scale.
Conclusions: Resilience predicts emotional wellbeing in both
diabetes patients and a community sample. In diabetes patients,
extraversion may facilitate social support and therefore reduce
depressive symptoms. However, the factor structure of the resilience
scale arising from these data differs from that reported by its authors
and requires further investigation.
P244
A rough guide of how youre doing: young
peoples understanding of clinical markers
in Type 1 diabetes
B Johnson1,2, S Brierley1,2, V Young1,2, C Eiser1,2, S Heller1,3,
Diabetes Theme Research Group and CLAHRC South Yorks1
1
Diabetes Theme, National Institute for Health Research (NIHR) CLAHRC for
South Yorkshire, Sheffield, UK, 2Child and Family Research Group,
Department of Psychology, University of Sheffield, Sheffield, UK, 3Academic
Unit of Diabetes, Endocrinology and Metabolism, School of Medicine,
University of Sheffield, Sheffield, UK
Aim: This study examined understanding and accuracy of reported

HbA1c among young people (YP) with Type 1 diabetes attending
transition clinics.
Method: In total, 105 YP (aged 1621 years) were asked their latest
HbA1c, their own and their doctors opinion of this result, a description
of HbA1c, whether they were worried by high and low blood sugars and
what levels were considered worryingly high and low. Reported
HbA1cs were checked for accuracy. Descriptions of HbA1c were coded
for understanding.
Results: Eighty-three YP reported their latest HbA1c score with 61 per
cent accurate within 0.5 per cent. When asked about their ideal HbA1c
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88 per cent of YP reported the recommended level of 7.5 or below.

However, 87.6 per cent of YP had an HbA1c higher than 7.5 (mean
9.85, SD = 2.03). Most YP could describe HbA1c. Most said it was an
average, spanning around 3 months. Some outlined its purpose [to
check] whether Ive kept good control over my diabetes while others
mentioned its impact: it plays on my mind when it is nearer to clinic.
Conclusions: While most exhibited an understanding of HbA1c,
fewer knew their own HbA1c and mean HbA1c was high. This suggests
that although YP provide a one-line answer explaining HbA1c they may
not understand its relevance to them. As many of these YP are diagnosed
since early childhood, education may have been delivered to parents so
sufficient knowledge of Type 1 diabetes cannot be assumed. Further
education for YP may be needed to communicate the present and future
consequences of high HbA1c results for them and to encourage better
self-management.
P245
Development of the Adolescent Diabetes
Needs Assessment Tool (ADNAT)
H Cooper1, J Spencer1, G Lancaster2, M Johnson3, R Lwin4,
A Titman2, S Wheeler1 and M Didi5
1
Child Health, University of Chester, Chester, UK, 2Mathematics and

Statistics, Lancaster University, Lancaster, UK, 3Games Computing and
Creative Technologies, University of Bolton, Bolton, UK, 4Paediatric
Psychological Services, Royal Liverpool Childrens NHS Trust, Alder Hey,
Liverpool, UK, 5Paediatric Endocrinology, Royal Liverpool Childrens NHS
Trust, Alder Hey, Liverpool, UK
Aim: To create an on-line interactive learning needs self-assessment

tool for adolescents (1218 years) with Type 1 diabetes.
Design: Secondary analysis of data from our previous qualitative
research studies identified questionnaire items which were categorised
using the Diabetes Self-Management Education Framework. The
performance of each item was examined through expert, user and carer
review using the Delphi method, cognitive interviews with 14
adolescents to pre-test the revised items, and pilot work with 50
young people to check for variations in relation to levels of missing data
and floor and ceiling effects.
Results: The Adolescent Diabetes Needs Assessment Tool (ADNAT)
uses six interconnecting domains relating to diabetes self-management:
all about me, physical activity, eating, medication, blood glucose
monitoring and living with diabetes. Questions relating to mental
health and independence are included within the domains. It consists of
134 questions, the number answered dependent upon drop-down
menus and treatment filters, and can be used in its entirety or as
individual domains.
Conclusions: ADNAT provides a communication tool for use in
consultations. Feedback indicates that completion is a learning exercise
in its own right and preliminary analysis has shown that it discriminates
between the different needs of users through its traffic light (red/amber/
green) response system. Outcome of use is detailed, recorded
information on individual learning and support needs, allowing users
and practitioners to audit progress at both individual and population
levels. Reliability, validity and psychometric properties of ADNAT are
being tested with 155 young people alongside four focus groups to test
respondent validity and explore clinical application.
104
P246
Development and piloting of a structured
education curriculum for insulin pump
therapy prior to the REPOSE (Relative
Effectiveness of Pumps over MDI with
Structured Education) trial
CD Taylor1, H Rogers2, C Ward3, J Carling4, D Kitchener5 and
L Oliver6
1
Department of Diabetes, Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK, 2Department of Diabetes, Kings College Hospital NHS
Foundation Trust, London, UK, 3Department of Diabetes, Cambridge
University Hospitals NHS Trust, Cambridge, UK, 4Department of Diabetes,
Harrogate NHS Foundation Trust, Harrogate, UK, 5Department of Diabetes,
University Hospitals of Leicester NHS Trust, Leicester, UK, 6Department of
Diabetes, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
Aims: The Dose Adjustment for Normal Eating (DAFNE) curriculum

for people with Type 1 diabetes using multiple dose injections (MDI)
has been developed and evaluated over 11 years. In preparation for a
multicentre randomised controlled trial comparing MDI with
continuous subcutaneous insulin infusion (CSII), the DAFNE
educator group adapted the standard MDI curriculum for CSII.
Methods: DAFNE educators experienced in CSII worked
collaboratively to rewrite the 5-day evidence-based curriculum and
develop the supporting resources. Significant session differences
included insulin regimen and dose adjustment theory, exercise,
alcohol, hyperglycaemia and illness management, with additional
focus on key features of CSII such as bolus calculators and delivery
options. Total educator time amounted to 24 days (180 h). The draft
curriculum and resources were piloted with existing pump users in two
DAFNE centres and revisions were made prior to a multicentre pilot
when the curriculum was delivered by trained educators in five 5-day
courses to DAFNE and CSII naive participants in three centres.
Results: Thirty participants completed CSII courses, commencing
pump therapy whilst undertaking the DAFNE programme, which was
well received. It proved possible to teach both the DAFNE approach
and pump skills over 5 days and HbA1c improved from 8.8 to 8.3 per
cent at 6 months in the 21 individuals whose starting HbA1c was > 7.5
per cent.
Conclusions: The DAFNE curriculum has been successfully adapted
and piloted for CSII therapy, providing a standardised course for a
multicentre randomised controlled trial as well as an option for existing
pump users to access structured education meeting NICE criteria.
P247
The role of social networks in the South
Asian population with diabetes: an
exploratory study
NR Patel, AP Kennedy, CA Chew-Graham, D Reeves and
C Blickem
Health Sciences and Primary Care Research Group, Greater Manchester
CLAHRC, University of Manchester, Manchester, UK
Aims: Evidence is emerging that social networks are important for

patients in managing diabetes. This study examines how much and
what types of diabetes work is undertaken by social networks in the
South Asian population.
Methods: Semi-structured interviews were carried out with 35 South
Asians with diabetes recruited using random and opportunistic
sampling, as part of the wider Greater Manchester CLAHRC study.
The interview included identifying the people, groups and others
(eg deities) in each patients social network, closed questions on the
2012 The Authors.

amount of work done by each network member and a topic guide of

open-ended questions on diabetes-related beliefs. All interviews were
audio-taped, transcribed verbatim and analysed thematically using a
constant comparison approach. SPSS and UCINET were used to
analyse ratings and visualise network structures.
Results: Preliminaryfindingssuggestthatfamilyandfriendsarecentral
to daily diabetes management across three types of work: illness work,
everyday life work and biographical work. Division of work depends on
the type of relationship, perceived importance of the network member,
perceived control over diabetes and the patients personal model of
illness, often influenced by cultural and fatalistic beliefs.
Conclusions: Current self-management policies focus on supporting
and empowering patients as individuals. This study provides a novel
and detailed insight into who does the work and what and how much
diabetes work is undertaken in the context of the patients daily
activities and relationships; and questions whether guidelines and
practitioners need to move beyond the notion of self to include support
for the social networks and community resources involved in diabetes
management.
P248
Evaluation of the NewDEAL education
programme for Type 1 diabetes using
patient stories
K Fraser1, E Sharp2, H Millar1, A Bramley1, AJ Mackenzie1 and
CJ Kelly1
1
Department of Diabetes, NHS Forth Valley, Larbert, UK, 2Practice

Development Unit, NHS Forth Valley, Stirling, UK
Aim: Department of Health guidelines (2005) on structured patient

education for diabetes specify that education programmes are audited.
Biomedical and quality of life audit show improvement with
NewDEAL [1] and written patient feedback shows that participants
find the courses useful and well delivered. These sources, however, do
not capture the enthusiastic verbal feedback received during each
course. Our aim was to capture the views of participants on our
NewDEAL education course to ensure that patients influence the future
development of our education.
Method: Members of the diabetes team invited patients who had
participated in the NewDEAL education programme to undertake a
patient story. Stories are a recognised tool for collecting qualitative
information [2]. Eight stories were undertaken following prompts
devised by the diabetes team and the facilitator. Stories were recorded,
transcribed and themed.
Results: Themes highlighted the value of the NewDEAL education
programme for the participants. Participants described the course using
phrases such as life changing and valued the group working and
sharing of experiences with other people with diabetes. Participants also
made suggestions for improvements such as reviewing language used
and having different approaches to carbohydrate counting to ensure the
inclusion of participants with varying learning requirements.
Conclusion: Patient stories captured the verbal feedback from
participants and confirmed this approach to education to be of great
benefit. Participants described how their approach to diabetes and their
glycaemic control had changed as a result. Suggestions for improvement
in delivery were recorded and will be used to review the education
sessions.
References:
[1] Fraser K et al 2009. A NewDEAL: Benefits of a structured education
programme for people with Type 1 Diabetes (unpublished poster
abstract).
[2] NHS Modernisation Agency, Learning from patient and carer
experience:AGuidetousingDiscoveryInterviewstoimprovecare,2004.
2012 The Authors.

DIABETICMedicine
Department of Health Diabetes UK, Structured patient education in

diabetes: Report from the Patient Education Working Group, 2005.
P249
Glycaemic control and weight seven years
after DAFNE structured education in Type 1
diabetes
P Mansell1 and D Gunn2
1
Diabetes and Endocrinology, Nottingham University Hospitals, Nottingham,
UK, 2Medical School, University of Nottingham, Nottingham, UK
Aims: The provision of structured education is increasingly prevalent

in the management of Type 1 diabetes (T1DM). There is little long-term
follow-up data from such programmes. We have assessed HbA1c and
weight over a 7-year period following the DAFNE (Dosage Adjustment
for Normal Eating) structured education course.
Methods: We obtained annual HbA1c and weight data for 111
patients who attended the initial series of DAFNE courses in our centre
from June 2002 to end 2003 and in a matched group of patients with
T1DM of similar age and duration of diabetes.
Results: With DAFNE structured education, the mean (SD) HbA1c
fell from 8.6 1.1 per cent (70 mmol/mol) at baseline to 8.1 1.1 per
cent (65 mmol/mol) at year 1 with a subsequent rise to 8.3 1.2 per
cent (67 mmol/mol) at year 7 (P = 0.0048 vs. baseline). In the
comparator group, the baseline HbA1c level was 8.5 1.3 per cent
(69 mmol/mol) and remained approximately constant during 7 years
of follow-up. Weight increased by 2.4 6.0kg and 2.8 6.6kg in the
DAFNE and comparator group respectively during follow-up (NS).
Conclusion: DAFNE structured education is associated with an
improvement in glycaemic control at 1 year and there remains a
persistent and clinically relevant reduction in HbA1c of 0.3 per cent
after 7 years. The improvement in glycaemic control after DAFNE is
achieved without excess weight gain.
P250
A qualitative study to explore how women
with Type 1 diabetes manage their diabetes
during the menopausal transition
L Mackay1, L Kilbride2 and D Horsburgh2
1
Metabolic Unit, Western General Hospital, Edinburgh, UK, 2Faculty of
Health, Life and Social Sciences, Edinburgh Napier University, Edinburgh, UK
Aim: To explore the experiences of women with Type 1 diabetes

during the menopausal transition and, from the data, develop a
substantive theory that will have potential implications for service users
and service providers.
Methods: A qualitative exploratory research framework was
employed using grounded theory as an approach. Data have been
collected from 10 participants using transcribed audio-taped semistructured interviews and field notes. The transcripts, audio recordings
and field notes were reviewed and a coding process facilitated data
analysis.
Results: A wide range of conceptions was revealed. Data are presented
in seven categories that reflect the experience of the menopausal
transition for women with Type 1 diabetes: Blank wall (relates to the
lack of information regarding menopause and diabetes), Juggling game
(relates to glycaemic control), Anxiety and fear, Self-management,
Haywire (relates to the signs and symptoms of menopausal transition),
Treating symptoms, Depression and mood, Im old (relates to aging
and mortality).
105
DIABETICMedicine
Conclusion: What emerged from the study is a substantive theory in

which absence of information regarding the menopause and its impact
on Type 1 diabetes was identified as the main problem facing women
with Type 1 diabetes during their menopausal transition. The findings
may enable practitioners to identify the types of information, advice and
support that should be made available to these women and contributes
to the limited knowledge base currently available. The findings indicate
also that further research into this under-studied but important area of
diabetes care is required.
P251
Barriers associated with uptake of diabetes
multidisciplinary group education: a survey
of patients view in a PCT in southeast
England
MO Lawal
Faculty of Health, University of West London, London, UK
Aims: The paradigm shift in management of diabetes from the basic

disease model of the 1930s which centred exclusively on treatment by
healthcare professionals to the recent integrated healthcare approach
involving the patients (Diabetes UK 2008) stresses the importance of
patient empowerment. The aim of this study was to explore the barriers
and facilitators to patient attendance in group education designed to
promote self-care.
Method: A questionnaire survey which contains both closed and
open-ended questions was administered to elicit data from 207 (105
non-attenders and 102 attenders) newly diagnosed diabetes patients
who were referred for structured patient education.
Results: The patients views were analysed by using SPSS software and
the qualitative comments were categorised into themes. In comparison
to 94 (45 per cent) attenders, 35 (17 per cent) non-attenders either
strongly agree or agree that attending the session is important to develop
self-care ability. This result shows a significant difference among the
two groups (0.000, P < 0.05). A substantial number of respondents
among the non-attenders (n = 43, 21 per cent) did not have flexible
working arrangements compared with the attenders (n = 24, 12 per
cent). Although more than half of the total number of respondents have
a family history of diabetes (n = 112, 54 per cent), the majority of them
are non-attenders (n = 73, 35 per cent) showing a significant difference
(0.000, P < 0.05) between the two groups. Key themes from qualitative
data included personal difficulties, lack of motivation and healthcare
practitioners influence.
Conclusion: The results were consistent with the findings of previous
studies and suggest that patients perceived benefits of structured
education may influence attendance.
Acknowledgements: J Magill-Cuerden, T Olden, D Sookhoo, J
Durrant, A Debowy.
P252
Successful weight reducers in the
workplace: experiences of men and women
who participated in the Prosiect Sir Gar
lifestyle intervention programme
EM Di Battista1,3, M Williams2, S Rice2, JW Stephens3,
RM Bracken3 and SD Mellalieu3
1
Nutrition and Dietetics Department, Hywel Dda Health Board, Llanelli, UK,
Diabetes Centre, Hywel Dda Health Board, Llanelli, UK, 3College of
Engineering, Swansea University, Swansea, UK
2
106
Aim: The objective of this qualitative study was to evaluate

participants experiences associated with maintained weight loss at
6 months following the Prosiect Sir Gar (the Carmarthenshire project)
10-year cardiovascular disease (CVD) risk assessment and lifestyle
intervention programme.
Methods: The lifestyle intervention programme (LIP) consisted of
eight 75min group sessions, delivered once weekly by a dietitian (seven
sessions) and an exercise specialist (one session) with an emphasis on
behaviour change. At 2 weeks post LIP 1 h semi-structured face-to-face
interviews were conducted and body weight data were tracked over
6 months. Eight successful weight reducers (defined as an individual
who had lost and sustained5 per cent body weight over 6 months)
were targeted for thematic analysis by applying the constant
comparison method. Four male blue collar workers and four female
health workers aged 4057 years with a body mass index range of
3039 kg/m2 took part in the study.
Results: All participants reported a change of mind regarding their
attitude toward weight loss. Some attributed this to a wake-up call
following the CVD risk assessment; others believed it to be a more
gradual process during LIP. Accepting lapses of undesirable behaviours
as normal was a common theme in both genders, as too was a focus and
commitment to goals. Both genders described the group environment of
LIP as humorous at times, yet supportive.
Conclusions: These findings suggest that in successful weight reducers
a combination of health risk assessment and lifestyle intervention
programme may have added value in evoking motivation to commit to
weight management.
P253
Do we care about the road safety of people
living with diabetes?
RA Dixon, A Lloyd and M Saeed
Department of Diabetes, University Hospitals Birmingham NHS Foundation
Trust, Birmingham, UK
Aim: Currently there are 2.8 million people in the UK living with
diabetes. Several studies have demonstrated a link between
hypoglycaemia and driving mishaps. The aim of the study was to
assess patient awareness of recently imposed changes to driving
regulations relevant to diabetes.
Methods: A 37-point anonymous structured questionnaire was
distributed amongst 47 registered drivers attending a secondary care
diabetes clinic in Birmingham. Information concerning diabetes
treatment and knowledge of Driver and Vehicle Licensing Agency
(DVLA) regulations, including recognition of hypoglycaemic episodes,
in addition to general precautions regarding hypoglycaemia, was
sought.
Results: Despite finding that 72.3 per cent of participants had received
information concerning DVLA regulations and advised precautions,
the present study showed a surprising lack of awareness of details
important for safe driving. Amongst those surveyed, only 73.3 per cent
were always aware of when they were becoming hypoglycaemic, an
absolute licence stipulation according to DVLA regulations. With
regard to advised precautions, 29.8 per cent of patients were unable to
identify a capillary blood glucose level of 5 mmol/l or greater as a safe
level for driving. Interestingly, only 14.9 per cent of patients understood
the recommendation of a 45min wait after achieving this recommended
safe capillary blood glucose level.
Conclusions: Whilst the majority of people living with diabetes have
received information concerning the driving regulations, there is a
worrying lack of understanding of safe driving practices, indicating that
2012 The Authors.

further efforts from healthcare professionals, charities and the DVLA

are required.
NB: Co-first authorship RA Dixon and A Lloyd.
P254
An exploration of the perceptions and
requirements of using email communication
for people with diabetes and on insulin
therapy requiring specialist nurse care
DIABETICMedicine
carbohydrate count improved from 28.6 per cent (n = 8) to 67.8 per

cent (n = 19), and 92.8 per cent of children felt that they could manage
their diabetes more independently by the end of the holiday. The
children felt very positive about making new friends, and enjoyed the
activities at the camp. Most (82.1 per cent) would like to return, and
92.8 per cent would recommend the holiday to others.
Conclusions: This study highlights that childrens support holidays
are a valuable educational and social experience for children living with
diabetes. Diabetes UK should offer such opportunities to a greater
number of children each year.
K Woolley and I Caramlau

Warwick Medical School, University of Warwick, Coventry, UK
Objective: To explore the feasibility, acceptability, potential benefits

and barriers to the use of email which aims to address communication
for those patients with diabetes requiring support to optimise diabetes
management.
Methods: A questionnaire was completed by 23 patients newly
referred to the specialist diabetes service for assessment and 11 diabetes
specialist nurses (DSNs) locally. This was followed by eight semistructured interviews. The quantitative analysis was using the software
programme SPSS 16, the interviews by content analysis.
Results: The results were grouped into five domains: confidence in the
use of email, the nurse/patient relationship, use in insulin therapy, email
communication integration within the DSN service and choice. The
perceived key benefits were access to and convenience and speed of
support. Email advice relating to insulin therapy differed depending on
the participants experience and knowledge. Patients would favour
direct access to the DSN service to seek advice after discharge,
particularly as there was a perception of patient clinical details shared
across providers. Limitations and understanding of the implications are
required by both patients and DSNs.
Conclusion: Email perception by most participants is a valuable
additional tool to aid communication and improve service delivery.
Patients views have added a different perception on direct access to the
specialist service. How this can be incorporated as services increasingly
are delivered across various providers will be a challenge.
P255
The educational value of childrens support
holidays organised by Diabetes UK
MD Sinczak1 and MA Saeed2
1
Ophthalmology, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK,

Diabetes, University Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
P256
The educational value of childrens support
holidays organised by Diabetes UK:
volunteers perspective
MD Sinczak1 and MA Saeed2
1
Ophthalmology, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK,

Diabetes, University Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
2
Aims: Diabetes UK organises yearly childrens support holidays in

order to help children learn to manage their diabetes more
independently. The aim of the study was to evaluate whether such
holidays have an educational value for adult volunteers.
Methods: Seventeen volunteers were asked to answer questions about
diabetes and its management at the beginning and end of the holiday.
Answers were ranked 05, with 01 being assessed as poor, 23 as
moderate, and 45 as a high level of confidence.
Results: Of the 17 volunteers, eight had a medical background and
seven lived with diabetes, which would indicate an overall high level of
experience with diabetes. However, a majority initially responded with
poor or moderate confidence levels with regard to insulin
administration (64.7 per cent, n = 11) and carbohydrate counting
(70.6 per cent, n = 12) which decreased by the end of the week to 17.6
per cent (n = 3) and 29.4 per cent (n = 5), respectively. Ability to adjust
pumps improved from 41.2 per cent (n = 7) to 52.9 per cent (n = 9),
and confidence in managing pump malfunction increased from 29.4 per
cent (n = 5) to 47.1 per cent (n = 8). All of the volunteers reported to
have enjoyed the social interactions and activities and would like to
return to a similar holiday in the future.
Conclusions: This study highlights that childrens support holidays
are a valuable educational and social experience for adult volunteers.
Volunteering opportunities should continue to be publicised, especially
amongst the medical community.
Aim: The current estimated prevalence of Type 1 diabetes in children

in the UK is one per 7001,000. Diabetes UK organises yearly childrens
support holidays in order to help children learn to manage their diabetes
more independently. The aim of the study was to evaluate the impact
and educational effectiveness of one of the holidays on childrens
confidence and independence in managing their diabetes.
Methods: Twenty-eight children at a childrens support holiday were
asked to answer yes, no or maybe to a series of questions about diabetes
and its management before and after the holiday.
Results: While most children (96.4 per cent, n = 27) initially felt
confident about monitoring their own capillary blood glucose levels,
only 32.2 per cent (n = 8) felt able to administer their own insulin,
which improved to 92.8 per cent (n = 26) by the end of the week. Half
of the children felt uncomfortable sharing their diagnosis with others,
which decreased to 32 per cent (n = 9) by the end of the event. Ability to
2012 The Authors.

P257
The relationship between diabetes self-care,
psychological adjustment, social support
and glycaemic control in the Lebanese
population with Type 2 diabetes
O Sukkarieh-Haraty1, E Howard2, R Nemr3 and M Nasrallah4
1
School of Nursing, Lebanese American University, Byblos, Lebanon, 2School

of Nursing, Northeastern University, Boston, USA, 3School of Medicine,
Lebanese American University, Byblos, Lebanon, 4Internal Medicine,
American University of Beirut Medical Center, Beirut, Lebanon
Objective: The purpose of this study was to assess the relationships

between diabetes self-care, psychological adjustment, social support
and glycaemic control (HbA1c levels) among Lebanese adults with
Type 2 diabetes.
107
DIABETICMedicine
Methods: A descriptive correlational design was used with a

convenience sample of adults (n = 140) recruited from two diabetes
clinics. The participants completed a set of three questionnaires in
Arabic: Summary of Diabetes Self-care Activities (SDSCA), Social
Support Subscale of the Diabetes Care Profile and Problem Areas in
Diabetes (PAID), and a demographic and physiological sheet.
Results: The relationship between diabetes self-care and glycaemic
control was supported partially (beta = 0.66, SE = 0.29, P = 0.02).
There was a statistically significant relationship between PAID score
and glycaemic control (beta = 0.02, SE = 0.01, P = 0.036). Social
support was significantly associated with glycaemic control
(beta = 0.02, SE = 0.01, P = 0.01), but in a positive direction as
opposed to having a negative significant relationship. Age, gender, type
of treatment, problems associated with Type 2 diabetes and body
mass index each had a significant relationship with glycaemic
control (beta = 1.36, SE = 0.35, P = 0.000; beta = 0.53, SE = 0.25,
P = 0.037; beta = 0.99, SE = 0.31, P = 0.002; beta = 1.006,
SE = 0.24, P = 0.00; beta = 0.04, SE = 0.02. P = 0.033 respectively).
Conclusions: Participants adhered only to their medication regimen.
Denial prevailed in the light of uncontrolled levels of HbA1c. Social
support was positively associated with HbA1c level, ie participants with
uncontrolled glycaemic levels report higher levels of social support from
their network.
P258
Diabetes awareness among patients with
diabetes at West Middlesex University
Hospital NHS Trust
A Falinska, C Lim, P Rihal, C Gunpot, K Ahmed and R Kaushal
Diabetes, West Middlesex University Hospital, London, UK
NICE recommends that people with diabetes receive structured

education and support to enable them to manage their disease. It
advocates annual retinal and neuropathy screening. Our audit aimed
to assess the level of diabetic awareness in patients visiting our
department. We received 104 replies: 74 per cent of responders were
below 65 years of age and 46 per cent were male. Over 55 per cent of the
patients were from ethnic minorities. In all, 53 per cent of patients had
Type 2 diabetes but 18 per cent did not know what type of diabetes they
had; 51 per cent responders had diabetes over 10 years. Only 82 per
cent of patients admitted taking medications every day. The remaining
18 per cent admitted to taking medications occasionally, never or left
the questions blank. The reasons for poor compliance were too busy,
forgetting, feeling sick, but most were left blank. Over 42 per cent of
responders did not know their HbA1c or left the question blank. Over
23 per cent of patients marked three or more complications (eye, renal,
feet, IHD, HTN). Nearly 30 per cent of patients were not aware of
annual retinal screening and over 42 per cent of responders were not
aware of an annual feet check or left the question blank. This audit
suggested that our patients are not well educated. Despite educational
input from specialist nurses, dietitians and doctors and education
programmes (HIDAP and X-PERT) further work is still needed. Future
plans include patient leaflets, which meet cultural and linguistic needs
within our local area. We are planning to perform another
questionnaire to ask how patients want to be educated. Finally we are
considering online information and e-learning platforms for patients
with diabetes on the hospital website.
108
P259
Implementation of a Type 2 diabetes
prevention pathway within routine primary
care
T Yates1, S Rogers2, B Stribling3, S Hyatt4, M Davies4 and
MJ Davies4
1
Cardiovascular Sciences, University of Leicester, Leicester, UK, 2Consultant in
Public Health, NHS Northamptonshire, Northampton, UK, 3DESMOND
National Office, University Hospitals of Leicester NHS Trust, Leicester, UK,
4
Nene Commissioning, Northampton, UK
Aim: To evaluate the implementation of an evidence-based diabetes

prevention pathway.
Methods: Five general practices, Northamptonshire, implemented
Walking Away from Type 2 Diabetes, a theory-driven structured
education programme delivered by two trained educators to 610
individuals over 3 h aimed at promoting health behaviour, particularly
walking, in individuals with a high risk of diabetes. High risk
individuals were identified using the automated Leicester Diabetes
Risk Score. Between April and June 2011, data were captured prior to
programme attendance to quantify key patient characteristics,
including perceived knowledge and perceptions of diabetes risk and
activity levels. Perceptions of the programme were captured on
completion.
Results: Seventy-seven individuals were offered the programme, and
64 (83 per cent) attended (42 per cent female; age 66 9 years). Prior
to attendance, individuals reported low levels of perceived knowledge
of diabetes and diabetes risk and moderate to high levels of concern with
being identified as high risk. The majority (90 per cent) reported
undertaking regular walking, although only 25 per cent reported
walking for at least 30min a day; however, high levels of confidence for
increasing walking activity were reported. Vigorous activity was
infrequently reported. Following the programme, all participants
agreed that the educators were friendly; took their concerns seriously;
provided the opportunity for self-expression; and delivered the content
clearly. Sixty-three (98 per cent) agreed that making lifestyle changes
would be worthwhile.
Conclusions: Group-based structured education aimed at diabetes
prevention is highly acceptable within primary care to those with a risk
score detected as high risk status. Furthermore, promoting walking
activity was found to be appropriate.
P260
Proactive education of inpatients with
diabetes and healthcare professionals
works
AP Brooks, J Chong, K Haynes, S Nero and A Norris
Specialist Diabetes Care Inpatient Team, Royal Hampshire County Hospital,
Winchester, UK
Aims: To provide a continuous high standard of care and education to

people with diabetes who are inpatients in an acute secondary care
hospital, and education of healthcare professionals (HCPs) through a
specialist diabetes care inpatient team.
Methods: The team, consisting of consultant physician, diabetes
nurse specialist, junior doctors in training, joined by medical students
and nurses in training, provides twice weekly formalised inpatient
diabetes ward rounds in a district general hospital. The goals are to
provide effective safe care of inpatients in an acute hospital, with a one
to one patient education component to visits, and to educate nonspecialist ward HCPs and trainees by good practice and on-the-job
2012 The Authors.

learning. The National Diabetes Inpatient Audits (NDIAs) in 2009 and

2010 allowed measurement of the effectiveness of these interventions.
Results: In 2010 92.7 per cent inpatients reported a team visit vs. 30.6
per cent nationally (P < 0.01). In 2009 and 2010 respectively there were
5 per cent and 11.4 per cent prescription errors (vs. 19 per cent and 26
per cent nationally, P < 0.05); 3 per cent and 18.6 per cent management
errors (vs. 14 per cent and 20 per cent, P < 0.05, for 2009); 100 per cent
and 95 per cent appropriate blood glucose monitoring (vs. 86 per cent
and 90 per cent); 5.5 and 3.8 good diabetes days (vs. 4.2 and 4.3); and
83 per cent and 85.5 per cent of patients reporting a positive experience
of diabetes care (vs. 73 per cent and 75 per cent, P < 0.05).
Conclusions: A specialist diabetes inpatient team proactively visiting
patients and actively educating HCPs can provide high levels of care
based on education as measured in the NDIAs. This requires repetition
of teaching by a committed team of educators and learning by HCPs.
P261
Hypoglycaemia and driving: assessing the
knowledge of our patients with Type 1 and
insulin treated Type 2 diabetes
MJ Boyd1, D Holton1 and AW Patrick1,2
1
2
Department of Diabetes, Roodlands General Hospital, Haddington, UK,

Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
Driving regulations for people with insulin treated diabetes have

changed recently. The aim of our audit was to assess the knowledge of
our patients regarding driving and hypoglycaemia. An anonymous
nine-point questionnaire was completed by 157 people with both Type
1 and insulin treated Type 2 diabetes attending the diabetes clinic. Our
audit indicated only 28.6 per cent of our patients regularly test their
blood glucose before driving, with 19.5 per cent admitting to never
testing; 58.4 per cent do not routinely carry means for blood testing in
their vehicle, while 90.9 per cent did carry some quick acting
carbohydrate and 66.9 per cent carried a longer acting carbohydrate
snack. In all, 83.1 per cent denied ever feeling hypoglycaemic whilst
driving. However, 92.9 per cent knew to pull over as soon as it was safe
to do so if they felt their blood glucose was dropping, and 73.4 per cent
knew to remove the keys from the ignition; but 57.8 per cent would not
move into the passenger seat to treat their hypoglycaemia, ensuring they
were not in control of the vehicle. After hypoglycaemia, only 41.6 per
cent wait between 10 and 30min before driving off again whereas 39 per
cent stated they would drive off as soon as they felt better, irrespective of
time. During the consultation with the healthcare professional, driving
and hypoglycaemia was discussed and the patient was provided with an
abbreviated set of guidelines highlighting the main points of driving and
hypoglycaemia. This aims to ensure that all insulin-treated patients who
drive are provided with clear, written information. The provision of
written guidelines is documented in the patients case notes.
DIABETICMedicine
P262
Integrating SweetText, a mobile phone
behavioural support programme for young
people with Type 1 diabetes, into clinical
service in Kuwait and Scotland
A Greene1, A Shaltout2, V Alexander1, M Brillante3,
SG Cunningham4, E Fairley2, N Halawa2, D AlHuwail2,
D Wake5, RR McAlpine4 and SA Greene1
1
Child Health, University of Dundee, Dundee, UK, 2KSeHIN, Dasman Diabetes
Institute, Kuwait, 3Health Informatics Centre, University of Dundee, Dundee,
UK, 4Clinical Technology Centre, University of Dundee, Dundee, UK, 5Clinical
Research Centre, University of Dundee, Dundee, UK
Introduction: Adherence to self-management in Type 1 diabetes is

recognised to be poor, particularly in adolescence. Behavioural
interventions are effective in improving psychological wellbeing and
clinical outcome. Support programmes are resource intensive and
difficult to implement. We describe the integration of SweetText into
Kuwait and Scotland on behalf of the KuwaitScotland eHealth
Innovation Network.
Methods: SweetText is a modular-based goal-setting text messaging
system delivered by mobile phone. It is based on empirical observations
and the success of our previous randomised controlled trial of the
factors influencing effective diabetes management in the young. Design
considerations acknowledge the different cultural contexts of the two
countries: language; clinical practice; gender; age; service and IT
resources; mobile phone access and use. Patients are enrolled into the
system at clinic visits through the local patient management system. The
system draws randomly from the appropriate module, delivering an
SMS at designated times.
Results: A programme was developed consisting of eight modules
containing clinically appropriate short text messages, delivered for a
pre-determined time (2, 4 or 26 weeks), either daily or three per week:
new patient (45 texts; 26 weeks; three per week); post DKA admission
(27 texts; 2 weeks; daily); intensive routine (141 texts; 26 weeks; three
per week); carb counting (16 texts; 2 weeks; daily); pump start (21
texts; 2 weeks; daily); pump suboptimal control (26 texts; 4 weeks;
daily); transition (27 texts; 4 weeks; daily); wellbeing (121 texts;
26 weeks; three per week).
Summary: SweetText provides an acceptable system for two
culturally contrasting societies, with differing requirements in the
delivery of support for diabetes self-management. It uses mobile
communication technology and is easily integrated into patient
management systems and clinical consultations. It requires
adaptation for each country, influenced by the health needs of host
patients and health professionals.
P263
Involving end-users in the development of a
pre-consultation information booklet for
people with Type 2 diabetes attending an
outpatient review appointment: a
qualitative study
M ODonnell1, B McGuire2 and SF Dinneen1,3
1
Department of Medicine, National University of Ireland Galway, Galway,
Ireland, 2School of Psychology, National University of Ireland Galway, Galway,
Ireland, 3Diabetes Day Centre, University Hospitals Galway, Galway, Ireland
Aim: To involve people with Type 2 diabetes in the development

of a pre-consultation patient information booklet (incorporating
personalised clinical data) to enhance the diabetes review experience.
2012 The Authors.

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Methods: In addition to healthcare professionals, seven people with

Type 2 diabetes attending an outpatient diabetes clinic were
interviewed about their diabetes and what information to include in a
pre-consultation booklet. A draft booklet was pilot-tested with six
different clinic attendees and refined based on feedback.
Results: Fear of diabetes and its complications, low and high blood
glucose levels, and having to inject medication was common among
participants. Lack of understanding of the causes and progression of
diabetes, how to manage low blood glucose levels, screening tests,
targets for key clinical indicators, and medical terms used in the
consultation was also apparent. Information on the purpose of different
screening tests, on diet and medications was identified as important to
include in a booklet. Encouraging people to ask questions during
consultations was also perceived as important. Pilot testing of the draft
booklet found that most participants found the booklet appropriate,
relevant and useful. Only one individual felt it contained too much
information.
Conclusions: People with Type 2 diabetes were actively involved in
informing the content of the research intervention. Pilot testing of the
booklet found that most, but not all, people want written information
about their condition. This intervention booklet is currently being
evaluated using a randomised controlled trial design to measure its
effects on the consultation and patient outcomes.
P264
Patients practice and knowledge of
diabetic foot care in a regional care setting
PS Yap1, N Barclay2, K Spence2 and WA Watson1,2
1
Division of Medical and Dental Education, University of Aberdeen,
Aberdeen, UK, 2Diabetes Centre, NHS Grampian, Aberdeen, UK
Aims: To ascertain and compare the practice and knowledge of

diabetic foot care between the patients seen in primary and secondary
care settings.
Methods: An anonymous questionnaire was designed to capture
demographic data, personal practice, knowledge and education relating
to diabetic foot care.
Results: A total of 180 patients responded of whom 46.1 per cent have
Type 1 diabetes, 48.9 per cent Type 2 diabetes and 5.1 per cent unsure.
The patients were classified based on self-reported foot risk: low risk
40.8 per cent, moderate risk 6.5 per cent, high risk 14.8 per cent and
unknown 37.9 per cent. It was found that 44.9 per cent of patients
inspect their feet daily. Patients with foot problems are more likely to
examine their feet daily compared with those without foot problems
(P = 0.001). A large proportion of patients would turn to general
practitioners and podiatrists regarding foot problems. In relation to
delivery of foot care education, the majority favour verbal information
from the podiatrist or diabetes team (58.4 per cent) followed by leaflets
(47.2 per cent), email (19.3 per cent) and education classes (11.8
per cent).
Conclusion: Our project highlighted that knowledge and practice of
foot care could be improved. Despite knowledge gaps, our high risk
group are more aware of educational objectives relating to foot
complications. We need to highlight personal, tailor-made care
packages to prevent complications and risk stratify where
appropriate. We should target our educational opportunities and be
aware of the benefits of the one to one personal consultation.
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P265
Accuracy of nutritional scales used for
carbohydrate counting and insulin dose
adjusting
NR McConnell
Nutrition and Dietetic Department, Bradford Teaching Hospitals NHS
Foundation Trust, Bradford, UK
Aims: To assess the accuracy of nutritional scales recommended to

people with Type 1 diabetes who use them to estimate carbohydrate in
their food to calculate insulin dose.
Methods: West Yorkshire Trading Standards Service was invited into
Bradford Teaching Hospitals NHS Foundation Trust by the dietetic
team to test the accuracy of 14 digital nutritional weighing scales (four
brands). All scales were placed on the same solid, stable surface and
crown stamped 50 g, 100 g, 200 g, 500 g and 1,000 g calibrated
weights were applied to the centre of each weighing plate. The 100 g
weight was applied a further four times to each scale, placed once on
each corner of the weighing plate to check if it was possible to induce
error by placing the load off centre.
Results: The heaviest weight, 1,000 g, revealed the greatest degree of
error. Thirteen sets of scales weighed the 1,000 g weight as between
998 g and 1,006 g. One set, however, recorded 1,000 g as 1,250 g; this
25 per cent error was apparent at all weights. Placing the 100 g load off
centre made only 1 g variation on any of the scales.
Conclusions: Whilst the majority of scales tested functioned within
acceptable tolerance, one set did not; the degree of error would have led
to a 25 per cent overestimate in insulin dose had the scales been used
unwittingly. We will be purchasing a calibrated 1,000 g weight to offer
a scale checking service for patients as well as being able to assess our
own equipment.
P266
Having a visual reference, Carbs and Cals,
makes insulin pump users carbohydrate
estimates more accurate
NR McConnell
Dietetic Department, Bradford Teaching Hospitals NHS Foundation Trust,
Bradford, UK
Aim: To measure the accuracy of carbohydrate estimates by adult

insulin pump users (or their partner if the main carbohydrate counter is
in the household) and then to see if using Carbs and Cals improves
accuracy. One method of calculating the insulin required for a meal is
based on a ratio of units of insulin to grams of carbohydrate. An
overestimate of only 10 g carbohydrate can result in hypoglycaemia.
All Bradfords insulin pump users (or a partner) are taught to
carbohydrate count and an inability to do so precludes transfer to
pump therapy. Carbs and Cals provides pictures of foods in different
portion sizes labelled with the carbohydrate content.
Method: We asked 36 insulin pump users and two carers to a
carbohydrate counting workshop. Twelve meals/snacks were prepared
and individuals were asked to estimate the amount of carbohydrate in
grams on each plate. Answers were recorded on a data collection sheet.
Once the estimates were made participants were given a copy of Carbs
and Cals and asked to reassess their estimate.
Results: In all, 55 per cent of participants estimates were within 10 g,
65 per cent were within 15 g. Using Carbs and Cals improved
accuracy to 63 per cent within 10 g and 72 per cent to within 15 g.
Conclusion: Carbs and Cals is a visual resource that improves insulin
pump patients estimates of carbohydrate in meals.
2012 The Authors.

P267
Carbohydrate counting and insulin
adjustment group sessions for patients with
Type 2 diabetes on a multiple insulin
injection regime
E Adams and S Hood
Diabetes Centre, Dorset County Hospital, Dorchester, UK
Aims: DAFNE (Dose Adjustment for Normal Eating) and other

carbohydrate counting courses are well established for people with
Type 1 diabetes on multiple insulin injection regimes (basal bolus).
However, less is known about the effectiveness and benefits to patients
with Type 2 diabetes. In 2009 it was decided to offer our carbohydrate
counting course FREEDOM (Flexible Regimes for Eating and Exercise
in Diabetes for Optimal Management) to this group of patients.
Results: It has been demonstrated that people with Type 2 diabetes
have a poor understanding of food groups or recommended portion size
compared with those who attend our course with Type 1 diabetes. It
provided patients with the opportunity to share their frustrations and
achievements with their peers. At 3 months follow-up there was on
average a modest reduction in HbA1c of 0.5 per cent (5 mmol/mol) but
some individuals had achieved a reduction of 3 per cent (30 mmol/mol),
range +1.5 per cent to 3 per cent. On average there was a weight loss of
2kg, range +2 to 4 kg; there was no significant change in cholesterol
levels; all had seen a reduction in their insulin doses, both basal and
bolus. Hypoglycaemia is always a concern to our patient groups, but
having a better understanding about their diabetes management has
reduced the risk and this is demonstrated by reviewing feelings pre- and
post-course. We are continuing to analyse the results of our Type 1 and
Type 2 groups to review outcomes and identify differences.
Conclusions: Carbohydrate counting provides effective strategies for
receptive patients to make lifestyle changes that improve glucose
control, significantly improving long-term complication risks.
P268
The cost-effectiveness of providing DAFNE
to subgroups of predicted responders
J Kruger1, A Brennan1, P Thokala1 and S Heller2
1
2
School of Health and Related Research, University of Sheffield, Sheffield, UK,

Division of Clinical Services, Sheffield Teaching Hospitals, Sheffield, UK
Aims: Dose Adjustment for Normal Eating (DAFNE) is currently

offered to all adults with Type 1 diabetes (T1D) but it has been shown
that HbA1c response to DAFNE is variable between patients (some
patients do not experience an improvement). This study aims to
investigate the cost-effectiveness of providing DAFNE only to
subgroups of predicted responders.
Methods: Data from the National Institute for Health Research
DAFNE Research Programme were used to support all analyses. Two
multiple linear regression models and one logistic regression model
were used to investigate the relationships between patients
psychosocial characteristics before attending DAFNE and their 12month HbA1c response to DAFNE. The regression models were
integrated with a patient level simulation model of T1D. The model
estimated costs and quality-adjusted life-years (QALYs) over a 50-year
time horizon from an NHS perspective. Incremental analyses were
conducted with a comparator of current practice (providing DAFNE to
all adults with T1D).
Results: The results suggest that providing DAFNE only to a subgroup
of predicted responders generates fewer QALYs for higher costs and is
therefore dominated by current practice. The results were insensitive to
2012 The Authors.

DIABETICMedicine
the treatment response prediction model used and to alternative model

assumptions tested in one-way sensitivity analysis.
Conclusions: No changes to clinical practice are recommended. The
adapted economic model offers the opportunity to investigate research
questions about the cost-effectiveness of DAFNE that could not be
assessed using previously published cost-effectiveness models of T1D.
The model could be used to evaluate and compare future developments
of the DAFNE intervention.
P269
Evaluating the effectiveness of two
diabetes education programmes (DESMOND
vs. Conversation Map) for newly diagnosed
Type 2 diabetes patients at NHS Bromley
S Emmambux1 and JW Huber2
1
Life Sciences, Roehampton University, London, UK, 2Centre for Health &
Wellbeing Research, The University of Northampton, Northampton, UK
Aim: To evaluate the effectiveness of two different group education

programmes (DESMOND vs. Conversation Map) for people who are
newly diagnosed with Type 2 diabetes.
Method: Fifty-four patients agreed to participate in this study,
DESMOND (n = 20) and Conversation Map (n = 34). Preevaluation questionnaires were completed to explore patients views
on self-management and post-evaluation questionnaires to measure
patients satisfaction. Metabolic data including fasting blood glucose
level, HbA1c, total cholesterol, creatinine, body mass index and blood
pressure were recorded before and 3 months after. Costs of delivering
both education programmes were calculated.
Results: Most patients were positive about self-managing their
diabetes. Patients satisfaction ratings were high in both cases and the
difference was not statistically significant. In terms of metabolic control,
beside systolic blood pressure, there were no significant changes
between the two group education programmes. When comparing the
cost of delivering the education programmes, it was less costly to run
Conversation Map.
Conclusion: Both group education programmes (DESMOND and
Conversation Map) were effective tools in diabetes self-management.
However, it was more cost effective to run Conversation Map group
education programme.
P270
The cost-effectiveness of providing a DAFNE
follow-up intervention to predicted nonresponders
J Kruger1, A Brennan1, P Thokala1 and S Heller2
1
2
School of Health and Related Research, University of Sheffield, Sheffield, UK,

Division of Clinical Sciences, Sheffield Teaching Hospitals, Sheffield, UK
Aims: Dose Adjustment for Normal Eating (DAFNE) is currently

offered to all adults with Type 1 diabetes (T1D) but it has been shown
that HbA1c response to DAFNE is variable between patients (some
patients do not respond). This study aims to investigate the costeffectiveness of providing an additional follow-up intervention to
subgroups of predicted non-responders.
Methods: One multiple linear regression and one logistic regression
model were used to investigate the relationships between initial 3month change in patients psychosocial characteristics before attending
DAFNE and 12-month HbA1c response to DAFNE. The regression
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models were integrated with a patient level simulation model of T1D.

The model estimated costs and quality-adjusted life-years (QALYs)
over a 50-year time horizon from an NHS perspective. Incremental
analyses were conducted with a comparator of current practice
(providing no follow-up intervention to DAFNE graduates).
Results: The results suggest that providing a follow-up intervention
costing 150 or 359 to predicted non-responders generates more
QALYs for lower costs and therefore dominates current practice. This
result was sensitive to the prediction model used and one-way sensitivity
analyses suggested that a follow-up intervention would still be cost
effective if it provided a 12-month HbA1c reduction of between 0.5 and
1 per cent.
Conclusions: The results provide a useful starting point for
consideration of the required benefit of a DAFNE follow-up
intervention targeted at HbA1c reduction to demonstrate costeffectiveness. The adapted economic model offers the opportunity to
investigate research questions about the cost-effectiveness of DAFNE
that could not be assessed using previously published cost-effectiveness
models of T1D.
P271
A single session of structured education for
newly diagnosed individuals with Type 2
diabetes enhances confidence in engaging
group education and ability to self-manage
G Nasteva1, E Jennings2, P Greene2, J Harvey3 and D Mellor1
1
Clinical Sciences, University of Chester, Chester, UK, 2Nutrition and Dietetics,
Betsi Cadwaladr University Health Board, Wrexham, UK, 3Diabetes and
Endocrinology, Betsi Cadwaladr University Health Board, Wrexham, UK
Aim: To investigate the effect of a single structured education group

session on confidence to engage in group activity and self-management.
Structured education is an essential part of the management of diabetes.
However, a number of issues have been observed, which include that in
some areas only 10 per cent of individuals report being able to access
structured education. This suggests that there may be barriers to access.
Method: A retrospective audit of a single-session group education
programme for individuals with newly diagnosed Type 2 diabetes was
undertaken between 2009 and 2011. These sessions took place in four
locations and were led by three dietitians. A 10-point scale was used to
assess confidence to engage in group education and self-manage
diabetes; these parameters were assessed before and following
attendance at a 2 h structured education session. Differences in
confidence were assessed by Wilcoxon signed ranks and between
location and educator by chi-squared.
Results: For the 271 responses, there was a significant improvement in
confidence to engage in group education (P < 0.001). This change was
also accompanied by a significant improvement in individuals
confidence in their own ability to self-manage their diabetes
(P < 0.001). There was no difference in change in confidence for
either parameter when comparing different locations or dietitians.
Conclusion: It is possible that a single structured group session may
improve patients confidence in engaging in this type of session. Also use
of a simple questionnaire can be used for quality assurance in
quantifying effects of different facilitators and sites of delivery.
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P272
Prevention in practice: diabetes
N Kanumilli and N Milne
General Practice, Northenden Group Practice, Manchester, UK
Aims: To ascertain if lifestyle modification in individuals with either

impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)
could have a positive effect on physical and psychological wellbeing and
if ultimately this could delay or prevent the progression to Type 2
diabetes.
Methods: Twenty-four patients with either IFG or IGT were
randomly recruited from the practice population. A programme of
structured education was delivered over a period of 6 months with
input from the following: practice nurse, general practitioner, health
trainer, dietitians and exercise consultants. Four groups were seen
monthly and the following parameters were observed: glucose
tolerance, body mass index, waist circumference, blood pressure,
lipid profile and wellbeing questionnaires.
Results: Seventeen patients completed the programme. Two had
progressed to Type 2 diabetes at onset. There was a total weight loss of
52kg and reduction in waist circumference of 53cm. Fasting glucose
measurements showed no significant change but the average 2 h
postprandial glucose level dropped from 8.2mmo/l to 6.5 mmol/l.
Wellbeing questionnaires showed a positive improvement.
Conclusion: These results support the statement that lifestyle
modification in those with either IFG or IGT does have a positive
impact on both physical and psychological wellbeing. The reduction in
the average postprandial glucose level suggests that a delay in the
progression to Type 2 diabetes may be implicated but further research
involving greater numbers over a longer period of time would be
required to demonstrate this significantly.
P273
Providing patients access to their online
electronic patient records: an evaluation of
usage and usefulness
F Mukoro, G Sweeney and B Mathews
Research and Evaluation, NHS Kidney Care, London, UK
Background: A system which enables patients with long-term

conditions to access their live test results online may lead to better
self-management and improved health. Renal Patient View (RPV)
provides patients with kidney disease with secure access to their live test
results over the internet, and includes a wide-ranging online discussion
forum. This evaluation aimed to assess the usage and usefulness of RPV
to patients and healthcare professionals.
Methods: The study has been conducted in two phases. Phase 1
examined usage data from Google Analytics and thematic analysis of
comments on the discussion forum. Phase 2 involved surveys and
interviews of patients and healthcare professionals in 10 renal units
which were selected from the 43 participating units in England.
Results: A total of 9,000 visitors make 25,000 visits to RPV each
month. Over 80 per cent of users log in more than once every month.
The Results pages are the most visited pages implying high interest
in viewing live results online, and 7 per cent of RPV users have added
at least one result themselves during the period. Blood pressure
readings were the most frequently entered data. Uptake of the online
discussion forum is 11 per cent. Thematic analysis of all 513 forum
entries revealed that patients use the forum as a resource for
information, a place to share concerns or problems, and to find help
and support.
2012 The Authors.

Conclusions: This study suggests how a system designed to help

patients with kidney disease access their live test results online is used,
and how users may benefit from its usage.
P274
Evaluation of initial structured group
education in newly diagnosed Type 2
diabetes
E Jennings1, P Greene1, G Nasteva2, D Mellor2, P Cowley1 and J
Harvey3
1
Nutrition and Dietetic Department, Betsi Cadwaladr University Health Board,
Wrexham, UK, 2Department of Clinical Sciences, University of Chester,
Chester, UK, 3Diabetes, Endocrinology and Metabolism, Cardiff University,
Cardiff, UK
Background: Established educational programmes for Type 2

diabetes (eg DESMOND, X-PERT) may be more suitable for patients
with some experience and knowledge of diabetes. A shorter initial
education session is likely to be more appropriate at diagnosis. We offer
a single structured session in group format delivered by a dietitian (seven
trained dietitians are used in five localities) within 4 weeks of referral.
This analysis aims to assess which aspects of knowledge are weakest and
which can be most improved.
Method: An 11-item questionnaire was devised to assess knowledge
of diet and exercise in diabetes self-management. Answers were yes/no
and dont know. Subjects completed the questionnaire immediately
before and after participating in a group session. Changes in
proportions correct were assessed by chi-squared test.
Results: Atotalof126patientscompletedallquestionsbeforeandafter
the session. Pre-education scores were lowest for knowledge about the
effects of fat (8.6 per cent correct), fruit (28.7 per cent) and diabetic
products(26.8percent).Scoreswerehighestforeffectofweight(94.4per
cent correct) and exercise in diabetes (94.2 per cent). Large absolute
improvements in knowledge were shown for fruit, diet drinks, diabetic
products,influenceofsnacks,andsugarycarbohydrate(eachP < 0.001).
Lesserimprovementswereshownforknowledgeofpotatocarbohydrate,
exercise and blood pressure and dietary fat (each P < 0.01).
Conclusion: A single group education session increases knowledge of
self-management in newly diagnosed Type 2 diabetes. These results
indicate the areas where patients knowledge is weakest and where a
simple educational message is most effective.
P275
Delivery of the Berger Accu Chek education
programme for patients with Type 1
diabetes: time well spent? A clinical audit
F Hegarty, A Griffin and A Gavaghan
Diabetes Team, Letterkenny General Hospital, Letterkenny, Ireland
Aim: This audit aims to evaluate if attendance at the Berger programme

is beneficial in promoting self-management and improving long-term
glycaemic control (HbA1c) in patients with Type 1 diabetes.
Methods: Six group sessions where held over a 14-month period.
Fifty-five individuals with Type 1 diabetes who attend a diabetes
consultant led clinic were invited to attend. The Berger programme is
delivered jointly by the diabetes specialist nurse and diabetes specialist
dietitian. The main focus of the group is carbohydrate counting and
insulin adjustment. Patients are commenced on the Accu Chek expert
bolus advisor meter. The group is run over two and a half consecutive
2012 The Authors.

DIABETICMedicine
days. Attendees complete a pre- and post-course knowledge

questionnaire. HbA1c is measured at the start of the group and at a
follow-up clinic appointment 36 months later. Clinical data are
collected onto the Prowellness system.
Results: Preliminary data available indicate that 100 per cent of
attendees showed an increase in knowledge regarding their diabetes on
evaluation of their post-course knowledge questionnaires (20
patients).The data available so far have shown an average of 0.8 per
cent reduction in HbA1c from pre-course to clinic follow-up 3
6 months later (23 patients).The group has had a 100 per cent
attendance rate so far (45 patients), with 94 per cent attendance at
1 month follow-up (30/32 patients).
Comments: Full results will be available when the audit is completed
in January 2012.
P276
An interpretative phenomenological
analysis of womens experience of living
with diabetes
JR Smith
Health and Social Care, Open University, Milton Keynes, UK
Aims: To explore how women in midlife perceive the experience of

living with diabetes. Research questions were: What do women describe
as stressful in relation to their diabetes? What impact do these stressors
have on womens lives? How do women with diabetes interpret and
manage their lives?
Methods: An exploratory sequential mixed methods approach
examined the experiences of women aged 4146 with insulin treated
diabetes. Data collection methods included a focus group (n = 5),
survey (n = 59) and face to face interviews and journal keeping (n = 23
and n = 18). Ethical approval was obtained from the university ethics
committee.
Results: Two overarching and interlinked themes of experiencing
stress and maintaining control were identified from interpretative
phenomenological analysis. Three additional major themes were
diabetes as a nuisance, diabetes in daily life, and diabetes during times
of crisis.
Conclusion: Women in midlife who live with diabetes experience a
range of stressors, and there is a complex cyclical relationship between
stress and diabetes with the potential for this to become a spiralling one.
The originality of the study is in the area of identifying diabetes as a
nuisance. Poetic representation has been used to illustrate this theme,
which will be used in dissemination of findings to both lay and
professional audiences. There is the potential for both clinical
application of these findings and future research.
P277
Applying a cognitive behavioural model to a
diabetes self-management education
programme
Y Doherty1, H Daly1, L Martin Stacey1, C Taylor1, J Troughton1
and S Cradock2
1
Diabetes Research Group, University Hospitals of Leicester NHS Trust,
Leicester, UK, 2Department of Health Sciences, University of Leicester,
Leicester, UK
Aim: To address psychological barriers to adoption of self-care

strategies in people with established Type 2 diabetes. DESMOND
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(Diabetes Education and Self-management for Ongoing and Newly

Diagnosed) is a nationally recognised evidence-based programme
promoting self-management of Type 2 diabetes. The programme is best
known for its initial session of education. The follow-up module,
Going Forward with Diabetes, is aimed at longer-term selfmanagement. This model is undergoing investigation via a
randomised controlled trial following a substantial development phase.
Methods: Pilot work on the patient education programme identified
that participants were constantly highlighting psychological issues as
barriers to adopting self-management strategies. To address this issue, a
psychological support intervention was developed and integrated as a
core component of the patient curriculum. The six cycles maintenance
model for depression (Moorey, 2010) has been adapted and employed
to facilitate participants discovering and exploring factors impacting on
psychological wellbeing and capacity to engage in self-care and lifestyle
change. Our model consists of four separate interactive sessions and
personalised work sheets delivered at the start of each quarterly patient
education session of the DESMOND ongoing study randomised
controlled trial.
Results: Initial results from the iterative cycle of development have
demonstrated that it is essential to address psychological barriers for
self-management interventions to be effective; this model is acceptable
to patient participants; the model is deliverable by trained healthcare
professional educators in primary care.
Conclusion: This model and its tools are transferable to other selfmanagement programmes independent of this study.
Reference:
[1] Stirling Moorey (2010). The six cycles maintenance model: Growing
a vicious flower for depression. Behavioural and cognitive
psychotherapy 38: 173184.
P278
Early changes in glycated haemoglobin
(HbA1c) can be used to predict glycaemic
outcomes at 1 year following the Dose
Adjustment for Normal Eating (DAFNE)
course
C Cheyette and A Beckwith
Diabetes, Kings College Hospital, London, UK
Objectives: Structured follow-up of the DAFNE programme

incorporates group review at 2 and 12 months post-course. We
analysed the predictive impact of HbA1c and educator documentation
at first review in determining 1 year glycaemic outcomes.
Methods: Case notes of 52 people with Type 1 diabetes who
completed the DAFNE course at Kings College Hospital during
2009 were analysed retrospectively. HbA1c data were extrapolated at
baseline and at 2 and 12 months. The proportion of patients who
benefited clinically was calculated and the quality of documentation
was scored for completeness.
Results: Completed records of 34 patients were retrieved; 26 of these
had an HbA1c of 7.5 per cent or above at baseline. A clinically significant
fall in HbA1c was demonstrated in 54 per cent (n = 14) of these patients
from baseline (9.2 per cent 1.0) to 2 months (8.1 per cent 1.1); this
was maintained at 1 year (8.2 1.4). Deterioration in HbA1c was
observed in 30 per cent (n = 7) from baseline (8.3 per cent 0.8) to
2 months (8.7 per cent 0.9) and at 1 year (8.4 per cent 0.6).
Inferences cannot be drawn between the quality of the healthcare
records and long-term glycaemic outcomes due to the lack of structured
documentation. The small sample further impeded this analysis.
114
Conclusions: Early changes in HbA1c predict glycaemic outcomes at

1 year post-course; this association was not related to the quality of
healthcare records. Adopting a systematic approach whereby patient
progress is embedded within an individualised shared care plan would
ensure completeness of review.
P279
Diabetes Improvement through Mentoring
and Peer-led Education (DIMPLE)
C Mead1, P Gilbert2, S Husbands3, J OBrien5, R Matthews4 and
DIMPLE Project Group6
1
Public Health, NHS Hammersmith and Fulham, London, UK, 2Hammersmith
and Fulham Diabetes User Group, London, UK, 3Public Health, NHS Harrow,
London, UK, 4Patient and Public Involvement, National Institute for Health
Research (NIHR) CLAHRC for Northwest London, London, UK, 5Equality and
Diversity Team, Diabetes UK, London, UK, 6NHS North West London, London,
UK
Aims: The aim of the study is to improve and spread self-care

management for people with and at risk of Type 2 diabetes, through
partnership. We are testing three types of peer intervention on
preventing Type 2 diabetes and improving outcomes for people with
diabetes: peer educators, peer mentors and diabetes champions.
Methods: Peer educators and mentors are recruited mainly from
people living with diabetes. They are trained to deliver the X-PERT
structured education course alongside healthcare professionals, or in
one to one sessions. Peer mentors and diabetes champions are recruited
from communities with a high prevalence or high risk of diabetes.
Champions will deliver culturally appropriate health promotion
messages on reducing risk factors and recognising signs and
symptoms of diabetes. The impact of each intervention on the peer
educators, mentors and champions is being evaluated, as well as the
outcomes and impact of their work on others. Outcome measures
include demographic data; clinical outcome measurements, such as
HbA1c; knowledge and understanding of diabetes; and measures of
health behaviour and self-efficacy. Validated questionnaires are used to
determine the latter. People with diabetes receiving peer education or
mentoring will also be surveyed about their satisfaction with the service.
Results: To date 10 people with diabetes have been recruited and
undergone training as peer educators. Five of them have started to codeliver X-PERT and introduction to diabetes courses. Potential mentors
are undergoing selection to assess their suitability and readiness. Sixteen
champions have been recruited, trained and taken part in community
events.
P280
Primary to secondary school transition for
children living with Type 1 diabetes
ME Wasserfall1, B Widmer2, P Jackson3, J Cropper4 and C
Harbutt5
1
Nutrition and Dietetics, Evelina Childrens Hospital, Kings College NHS
Foundation Trust, London, UK, 2General Paediatrics, Evelina Childrens
Hospital, Kings College NHS Foundation Trust, London, UK, 3Nutrition and
Dietetics, Guys and St Thomas NHS Foundation Trust, London, UK,
4
Childrens Psychological Medicine, Evelina Childrens Hospital, Kings College
NHS Foundation Trust, London, UK, 5General Paediatrics, Kings College NHS
Background: Many schools have well established pathways to

smooth transition from primary to secondary school. There is little
2012 The Authors.

published, however, on the support for children with chronic

conditions, specifically Type 1 diabetes.
Methods: In the past 3 years, Year 6 children with Type 1 diabetes
have been invited with their families to a session to discuss issues around
managing diabetes in the secondary school environment. These sessions
have been facilitated by the paediatric diabetes team. Parents and
children were able to discuss concerns they had in separate groups.
Questions were recorded on flipcharts and groups were encouraged to
discuss strategies. The final session was attended by a Year 7 pupil who
talked about her experience of life at secondary school.
Results: This year six families attended (out of 20 invited). Facilitated
discussions raised questions such as where will I do my lunchtime
injection?, who will be responsible for supervision of injections and
hypoglycaemia treatment? where will I keep my hypoglycaemia
treatment when I move to different classes?. Questions from both
groups were similar in content, but parents had more concerns
regarding diabetes and children had more regarding the social aspects
of school life.
Summary: This forum provided children and their families a platform
to voice concerns they had. These sessions have been a useful addition in
supporting families in anticipating and planning for change.
Evaluations show that both parents and children have found them
useful and enjoyable. The personal account of a child in Year 7 was
particularly well received.
P281
The impact and outputs from the Year of
Care programme
SH Roberts1,2, S Dilks3, S Eaton1, I Hodkinson4, G Johnson5, N
Lewis-Barned1, L Oliver1, B Turner2 and A Worthington4
1
Diabetes Resource Centre, Northumbria Healthcare NHS Foundation Trust,
North Shields, UK, 2Diabetes UK, London, UK, 3NHS Kirklees and Calderdale,
Huddersfield, UK, 4NHS Tower Hamlets, London, UK, 5NHS Diabetes,
Newcastle-upon-Tyne, UK
Aim: The Year of Care (YOC) programme aimed to demonstrate how

to introduce personalised care planning (CP) into routine practice, and
ensured that community services to support self-management were
available via commissioning.
Methods: A framework for delivery and quality assured training and
training the trainers programmes were developed, piloted and
evaluated using mixed methods in three diverse communities and
subsequently scaled up to 12 others, including primary and specialist
diabetes care.
Results: CP became routine for the majority of practices in the pilot
communities: Tower Hamlets 97 per cent, Kirklees 83 per cent, North
Tyneside 79 per cent and West Northumberland 73 per cent. In all, 76
per cent of people with Type 2 diabetes had one or more CP
consultations. A total of 1,000 professionals and 45 local trainers were
trained. People with Type 2 diabetes reported improved experience of
care and self-care behaviour. Professionals reported improved job
2012 The Authors.

DIABETICMedicine
satisfaction, practice organisation, team work and productivity.

Changes in clinical indicators across populations were seen after two
or three CP cycles including improving weight, blood pressure and
maintenance of glycaemic control with low cost prescribing.
Productivity: CP is cost neutral at a practice level, and there are
potential savings for some. Successful implementation involved strong
leadership, flexible commissioning, practice facilitation and tailored
training and led to wider service redesign.
Conclusion: CP can be successfully introduced into routine practice
for people with Type 2 diabetes using the YOC approach, with
improvements in quality and productivity; addressing NICE Quality
Standard 3, contributing to QIPP and reducing inequalities for
disadvantaged populations.
P282
Short-term evaluation of care planning
implementation in primary care
W Malik1, P Hill2 and M Ince3
1
Community Specialist Diabetes Team, Birmingham Community Healthcare
Trust, Birmingham, UK, 2Clinical Health Psychology, Birmingham Community
Healthcare Trust, Birmingham, UK, 3The Hawthorns, GP Surgery, Redhill, UK
Background: Incorporating care planning as routine will be

challenging for diabetes services; however, the recent NICE Quality
Standard 3 in diabetes suggests that people with diabetes should
participate in annual care planning in order to document agreed goals
and an action plan. Further, the National Year of Care (YOC) project
indicated that care planning could be adopted as the norm in the
majority of practices across their pilot sites. We describe the short-term
achievements of locally developed and delivered care planning training
for staff across two sites in the UK.
Method: A locally designed workshop included a whole day of the
communication skills needed for care planning and half a day of
exploring processes which needed to change within the GP surgery
setting for care planning to succeed. Practices were encouraged to come
up with their own solutions. Practices were asked to collect baseline
data on patient satisfaction with the consultation, resource utilisation
and weight/blood pressure and HBA1c. A satisfaction questionnaire
was re-administered after the care planning consultation and other
parameters after the second consultation.
Results: Evaluable data were available for up to 57 patients. More
patients (61.4 per cent to 70 per cent) reported confidence in managing
their diabetes; unplanned visits were reduced and planned visits to GPs
increased. There was no difference between baseline blood pressure and
HbA1c cholesterol and measures made on the second visit.
Conclusion: Short-term evaluation suggests improved patient
confidence in managing diabetes, fewer unplanned consultations,
more planned consultations, but no effect on clinical measures taken.
Long-term evaluation is needed to understand the possible impact of
care planning.
115
DIABETICMedicine
Clinical care and other categories posters: ethnic
Clinical care and other categories posters: ethnic

P283
Knowledge and beliefs of people of SubSaharan African origin residing in Medway,
Kent, about Type 2 diabetes and their
willingness to accept church-based
interventions: could this be an effective
case of a Big Society intervention?
OM Oduniyi1,2 and M Edwards1
1
Public Health, University of Liverpool, Liverpool, UK, 2Medway School of

Pharmacy, University of Kent, Chatham, UK
Aims: People of Sub-Saharan African (SSA) origin are a recognised

high risk group for Type 2 diabetes (T2D). Innovative and culturally
relevant strategies are needed for early detection and targeted
prevention. The inclusion of church-based interventions would be
very timely given the current UK governments push for the
introduction of a Big Society approach to future healthcare. This is
an exploratory study using a qualitative approach to gain an insight into
the beliefs of people of SSA origin about diabetes and the place of the
church in health promotion with the goal of making recommendations
towards prevention strategies.
Methods: Twenty-one adults were purposively recruited from Black
majority churches in Medway. Four focus group discussions were held,
stratified by gender and age group. Interviews were recorded,
transcribed and analysed by thematic content analysis and the PEN3
Framework.
Results: Knowledge was generally limited with several
misconceptions about diabetes. Health seeking behaviours were poor,
views about healthcare professionals were mostly negative and many
expressed that most people of SSA origin fail to adopt healthy lifestyles.
There was a lack of apparent openness where health issues are
concerned. This would impact on how to implement interventions. The
church was seen as an acceptable venue for educational programmes.
Pastors are highly regarded and would be very influential in creating
awareness and encouraging lifestyle changes.
Conclusions: These findings highlight the need for more public health
education about diabetes to people of SSA origin and the great potential
for church-based community-level interventions for this hard to reach
group.
P284
A systematic review of cultural barriers
impeding ethnic minority groups from
accessing effective diabetes care services
P Zeh1,2, HK Sandhu1, AM Cannaby2 and JA Sturt1,2
1
Warwick Medical School, University of Warwick, Coventry, UK, 2Research
and Development, University Hospitals Coventry and Warwickshire NHS Trust,
Coventry, UK
Aim: To identify cultural barriers and opportunities for effective

diabetes care delivery in ethnic minority groups (EMGs).
Methods: Papers from four databases (Medline, CINAHL,
Cochrane, DARE) from inception to September 2011 and from NHS
specialist libraries for diabetes, ethnicity and health were retrieved for
this review, together with reference lists of the retrieved papers.
Inclusion criteria were qualitative or survey studies. Randomised
controlled trials involving EMGs with diabetes within a global majority
116
population were excluded. Data were collected on all relevant themes.

Two reviewers independently conducted paper selection and appraisal.
Results: Twenty-two out of 317 papers were analysed. Due to the
heterogeneity of the studies, a narrative analysis was undertaken. The
results revealed outcomes from eight emerging themes: (1) strong
adherence to culture in diet, exercise and social interactions; (2) strong
adherence to religious beliefs; (3) linguistic differences between patients
and health workers; (4) low health literacy levels; (5) different beliefs
about health and illness; (6) diverse perceptions of professional
competency and preference of care settings; (7) low accessibility of
culturally sensitive information/services; (8) low compliance and
concordance with professional advice.
Conclusions: Cultural and linguistic barriers were identified and
found to compromise the level of diabetes service delivery to EMGs,
especially South Asians, by service providers. A better understanding
and respect for cultural differences by service providers can bridge some
health inequality gaps during care and service delivery to EMGs with
diabetes. Culturally competent training for service providers and
integration of health education/promotion programmes into the
customs of specific South Asians should be carried out.
P285
The provision of culturally competent
diversity interventions to ethnic minority
groups with diabetes: a systematic review
P Zeh1,2, HK Sandhu1, AM Cannaby2 and JA Sturt1,2
1
Warwick Medical School, University of Warwick, Coventry, UK, 2Research
and Development, University Hospitals Coventry and Warwickshire NHS Trust,
Coventry, UK
Aim: To examine the effectiveness of culturally competent

interventions tailored to the needs of people from ethnic minority
groups (EMGs) with all types of diabetes.
Methods: Medline (NHS Evidence), CINAHL and reference lists of
retrieved papers were searched from inception to September 2011 with
two NHS specialist libraries for diabetes, and ethnicity and health. In
addition, Google, Cochrane and DARE databases were searched, and
experts in the field were consulted. Studies were quality assessed.
Studies were eligible for inclusion if they reported primary research on
the impact of culturally competent interventions on any outcome
measures to any EMG with any type of diabetes. Paper selection and
appraisal were conducted independently by two reviewers.
Results: Eleven papers out of 320 were analysed. The heterogeneity of
the studies required narrative analysis. Study designs varied with
delivery by a diverse range of health workers. Quality assessment of the
studies found 55 per cent of the interventions to be highly culturally
competent (scoring 90100 per cent) and 45 per cent moderately
culturally competent, scoring 7089 per cent. The consistent
fundamental finding was that any intervention, tailored to EMGs by
integrating the elements of culture, language, religion and health literacy
skills, produced a positive impact on the wellbeing of the patient.
Conclusions: Benefits in using culturally competent interventions
with EMGs with diabetes were identified. Due to mixed methodologies
and outcome measures in the review, the data did not allow for
convincing comparisons across countries, EMGs or intervention types.
Further culturally competent interventions are required to improve care
and should include a cost-effectiveness evaluation which can influence
diabetes service commissioners to decide on its implementation.
2012 The Authors.

Clinical care and other categories posters: foot and neuropathy
DIABETICMedicine
Clinical care and other categories posters: foot and

neuropathy
P286
The proinflammatory cytokine TNF-a
modulates RANKL-mediated osteoclastic
resorption in vitro in patients with acute
Charcot osteoarthropathy
NL Petrova1, C Shanahan2 and ME Edmonds1
1
Diabetic Foot Clinic, Kings College Hospital, London, UK, 2Cardiovascular
Department, Kings College London, London, UK
P290
Trends in the incidence of lower extremity
amputations in individuals with and
without diabetes over a five year period in
the Republic of Ireland
C Buckley1,2, A OFarrell3, R Cavanagh4, AD Lynch1, D De la
Harpe3, H Johnson3, IJ Perry2, C Bradley1 and M Horgan1
1
Department of General Practice, University College Cork, Cork, Ireland,

Department of Epidemiology and Public Health, University College Cork,
Cork, Ireland, 3Health Intelligence Unit, Health Service Executive, Dublin,
Ireland, 4Department of Endocrinology, St Vincents Hospital, Dublin, Ireland
2
P287
Hospital admissions for diabetic foot
disease
P Follett1, R Young2 and N Holman1
1
Diabetes Health Intelligence, Yorkshire and Humber Public Health
Observatory, York, UK, 2Diabetes and Endocrinology, Salford Royal NHS
Foundation Trust, Salford, UK
P288
NICE feet shame about the sores: an audit
of foot inspection of inpatients suffering
with diabetes
R Thomas
Podiatry Department, Morriston Hospital, Swansea, UK
P289
A population-based study of the
relationship between neuropathic pain
severity and important patient-related
health outcomes in diabetic neuropathy:
time to revaluate current clinical practice?
Aims: Diabetic foot disease is a major health problem and lower

extremity amputation remains a common outcome. Studies estimating
the incidence of lower extremity amputation in Ireland are lacking. The
aims of this study are to describe trends in the incidence of nontraumatic amputations in individuals with and without diabetes and
estimate the relative risk of an individual with diabetes undergoing a
non-traumatic amputation compared with an individual without
diabetes.
Methods: All adults who underwent a non-traumatic amputation in
Ireland during 20052009 were identified using Hospital Inpatient
Enquiry data. Participants were classified as diabetic or non-diabetic.
Incidence rates were calculated using the number of admissions for
diabetes- and non-diabetes-related lower extremity amputations as
the numerator and estimates of the resident population with and
without diabetes as the denominator. Trends over 5 years were
analysed.
Results: Total diabetes-related amputation rates remained steady
during the study period: 221.7 in 2005 and 193.1 in 2009 per
100,000 people with diabetes (P = 0.69). Total non-diabetes-related
amputation rates dropped non-significantly from 12.2 in 2005 to 8.8
in 2009 per 100,000 people without diabetes (P = 0.07). An
individual with diabetes was 18.2 (95 per cent CI 15.621.2) times
more likely to undergo a non-traumatic amputation than an
individual without diabetes in 2005 and this did not change
significantly by 2009.
Conclusion: This study provides the first national estimate of lower
extremity amputation. Diabetes-related amputation rates have
remained steady despite an increase in people with diabetes. These
estimates provide a baseline to allow follow-up over time.
TC Cash, D Selvarajah, A Roddick, L Thomas, R Gandhi and S

Tesfaye
Diabetes, Royal Hallamshire Hospital, Sheffield, UK
2012 The Authors.

117
DIABETICMedicine
P291
The West of Ireland diabetes foot study:
prevalence of risk factors for diabetic foot
ulceration in Irish general practice
L Kelly1, L Hurley1, AP Garrow2, LG Glynn3, C McIntosh4, P
Gillespie5 and SF Dinneen1,6
1
Diabetes Centre, Galway University Hospitals, Health Service Executive (HSE)
West, Galway, Ireland, 2School of Health Sciences, University of Salford,
Salford, UK, 3Department of General Practice, National University of Ireland
Galway, Galway, Ireland, 4Discipline of Podiatry, School of Health Sciences,
National University of Ireland Galway, Galway, Ireland, 5Irish Centre for Social
Gerontology, School of Business and Economics, National University of
Ireland Galway, Galway, Ireland, 6Department of Medicine, National
University of Ireland Galway, Galway, Ireland
Objectives: The Irish National Diabetes Programme recommends

diabetic foot screening in general practice with subsequent care
determined by the patients risk status. This study aims to describe
the prevalence of foot complication in Irish general practice.
Methods: All patients with diabetes attending 12 general practices
were invited for foot screening. Examination comprised 10 g
monofilament cutaneous pressure perception (CPP), vibration
perception threshold (VPT) and a composite modified neuropathy
disability score (mNDS). Vascular status was assessed by palpation of
pedal pulses. As an indicator of foot deformity we used the hallux valgus
(HAV) scale.
Results: In all, 563 of 827 (68 per cent) patients attended for
screening. Mean age was 64 years (SD 13), 60 per cent were male and
90 per cent had Type 2 diabetes. Mean HbA1c was 7.3 per cent (SD
1.4), 51 per cent had hypertension, 26 per cent cardiovascular disease,
3.7 per cent reported a prior foot ulcer and 1.6 per cent an amputation.
On examination 25 per cent had impaired CPP, 23 per cent had
impaired VPT and 24 per cent had an abnormal mNDS. All three
modalities were abnormal in 10 per cent of patients; 18 per cent had two
or more pedal pulses absent and 2.4 per cent had severe HAV deformity.
Applying these findings to the Scottish Intercollegiate Guidelines
Network risk stratification system showed 64 per cent, 25 per cent
and 11 per cent respectively were at low, moderate and high risk of
future ulceration. Of those at high risk, 32 per cent were receiving
diabetes care exclusively in general practice.
Summary: Our data show for the first time the extent of diabetic foot
problems in a representative sample of patients in Irish general
practice. Extrapolating these data will inform national policy in this
area.
P292
Vascular intervention in diabetic foot ulcer
patients promotes healing and prevents
amputation only when performed early
after presentation of ulcer
R Gornall1, R MacCarthy2, J Isaacs3, S Cliff4, I Dimitropoulos5
and RB Paisey5
1
Podiatry, Torbay Care Trust, Torquay, UK, 2Vascular Surgery, South Devon
Healthcare NHS Foundation Trust, Torquay, UK, 3Radiology, South Devon
Healthcare NHS Foundation Trust, Torquay, UK, 4Nuffield Studentship, South
Devon Healthcare NHS Foundation Trust, Torquay, UK, 5Medicine, South
Devon Healthcare NHS Foundation Trust, Torquay, UK
Aim: Lower limb peripheral arterial disease is a common contributory

factor in the need for lower extremity amputation in diabetic persons
with foot ulcers. Revascularisation can be effective but timing may be
118
critical. Our aim was to audit the effectiveness of lower limb angioplasty
and bypass grafting in ulcer healing and prevention of amputation and
death in diabetic subjects with foot ulceration.
Methods: In total 250 foot ulcers in persons with diabetes were
treated in South Devon Healthcare Trust clinics between August 2009
and July 2011 and their details, interventions and outcomes were
recorded prospectively on a database.
Results: Sixty-three were clinically diagnosed with significant
ischaemia and underwent duplex scanning. Thirty-seven proceeded to
angioplasty and eight to femoral-popliteal bypass grafting. Intervention
within 20 days of ulcer presentation resulted in healing in all 16 cases,
whilst delay beyond this time in 29 subjects was associated with healing
in eight, minor amputation in 11, major amputation in five and death in
five. Fishers exact test showed significant difference in outcome
according to the timing of intervention not explained by differences in
age, gender or renal function. This is in the context of 20 minor
amputations, nine major amputations and 20 deaths in the 187 subjects
without critical lower limb vascular disease.
Conclusions: Foot ulcers complicated by ischaemia in those with
diabetes should be revascularised early to improve outcome.
P293
An analysis of PressureStat measurements
collected during the West of Ireland
Diabetes Foot Study
S Cormican1, L Kelly2, L Hurley2, AP Garrow3, LG Glynn4,
C McIntosh5 and SF Dinneen1,2
1
Department of Medicine, National University of Ireland Galway, Galway,
Ireland, 2Diabetes Centre, Galway University Hospitals, HSE West, Galway,
Ireland, 3School of Health Sciences, University of Salford, Salford, UK,
4
Department of General Practice, National University of Ireland Galway,
Galway, Ireland, 5Discipline of Podiatry,School of Health Sciences, National
University of Ireland Galway, Galway, Ireland
Aim: Elevated plantar pressure (EPP) is a risk factor for diabetic foot
ulceration but is difficult to measure and define clinically. We aimed to
determine the usefulness of PressureStat measurements in diabetic foot
assessments.
Methods: The PressureStat device enables quantification of EPP by
creating a carbon footprint. A total of 530 pairs of PressureStat
measurements were collected during the West of Ireland Diabetes Foot
Study. These inprints were analysed and described according to
presence or absence, site and area of EPP, and foot arch type. Chisquared tests were used to determine correlations between these data
and other risk factors.
Results: Based on the definition used (> 6.5kPa of plantar pressure) 76
per cent of individuals had one or more areas of EPP. The mean number
of EPP sites was three on the right foot and four on the left. In all, 8 per
cent had EPP based on a definition of > 10 sites with pressure > 6.5kPa.
The commonest EPP sites were the first and fifth metatarsal heads (50
per cent and 28 per cent respectively) and the hallux (44 per cent). Pes
cavus, pes planus and neutral feet were present in 6 per cent, 9 per cent
and 80 per cent respectively. Insensitivity to the 10 g monofilament, an
indicator of sensory dysfunction, was commoner among individuals
with vs. without EPP (25 per cent vs. 15 per cent for > 6.5kPa,
p = 0.043; and 48 per cent vs. 21 per cent for EPP at > 10 sites;
p < 0.001). EPP was not associated with abnormal vibration perception
threshold or neuropathy disability score. EPP defined as > 10 sites was
associated with future risk of ulceration (odds ratio 10.4; 95 per cent CI
2.740.6).
Conclusion: We conclude that measurement of EPP adds value to
diabetic foot assessment in a research setting.
2012 The Authors.

P294
The West of Ireland Diabetes Foot Study: the
incremental costs of diabetic foot ulceration
in Ireland
P Gillespie1, L Kelly2, L Hurley2, AP Garrow3, LG Glynn4,
SF Dinneen1,5 and C McIntosh6
1
Irish Centre for Social Gerontology, School of Business and Economics,
National University of Ireland Galway, Galway, Ireland, 2Diabetes Centre,
Galway University Hospitals, Health Service Executive (HSE) West, Galway,
Ireland, 3The School of Health Sciences, University of Salford, Salford, UK,
4
Department of General Practice, National University of Ireland Galway,
Galway, Ireland, 5Department of Medicine, National University of Ireland
Galway, Galway, Ireland, 6Discipline of Podiatry, School of Health Sciences,
National University of Ireland Galway, Galway, Ireland
Aim: To explore the incremental costs of diabetic foot ulceration in

Ireland.
Methods: Data from the West of Ireland Diabetes Foot Study were
used for the analysis. In the study, patients on the diabetes registers of 12
general practices were invited to attend for foot screening. Of 563
participants, 16 (3 per cent) developed new ulcers over the next
18 months. A retrospective cost analysis was conducted for all who
developed ulcers and for a representative sample (209, or 38 per cent) of
the non-ulcerated population. A societal perspective was adopted in
that costs to the healthcare system and the patient were considered. The
former included primary, secondary and community care service usage.
The latter included patients own-time input in treatment and travel
costs. Resource usage was identified via patient questionnaires at
18 months post screening and a vector of unit costs was applied to
calculate costs. Multivariate regression analysis was used to examine
the effect of experiencing a new ulcer on costs of care.
Results: Mean healthcare cost at 18 months was 2,785 (SD 6,472)
for non-ulcerated patients and 9,566 (SD 18,753) for ulcerated
patients. The equivalent patient cost estimates were 189 (SD 257) and
688 (SD 479) respectively. After controlling for other clinical and
socio-demographic variables, ulceration was associated with a
statistically significant increase of 7,308 (P = 0.004) in healthcare
costs and 499 (P < 0.001) in patient costs.
Conclusions: The incremental costs of diabetic foot ulceration in
Ireland are substantial. These data can help inform policy and planning
in this area in the future.
P295
Do we care about our patients with diabetes
feet? Diabetic foot examination at the
front-door
SN Iqbal1, Z Majid1, A Tiwari2, I Wilson3 and MA Saeed4
1
College of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK, 2Department of Vascular Surgery, University Hospitals
Birmingham NHS Foundation Trust, Birmingham, UK, 3Department of
Podiatry, University Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK, 4Department of Diabetes, University Hospitals Birmingham
NHS Foundation Trust, Birmingham, UK
Aims: National Institute for Health and Clinical Excellence (NICE)

guidelines were published in March 2011 outlining inpatient
management of diabetic foot care. Our aim was to assess how the
University Hospital Birmingham NHS Foundation Trust was
performing.
Methods: Relevant parts of NICE Guideline CG119 were used to
audit the clinical practice of patient assessment within the first 24 h of
diabetic foot related emergency admissions. Fifty-eight admissions over
2012 The Authors.

DIABETICMedicine
a 5-year period were identified by search terms cellulitis or

osteomyelitis of toe or foot and case notes and electronic records
were studied.
Results: The ratio of males to females was 67 to 33 per cent; age range
2884 years (median 60.43 years); and the ratio of Type 1 to Type 2
diabetes was 17.20 to 82.85 per cent. Unilateral cellulitis was the main
reason for admission (77.6 per cent). Although 96.6 per cent of patients
had their feet examined, this was not always adequate: only 43.1 per
cent of patients had peripheral vascular disease assessment, with the
highest (56.3 per cent) and lowest (25 per cent) proportions of
assessment done by foundation and middle-grade clinicians,
respectively; peripheral neuropathy was assessed in only 29.3 per cent
of patients with the highest (37.5 per cent) and lowest (25 per cent)
proportions of assessment performed by middle-grade clinicians and
consultants, respectively. Although not part of the NICE guidelines,
Waterlow scoring by nursing staff, for pressure sore risk assessment,
was only done in 34.5 per cent of patients.
Conclusion: There is a clear need for improved examination of the
diabetic foot upon emergency admission in order to provide adequate
care and to identify high risk patients. Diabetes UK should endeavour to
heighten awareness of diabetic foot care amongst non-diabetes
clinicians.
NB: Co-first authorship SN Iqbal and Z Majid
P296
The cost of foot care for people with
diabetes in England and the potential for
quality improvement and savings: an
economic analysis
M Kerr1,2
1
2
NHS Diabetes, NHS Diabetes and Kidney Care, Newcastle-Upon-Tyne, UK,

Insight Health Economics, London, UK
Aim: To estimate annual NHS expenditure in England on foot

ulceration and amputation in people with diabetes and the potential
for high quality targeted care to improve outcomes and reduce costs.
Methods: An economic model was constructed to estimate NHS
expenditure on care for people with diabetic foot complications. Model
parameters were derived from routine data sets, supplemented by
evidence from clinical studies and patient survey data. Expenditure
estimates were produced for community, outpatient and inpatient care.
The cost of multidisciplinary foot care teams was estimated, based on
resource data from two English providers, and potential savings and
quality of life impacts were modelled, based on evidence from clinical
studies.
Results: It is estimated that the NHS in England spends 450 million
580 million a year on foot care for people with diabetes. Clinical
evidence suggests that multidisciplinary foot care teams can reduce
ulcer duration, amputation rates and mortality. Many of the benefits
arise through early access to specialist care. The quality-adjusted lifeyear (QALY) gains from a 50 per cent reduction in late referrals of
diabetic foot ulcers to specialist care are estimated at 37 million45
million a year. It is likely that multidisciplinary foot care teams are cost
saving or cost neutral to the NHS.
Summary: The cost to the NHS of foot care for people with diabetes is
substantial. Commissioners and providers have the potential to
improve patient outcomes and increase NHS productivity through
increased use of multidisciplinary foot care teams.
119
DIABETICMedicine
P297
Improvement in foot examination and
documentation in inpatients with diabetes
following introduction of a foot stamp
A Norris, JSW Li Von Chong, AP Brooks, S Nero, K Haines,
K Lambert, G Mlawa, E Tang, R Goodwin, S Kirby and S Zarif
Diabetes Team, Winchester and Eastleigh Healthcare NHS Trust, Winchester,
UK
Aim: Many diabetic foot ulcers begin or deteriorate during hospital

admission. Diabetic foot problems impact severely on patients quality
of life in addition to the financial burdens to the NHS. Delays in
diagnosis and management contribute to higher amputation rates.
Putting Feet First 2009 and NICE 2011 give clear guidance on
establishing pathways of care for the feet of inpatients with diabetes. In
line with the National Diabetes Inpatient Audit 2010 27.3 per cent
(n = 45) of patients had a documented foot assessment in our hospital.
Our aim was to ensure that all inpatients receive a foot assessment and
all patients admitted via the medical assessment unit receive a foot check
within 4 h.
Method: An educational talk was presented at the Trust induction
programme to all junior doctors outlining the risk to patients with
diabetes from an inpatient stay and importance of early detection. A
display of key facts and how to assess the foot was added to the screen
saver of all hospital computers and an information board was displayed
on the medical admission ward. A foot-shaped stamp was used to
record findings. High risk patients were identified to the diabetes team.
Results: At 3 weeks 62 per cent (n = 47) patients had a documented
foot review.
Conclusions: Raising awareness has improved the recorded number
of feet examined during admission. Timely review occurred on
patients entering hospital via the medical assessment unit. Challenges
remain to sustain improvement in the longer term. The 2011 national
audit aims are to ensure patients entering hospital via A&E or surgical
admissions are examined within 4 h and to establish a
multidisciplinary foot team for ongoing management once at risk
individuals are identified.
P298
Establishing a multidisciplinary diabetes
foot clinic does not ensure attendance nor
reduce amputation rates
JM Mongan1, TO Olateju1, S Tuck2 and D Meeking1
1
Diabetes Centre, Queen Alexandra Hospital, Portsmouth Hospital NHS Trust,
Portsmouth, UK, 2Podiatry, Solent Healthcare, Portsmouth, UK
Aims: Despite the presence of a local multidisciplinary diabetes foot

clinic (MDFC) our amputation rate in patients with diabetes remains
above the national average. Our aim was to examine several crossservice databases and ascertain the pathways of care patients with
diabetes have received prior to and following amputation.
Methods: We examined data from 103 patients undergoing major
amputation compiled from disablement services, community podiatry
and hospital databases in 2009 and 2010. We ascertained whether
patients had been seen in community podiatry and/or the MDFC
preceding amputation, and if there was a yearly change in referral rates.
Results: Of 103 patients seen in the disablement services following
amputation in 20092010, 48 (47 per cent) had diabetes. In 2009 14/25
(56 per cent) of patients with diabetes were reviewed by community
podiatry and only 7/25 (28 per cent) by the MDFC during the
12 months preceding amputation. In 2010 18/23 (78 per cent) had been
reviewed in community podiatry and only 3/23 (13 per cent) in the
120
MDFC. This increase in podiatry review from 2009 to 2010 was

significant (P < 0.02, df = 1) but was accompanied by a reduction in
referrals to the MDFC. Post amputation, none of the 2009 patients saw
podiatry within 6 months compared with five (23 per cent) in 2010.
Only five (20 per cent) in 2009 and two (9 per cent) in 2010 were seen in
the MDFC.
Conclusions: Our results emphasise the need for ongoing education
of podiatrists and primary care workers about the importance of
multidisciplinary foot care to ensure that patients with diabetic foot
disease are referred to the MDFC before it is too late!
P299
Development of a podiatry led community
foot screening service in North Wales
CL Morrison1, G Morrison2 and S Harmes3
1
Pendyffryn Medical Group, Prestatyn, UK, 2Diabetes Centre, Royal Liverpool
University Hospital, Liverpool, UK, 3Betsi Cadwaladr University Health Board,
Royal Alexandra Hospital, Rhyl, UK
Background: Since the inception of the Quality and Outcomes

Framework (QOF) in 2004, peripheral pulse examination and
neuropathy testing have been emphasised as an important component
of the diabetes annual review. However, many in primary care lack the
confidence and proficiency to undertake the examination adequately
and there is no governance system to ensure competencies and monitor
quality standards. In 2009, the central division of Betsi Cadwaladr
University Health Board comprising the local health boards of Conway
and Denbighshire reconfigured podiatry services to provide a
community based foot screening service for patients with diabetes
registered in primary care.
Results: The podiatry screening service comprises a team of podiatry
assistants and a supervising extended scope practitioner undertaking
367 screening sessions in a year, located within 30 GP surgeries
(prevalence ranging from 3.9 per cent to 8.6 per cent). Podiatry
assistants are trained to use Doppler, neurothesiometer and manual
examination. The diabetes register is supplied by primary care practices
and patient details are maintained on a Therapy Manager IT system.
The previous 12 months outcomes comprise low risk 68.1 per cent
(5,520), medium risk 22.9 per cent (1,860), high risk 8.2 per cent (661)
and very high risk 0.8 per cent (64). Medium/high risk have ongoing atrisk podiatry management and very high risk have direct referral into
secondary care.
Conclusion: With the introduction into the QOF of risk stratification
recording and the recommended use of biomedical equipment, it is
possible that some areas of primary care will be unable to maintain the
necessary skills. To provide a satisfactory screening service delivered by
suitably competent professionals, other localities may have to consider
designing comparable models.
P300
A three year audit from 2007 to 2010 of
community podiatry follow-up of patients
discharged from secondary care
P Solanki1 and KS Leong2
1
Podiatry, Wirral University Teaching Hospital, Wirral, UK, 2Endocrinology,
Wirral University Teaching Hospital, Wirral, UK
Aim: Patients discharged from hospital podiatry clinics are at high risk
of re-ulceration and need regular follow-up by community podiatry. In
2012 The Authors.

20072008, we demonstrated that most patients were not followed up

and a message to reiterate the importance of follow-up was conveyed to
all community podiatrists. Our aim here was to audit follow-up of
patients discharged from hospital podiatry in the community after
intervention in 2008.
Method: A retrospective audit was carried out of patients discharged
from hospital podiatry clinics from 20089 and 200910 compared
with baseline (20078) to assess follow-up of patients in the
community.
Results: Data are given as n (per cent) and were analysed with the chisquared test. A total of 118 patients were discharged from 2007 to
2010: 51 in 20078, 39 in 20089 and 28 in 200910. Twenty-two
patients (43 per cent) were followed up in 20078 and this increased
significantly (p = 0.006) to 25 (64 per cent) in 20089 but then dropped
to 16 (57 per cent), P = 0.062, the following year. Two (3.9 per cent),
four (10.2 per cent) and two (7.1 per cent) patients re-ulcerated in 2007
8, 20089 and 200910 respectively. Approximately 20 per cent of
patients were rebooked in the community but subsequently lost to
follow-up in each audit year.
Conclusion: Improvements to follow-up seen in the year after the
intervention was not sustained. Fortunately this did not result in
increased re-ulceration rates. A review of follow-up processes in the
community is required with reinforcement of existing arrangements.
Since 2010, patients discharged from hospital are given a card (which
contains podiatry contact details) to facilitate continual follow-up by
community podiatry.
P301
A pilot podiatric audit of people with
diabetes receiving haemodialysis
P Solanki1, KS Leong2 and A Crowe3
1
Podiatry, Wirral University Teaching Hospital, Wirral, UK, 2Endocrine, Wirral
University Teaching Hospital, Wirral, UK, 3Nephrology, Wirral University
Teaching Hospital, Wirral, UK
Aim: To assess podiatry care in outpatient diabetic haemodialysis

patients.
Methods: Seventeen diabetic haemodialysis patients were identified
from 67 haemodialysis patients. Informed consent was obtained prior
to completion of a questionnaire.
Results: The mean age of the patients was 60 years; 10 (59 per cent)
were male. Twelve patients (71 per cent) recalled having an annual foot
screen, eight (47 per cent) performed by a podiatrist. Ten patients (59
per cent) did could not recall their foot risk categorisation. Fourteen
patients (82 per cent) had regular podiatry ranging from weekly to
annually. Most appointments were made by the podiatry clinic (8
patients, 57 per cent), whilst three patients (18 per cent) had an ulcer at
the time of audit; three on the heel and one of the mid foot treated by a
variety of services. There was a past history of foot ulceration in seven
patients (41 per cent), and a history of amputation in five patients (29
per cent), with four patients (24 per cent) having a trans-tibial
amputation. Four patients (24 per cent) had hospital footwear but none
wore them to clinic. One patient was a smoker but did not wish to quit;
11 patients (65 per cent) were past smokers.
Conclusions: Diabetic foot ulcer in haemodialysis patients has a
significant impact on patient prognosis. This audit provides valuable
data and should be conducted in the other dialysis sites in order to
promote podiatry as part of the multidisciplinary approach to the care
of the diabetic haemodialysis patient. Patient education regarding their
risk category, footwear, smoking status and ulcer care needs to be
developed. Ulcerated patients would benefit from ward based
multidisciplinary care including podiatry.
2012 The Authors.

DIABETICMedicine
P302
Impact of a multidisciplinary foot ward
round on inpatients with active foot disease
V Chikthimmah1, R Pickin2, R Cooke3, P Lal3 and S Benbow1
1
Department of Diabetes and Endocrinology, Aintree University Hospitals

NHS Foundation Trust, Liverpool, UK, 2Department of Podiatry, Aintree
University Hospitals NHS Foundation Trust, Liverpool, UK, 3Department of
Medical Microbiology, Aintree University Hospitals NHS Foundation Trust,
Liverpool, UK
Aims: Putting Feet First and NICE guidance highlight the importance
of appropriate inpatient management of the diabetic foot. Therefore we
have determined the impact of an innovative multidisciplinary foot
team (MDFT) ward round set up to provide specialised input to
inpatients with active foot disease and we review adherence to the local
hospital antibiotic policy.
Methods: The MDFT (diabetologist, podiatrist, microbiologist,
pharmacist) initiated a pilot weekly ward round, initially across
medical wards, providing expert opinion on active foot disease
management. Data collected prospectively over 7 months (January
July 2011) were analysed.
Results: Fifty-seven patients (mean age 66.9, range 3291 years; male
to female ratio 37 to 20; Type 1 to Type 2 diabetes 8 to 47; two no
diabetes) were seen on 216 occasions in total. Only 36.8 per cent (21/
57) were on a diabetes ward. Twenty-seven (47.3 per cent) were
primary foot admissions. Fifteen had neuropathic, 21 neuroischaemic
and three ischaemic ulcers (18 miscellaneous foot conditions including
pre-ulcerative lesions). On initial review inappropriate antibiotic
prescriptions were altered/stopped in 30 per cent (10/33) and initiated
in 12 per cent (7/57), and on subsequent reviews dosages were altered/
antibiotics were changed in 31 per cent (12/38). Pressure relief was
organised in 21 per cent (12/57). The MDFT coordinated care with
vascular surgeons, diabetes specialist nurses and radiologists and
advised on appropriate investigations. Two patients died of causes
related to primary foot condition (five other deaths), 9 per cent (5/57)
underwent minor amputations, and for 16 per cent (9/57) the foot
lesions healed by discharge. Forty-two of 44 (95 per cent) had
appropriate follow-up arranged and 10 per cent (6/57) were discharged
to community care. The MDFT contributed significantly to 68 per cent
of patients (39/57).
Conclusion: An MDFT ward round can increase awareness, help
integrate and coordinate care and improve management of foot related
issues. Timely and appropriate provision of antibiotics, off-loading and
effective wound management can contribute to improved outcomes
and also improve patient safety.
P303
Discontinuation of treatment in patients
with painful diabetic peripheral neuropathy
BHT Miller, A Aparnareddy, M Soliman and SM Rajbhandari
Department of Diabetes, Lancashire Teaching Hospitals Trust, Chorley, UK
Aims: Clinical trials for the treatment of painful diabetic peripheral

neuropathy (PDPN) do not always reflect the real patient. In order to
investigate what happens to real-life patients we studied treatment given
to patients with PDPN and evaluated its response.
Methods: In this retrospective study, 128 case records (84 males) of
PDPN patients between 2003 and 2009 were analysed. Mean age (SD)
was 62.7 ( 12.4) years and 15 per cent had Type 1 diabetes. The
severity of pain using the visual analogue scale was 8.3/10 ( 1.6) at
presentation.
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DIABETICMedicine
Results: Mean HbA1c was 8.7 ( 2.5) per cent and the median
follow-up was of 26 weeks duration. Of these, 15 subjects did not need
any treatment apart from reassurance; 40 (31.3 per cent) patients had a
good response and 41 (32.0 per cent) had tolerable pain with treatment;
13 (10.2 per cent) did not respond to treatment. There was no difference
in the response to treatment between males and females (P = NS) or
those above and below 60 years of age (P = NS). Amitriptiline was
prescribed in 71 cases and was continued on 49.3 per cent of these cases.
Pregabalin was prescribed in 61 cases with 37.7 per cent continuing it
and duloxetin was prescribed in 33 cases with 51.5 per cent continuing
it.
Conclusions: Our study shows that two-thirds of patients with PDPN
have satisfactory response to treatment; however, there is a need to try
various medications until a favourable outcome is achieved. The
withdrawal rate of various treatments may be more than 50 per cent
when treating patients with PDPN in real life.
for cholesterol, LDL, HDL, triglyceride, systolic blood pressure, ACR,

body mass index, and the use of ACE inhibitors, statins and aspirin
between these groups.
Conclusions: Within our clinical sample of patients with an
eGFR < 40 ml/min/1.73m2, 11 per cent were taking metformin and
the majority of patients (69 per cent) were taking insulin/sulfonylurea.
Of interest the eGFR was higher in this group compared with the group
treated with insulin/sulfonylurea/no treatment.
P305
Chronic kidney disease and diabetes:
visiting the NICE guidelines
J Jack, S Williams, A Velusamy, A Crown, A Smith and N
Vaughan
Diabetes and Endocrinology, Brighton and Sussex University Hospitals,
Brighton, UK
P304
Treatment choices for managing
hyperglycaemia in patients with diabetes
and a moderate to severe renal disease
F Palmer1, SL Prior1, DA Jones1, DE Price2 and JW Stephens1,2
1
Diabetes Research Group, Institute of Life Science, Swansea University,
Swansea, UK, 2Department of Diabetes and Endocrinology, Morriston
Hospital, Abertawe Bro Morgannwg (ABM) University Health, Swansea, UK
Aims: Current recommendations suggest that metformin and

exenatide should be avoided in patients with a creatinine
of > 150 lmol/l or with an estimated glomerular filtration rate
(eGFR) < 40 ml/min/1.73 m2. Our aim was to examine treatment
choices for glucose control in our secondary care clinic for patients with
an eGFR < 40 ml/min/1.73 m2.
Methods: Using the electronic computer database at the hospital we
identified 1,341 patients who had been seen in the diabetic clinic
between 1 September 2010 and 31 August 2011. We identified patients
with an eGFR < 40 ml/min/1.73m2 and examined the therapy choice
and the clinical characteristics of these patients.
Results: Of the 1,341 patients, 116 (8.7 per cent) had an
eGFR < 40 ml/min/1.73m2. Of these 90 were treated with insulin/
sulfonylurea, two with exenatide and 13 with metformin (alone or with
insulin or sulfonylurea) and 11 with no therapy. The mean eGFR was
significantly higher in the metformin vs. insulin/sulfonylurea/no
treatment group [eGFR 37.5 (4.3) vs. 28.2 (10.0), P = 0.001;
creatinine 159 (156171) vs. 194 (194252), P < 0.001]. Diastolic
blood pressure was significantly higher in the metformin group [77
(11.4) vs. 70 (9.5), P = 0.02]. No significant differences were observed
122
Aim: To investigate the management of patients with diabetes and

chronic kidney disease and compliance with the NICE guidelines.
Method: Data were collected retrospectively from our diabetes
outpatients clinic from January to July 2011. We compared our
management against the following NICE guidelines: Management of
Type 2 diabetes (CG87), Chronic kidney disease (CG73), Anaemia and
chronic kidney disease (CG114). In all, 120 patients with CKD3b and 4
were included ranging from 40 to 90 years (median 74); 73 per cent had
CKD 3b and 27 per cent CKD4.
Results: Only 71 per cent of our study population had their annual
urine albumin creatinine ratio checked. 21.7 per cent had
haemoglobin < 11, and only 25 per cent of these were on oral iron;
6.7 per cent of the population had functional iron deficiency of which 50
per cent had iron studies. Only 35.5 per cent of patients had
HbA1c < 7.5 per cent. 74 per cent were on ACE inhibitor and 16 per
cent were not with no reason documented. 56 per cent of patients
achieved a target blood pressure < 130/80mm Hg. 84 per cent of
patients were on a statin; 4.8 per cent did not tolerate statins and in 11.2
per cent statin was not prescribed and no reason was documented. 62.8
per cent of patients achieved the lipid target. 64.7 per cent of patients
with CKD4 had their PTH checked. Metformin was stopped in 96 per
cent of cases in patients with CKD4 and still prescribed in 3 per cent. 88
per cent of patients with CKD4 had renal imaging in the form of
ultrasound or MRI.
Conclusion: This audit highlights the need for increased awareness in
the management of anaemia, bone disease and glycaemic control in
these high risk patients. Particular attention should be paid to avoiding
hypoglycaemia and following these guidelines to improve their
cardiovascular risk.
2012 The Authors.

Clinical care and other categories posters: healthcare delivery
DIABETICMedicine
Clinical care and other categories posters: healthcare

delivery
P306
Factors affecting prescribing of statins in
people with diabetes in Scotland
NRV Jones
Global Public Health Unit, University of Edinburgh, Edinburgh, UK
Aims: To investigate factors associated with prescribing of statins

among people with diabetes.
Methods: Data were used from a 2008 extract of a population-based
register of people with diabetes in Scotland for 57,514 people.
Prescription of statins was assessed for people with total
cholesterol > 5 mmol/l (TC > 5), using the most simple guideline
recommendations. Odds ratios (OR) and 95 per cent confidence
intervals were estimated using logistic regression to describe
associations between factors including hypertension (diastolic blood
pressure > 80mm Hg) and an area-based measure of socioeconomic
position (SEP) with statin prescription. Age-adjusted analyses were
stratified by sex and cardiovascular disease (CVD) history.
Results: Statins were not prescribed for 23 per cent of people with
diabetes and TC > 5: 13 per cent of men > 80 years old, 35 per cent of
women 4059 years old, 14 per cent of men with CVD and 32 per cent
of women with no CVD. In people without CVD, no record of statin
prescription was more common among smokers than non-smokers
[OR 1.14 (1.051.22) for women; 1.31 (1.221.40) for men], among
people with hypertension [OR 1.41 (1.321.51) for women; OR 1.58
(1.481.68) for men] and for women in the least compared with the
most deprived SEP quintile [OR 1.34 (1.221.47)]. Hypertension was
associated with not having a statin prescription [OR 2.53 (1.574.09)]
in women with CVD. There were no significant associations with statin
prescription for men with CVD.
Conclusions: Clinical and socioeconomic factors affect the odds of
prescription of statins among people with diabetes and TC > 5. The
findings may reflect appropriate prescription based on cardiovascular
risk scores and occurrence of side-effects.
Acknowledgement: The Scottish Diabetes Research Network
Epidemiology Group.
P307
Management of diabetic ketoacidosis
improves with implementation of care
pathway
RM Manikandan, J Abel, R Verdaguer, R Rajendran and
MG Masding
Department of Diabetes and Endocrinology, Poole Hospital NHS Foundation
Trust, Poole, UK
Objective: We introduced a care pathway (CP) for the management of

diabetic ketoacidosis (DKA) following the publication of national
guidelines. The CP included capillary ketone measurements, fluid and
potassium replacement, fixed rate intravenous insulin infusion regimen,
timely medical review and mandatory prompt referral to the diabetes
specialist team. We audited the management of DKA in our Trust after
its implementation.
Method: This was a retrospective audit of all admissions with DKA
from August 2010 to January 2011 (n = 26), compared with the audit
2012 The Authors.

between January and July 2009 (n = 28) prior to the introduction of the
CP.
Results: In both years, the majority of admissions were through the
emergency department 20/28 in 2009 and 20/26 in 201011. After
implementing the CP, hospital stay was reduced from a median of
4.0 days (range 247) to 2.9 days (range 188; P = 0.05). The duration
of intravenous insulin fell from a median of 26 h (range 876 h) to
17.5 h (range 442 h; P < 0.04). The numbers of patients reviewed by
the diabetes team increased from 18/28 seen in 2009 to 22/26 in 2010.
Continuation of long-acting insulin analogues went up from 13/20 to
13/17. However, 7/26 patients developed hypoglycaemia on the CP
fixed insulin infusion regime.
Conclusions: The implementation of a CP for DKA management,
with introduction of bedside capillary ketones measurement and fixed
rate insulin infusion, was associated with a reduction in length of stay
and less time on intravenous insulin. We believe that DKA management
has markedly improved in our Trust with these changes.
P308
Engaging in a new culture of innovative
collaboration for diabetes services redesign
MS Freeman1, W Gillibrand2, V Newton2, PW Holdich2 and
J Oldroyd1
1
Long Term Conditions, NHS Kirklees, Huddersfield, UK, 2Division of Podiatry &
Clinical Sciences, School of Human & Health Sciences, University of
Huddersfield, Huddersfield, UK
Aims: In a challenging financial environment, the aim of the

redesigned diabetes service was to deliver high quality levels of care
closer to patients homes promoting patient self-management and selfcare. This was to be achieved by enhancing primary care training with
seamless specialist care support. It involved collaboration with local
stakeholders, NHS Diabetes and the commercial sector.
Methods: The service design was developed following a diabetes care
review, stakeholder consultation and training needs analysis, delivery
being aided by novel working with the local university and a number of
pharmaceutical companies: (1) a university developed and delivered
bespoke work-based learning programme covering key aspects of
diabetes care; (2) a mentorship programme delivered by the specialist
teams; (3) an e-consultation process between primary and secondary
care; (4) a Year of Care based patient Self Care Handbook; (5) a local
enhanced care financial scheme for accredited practices (LES); (6)
annual diabetes e-participation by all service providers.
Results: 90 per cent of practices have signed up to the new model.
There is full involvement from the specialist teams, and 74 practitioners
have attended university programmes. Mentorship is ongoing and
positively evaluated 20 practices access to e-consultation. Six practices
are accredited with the diabetes LES piloting of the Self Care Handbook.
Patient service needs were identified using care planning data. Tailored
healthcare professional ongoing support requirements were identified.
Summary: The new service has been well received by both primary
and secondary care resulting in closer collaborative working patterns.
New working patterns have developed between the NHS and the
private sector. The introduction of e-consultation has facilitated
the installation of a clinical record system into secondary care
allowing the sharing of patient information.
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DIABETICMedicine
P309
Annual audits and a diabetes practice
development team: improving diabetes care
and outcomes for patients in general
practice
A Goodchild, K Ellard, S Berg and H Brenchely-King
Community Diabetes Team, Bexley Care Trust, Bexleyheath, UK
Aim: According to Healthcare for London [1] most essential care and
some enhanced services should take place in GP practices. Our aim was
to determine if annual performance monitoring and assessment would
raise the standard of diabetes care in GP practices and establish their
training needs.
Method: The Diabetes Practice Development Team (DPDT),
established in 2009, comprises a GP with special interest, diabetes
specialist nurse and patient representative. Their role was to visit all 28
practices following the DPDT designed annual diabetes audit. They
then supported practices to develop diabetes service management plans
depending on audit results, training needs, quality of registers and
patient survey results and to agree their tier status according to
Healthcare for London.
Results: All practices were audited and 97 per cent were visited
annually. Twenty-seven practices now have accurate diabetes,
prediabetes and gestation registers. Twenty-five teams are trained to
deliver a care planning approach (Year of Care); 356 healthcare
professionals attended training courses; referral to X-PERT structured
education increased from 80 to 742 to 1,659 each year. 91 per cent of
patients were happy with the diabetes care received at their practice.
Bexley has achieved the highest DM23 QOF outcome in London at 61
per cent (HbA1c less than 7 per cent). Eighty insulin starts have been
achieved in Tier 2 practices. A phone survey of practice teams found the
DPDT helped focus attention and improve competence and confidence
in diabetes management.
Conclusion: Ongoing assessment and review by a dedicated team
(including patients) is improving general practice standards and has
enabled an understanding of practices needs.
Reference:
[1] Healthcare for London: Diabetes Guide for London. (Dr Steve
Thomas led the working group, 2008).
P310
Evaluation of a community-based diabetic
retinopathy screening initiative
J Alade1, S McHugh1, C Buckley1,2,3, K Murphy3, S Doherty3,
G OKeeffe3, E Keane3, M James3, C Coughlan3, J Traynor3,
IJ Perry1, D Quinlan2,3 and M Horgan2
1
Department of Epidemiology and Public Health, University College Cork,
Cork, Ireland, 2Diabetes in General Practice (DiGP) Ltd, University College
Cork, Cork, Ireland, 3Retinopathy Subgroup, Diabetes Services
Implementation Group (DSIG), Health Service Executive (HSE) South, Ireland
Background: Despite international emphasis on retinopathy

screening over the last two decades, there is no such programme
available to people with diabetes in Ireland at present. In 2008, the
development of retinopathy screening was prioritised by the Expert
Advisory Group for Diabetes. In anticipation of a national programme,
a community-based screening initiative was established in the south of
Ireland which utilised existing services. The aim of this study was to
evaluate the community-based model of diabetic retinopathy screening.
Methods: Asampleofpracticesandpatientsinvolvedinalocalprimary
care diabetesinitiativewererecruited.Atotalof 32practiceswereinvited
124
to participate. An invitation letter to attend a free eye examination for

diabetic retinopathy screening was issued by each practice to eligible
patients. A total of 3,447 adult patients with diabetes were invited to
attend for screening. An evaluation of the structure, processes and
outcomes of the screening programme is under way. The results will be
benchmarked against the standards outlined in the National Diabetic
Retinopathy Framework to assure the quality of the service.
Results: Overall 30 practices took part in the screening initiative (94
per cent). By the end of June 2011, 45 per cent of patients (n = 1,552)
had participated and screening is ongoing. Preliminary analysis
suggests<1 per cent of patients required urgent referral (within
2 weeks) and<3 per cent of patients required 13 week referral
(n = 53). 53 per cent of those screened reported no previous screening
prior to the initiative (n = 827).
Discussion: This study demonstrates the feasibility of a communitybased model of retinopathy screening using existing resources. Results
will inform the imminent national retinopathy screening programme in
Ireland.
P311
Cost-effective analysis of U-500 compared
with U-100 insulin among obese patients
with Type 2 diabetes with suboptimal
glucose control: retrospective observational
study of routine clinical care
R Jacob1, P Thomson2, K Ward2, E Higgins2 and I Idris2,3
1
Trent Research Design Services for East Midlands, University of Nottingham,
Nottingham, UK, 2Diabetes and Endocrinology, Sherwood Forest Hospitals
Foundation Trust, Nottinghamshire, UK, 3School of Graduate Entry Medicine,
University of Nottingham, Nottingham, UK
Background: We evaluated the cost-effectiveness of U-500 compared

with standard U-100 insulin therapy on obese patients with Type 2
diabetes with suboptimal glucose control. This retrospective database
study analysed the direct NHS costs and proportion of patients
achieving a 0.5 per cent reduction in HbA1c level over 4 months in the
two groups.
Methods: Adecisionanalyticalmodelintheformofadecisiontreewas
developed to assess the cost-effectiveness of U-500 compared with U100. Costs were expressed in UKpounds sterling at a 2010 price base and
benefits were expressed as 0.5 per cent reduction in HbA1c level. The
decision tree consists of a choice between two strategies: U-500 or
continueonU-100.Thedecisionanalysiswasbasedona4-monthmodel.
Results: Eight out of 12 patients in the U-500 arm experienced
benefits. A historical cohort of 71consecutive patients attending the
diabetes obesity clinic was used as the standard arm. Twenty-five
patients experienced benefit. The total cost of U-500 is 2909.66
compared with a U-100 cost of 9946.01. The model is probabilistic in
that all input parameters were entered as a probability distribution and
Monte Carlo simulation was used to reflect the uncertainty in the
model. The U-500 cost less; the mean cost of U-500 was 2951.35 with
mean effects U-500 = 0.6616133. The standard therapy cost more; U100 9545.981 with mean effects of U-100 = 0.3545707.
Conclusion: In our study the U-500 had a significantly smaller cost
and had a significantly larger effect than the total cost for U-100 insulin,
both at point estimates and in sensitivity analysis.
2012 The Authors.

P312
Patient and staff experiences of the East
Cambs and Fenland diabetes integrated care
initiative: a qualitative longitudinal study
E Harwood1, S Cohn2 and D Simmons1
1
Institute of Metabolic Science, Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK, 2General Practice and Primary Care
Research Unit, Institute of Public Health, Cambridge University, Cambridge,
UK
Aims: This study aims to understand the perceptions and experiences

of patients involved in the East Cambs and Fenland diabetes integrated
care initiative, specifically those with poorly controlled diabetes and
their carers.
Methods: Twenty-one patients (purposefully sampled) with a recent
HbA1c of 9 per cent or higher and/or recent hospitalisation and 24
healthcare professionals (HCPs) have been invited to participate. In line
with an ethnographic approach, semi-structured interviews are
conducted with participants and observations in healthcare settings
and homes are ongoing during the data collection period (12 months).
An additional follow-up interview will be conducted with patients at
the end of the data collection period. Transcripts, field notes and
questionnaire data will be analysed using Nvivo9 (a qualitative analysis
programme) to explore themes relating to availability of services and
treatment, how patients understand their condition, relationships
between HCPs and defining integrated care in practice.
Results: Key themes which have emerged include the complexity of
how patients perceive their diabetes (varied levels of priority, concern
and frustration), the value of continuity of care, trust, time and
knowledge, the perceived impact of healthcare setting on the patient
(hospital, primary care and home) and sharing information (HCP to
patient and HCP to HCP).
Conclusions: Results indicate the new integrated care approach has
provided East Cambs and Fenland patients with increased access to
diabetes care. The findings identify some of the strengths of the
integrated care approach, as well as the challenges in delivering
integrated care on both an individual and system level.
P313
Optimal interval and cost-effectiveness of
coeliac disease screening for patients with
Type 1 diabetes
WS Wong, C Goddard, H Gillett, J Walker and K Adamson
Diabetes Department, St Johns Hospital, Livingston, UK
Aim: This study aims to find out the optimal screening interval for
coeliac disease (CD) among patients with Type 1 diabetes and to
examine the cost-effectiveness of such screening programme.
Methods: CD screening was initially carried out at the Royal
Infirmary of Edinburgh (RIE) and St Johns Hospital (SJH) in 1996
and 2005 respectively. A total of 218 RIE patients were screened again
in 2005 while 867 SJH patients were screened in 2010. Antitransglutaminase antibodies (anti-TTG) level was measured in all
patients and patients with raised anti-TTG were referred to
gastroenterology for diagnostic intestinal biopsy.
2012 The Authors.

DIABETICMedicine
Results: Nine positive screens were identified in the 2005 RIE

screen, resulting in a minimum prevalence of 1.7 per cent, which is
comparable to the 1996 study (minimum prevalence 1.6 per cent).
Twenty-four positive screens were found in the 2010 SJH screen and
the minimum prevalence rate is established to be 2.8 per cent, which
is also similar to the previous study in 2005 (minimum prevalence 2.4
per cent). Using the data obtained from the Western General Hospital
Biochemistry Laboratory, the cost per positive screen is calculated to
be 912.55.
Conclusion: The prevalence of positively screened patients is similar
to that established 5 years ago, and hence 5 years is a reasonable
screening interval. The cost per histologically confirmed case is also
within acceptable levels of cost-effectiveness thresholds for approval by
the National Institute for Health and Clinical Excellence (NICE).
Therefore, 5-yearly CD screening for patients with Type 1 diabetes can
be an appropriate and cost-effective programme.
P314
A review of emergency calls to NHS
ambulance services in England from people
with diabetes suffering a hypoglycaemic
event
M Bailey1, S Mortley1 and AR Scott2
1
Clinical Audit and Research Department, East of England Ambulance Service
NHS Trust, Norwich, UK, 2Diabetes, Sheffield Teaching Hospitals, Sheffield,
UK
NICE Quality Standard 13 for adults with diabetes states that: People
with diabetes who have experienced hypoglycaemia requiring medical
attention should be referred to a specialist diabetes team. Previous
studies of ambulance call-outs to people with hypoglycaemia have been
generally confined to single localities or regions. All NHS ambulance
services in England participate in the benchmarking of a set of national
clinical performance indicators (NCPIs), one topic of which is
hypoglycaemia. The NCPI requires detailed information on all cases
occurring during the sample month OR a maximum of 300 cases.
Where this maximum is exceeded the Trusts are asked to indicate the
total number reported. All 12 ambulance authorities submitted data
collected during February 2010 (cycle 4) and August 2010 (cycle 5).
Detailed information was supplied on 2904 call-outs for
hypoglycaemia, with an additional 925 calls noted during that
period. In August 2010 the reported number was 2828.
Extrapolating these figures for a year gives 45,948 cases of
hypoglycaemia using the 999 system. Only 35.4 per cent (range 26.5
57.9 per cent) of patients were transported to hospital. Direct referral
was made to an appropriate health professional in 068.2 per cent of
999 calls for hypoglycaemia. It is not known how many ambulance
authorities have referral pathways to specialist diabetes services but
these data suggest that these are not widespread and that the burden of
hypoglycaemia is considerable. Discussions are under way at a national
level to ensure that the appropriate pathways of care exist between
ambulance services and specialist diabetes services to ensure better care
for people with diabetes.
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P315
Birth to designation: a safe
multidisciplinary bariatric service
G Jackson-Koku1, T OConnor1, L Halder1, J Abraham1,
N Reddy1,2, T Barber1,2, I Fraser1, V Menon1, MK Piya1,2 and
S Kumar1,2
1
2
University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK,

Warwick Medical School, University of Warwick, Coventry, UK
Aims: Bariatric surgery is an effective, safe and cost-effective treatment

for obesity. Most published data are from large volume surgical centres.
Our centre had a multidisciplinary obesity service, and bariatric surgery
was introduced with an experienced mentor. Our aim was to evaluate
the safety and efficacy of bariatric surgery through our development
into being designated a bariatric surgery centre in November 2010.
Methods: Case notes and biochemical data were reviewed for all
procedures performed since 2007 when bariatric surgery was first
performed.
Results: Until August 2011, 120 bariatric procedures were performed,
86 per cent laparoscopic gastric bands (LGBs). 45 per cent were NHS
funded, 86 per cent women, with mean age 44.1 11 (SD). Body mass
index 46.4 10 kg/m2 reduced by 8.0 3.6 kg/m2 (P < 0.001). 27
per cent had Type 2 diabetes. Preoperative HbA1c of 8.0 1.9 per cent
reduced to 6.5 1.6 per cent (p = 0.016). Fifteen LGBs were
performed in 2008, with 42 procedures already performed in 2011
before August. All but two operations until March 2011 were LGBs/
gastric balloons. One bilio-pancreatic diversion, four gastric bypass and
five sleeve gastrectomy operations have now been performed.
Laparoscopic/endoscopic surgery was performed in 98 per cent of
cases. There have been no mortalities or conversion of laparoscopic to
open surgeries. One patient developed port site infection, and two
patients had postoperative pneumonia.
Conclusions: The development of bariatric centres is necessary to
meet the increasing demand for bariatric surgery. The development of
our unit as a bariatric centre has been safe and effective, with the effort
of a multidisciplinary team and experienced mentor over several years.
This may serve as a model for further centres trying to achieve
designation as bariatric surgery centres.
P316
Use of analogue insulin in patients with
Type 2 diabetes: an unnecessary expense for
the NHS
M Shepherd1,2, BM Shields1, B Knight1,2, TJ McDonald1,3 and
AT Hattersley1,2
1
Exeter, UK, 2Research and Development, Royal Devon and Exeter NHS
Foundation Trust, Exeter, UK, 3Clinical Chemistry, Royal Devon and Exeter
NHS Foundation Trust, Exeter, UK
Aim: Analogue insulins account for 80 per cent of insulin

prescriptions. Analogue use in Type 1 diabetes lowers hypoglycaemic
risk and reduces glycaemic variability. However, these expensive
insulins are increasingly prescribed in Type 2 diabetes despite lack of
beneficial evidence. Analogue insulin use in Type 2 diabetes might be
126
justified if it was used when endogenous insulin secretion was low. We

aimed to identify the proportion of Type 2 diabetes patients on
analogues, whether analogue use was associated with endogenous
insulin production [measured by urine C-peptide creatinine ratio
(UCPCR)] and cost savings if those producing insulin were transferred
onto non-analogue equivalents.
Method: In total 201 insulin treated patients with Type 2 diabetes
(diagnosed>40 years and not requiring insulin within 12 months)
attending community based retinal screening within a 5-month period
were studied. Patients UCPCR was measured on a urine sample 2 h
after their largest daily meal.
Results: Of all Type 2 diabetes patients 184 (92 per cent) had
UCPCR 0.2 nmol/mmol indicating significant endogenous insulin
production. Of these 72 (39 per cent) were on analogue insulin. Level of
endogenous insulin production was not associated with analogue use
(mean UCPCR 1.6 vs. 2.0 nmol/mmol, P = 0.12). Cost savings if
analogue insulin was replaced with non-analogue alternatives in these
patients would be 68 p/patient/day, equating to 17,900/year for the 72
patients in this cohort.
Discussion: Reasons for the high proportion of Type 2 diabetes
patients on analogues may include (i) marketing, (ii) pharmaceutical
funding of nurses training others in insulin initiation, and (iii)
withdrawal of equivalent human insulins. Using UCPCR may identify
the few Type 2 diabetes patients for whom analogues are an appropriate
treatment. In the absence of evidence indicating clear benefit there are
clear potential cost savings of transferring Type 2 diabetes patients from
analogues to equivalent cheaper insulins.
P317
Prevalence and management of diabetes in
people with learning disabilities
LG Taggart
School of Nursing, University of Ulster, Coleraine, UK
Aim: People with learning disabilities (LD) are at a higher risk of

developing diabetes due to higher obesity levels and poor diets
compared with the general population. The aim of this study was to
explore the prevalence and management of diabetes in people with LD
in Northern Ireland.
Methods: Two methods were employed. First, all GP practices were
contacted and asked to provide figures for the number of people with
LD and diabetes registered within their practice. Second, a postal survey
was forwarded to nursing and residential staff caring for people with
LD who had diabetes. Ethical approval was obtained.
Results: Obtaining accurate prevalence figures of diabetes in people
with LD from the GP practices was found to be methodologically
problematic. The nursing and residential staff completed questionnaires
on 186 people with LD with diabetes: 67.2 per cent had Type 2 and 32.8
per cent had Type 1 diabetes. Overall, the diabetes management of this
population reported by staff was found to be poor.
Conclusion: Findings from this study highlight the difficulties that GP
practices encounter in recognising and coding a person to have LD as
well as diabetes, thereby deflating prevalence rates. The poor
management of this population raises concerns that require
immediate attention pertaining to staff training and education in
diabetes.
2012 The Authors.

P318
Impact of the 2010 Diabetic Ketoacidosis
(DKA) Guidelines (based on the 2010 Joint
British Diabetes Societies Inpatient Care
Group Standards of Care) and IV Insulin and
Fluid Prescription Chart on DKA
management at University Hospitals Bristol
NHS Foundation Trust
A Thomson-Moore, A Low, J Williams, K Bradley and
N Thorogood
Diabetes and Endocrinology, University Hospitals Bristol NHS Foundation
Trust, Bristol, UK
Objective: To assess understanding and management of diabetic

ketoacidosis (DKA) since introducing the 2010 DKA Guidelines and IV
Insulin and Fluid Prescription Chart.
Methods: Three methods of assessment were used: assessment of
DKA admission notes for concordance with guidelines; separate
medical and nursing personnel knowledge questionnaires; incident
forms analysis.
Results: Sixty-three doctors and 14 nurses were surveyed, and 34 sets
of notes were scrutinised. Diagnosis of DKA and appropriate initial
management was 100 per cent optimal in both theory and delivery of
care. Theoretical knowledge and concordance with the guidelines
diminished once treatment was under way. Infusion of 10 per cent
dextrose with capillary blood glucose (CBG) < 13 mmol/l, and correct
application of the resolution criteria, was managed inappropriately in
50 per cent of cases. All six incident forms arose at night and were
centred around hypoglycaemia.
Conclusions: Management of resolving DKA needs improvement.
The challenges are multifactorial and include insufficient
understanding, especially by nursing staff, of how insulin, dextrose
and the resolution criteria interlock; an incorrect perception that the IV
Insulin and Fluid Prescription Chart is a comprehensive integrated care
pathway; a culture in which doctors do not regularly reassess patients
once they have completed their clerking, nor suggest criteria by which
they should be recalled; diminished continuity, visibility and
accessibility of doctors out of hours because of the European
Working Time Directive and rapid patient transfers from the medical
assessment unit. These concerns are being addressed through targeted
education, amending the prescription chart and challenging current
culture around re-reviewing patients.
P319
Transcribing errors in insulin prescriptions:
are our patients in safe hands?
HJ Roderick1 and MA Saeed2
1
School of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK, 2Department of Diabetes, University Hospitals Birmingham
NHS Foundation Trust, Birmingham, UK
Aims: Insulin is commonly prescribed for the treatment of diabetes.

Insulin errors are likely to cause harm due to its narrow therapeutic
range; however, despite this, dosing is commonly incorrect. The
National Patient Safety Agency received 3,881 wrong dose insulin
reports (20032009), which included a death due to a 10-fold dosing
error. The aim of this audit was to investigate the incidence of
transcribing errors in the prescription of insulin from diabetes clinics at
a large teaching hospital.
Methods: The records of 100 patients on insulin attending diabetes
clinics between January and July 2011 were retrospectively analysed
2012 The Authors.

DIABETICMedicine
(male:female ratio 56:44 per cent; Type 1 to Type 2 diabetes, 48 to 52

per cent) . Details of insulin therapy in the clinic notes were compared
with the clinic letter and discrepancies were noted.
Results: Transcribing errors occurred in 18 per cent (n = 18) of insulin
prescriptions in our study sample and were more frequent in patients
receiving two insulin types compared with one (21.3 per cent vs. 15.1
per cent). The most frequently occurring error involved incorrect insulin
dosage (13 per cent, n = 13). Some errors were due to similar sounding
digits, eg 14 units transcribed as 40 and 79 units as 79.
Conclusions: Greater care needs to be taken when dictating letters to
avoid insulin errors, particularly with commonly confused digits.
Special attention should be taken with patients on multiple insulin
types. Letters should be thoroughly checked before being sent to the
patients general practitioner. Educational initiatives to increase the
awareness of these potential errors are important to ensure the safety of
people living with diabetes under our care.
P320
Introduction of a hyperglycaemia
management pathway safely reduces
hospital admissions
R Herring, C Pengilley, H Hopkins, B Tuthill and S Davidson
Centre for Endocrinology, Diabetes and Research, Royal Surrey County
Hospital, Guildford, UK
Background: Patients are frequently admitted to hospital with

hyperglycaemia. Our aim was to introduce a hyperglycaemia
management pathway for use in the medical assessment unit (MAU)
as an admission avoidance initiative.
Method: Clinical practice was evaluated in phase 1. All patients
presenting to the MAU with a blood glucose meter reading > 11.1 were
identified (11.1 was based on the World Health Organisation
diagnostic criteria for diabetes). Data were collected on acute
assessment, diagnosis and management. The hyperglycaemia
management pathway was then introduced and impact assessed in
phase 2. Key pathway requirements included plasma glucose, plasma
ketones and urea and electrolytes. Patients who did not require
admission were provided with an information leaflet and contacted by a
diabetes specialist nurse the next working day.
Results: Phase 1: Seventy-two patients were identified over a period of
156 days; 100 per cent were admitted and 63 per cent were started on
an insulin infusion. Hyperglycaemia was the primary admitting
diagnosis in 32 patients, of whom 15 patients had new or known
Type 1 diabetes and 17 Type 2 diabetes. The diagnosis hyperglycaemia
included hyperglycaemia hyperosmolar state and diabetic ketoacidosis.
Phase 2: The pathway has been used for 40 patients. Hyperglycaemia
was the primary diagnosis in 14 patients. Admission was avoided in six
of the 14 patients (43 per cent). Patients with Type 2 diabetes had the
greatest potential for admission avoidance.
Conclusion: The hyperglycaemia pathway can be used by medical
professionals to safely reduce hospital admissions. Crucial to the success
is the patient information leaflet and the prompt completion and faxing
of the hyperglycaemia pathway referral form to the diabetes specialist
nurses.
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Clinical care and other categories posters: hormone replacement therapy
Clinical care and other categories posters: hormone

replacement therapy
P321
Testosterone deficiency in men with
diabetes
CL Morrison1, S Wong2, M Hassanein2, G Morrison3,
TS Purewal3 and PJ Weston3
1
Pendyffryn Medical Group, Prestatyn, UK, 2Renal and Diabetes Centre, Glan
Clwyd Hospital, Rhyl, UK, 3Diabetes Centre, Royal Liverpool University
Hospital Trust, Liverpool, UK
Background: Many of the clinical manifestations of testosterone

deficiency can be too readily dismissed as of no medical relevance or as
having alternative explanations attributable to the ageing process, yet
replacement therapy can have a profound improvement upon quality of
life.
Methods: This study in a large primary care practice examines
testosterone deficiency in men with diabetes presenting with associated
symptoms in the absence of genetic and pituitary abnormalities. Early
morning venous sampling was taken for testosterone measurements.
Results: Of 91 males, 57 (62.6 per cent) [66.0 years, 10.1,
43.4388 (mean, SD, range), HbA1c-IFCC 61.0 mmol/mol, 17.3,
39.9144.8] had either a low total testosterone (7.4nmol/l, 2.7,

0.311.7) or low free testosterone (0.18nmol/l, 0.07, 0.040.36).
Other hormone parameters included sex hormone binding globulin
(31.9nmol/l, 14.8, 986), luteinising hormone (10.3u/l, 13.4,
1.884.3) and follicle stimulating hormone (11.3u/l, 11.6, 272).
There was no correlation between testosterone levels and HbA1c.
Seventeen (29.8 per cent) were receiving testosterone replacement
therapy [contra-indicated in five (8.8 per cent)], eight (47.1 per cent, 8/
17) were on transdermal gel preparations, and nine on intramuscular
injections (eight undecanoate, one propionate).
Conclusions: This study shows that testosterone deficiency is highly
prevalent amongst men with diabetes and accounts for the previously
indiscernible symptoms many present with. Primary care is the venue
where men will present with the subtle signs of testosterone deficiency
and clinicians should improve their awareness of this condition.
Screening for symptoms of testosterone deficiency should form part of
the diabetes annual review. Systems should be in place to ensure followup and then access to specialist opinion to establish the diagnosis and to
provide guidance on the appropriateness of replacement therapy.
Clinical care and other categories posters: hypoglycaemia

P322
The frequency of severe hypoglycaemia in
adults presenting to Accident and
Emergency in Forth Valley
J Doig, N Barwell and CJ Kelly
Department of Diabetes, NHS Forth Valley, Larbert, UK
P324
Factitious hypoglycaemia: diagnostic
pitfalls
S Kalathil1, C Napier1, S Pattman2, K Abouglila3 and RA James4
1
Diabetes and Endocrine, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK,

Metabolic Medicine, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK,
3
Diabetes and Endocrine, University Hospital of North Durham, Durham, UK,
4
Diabetes and Endocrine, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK
2
P323
Hypoglycaemia and accident risk in people
with Type 2 diabetes treated with
antidiabetes drugs without insulin
J Signorovitch1, D Macaulay2, M Diener2, EQ Wu1,
JB Gruenberger3 and BM Frier4
1
Health Care Practice, Analysis Group Inc., Boston, MA, USA, 2Health Care
Practice, Analysis Group Inc., New York, NY, USA, 3HE&OR Global CVM,
Novartis Pharmaceuticals Corporation, Basel, Switzerland, 4Department of
Diabetes, Royal Infirmary, Edinburgh, UK
P325
Increasing hospital attendances with
hypoglycaemia (from 2006 to 2011)
N Rashid1, E Baker1, E Denver2 and M Barnard1
1
Diabetes and Endocrinology, Whittington Hospital, London, UK, 2Centre for
Clinical Science and Technology, Whittington Hospital, London, UK
P326
Severe hypoglycaemia in the community:
development of a network-wide pathway
JE Rooney and S Benbow
North Mersey Diabetes Network, c/o NHS Knowsley, Huyton, Liverpool, UK
128
2012 The Authors.

P327
Incidence and management of inpatient
hypoglycaemic episodes
ZJ Cousland, N Phelan, N Patel, A Ososanya, K DuckworthBrown, S Dissanayake and E Jude
Department of Diabetes and General Medicine, Tameside General Hospital,
Ashton-Under-Lyne, UK
P328
Incidence of hypoglycaemia in the acute
medical admission unit
HK Tan and DE Flanagan
Diabetes and Endocrinology, Plymouth Hospital NHS Trust, Plymouth, UK
Aim: To study the prevalence and causes of hypoglycaemia in an acute

medical admission unit (AMU).
Methods: All capillary glucose measures performed on the AMU are
uploaded and stored on a central computer (Roche Inform II system).
This study analyses 6 months of data. Hospital coding data and edischarge summary are accessed to obtain the main diagnosis and the
length of stay (LOS) of these patients.
Results: A total number of 9,547 patients were admitted to the AMU
(4,195 had capillary glucose measured at 43.9 per cent) during the
6 months period, of whom 1,814 (19 per cent) have diabetes. A total of
219 patients (2.3 per cent of the total admission) had at least one episode
of hypoglycaemia during their admission; 135 of these had diabetes.
Sepsis was the most common cause at 26.7 per cent, followed by
diabetes or metabolic cause at 15.5 per cent; 6.8 per cent were admitted
with acute renal failure, and 4.9 per cent with falls. 65 per cent of
patients with hypoglycaemia are aged 70 and above. The average LOS
of patients admitted with hypoglycaemia was 10.20 11.27 days vs.
6.34 9.27 days (p < 0.001) for the general population.
Discussion: We showed that the incidence of hypoglycaemia in the
AMU is common. This may still be an underestimation as not all
patients admitted to the AMU have their blood glucose tested.
However, use of the Inform II system provided us with a more robust
method to identify patients at risk of hypoglycaemia.
P329
An evaluation of the effectiveness of hypo
boxes on the management of adult
inpatient hypoglycaemia at Cardiff
University Hospital Wales (UHW)
AS Howe and C Dustan
Diabetes and Endocrinology, University Hospital Wales, Cardiff, UK
Introduction: The Diabetes Inpatient Group at Cardiff and Vale

University Health Board has recently drafted new guidelines for the
management of inpatient hypoglycaemia. Audit of these guidelines
showed that ward management and knowledge of hypoglycaemic
events was poor. This led to the introduction of hypo boxes. This audit
2012 The Authors.

DIABETICMedicine
was to evaluate the effectiveness of hypo boxes on the management of

adult inpatient hypoglycaemia at UHW. Practice was audited against
the new draft guidelines with all audit standards set at 100 per cent.
Method: All adult medical and surgical wards were visited. The hypo
books on each ward were reviewed for entries during the time period of
00.00 25 July and 00.00 27 July. A data collection form was completed
for 21 cases.
Results: The 21 patients included in the audit had a combined total of
29 individual blood glucose measurements of < 4 mmol/l. Overall, 100
per cent of these events were treated appropriately. 97 per cent of
hypoglycaemic events received 1520 g of quick acting oral
carbohydrate. Blood glucose was treated until it returned
to > 4 mmol/l in 95 per cent of cases. Patients should have their
blood glucose re-measured within 15min of a blood glucose
measurement of > 4 mmol/l; this happened in only 34 per cent of
cases. Patients received a long-acting carbohydrate after their
hypoglycaemia had resolved in 14 per cent of cases.
Discussion: The introduction of hypo boxes has greatly improved
inpatient treatment of hypoglycaemic events. The main issue found is
that patients are not being given long-acting carbohydrates following
recovery from the hypoglycaemic event: this needs to be addressed.
P330
A review of hypoglycaemia in Bedford
Hospital inpatients
L Faghahati, L Cowley and A Melvin
Diabetes Centre, Bedford Hospital NHS Trust, Bedford, UK
Background: Hypoglycaemia amongst inpatients remains a frequent

potentially life threatening problem. Hypoglycaemia needs to be
identified, treated appropriately and precipitating causes investigated.
Hypoglycaemia is identified with patients taking insulin but is perceived
to be less of a problem in patients on oral hypoglycaemic agents.
Previous inpatient studies have concentrated upon incidence of
hypoglycaemia rather than timing. We audited the frequency, timing
and immediate treatment of hypoglycaemia, and we tried to identify
precipitants.
Method: During two separate periods in March and August 2010, 91
patients with diabetes were identified on most adult wards at Bedford
Hospital. The capillary blood glucose monitoring (CBGM) chart, drug
chart and notes were reviewed.
Results: Four patients with Type 1 diabetes and 87 with Type 2
diabetes had 158 episodes of hypoglycaemia. The episodes were split
equally between patients on insulin or sulfonylureas (SU). The majority
of episodes were before breakfast or before bed. Fewer than half of the
episodes were treated adequately. The commonest identified likely
causes of hypoglycaemia were poor nutrition and lack of snacks, renal
impairment and sepsis/infection.
Conclusions: Hypoglycaemia is very common in inpatients with
diabetes and is not limited to patients on insulin. All patients with
diabetes on insulin or SU must have regular CBGM performed targeting
pre-breakfast and pre-bed especially. More patients should have access
to a snack before bed to include complex carbohydrate. A need for
further training of ward staff for appropriate action of hypoglycaemia
was identified. Medical teams must review CBGM charts daily and act
on the results.
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P331
Innovative hypoglycaemia care pathway for
admission avoidance; a partnership
approach with a local ambulance trust
S Jackson, J James, J Fairfield, J Spiers, M Roshan, J Ferns,
O Sudar and R Gregory
Department of Metabolic Medicine, University Hospitals of Leicester NHS
Trust, Leicester, UK
Background: From 1 September 2010 to 31 March 2011 there were

388 diabetic emergency ambulance call-outs locally including those for
hypoglycaemic patients. The City PCT commissioned an intermediate
care service, which encompassed diabetes specialist nurse (DSN)
assessment within two working days for all hypoglycaemic people
accessing ambulance services. Ambulance crews referred to a DSN
service via a single point of access service. Patients had to consent for
information to be shared with DSNs, Trusts and GPs. A patient
information leaflet was designed by DSNs and distributed by
ambulance crews to affected patients. Our aim was to audit the
number and demographic, clinical and admission data relating to
hypoglycaemic patients accessing ambulance services over a 7-month
period.
Method: Retrospective data was collected using hospital systems and
patient records including the number of patients seen, number of
contacts, demographics, clinical and admission data.
Results: The cohort was 43, mean age 58 years, male 42 per cent,
English speakers 88 per cent; mean HbA1c 8.18 mmol/l, HbA1c < 7.5
per cent for 26 per cent; 26 (60 per cent) Type 1; 40 (88 per cent) insulin
treated Type 1 and Type 2 diabetes. The mean number of contacts per
patient was 1.37, telephone contacts 88 per cent; five patients had face
to face contacts. Two patients were admitted (4.87 per cent): one
sulfonylurea treated aged 93 years, HbA1c 7.1 per cent; one insulin
treated aged 89 years, HbA1c 5.8 per cent. One-quarter of patients had
HbA1c under 7.5 per cent.
Conclusion: The majority of hypoglycaemic referrals were insulin
treated and 25 per cent of them had an HbA1c under 7.5 per cent.
Partnership working with hospital, community trust and ambulance
trust resulted in 5 per cent admissions in 7 months. This pathway offers
ambulance services a practical alternative to routine admission for
hypoglycaemia.
P332
Impaired hypoglycaemia awareness in Type
1 diabetes in an outpatient setting
HK Tan and DE Flanagan
Aim: To determine the prevalence of impaired hypoglycaemia

awareness (IHA) among Type 1 diabetes (T1DM) patients in an
outpatient setting.
Methods: Thirty T1DM patients attending outpatients across a 3week period were interviewed, completing the Clarkes questionnaire
and Gold Score. Clarkes questionnaire consists of eight questions
regarding hypoglycaemia episodes and symptoms while Gold Score is
rated on a seven-point Likert scale where a score of 4 and above implies
the presence of IHA. We looked at the proportion of patients with IHA.
We related this to patient characteristics including duration of diabetes
and HbA1c.
Results: Eight patients (27 per cent) had a Gold Score of 4 and above.
HbA1c of patients without IHA is 8.52 per cent 2 per cent vs. 8.2 per
cent 1.23 per cent for patients with IHA (p = 0.674). Patients with
130
IHA had longer mean duration diabetes, 30.1 15.1 years vs.
15.2 14.7 years for patients without IHA (p = 0.021). Seven
patients had at least one episode of severe hypoglycaemia within
12 months, of whom two have a Gold Score of 3 or below. All with IHA
were using basal bolus analogue insulin regimens. Three were
considering pump therapy. Seven patients (87.5 per cent) with IHA
discussed hypoglycaemia during their consultation with a specialist
compared with 14 patients (63.6 per cent) without IHA.
Conclusion: The prevalence of IHA was higher in this study than in
previous work suggesting that the problem may still be underestimated.
It was appropriately recognised, and treatment strategies documented
for the majority, on attendance at specialist clinics.
P333
The value of electronic recording of blood
glucose in the surveillance for inpatient
hypoglycaemia
K Nirantharakumar1,2, A Kennedy2,3, T Marshall1,
P Narendran2,3 and JJ Coleman2,3
1
Department of Public Health, Epidemiology and Biostatistics, University of
Birmingham, UK, 2Queen Elizabeth Hospital, Edgbaston, Birmingham, UK,
3
School of Clinical and Experimental Medicine, University of Birmingham, UK
Aim: To determine the value of recording blood glucose (BG) values

electronically in the surveillance of in-patient (IP) hypoglycaemia in a
tertiary hospital in UK.
Methods: Here we present a descriptive analysis of the BG values
(point of care and laboratory) that are entered into electronic patient
observations with a view of looking at data on hypoglycaemia. We only
included values from non critical care setting who had a greater than
one day of IP stay at University Hospital Birmingham in 2010. We
looked for any determinants of IP hypoglycaemic occurrence by using
logistic regression.
Results: Only a fraction (33 per cent) of those patients with diabetes
meeting the inclusion criteria had their BG values entered into the
electronic observation system (1666 admissions). 18.5 percent
(n = 308) had at least one episode of hypoglycaemic value
(<4 mmol/l) during their IP stay. Patients admitted as non-elective
(p = 0.036), on insulin (p < 0.001) and with increased length of stay
(p < 0.001) were more likely to have an IP hypoglycaemic episode.
Conclusion: Electronic BG observations can alert specialist team of IP
hypoglycaemia, help monitor incidence of IP hypoglycaemia and are
useful for quality assurance in looking at IP glycaemic control. However
poor manual recording of point of care BG into electronic patient
records can make this less valuable. In our results selective recording
may have overestimated the occurrence of IP hypoglycaemia.
Nevertheless our findings of the determinants for occurrence of IP
hypoglycaemia are consistent with previous literature. For greater
efficiency newer glucose monitoring equipments that directly feed into
centralised laboratory reporting system are essential.
Acknowledgement This abstract was funded by the National
Institute for Health Research (NIHR) through the Collaborations for
Leadership in Applied Health Research and Care for Birmingham and
Black Country (CLAHRC-BBC) programme.
Disclaimer: The views expressed in this abstract are not necessarily
those of the NIHR, the Department of Health, NHS Partner Trusts,
University of Birmingham or the CLAHRC-BBC Theme 9
Management/Steering Group.
2012 The Authors.

P334
Tight glycaemic control and hypoglycaemia
in elderly patients admitted to hospital: are
these patients overtreated?
KA Jackson and M Teh
Department of Diabetes and Endocrinology, Good Hope Hospital, Sutton
Coldfield, UK
Aim: Intensive diabetes treatment in elderly patients is associated with

a high risk of severe hypoglycaemia. There is no specific guideline for
management of diabetes in elderly patients. Therefore, special
considerations need to be made when treating them. Our aim was to
determine the correlation between hypoglycaemia, glycaemic control
and pharmacological management of diabetes in elderly patients.
Method: This was a retrospective interrogation of laboratory records
to identify diabetes patients older than 75 years with venous glucose of
less than 4 mmol/l in a 1-year period. Data on HbA1c, patients
demographics and diabetes treatments were extracted from electronic
patients records.
Results: Forty-six patients were included. There were 23 men and 23
women, with mean age 81 years. The venous glucose of the group was
2.8 0.8 mmol/l (mean SD); HbA1c was 7.4 1.3 per cent.
Twenty-three of the 46 (50 per cent) patients were on insulin only
with HbA1c of 8.2 1.3 per cent. Eighteen of the 46 (39 per cent)
patients were on oral hypoglycaemic agents only. Of these, nine patients
were on a sulfonylurea alone, HbA1c 6.2 0.7 per cent, six were on
metformin alone with HbA1c 6.7 0.4 per cent and three patients
were on sulfonylurea and metformin with HbA1c 7.9 0.9 per cent.
Five patients were on insulin and metformin with HbA1c 6.8 0.8 per
cent.
Conclusion: Tight glycaemic control in elderly patients is associated
with hypoglycaemia. A significant proportion of hypoglycaemia
episodes are associated with treatment with oral hypoglycaemic drugs
alone and even metformin is associated with hypoglycaemia in this
group. Diabetes management and glycaemic control in the elderly needs
to be individualised.
P335
An analysis of all cases of severe
hypoglycaemia presenting to a major
teaching hospital over one year
VJ Parfitt and R Bhake
Department of Diabetes and Endocrinology, North Bristol NHS Trust, Bristol,
UK
Aims: Severe hypoglycaemia has significant morbidity but is managed

mainly by non-specialist front-line emergency staff working to
guidelines. We reviewed the epidemiology and audited the
management of all patients presenting over 1 year.
Methods: This was a retrospective audit.
Results: Forty-nine episodes occurred in 49 patients: 30 male; age
(mean SD) 60 20 years; diabetes duration (known in 28/49),
median (range) 19.5 (465) years; 21 Type 1 diabetes (three on animal
insulins), 18 insulin treated Type 2 or other diabetes, 10 tablet treated
Type 2 diabetes. The number of significant comorbidities (in 48/49) was
nil, eight patients; one, nine; two, 11; three or more, 20. Causes of
hypoglycaemia were a missed meal, 17; extra activity, three; alcohol,
five; insulin dose error, six; deliberate insulin overdose, two; and
unclear, 18. The clinical presentation was collapse, 17; confusion, five;
seizure, five; unconscious, 12; unclear, 10. Four hypos occurred whilst
driving. The initial caregiver was the partner in five cases; the GP in two;
2012 The Authors.

DIABETICMedicine
a paramedic, 31; the emergency department, seven. Outcomes: twentyfive patients were admitted; the rest were discharged after initial
treatment (two against medical advice). None died. Management
followed local guidelines in 38 cases. All frail elderly/slow to recover
patients (17) were admitted, but only 8/10 of those with sulfonylurea
related hypos. Only 17 patients were given advice for preventing future
hypos, only two advice regarding driving and in only six was evidence of
hypoglycaemia unawareness sought.
Conclusions: Patients on animal insulins were overrepresented,
suggesting an increased risk. Principal management deficiencies were
in plans and advice to patients to prevent future hypos, detection of
hypoglycaemia unawareness and communication with usual
caregivers.
P336
Drivers of recurrent severe hypoglycaemia
and implications for its prevention: a
qualitative study of adults with Type 1
diabetes
SM Barendse1, H Singh2, S Little3, M Rutter4,5, JAM Shaw3,
J Speight1,6,7 and S Heller8
1
AHP Research, Hornchurch, UK, 2Department of Psychiatry and

Neurobehavioral Sciences, University of Virginia Health System,
Charlottesville, USA, 3Institute of Cellular Medicine, Newcastle University,
Newcastle-Upon-Tyne, UK, 4Manchester Diabetes Centre, Central
Manchester University Hospitals NHS Foundation Trust, Manchester, UK,
5
Cardiovascular Medicine Research Group, University of Manchester,
Manchester, UK, 6Australian Centre for Behavioural Research in Diabetes,
Melbourne, Australia, 7Centre for Mental Health and Wellbeing Research,
Deakin University, Burwood, Australia, 8Academic Unit of Diabetes,
Endocrinology and Metabolism, University of Sheffield, UK
Aims: Severe hypoglycaemia (SH) affects approximately one in three

adults with established Type 1 diabetes annually, causing individuals as
much concern as the risk of blindness. Despite the idiosyncratic nature
of hypoglycaemia (eg symptom experience and progression from mild
to severe), there is a dearth of qualitative research investigating its
drivers and prevention.
Methods: We conducted in-depth semi-structured interviews with a
purposive sample of 17 adults (53 per cent women, aged 46 11 years,
Type 1 diabetes duration 26 14 years) with a history of recurrent SH
and retained or partial awareness of hypoglycaemia, recruited from two
UK tertiary clinics. The interview schedule included experience of
hypoglycaemia (symptoms/awareness, progression from mild to
severe), and prevention/treatment strategies. Interviews were analysed
using an adapted grounded theory approach.
Results: Three main themes emerged as recurrent barriers to
prevention of SH: hypoglycaemia-induced cognitive impairment,
behavioural factors and psychosocial factors. Despite experiencing
early symptoms, individuals often delayed intervention for reasons
including impaired or distracted attention, inaccurate judgement of
risk, embarrassment, and worry about rebound hyperglycaemia or
unavailability of preferred glucose sources. Moreover, delay in
treatment of mild hypoglycaemia coupled with use of slow-acting
glucose sources made successful prevention of SH less likely.
Conclusions: Our data highlight the multi-faceted and idiosyncratic
nature of SH. Individuals with a history of recurrent SH may have
specific thought and behaviour risk profiles. Individualised prevention
plans are needed, emphasising active attention to individual symptoms
of mild hypoglycaemia and prompt intervention at personal cues with an
appropriate and patient-preferred glucose source in order to prevent SH.
131
DIABETICMedicine
P337
Does having a hypoglycaemia treatment
algorithm and a hypo box improve
knowledge regarding awareness about the
appropriate management of hypoglycaemia
amongst nursing staff?
D Beeharry1, I Lamen1, T Reid2, R Burnham2, D Sharma1 and
A Meldon1
1
Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool,
UK, 2Medical School, Liverpool University, Liverpool, UK
Aims: Hypoglycaemia is a serious complication of the treatment of

diabetes, and 15 per cent of inpatient beds in England are occupied by
patients with diabetes, with one in four having a hypoglycaemic episode
during their hospital stay. The Joint British Diabetes Society Guidelines
(2010) recommended having a hypo box on the wards. A hypo box was
introduced in December 2010 in all the wards in our Trust.
Methods: Five questionnaires were sent to nursing staff in 35 wards,
including medical, surgical and orthopaedics. A hundred nursing staff
responded to the questionnaires. This was re-audited in August 2011.
Clinical care and other categories posters: innovation
Results: In total, 76 per cent were aware of the existence of

hypoglycaemia guidelines and a hypo box compared with 85 per cent
during re-audit. When questioned about treatment of hypoglycaemia in
a conscious patient, 68 per cent in the audit and re-audit group opted for
100ml of lucozade; 30 per cent in the audit group and 20 per cent in the
re-audit group gave inappropriate answers. Regarding management of
unconscious hypoglycaemic patients, 9 per cent chose a combination of
intramuscular glucagon, intravenous dextrose and calling the doctor
(vs. 27 per cent in the re-audit group). The remaining participants chose
one or two of the latter options. 77 per cent in the audit group and 85 per
cent in the re-audit group opted to recheck blood glucose at 510min
post treatment.
Conclusion: Our audit demonstrates that although 70 per cent of staff
are aware of the hypo box, more education sessions are required. Our
audit re-emphasises the need for robust ongoing education sessions
regarding management of hypoglycaemia and other aspects of diabetes
treatment.
Clinical care and other categories posters: innovation

P338
Blood glucose control during enteral
feeding in patients with diabetes: a safe,
simple solution
SV Sagi1, C Home2 and SO Oyibo1
1
Department of Diabetes and Endocrinology, Peterborough City Hospital,
Peterborough, UK, 2Department of Diatetics, Peterborough City Hospital,
Peterborough, UK
Background: Uncontrolled hyperglycaemia affects patients with

diabetes having enteral feeding. There is a sustained glucose rise as
opposed to the postprandial peaks of normal eating. In the absence of
local guidelines, we aimed to provide a safe, simple insulin regimen for
our patients.
Methods: Patients with diabetes requiring enteral feeding were given
insulin twice a day (at the start and half way through the feed); dosage
was calculated based on estimated carbohydrate to insulin ratio (based
on prior insulin use), feed carbohydrate concentration, infusion rate and
duration. It was adjusted according to capillary glucose (target range 6
12 mmol/l). Uncontrolled hyperglycaemia prompted screening for

ketoacidosis or hyperosmolality.
Results: Twenty-one patients required enteral feeding (12 previously
insulin treated). The average age was 72 years and weight 73.8kg. The
median (range) feed carbohydrate concentration was 12.3 (12.3
20.1)g/100ml; initial infusion rate 50 (2075)ml/h; initial feed duration
20 (1024)h/day; and carbohydrate-to-insulin ratio 10 (610). Initial
insulin doses ranged from 6 to 16 units twice a day. The target capillary
glucose range was achieved in 14 patients. Of the seven patients that did
not achieve the target range, five pulled out their feeding tubes too early,
one had aspiration pneumonia and one had a very complex feeding
regimen. Capillary glucose levels never fell below 4 mmol/l in any of the
patients.
Conclusions: This study has provided us with a safe, simple twice-aday insulin regimen for patients with diabetes who require enteral
feeding. The importance of frequent blood glucose monitoring in these
patients cannot be overemphasised.
Clinical care and other categories posters: inpatient care

P339
The dynamic of glycaemia among adults
admitted to hospital with acute stroke:
implications for practice from a cohort
study
EA Mitchell1, VE Coates2, MO McCarron3, AA Ryan2 and
M Armstrong4
P340
Mortality among inpatients with diabetes
N Holman
Observatory, York, UK
School of Nursing, University of Ulster, Londonderry, UK, 2Institute of

Nursing Research, University of Ulster & Western Health and Social Care Trust,
University of Ulster, Coleraine, UK, 3Department of Neurology, Altnagelvin
Area Hospital, Londonderry, UK, 4Stroke Unit, Altnagelvin Area Hospital,
Western Health and Social Care Trust, UK
132
2012 The Authors.

DIABETICMedicine
P341
Assessment of glucose homeostasis in
coronary care in Birmingham
became unwell with tachypnoea, tachycardia and hypotension. Her

arterial blood gases showed a pH of 7.1, with evidence of ketonaemia.
Her ECG was now a sinus tachycardia (ventricular rate of 132) with
new left bundle branch block in the lateral leads. Her initial troponin
was 400 ng/l (<14) and a repeat was 420 ng/l. She was treated with
intravenous insulin and fluids for the DKA, and aspirin and enoxaparin
for ACS. Subsequent echocardiogram showed normal left ventricular
size and function.
Conclusion: This case shows the difficulty in recognising silent MI as a
precipitating event for DKA. Although DKA could precipitate an ACS,
it is not clear if a silent MI has triggered her DKA in the first place. Her
epigastric pain could have been an atypical presentation for an ACS. It is
imperative to think laterally for rare causes of DKA, when an obvious
cause has not been identified.
MA Karamat1, AA Taharani1, UY Raja2, W Hanif2, SE Manley3

and MJ Stevens1
1
Centre for Endocrinology, Diabetes and Metabolism, University of
Birmingham, Birmingham, UK, 2Diabetes Centre, Queen Elizabeth Hospital
Birmingham, Birmingham, UK, 3Department of Clinical Chemistry, Queen
Elizabeth Hospital Birmingham, Birmingham, UK
P342
Demonstration of improvement in
management in diabetic ketoacidosis with
yearly audits
N Tufton, WH Cheung, R Freudenthal and M Rossi
Diabetes and Endocrine, Whittington Hospital NHS Trust, London, UK
Aim: The National Diabetes Inpatient Audit has identified lack of

recognition and delay in treatments in patient admitted with diabetic
ketoacidosis (DKA) as an area of concern. We undertake yearly audits
in the management of patients admitted with DKA. Our last audit
assessed if recently updated local guidelines were being adhered to and
compared door to needle time with data from previous years.
Method and results: Data for all adult admissions with DKA in
2010 were audited. There were 29 admissions. 76 per cent of patients
had known diabetes; 33 per cent were precipitated due to an infection,
20 per cent were due to non-compliance with medications and in 8 per
cent no precipitant was found. These data were similar to previous
years. Time to intravenous fluids ranged from 0 to 123min (average
55min) and was improved from previous years. Time to insulin ranged
from 5 to 204min (average 82min). 58 per cent received intravenous
fluids and 42 per cent received insulin within 1 h. 96 per cent and 76 per
cent received intravenous fluids and insulin respectively within 2 h.
Continuation of basal insulin, increased monitoring of capillary blood
glucose, electrolytes and observations all improved compared with
previous years. Duration of stay decreased to a median of 3 days.
Conclusion: Update of our Trust guideline, yearly audits of DKA
admissions and yearly presentations to all our medical staff have
demonstrated year on year improvements in management of patients
with DKA. We continue to strive to implement changes to optimise care
further in the future.
P343
Which came first? Myocardial infarction or
diabetic ketoacidosis
D Beeharry, R Shankland and D Sharma
Diabetes Department, Royal Liverpool University Hospital, Liverpool, UK
Background: Myocardial infarction (MI) is a recognised trigger

factor causing diabetic ketoacidosis (DKA). However, DKA can cause
an acute coronary event. We present the case of a 44-year-old female
with Type 1 diabetes of 20 years duration, admitted with DKA which
was recurrent during admission. She had no previous hospital
admissions for DKA and was found to have a silent acute coronary
syndrome (ACS) whilst she was being treated.
Case report: The patient was admitted with abdominal pain. Her
admission investigations were normal with a normal ECG. Liver
ultrasound was normal including pancreas. Shortly after admission she
2012 The Authors.

P344
Introduction of an insulin prescribing chart
is associated with a reduction in insulin
prescribing errors
NE Hawkins, J Abel and MG Masding
Diabetes and Endocrinology, Poole Hospital NHS Foundation Trust, Poole, UK
Aim: In hospitals, insulin is a common source of prescription error. We

assessed the impact of the introduction of a separate tailored insulin
prescription chart on these errors.
Method: As part of the National Diabetes Inpatient Audit (November
2010), we measured insulin and oral hypoglycaemic agent (OHA)
prescription errors in a cross-sectional 1-day audit of our district general
hospital. In February 2011, we introduced a separate insulin
prescription chart for medical, surgical and elderly care wards. In July
2011, we repeated the cross-sectional 1-day audit of prescription errors
of both insulin and OHAs of patients with diabetes on the same wards.
Results: In November 2010 there were 23 patients on insulin (eight
Type 1, 15 Type 2), of whom 20 (87 per cent) had at least one
prescription error, and 22 patients on OHAs, of whom 10 (45 per cent)
had at least one prescription error. In the July 2011 re-audit, of 24
patients (five Type 1, 19 Type 2) taking insulin, 11 (46 per cent) had at
least one prescription error P = 0.006 compared with 2010). The
greatest error reduction was seen in clarity of the word units being used
in insulin prescriptions (p < 0.001). However, there was no change in
OHA prescription error (10 of 16 patients, 62 per cent; P = 0.204).
Conclusion: Following the introduction of a specific insulin
prescription chart, there was a reduction in insulin prescription
errors. A reduction in OHA errors was not observed, suggesting that
the insulin prescription chart itself was important, rather than a general
improvement in prescribing.
P345
Does the introduction of diabetes inpatient
specialist nurses have an effect on the
average length of stay for adult inpatients
with diabetes? An interrupted time series
analysis
SA Jones
Observatory, York, UK
Aims: To investigate whether the introduction of diabetes inpatient

specialist nurses (DISNs) reduced the average length of stay (LOS) for
adult inpatients with diabetes.
133
DIABETICMedicine
Methods: Diabetes inpatient spells were identified at Trusts A and B,

using Hospital Episode Statistics, if they included a diagnosis of diabetes
(ICD-10: E10E14). Both Trusts are relatively small foundation trusts
in northern England. The primary outcome measure of average
monthly LOS was calculated for each trust between 1 February 2000
and 31 January 2010. The effect of the introduction of DISNs on
average LOS for patients with a diagnosis of diabetes was analysed
using an interrupted time series with segmented regression analysis. A
comparator group of inpatients in the same organisation without
diabetes was included.
Results: Following the introduction of a DISN in Trust A, no
statistically significant change in the average monthly LOS was
found. In Trust B, a sudden and statistically significant decrease of
3.1 days was observed in patients with diabetes, but a similar significant
decrease of 2.4 days was seen in patients without diabetes (P = 0.0001
and P < 0.0001, respectively). No statistically significant change was
found in the trend of average monthly LOS between the pre- and postintervention segments for either trust (P = 0.265 and P = 0.114,
respectively).
Conclusion: This study provides mixed evidence of the effectiveness
of DISNs on reducing the average LOS for adults with diabetes, possibly
due to an existing decreasing trend in LOS. It indicates that further work
is needed in order to fully understand the effect of DISNs on reducing
length of stay.
P346
Perioperative management of patients with
diabetes: a review of current clinical
practice
L McLaren1, A McIntosh2 and A Kernohan1
P347
Variation in inpatient activity
P Follett1, R Young2 and N Holman1
1
Observatory, York, UK, 2Diabetes and Endocrinology, Salford Royal NHS
Foundation Trust, Salford, UK
Aims: To assess excess bed days, emergency re-admissions and the

shortfall in day-case listings in patients with diabetes compared with
those without by the Health Resource Group (HRG).
Methods: Inpatient activity data for all hospitals in England between
1 April 2009 and 31 March 2010 were extracted from Hospital Episode
Statistics. Age-standardised ratios were calculated for bed days,
emergency re-admissions within 28 days and day-case listings as a
percentage of elective procedures for each HRG.
Results: Overall people with diabetes spent 795,000 (19.4 per cent)
more days as an inpatient than those without diabetes. Excess length of
stay was greatest in admissions for the vascular system (47.0 per cent)
and skin, breast and burns (42.1 per cent) but least for admissions for
the nervous system (2.8 per cent). Emergency re-admissions were 59.1
per cent more likely in people with diabetes. Excess emergency readmissions were greatest following admissions for skin, breast and
burns (115.7 per cent) and mouth, head, neck and ears (102.9 per cent).
People with diabetes were 10.4 per cent less likely to be admitted as a
day-case when attending for elective care. The greatest shortfall in daycase listings was found in procedures for the vascular system (35.4 per
cent) and the female reproductive system (22.7 per cent). Procedures
linked to eyes and the periorbita (0.2 per cent) and the nervous system
(3.5 per cent) had the smallest shortfall in day-case listings.
Conclusions: People with diabetes have longer stays in hospital, are
less likely to be listed as a day-case and are more likely to be re-admitted
as an emergency than people without of a similar age. Excess inpatient
activity in people with diabetes varies by HRG.
1
Department of Diabetes and Endocrinology, Southern General Hospital,
Glasgow, UK, 2Medical School, University of Glasgow, Glasgow, UK
Introduction: Some 10 per cent of patients undergoing surgery have

diabetes resulting in increased perioperative mortality and longer
admissions compared with patients without diabetes. With a view to
improving the perioperative management of people with diabetes we
conducted a review of current practice and outcomes in five surgical
wards prior to piloting the ThinkGlucose project.
Methods: We retrospectively identified 43 patients with diabetes
undergoing surgery or investigative procedures who had blood glucose
monitored using the Abbott Precision XceedPro Blood Glucose
Monitoring system. Notes were available for 25 patients. We
recorded usual diabetes treatment, perioperative diabetes regime,
blood glucose readings, postoperative complications and length of
stay.
Results: Four patients had Type 1 diabetes and 21 had Type 2 diabetes
[three diet-controlled, 16 on oral hypoglycaemic agents (OHAs) and
two taking insulin]. During the perioperative period, eight patients were
managed using an insulin sliding scale, one patient was given their usual
insulin, nine patients had OHAs withheld preoperatively and seven
patients had no documented diabetes management plan. Using the
national inpatient guidelines, 55 per cent of blood glucose readings were
out of the target range of 610 mmol/l; 33.9 per cent were out of the
acceptable range of 412 mmol/l with 9.3 per cent of readings below
4 mmol/l. Two patients developed postoperative acute kidney injury
and three developed sepsis. There were four admissions to high level
care beds. Mean length of stay was 11.84 days.
Conclusions: Patients with diabetes undergoing surgery are at
significant risk of complications and their current management is
suboptimal with the potential to increase complications and length of
stay.
134
P348
Hyperglycaemia and screening for diabetes
in the acute medical admissions unit
MPM Graham-Brown, B Champaneri, H Taki and S Ghosh
Department of Diabetes and Endocrinology, University Hospital Birmingham,
Birmingham, UK
Background: Our initial audit in 2008 showed that only 66 per cent
of acute medical patients had any form of blood (capillary or venous)
glucose measurements on admission. We then produced a guideline on
blood glucose measurement and diabetes screening. Blood glucose
measurement on admission and adherence to guidelines was audited on
two consecutive years.
Methods: This was a retrospective audit of glucose measurement on
admission to the medical assessment unit. Information gathered
included age, presenting complaint, previous diagnosis of diabetes,
glucose measurement on admission and follow-up of abnormal results.
Results: Data were collected on 180 patients in 2009 and 100 patients
in 2010. A diagnosis of diabetes prior to admission was seen in 14 per
cent (2009) and 28 per cent (2010). Of those patients without a
diagnosis of diabetes on admission, 65 per cent (2009) and 96 per cent
(2010) had glucose measured on admission. Hyperglycaemia in not
known diabetics, as defined by an admission blood glucose of 7 mmol/l
or more, was present in 42 per cent (2009) and 33 per cent (2010).
Hyperglycaemia in patients without known diabetes was not followed
up according to the guidelines.
Conclusions: Our serial audits show that although blood glucose
measurements are increasingly being done in acute medical patients,
2012 The Authors.

admission hyperglycaemia is largely not acted upon. This could possibly

be due to lack of our current understanding of the outcome of admission
hyperglycaemia in different medical conditions. This highlights the need
for further investigation to look into this and a national consensus
guideline for the screening of diabetes in hospital patients.
P349
Inpatient diabetes in the Black and Minority
Ethnic (BME) diabetes population
S Ghosh1, K Kimani2, R Potluri3, A Natalwala4, R Heun5 and
P Narendran6
1
Diabetes, University Hospital Birmingham NHS Trust, Selly Oak Hospital,
Birmingham, UK, 2University of Nairobi, Nairobi, Kenya, 3Cardiovascular
Medicine, University of Manchester, Manchester, UK, 4Neurosurgery, Royal
Hallamshire Hospital, Sheffield, UK, 5Psychiatry, Royal Derby Hospital, Derby,
UK, 6Clinical and Experimental Medicine, University of Birmingham,
Birmingham, UK
Aims: There is very little information available about the factors

influencing length of stay (LOS) in the diabetes black and minority
ethnic (BME) population in the UK, as current evidence is from studies
in predominantly Caucasian populations. This study aimed (1) to
compare LOS of diabetes BME patients to the Caucasian population
and (2) to determine factors influencing LOS in the BME diabetes
population.
Methods: Anonymised data of admissions to University Hospital
Birmingham NHS Foundation Trust, UK, between the years 2000 and
2007 were examined.
Results: There were 87,616 overnight admissions between 2000 and
2007. Of these, 5,267 were coded for diabetes. A significantly greater
proportion of BME than Caucasian admissions were coded for diabetes
(7 per cent vs. 5 per cent). Mean LOS of South Asians (8.6 days), AfroCaribbean (9.1 days) and mixed race (8 days) was significantly shorter
than for Caucasians (10.2 days). LOS in the BME population was
related to age but did not associate with comorbidity or insulin use.
Conclusions: LOS in the inpatient BME population is significantly
shorter despite the BME population having a higher prevalence of
diabetes. Reasons for the shorter LOS remain unclear. There is some
evidence that the BME population has less support at discharge, is
discharged at the wrong time and has greater chance of re-admission.
There is also evidence that the BME population has a more supportive
home environment that allows for earlier discharge. These factors
warrant further study.
P350
Inpatient costs for people with diabetes in
England and the potential for quality
improvement and savings: an economic
analysis
M Kerr1,2
1
2
NHS Diabetes, NHS Diabetes and Kidney Care, Newcastle-Upon-Tyne, UK,

Insight Health Economics, London, UK
Aims: To estimate total and excess expenditure on inpatient care for

people with diabetes in the English NHS, and to assess the potential for
specialist diabetes inpatient teams to improve patient outcomes and
reduce costs.
Methods: Hospital Episode Statistics for 200910 were examined to
identify all admissions with a recorded diabetes diagnosis. Expenditure
was estimated using Payment by Results tariffs. Excess admission rates
2012 The Authors.

DIABETICMedicine
and day-case rates (and associated expenditure) were then calculated,

relative to people of the same age and gender without diabetes. Costs,
impacts and potential savings from diabetes specialist inpatient teams
were estimated using data from published studies.
Results: It is estimated that the NHS in England spends 2.3 billion
2.5 billion a year on inpatient care for people with diabetes, around 11
per cent of total NHS inpatient expenditure. Of this sum, 573 million
686 million is excess expenditure, above the level for people of the
same age and gender without diabetes. Three-quarters of this excess is
accounted for by higher non-elective admission rates. Length of stay is
longer for people with diabetes and day-case rates are lower. Economic
analysis suggests that diabetes specialist inpatient teams can reduce
complication rates and length of stay. Savings can substantially
outweigh the cost of the teams.
Summary: Absolute and excess costs in inpatient care for people with
diabetes are substantial. Commissioners and acute providers of diabetes
care have the potential to improve patient outcomes and increase NHS
productivity through increased use of specialist diabetes inpatient
teams.
P351
Outcome data after implementing
ThinkGlucose in a district general hospital:
the Dudley experience
H Siddique, A Stroyde, K Crowley, C Holmes, J Dale and
K Gorton
Diabetes and Endocrinology, Dudley Group of Hospitals NHS Trust, Dudley,
UK
Objectives: The ThinkGlucose project was launched in the Dudley

Group of Hospitals across the Trust in April 2010 in response to the
National Diabetes Audit 2009. The objectives were to increase the
awareness of diabetes in inpatients and educate staff; an early specialist
involvement with early discharge/follow-up plan to reduce the average
length of stay; to reduce prescription errors and improve patient care
through updated guidelines.
Design: We conducted baseline audits on inpatient diabetes care
across the hospital. A dedicated consultant led diabetes outreach team
was formed. A rolling teaching programme for nurses and doctors
including night-time teaching was introduced. A 6-day ThinkGlucose
service was introduced including dedicated consultant sessions. Our
service was advertised to staff using trust intranet and patients through
magazines. Protocols, guidelines and proformas were introduced in
accordance with national guidelines.
Results: The number of inpatients with diabetes across the Trust
reduced from 22.4 per cent to 11.6 per cent. The average length of stay
reduced by 0.61 days, generating efficiencies for the Trust of 422,000
in less than a year. More than 70 per cent of staff caring for inpatients
were educated through ThinkGlucose. HbA1c reduced by 1.71 per cent
and 0.47 per cent for new-onset and known diabetes patients
respectively. Insulin prescription errors reduced from 24.6 per cent to
6.4 per cent. Appropriate hypoglycaemia management improved from
26.1 per cent to 65 per cent. Inappropriate referral to the specialist team
dropped from 23.3 per cent to 13.8 per cent.
Conclusion: Implementing ThinkGlucose in the Dudley Group has
resulted in improved outcomes for various diabetes related endpoints.
The data provided was independently verified by the NHS Institute for
Innovation and Improvement, UK.
NB The data provided is independently verified by the NHS Institute for
Innovation and Improvement UK.
135
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P352
Evaluation of an inpatient diabetes care
model that improves patient safety
D Selvarajah, C Nelson, C Stocks, C Nisbett, K Hudson and
FM Creagh
Diabetes Centre, Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
Objective: Up to one in five hospital patients has diabetes. Their

outcomes are directly linked to the quality of care provided.
Prolonged length of stay, morbidity and mortality can result from
harm events. It is unclear what models of care are important for
reducing harm and improving patient outcomes. The objective was to
investigate if an inpatient diabetes management programme improves
patient safety.
Methods: A multidisciplinary team performed a failure-modeseffects analysis of critical incident reports of diabetes management
errors. This identified potential triggers of harm and processes most
in need of change: inappropriate blood glucose monitoring; poor
identification/treatment of hypoglycaemia; prescription errors.
Therefore, separate care bundles were introduced; diabetes
prescription/monitoring charts; hypo boxes; ward based diabetes
education (ThinkGlucose). Harm events were recorded pre- and
post-intervention. An MCQ questionnaire and a self-administered
survey assessed staff knowledge and patient satisfaction
respectively.
Results: In total, 108 patients (52 pre-intervention) over 794.9
diabetic bed days (440.9 pre-intervention) were examined on two
medical and two surgical wards. Results presented were adjusted per
patient per 1,000 diabetic bed days. There was a 31.8 per cent reduction
(pre-intervention 20.2 vs. post-intervention 14.9) in the total number of
harm events. There was a 28.2 per cent reduction in hypoglycaemic
episodes (8.3 vs. 5.9) with 53.3 per cent improvement in episodes
treated appropriately. A 70.7 per cent reduction in prescription errors
(9.2 vs. 2.7) was also demonstrated. Staff knowledge scores improved
by 54 per cent and most components of the patient survey also
demonstrated significant improvements.
Conclusion: An inpatient diabetes management programme not only
improves patient safety but also staff knowledge and confidence and
patient satisfaction. These simple and inexpensive measures are easily
adaptable to other ward areas.
P353
Hyperglycaemia in acute coronary
syndromes: management within the Mersey
and North West deaneries
AB Reid and S Osula
Cardiology, Warrington Hospital, Warrington, UK
Introduction: Hyperglycaemia in acute coronary syndromes (ACSs)

is associated with poorer outcomes, regardless of pre-existing diabetes,
and can predict subsequent development of diabetes. NICE guidelines
are in the consultation phase. We explored current practices amongst 25
hospitals within the Mersey and North Western deaneries.
Methods: A telephone survey was conducted over 2 days. The nurse
in charge of the coronary care unit (CCU) at the time of contact
completed a questionnaire. Endpoints included the existence of local
protocols, management of hyperglycaemia (in patients with and
without previously diagnosed diabetes), screening for diabetes, and
follow-up.
136
Results: Protocols existed in 56 per cent of CCUs, with 86 per cent of

these initiating treatment for blood glucose 11.0 mmol/l. 86 per cent
used the DIGAMI regime. Three CCUs started DIGAMI in known
diabetics irrespective of blood glucose. 14 per cent used local
intravenous insulin policies. Management did not differ between
diabetics and non-diabetics. Where protocols did not exist,
management varied between consultants. Twenty-four of 25 CCUs
routinely screened for diabetes using fasting glucose (92 per cent on days
13, 4 per cent on day 4, 4 per cent no specific timing). Sixteen of 24 also
routinely assessed HbA1c. Patient education about their risk of
developing diabetes and referral to primary care for annual screening
was not routinely done in any hospital.
Conclusion: Management of hyperglycaemia in ACS varies between
hospitals. The DIGAMI protocol is the most commonly used. This
reflects the lack of consensus in the care of this cohort of patients. We
anticipate the release of NICE guidelines, and plan to re-audit to assess
their impact.
P354
Inpatient management of hyperglycaemia
following glucocorticoid therapy
JW Limbrick1, FEA Hartley1, A Barridge2, D Kariyawasam2 and
S Thomas2
1
Kings College London, University of London, London, UK, 2Diabetes and
Endocrine Department, Guys and St Thomas NHS Foundation Trust, London,
UK
Aims: Glucocorticoid therapy (GCT) is common in hospitalised

patients. Resulting hyperglycaemia can be difficult to manage, can
cause symptoms, increase morbidity and increase length of stay. This
study aimed to assess the management and glycaemic control in patients
receiving GCT in hospital.
Methods: Data were collected retrospectively on 52 patients with
hyperglycaemia identified between 2009 and 2011 who had had GCT
initiated during the hospital admission. Satisfactory glycaemic control
was defined as capillary glucose readings (CBG) between 4 and
11 mmol/l.
Results: In total 80.8 per cent of patients (mean age 64 years) had
Type 2 diabetes; 15.4 per cent did not have known pre-existing diabetes.
The mean HbA1c was 8.7 per cent on admission. After GCT only 22.5
per cent of CBG readings were satisfactory. 28.8 per cent received no
additional anti-hyperglycaemic medication after GCT. The mean
number of CBG readings was 1.21 (SD 2.1). Those receiving insulin
alone post GCT received a mean dose of 0.33 units/kg (SD 0.25, range
0.290.4 units/kg).
Conclusion: Post GCT glycaemic control was suboptimal. In
general there was inadequate CBG monitoring, insulin, doses
administered were relatively low (0.33 units/kg) and there was a
general failure to titrate appropriately. Management of
hyperglycaemia in GCT patients in hospital is an area that needs to
be focused on and improved.
2012 The Authors.

P355
No excess mortality from hypoglycaemia or
hypokalaemia during use of a standardised
variable rate intravenous insulin infusion in
the management of hyperglycaemia in
acute coronary syndrome: experience of the
Trial of Intravenous Insulin to Achieve
Normoglyacemia in Acute Coronary
Syndrome (TITAN-ACS)
MS Hammersley1 and JS Birkhead2
1
Nuffield Department of Medicine, University of Oxford, Oxford, UK,

Myocardial Ischaemia National Audit Project (MINAP), National Institute for
Clinical Outcomes, The Heart Hospital, London, UK
2
Aims: To evaluate the safety of a standardised variable rate

intravenous insulin infusion (VRIII) with concomitant dextrose and
potassium infusion for patients with acute coronary syndrome (ACS)
presenting with an admission blood glucose (BG) 10 mmol/l
(whether known to have diabetes or not). We investigated the
frequency of mild (3.03.9 mmol/l) and moderate (< 3 mmol/l)
hypoglyaemia during the VRIII, and whether the VRIII caused any
significant hypokalaemia or associated arrythmias.
Methods: Patients were recruited from 40/228 centres participating
in the Myocardial Ischaemia National Audit Project (MINAP) which
collects comprehensive data on all patients presenting with troponin
positive ACS. All patients received a validated VRIII and a low dose 5
per cent dextrose infusion with potassium for the first 24 h in hospital.
Results: There were 523 patients (65 per cent male) with ACS (71 per
cent nSTEMI) and admission BG > 10. Of these 146 (24 per cent) were
not known to have diabetes. Median admission BG was 14 (IQR 11,
18.2). BG between 3.0 and 3.9 mmol/l was found in 19.6 per cent
patients; 4 per cent had isolated BG > 3.0 mmol. There were no deaths
during or immediately following VRIII. Median potassium was
4.4 mmol/l at admission and 4.3 mmol/l at 24 h. Nineteen patients
developed an arrhythmia; in 15 (79 per cent) potassium was >
4.0 mmol/l at time of arryhthmia.
Conclusion: The use of a standardised VRIII was associated with mild
hypoglycaemia in 19.6 per cent and moderate hypoglycaemia in 4 per
cent; this was not associated with an excess mortality. There was no
significant fall in serum potassium or excess arrythmias during VRIII.
P356
Achieving and maintaining
normoglycaemia using a standardised
variable rate intravenous insulin infusion in
the management of hyperglycaemia in
acute coronary syndrome: experience of the
Trial of Intravenous Insulin to Achieve
Normoglycaemia in Acute Coronary
Syndrome (TITAN-ACS)
MS Hammersley1 and JS Birkhead2
1
Nuffield Department of Medicine, University of Oxford, Oxford, UK, 2MINAP,

National Institute for Clinical Outcomes, The Heart Hospital, London, UK
Aims: To evaluate the effectiveness of a standardised variable rate

intravenous insulin infusion (VRIII) in achieving normoglycaemia
[blood glucose (BG) range 48 mmol/l] for patients with acute coronary
syndrome (ACS) presenting with an admission BG of 10 mmol/l
(known to have diabetes or not), and to confirm the regime achieved
2012 The Authors.

DIABETICMedicine
target BG range (time to reach 8 mmol/l) and maintained target glucose

range (median BG over 24 h in the range 48 mmol/l) during the first
24 h of admission.
Methods: Patients were recruited from 34/228 centres participating
in the Myocardial Ischaemia National Audit Project (MINAP) which
collects comprehensive data on all patients presenting with troponin
positive ACS. An additional dataset was developed to capture
glucometrics for the participants of the TITAN-ACS study. All
patients within the study received a validated VRIII and a low dose 5
per cent dextrose infusion with potassium for the first 24 h in hospital.
Results: There were 523 patients (65 per cent male) with ACS (71 per
cent nSTEMI) and admission BG 10. Of these, 146 (24 per cent) were
not known to have diabetes. On admission the median BG was
14 mmol/l (IQR 11, 18.2), at 6 h it was 7.8 mmol/l (6.1, 10.9), at 12 h
7.95 mmol/l (6.1, 10.2) and at 24 h 8.4 mmol/l (6.4, 11.45). Time to
median BG < 10 mmol/l was 3 h and BG < 8 mmol/l was 6 h.
Initiation of VRIII was variable with significant delay in 50 per cent
in the first 8 h.
Conclusion: The standardised VRIII used in the TITAN-ACS study
was effective in achieving and maintaining target glucose range in
patients with hyperglycaemia and ACS.
P357
Applying basic principles in diabetes care:
case series of inpatient hypoglycaemia
J Jones1, B Mumford1, H Husband2, R Griffiths2, H Lawless2
and N Agarwal1
1
Diabetes Centre, Cwm Taf Health Board, Merthyr Tydfil, UK, 2Diabetes
Centre, Cwm Taf Health Board, Llantrisant, UK
Aim: Variations in diabetes care of hospitalised patients impact

adversely upon patient experience and length of in-hospital stay.
Local results from the National Diabetes Inpatient Audit 2010
highlighted aspects of diabetes care where ward management and
clinical practices can be developed further to improve patient outcome.
One area of concern locally was the frequency of hypoglycaemia
occurring between 14:00 and 15.30 hours in patients on multiple daily
injections of insulin (MDI). Our aim was to determine if inpatient midafternoon hypoglycaemia was related to timing of insulin
administration.
Method: Hypoglycaemia was defined as a capillary blood glucose
recording of below 4 mmol/l. A week-long observational study was
conducted on one medical and one surgical ward to determine meal
times, and corresponding prandial insulin. Case notes, medication and
observation charts of all patients on insulin were reviewed to identify
the number of episodes of hypoglycaemia occurring between 14:00 and
15:30 hours.
Results: Six patients, all on MDI, experienced hypoglycaemia
between 14:00 and 15:30 hours, which did not improve with
reductions in insulin doses. In all cases breakfast and lunch, and thus
two doses of quick-acting insulin, were delivered less than 4 h apart.
Ward breakfast and lunch times were therefore altered to ensure a
minimum interval of 4 h, which eliminated mid-afternoon
hypoglycaemia in this patient cohort. A repeat 1 week observation at
a later date only identified two episodes of hypoglycaemia between
14:00 and 15:30 hours attributable to other causes.
Conclusion: This study illustrates the importance and impact of
education and application of basic principles of diabetes care and
insulin management in avoiding adverse patient events.
137
DIABETICMedicine
Clinical care and other categories posters: insulin: actions, metabolism and therapy
Clinical care and other categories posters: insulin: actions,

metabolism and therapy
P358
Is weight gain inevitable when starting on
insulin? A review of the weight gain data
from insulin group starts for people with
Type 2 diabetes in North Tyneside
CE Forrest, L Kelleher, L Oliver and A Barnes
Northumbria Diabetes Service, Northumbria Healthcare NHS Foundation
Trust, Northumbria, UK
Aim: For many patients and health professionals a key barrier to

starting insulin is the potential for weight gain. Makimatilla et al. [1],
reviewing existing research, suggested that for every 1 per cent
(11 mmol/mol) improvement in HbA1c the average weight gain
would be approximately 2kg (4.4lb). However, this is variable and
can be reduced by careful food and lifestyle choices. Our aim was to
review our experience of group insulin starts and group follow-up at 3, 6
and 9 months, which include detailed consideration of options for
minimising weight gain, a goal setting/action planning approach and
ongoing peer support.
Method: Prospective routine data collection was carried out during
20082010.
Results: Seventy-five people participated, with follow-up data for 96
per cent at 3 months and for 83 per cent at 9 months. Initial mean
HbA1c was 9.6 per cent (81 mmol/mol). Mean HbA1c reduction was
1.4 per cent (15.4 mmol/mol) and 1.8 per cent (19.8 mmol/mol) at 3
and 9 months respectively. Mean weight gain was 0.7kg and 1.7kg at 3
and 9 months (median weight gain 0.8kg at 9 months). At 9 months, 35
per cent had lost weight from baseline, and 63 per cent had gained less
weight than expected by the above formula.
Conclusions: Our group insulin starts and follow-up programme
openly acknowledges the potential for weight gain with participants,
helps them to identify lifestyle changes to avoid this and provides
ongoing peer and professional support for self-management. This is
extremely effective at improving diabetes control whilst minimising
weight gain. Our results highlight that weight gain is not inevitable after
starting on insulin.
Reference: [1] Makimatilla et al. Diabetologia 1999; 42: 406412.
P359
Insulin requirements and the metabolic
syndrome in patients with Type 1 diabetes
of extreme (> 50 years) duration
S Bujawansa1, C Daousi1, SC Bain2, AH Barnett3 and GV Gill1
1
NHS Foundation Trust, Liverpool, UK, 2Department of Medicine, University of
Wales, Swansea, UK, 3Department of Diabetes, Birmingham Heartlands
Hospital, Birmingham, UK
Aims: Insulin resistance is a common finding in Type 1 diabetes. We

aimed to determine the prevalence of the metabolic syndrome (MS) in
patients with long duration (> 50 years) Type 1 diabetes and its impact
on glycaemic control and insulin requirements. We hypothesised that
the low insulin requirements previously reported in these patients may
imply increased insulin sensitivity.
138
Methods: As part of the Golden Years Project, clinical data and

samples were collected from 400 Diabetes UK Nabarro and Lawrence
medal holders. MS was defined according to National Cholesterol
Education Programme Adult Treatment Panel III diagnostic criteria.
Results: The overall prevalence of MS was 15.4 per cent. There was no
difference in HbA1c and insulin requirements between patients with
and without MS. In the entire cohort mean insulin dose requirement
was 0.5 units/kg. Insulin requirements correlated with body mass index
(r = 0.14, P = 0.02), waist to hip ratio (r = 0.18, P = 0.004) and
triglycerides (r = 0.167, P = 0.008) and inversely with HDLcholesterol (r = 0.18, P = 0.005). There was no correlation with
HbA1c or diabetes duration. When multiple regression analysis was
applied, only the inverse correlation with HDL-cholesterol retained
statistical significance.
Conclusions: The prevalence of MS in the Golden Years Cohort is
significantly lower than reported values (up to 42 per cent) from other
populations with Type 1 diabetes of medium duration (<20 years). Low
insulin requirements were associated with higher HDL levels (a wellknown characteristic of the Golden Years Cohort). Traditional markers
of insulin resistance such as insulin dose requirement and presence of
MS do not influence glycaemic control in this unique population.
P360
Associations between estimated glucose
disposal rate and chronic diabetes-related
complications in the Golden Years Cohort
(Type 1 diabetes > 50 years duration)
S Bujawansa1, GV Gill1, SC Bain2, AH Barnett
and C Daousi1

NHS Foundation Trust, Liverpool, UK, 2Department of Medicine, University of
Wales, Swansea, UK, 3Department of Diabetes, Birmingham Heartlands
Hospital, Birmingham, UK
Objectives: We aimed to assess whether an association exists between

insulin resistance (IR) quantified by estimated glucose disposal rate
(eGDR) and chronic complications in patients with extreme duration
(>50 years) Type 1 diabetes.
Methods: As part of the Golden Years Project, clinical data and
samples were collected from 400 Diabetes UK Nabarro and Lawrence
medal holders. eGDR was calculated according to the following
equation: 24.31 (12.22 waist to hip ratio) (3.29 hypertension)
(0.57 HbA1c), expressed in mg/kg/min. Metabolic syndrome (MS)
was defined according to National Cholesterol Education Programme
Adult Treatment Panel III diagnostic criteria.
Results: There was a significant difference in eGDR between patients
with and without macrovascular disease (7.54 vs. 8.16mg/kg/min,
P = 0.024), and between normoalbuminuric and microalbuminuric or
macroalbuminuric patients (8.1 vs. 7.4, P = 0.01). There was a
significant difference in the prevalence of macrovascular disease (64
vs. 41 per cent, P = 0.01) and laser treated retinopathy (48.3 vs. 29.5
per cent, P = 0.04) between patients within the lowest (indicating
higher IR) and highest (indicating lower IR) eGDR quartiles. The mean
eGDR was significantly lower in patients with at least one self-reported
diabetes-related complication compared with those without
complications (so called escapers) (7.55 vs. 8.74, P < 0.001). eGDR
2012 The Authors.

was also significantly lower in patients with MS compared with those

without (5.58 vs. 8.26, P < 0.001).
Conclusions: eGDR as an IR marker can prove useful in the
assessment of MS as well as chronic diabetes complications, mainly
macrovascular disease and nephropathy, in long duration (>50 years)
Type 1 diabetes.
P361
Audit of a district general hospitals practice
compared with NICE guidance TA151:
continuous subcutaneous insulin infusion
for the treatment of diabetes
DS Hughes, R Mahto, E Dilley, M Summers, T Gibbs and
P Horrocks
Diabetes Department, Warwick Hospital, Warwick, UK
Aims: To determine how our current practice differs from the national
standard NICE TA151 Diabetes: Insulin Pump Therapy published in
July 2008.
Method: Patients receiving insulin pump therapy (CSII) were
identified and available case notes were reviewed (audit period
FebruaryApril 2011). Data were collected regarding diabetes type,
indication for CSII therapy, date CSII therapy commenced, HbA1c,
indication for continuing CSII therapy and number of clinics attended.
Results: The number of patients identified as potentially using CSII
therapy was 74. The number of complete patient records available
which were reviewed was 39 (53 per cent). Median age of CSII therapy
users was 46 years (2581), with the median date that CSII therapy
commenced February 2006 (February 2002 to August 2010). The mean
number of new patients commencing CSII therapy each year was five.
The primary indication for starting CSII therapy was disabling
hypoglycaemia whilst trying to achieve HbA1c < 7.5 per cent. The
percentage of patients fulfilling NICE TA151 criteria for commencing
CSII therapy was 85 per cent, and the percentage of patients fulfilling
NICE TA151 criteria to continue CSII therapy after 1 year was 74 per
cent. The median number of clinics attended in the year before starting
CSII therapy was four, and the median number of clinics attended in the
year after commencing CSII therapy was three.
Conclusion: The audit has highlighted that the majority of our
patients started on CSII therapy fulfil the NICE TA151 criteria.
However, the department is doing less well when it comes to
withdrawing CSII therapy after 1 year for those patients who do not
continue to fulfil the NICE TA151 criteria.
P362
Improvement and maintenance of HbA1c
following continuous subcutaneous insulin
infusion therapy: a Welsh perspective
V Lewis-Jenkins, G Tagoury, J Beaverstock, A Bray and P Evans
Diabetes Centre, Cwm Taf LHB, Cwm Taf LHB, Wales
Aims: We explored the primary indicators for continuous

subcutaneous insulin infusion (CSII) therapy in our patients and the
relationship of their baseline HbA1c to subsequent glycaemic control
and hypoglycaemic episodes post CSII initiation.
Methods: The indicators for CSII treatment were collected from 72
patients at the Royal Glamorgan Hospital, South Wales. HbA1c and
hypoglycaemia data were collected prior to commencing CSII and
reviewed at years 1, 2 and 3 post initiation.
2012 The Authors.

DIABETICMedicine
Results: The average HbA1c of the cohort was 8 per cent prior to CSII
initiation followed by 7.6 per cent, 7.6 per cent and 7.7 per cent in years
1, 2 and 3. Of the cohort, 35 patients who started CSII therapy with an
HbA1c of greater than 8 per cent showed an improvement of 1.4 per
cent, 1.4 per cent and 1.2 per cent in years 1, 2 and 3 respectively.
The remaining 37 patients commencing with an HbA1c of less than
8 per cent remained stable from initiation to the end of year 3 (average
7.3 per cent pre CSII therapy followed by 7.3 per cent, 7.5 per cent
and 7.4 per cent).
Conclusions: The average HbA1c of all patients who commenced
CSII therapy improved over years 1 and 2; a slight deterioration was
observed in year 3, although this was not significant. As expected,
patients who started with an HbA1c above 8 per cent benefited from the
greatest reduction. The main concern in patients with an HbA1c less
than 8 per cent was severe hypoglycaemia and hypo unawareness, and
whilst these patients maintained rather than improved their HbA1c,
severe hypoglycaemic episodes were halved and hypo awareness
improved.
P363
Impact of the discontinuation of Mixtard 30
on people with diabetes
M Greig, Y Mohamed Elhassan, L Hunt, C Nisbet, H Stead,
S Hudson and R Gandhi
Department of Diabetes, Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
Aims: In June 2010, Novo Nordisk made a commercial decision to

discontinue the production of human Mixtard 30. Serious concerns
were raised about the impact of this decision on the approximately
90,000 people with diabetes in the UK using Mixtard 30. The aim of this
audit was to assess the impact of the switchover on patients in Sheffield.
Methods: A prospective audit was carried out of 289 subjects
attending our diabetes service for switchover between October 2010
and January 2011.
Results: The majority (87.9 per cent) changed to Humulin M3. There
has been no change in glycaemic control: HbA1c pre-switch
75.0 18.4 mmol/mol; most recent 74.2 18.2 mmol/mol
(mean SD). There was a negative correlation between pre-switch
HbA1c and change in HbA1c (r = 0.425, P < 0.001). Whereas most
patients were discharged back to usual care, 41 (14.2 per cent) were
deemed to require further multidisciplinary team input, resulting in a
fall in HbA1c (86.8 18.2 mmol/mol to 76.8 21.0 mmol/mol,
P = 0.001). Whilst there was no significant change in the insulin dose
(81.6 48.2 vs. 79.6 48.5IU/patient/day), there was a rise in cost
(1.04 0.63 vs. 1.20 0.76 per patient per day, p P < 0.001).
Patients requiring external help to administer insulin rose from 6.0 per
cent to 7.75 per cent (all previously using the Innolet device).
Conclusions: The discontinuation of Mixtard 30 and subsequent
switch to alternative regimens has not to date had any impact on overall
glycaemic control but has substantially increased the costs of
prescribing insulin and caused loss of independence for some patients.
If these results were reflective of the effect across the UK, the switch
would have resulted in an increase in prescribing costs by over 5
million a year and 1,575 patients losing their independence to
administer insulin.
139
DIABETICMedicine
P364
Metformin therapy reduces the
development of insulin resistance (HOMAIR)
in streptozotocin induced Type 1 diabetes
Wistar rats
JS Effendi and Z Haque
Biochemistry Department, Dow University of Health Sciences, Karachi,
Pakistan
Introduction: Insulin resistance (HOMAIR) is considered as a

complicated metabolic disorder. However, Type 1 diabetes is an
autoimmune disorder; it is also proven that insulin resistance is present
at the receptor level and its signalling pathway. It is reported that
hyperinsulinaemia desensitises insulin actions at the receptor level.
Traditionally Type 1 diabetes is treated by induction of exogenous
insulin. Insulin resistance leads to development complications of
cardivascular diseases. We studied the effects of metformin along
with insulin therapy on the development of HOMAIR in Wistar rats
with Type 1 diabetes. Change in body mass index (BMI) and the
chemical variables fasting blood glucose (FBS), fasting serum insulin,
serum hexosamine and HOMAIR were evaluated.
Method: Male Wistar rats 6 weeks old were made Type 1 diabetes
models with streptozotocin. They were equally divided into two groups,
group 1 with insulin therapy and group 2 with combined metformin
and insulin therapy. The chemical variables were assessed at the start of
the experiment and then three times at intervals of 10 days in 1 month.
HOMAIR was calculated by formula.
Results: One-way ANOVA showed a significant (P < 0.01) effect of
the combined therapy of metformin with insulin on the development of
HOMAIR between the two groups with respect to time
(F1,15 = 152.511, P < 0.000 on day 10; F1,15 = 54.110, P < 0.000 on
day 20; F1,15 = 58.635, P < 0.000 on day 30). Significant changes were
also seen in BMI (P < 0.01), FBS (P < 0.01), fasting serum insulin
(P < 0.01) and serum hexosamine (P < 0.01).
Conclusion: Metformin reduces the fasting circulating levels of serum
glucose, insulin and hexosamine. It delays the development of insulin
resistance and decreases the severity of the resistance.
P365
Humulin R (U-500) two years on: audit
results of patients with Type 2 diabetes
managed on Humulin R (U-500) insulin for
two years
Results: For the 19 patients who have completed 2 years therapy,

mean HbA1c fell from 9.8 per cent to 8.8 per cent whilst weight
increased modestly from 117.8kg to 119kg. Median (range) total daily
insulin dose decreased from 295 units (1741,000) to 195 units (105
390). The majority of patients were receiving multiple daily injections of
analogue insulin prior to conversion to twice daily U-500. This switch
resulted in a reduction of injection burden and an estimated cost saving
on average of 480 per person per annum.
Conclusion: Humulin R (U-500) provides sustainable improvement
in glycaemia control with only modest weight gain for some patients
with Type 2 diabetes requiring large doses of insulin.
P366
Development of a chemiluminescent assay
for measurement of insulin glargine
GJ Dunseath1, S Woodhead2, A Woodhead2 and S Luzio1
1
Diabetes Research Group, Swansea University, Swansea, Wales, 2Invitron
Ltd, Monmouth, Wales
Aims: The long-acting insulin analogue insulin glargine differs from

human insulin by the addition of two arginine residues to the Cterminus of the B chain and the substitution of asparagine with glycine
at the C-terminal of the A chain. Measurement of circulating insulin
glargine is difficult due to the variable cross-reactivity in most existing
insulin assays. Our aim was to develop a specific assay for glargine.
Methods: A monoclonal antibody (RR19.5) was raised to the 13
amino acid sequence representing the C-terminus of the B chain and
labelled with acridinium ester. Pharmaceutical glargine was diluted in
either fetal bovine serum (FBS) or human EDTA plasma in the range 0
250mU/l. These glargine standards were incubated alongside clinical
glargine samples for 4 h at 4C (39F) with a solid phase anti-insulin
antibody (3B1). Following a wash step, labelled RR19.5 was added and
incubated for 24 h at 4C (39F). Cross-reactivity was determined by
assaying high doses (250mU/l) of lispro, aspart, glulisine, detemir and
human insulin.
Results: Glargine was recognised in a dose-dependent manner in the
standards, with good agreement between FBS and EDTA plasma.
Glargine in the clinical samples was also measured in the appropriate
range. Cross-reactivity was < 3 per cent for the other insulin analogues
and human insulin.
Conclusion: We have developed a chemiluminescent assay for insulin
glargine that may prove useful in pharmaceutical development and
clinical applications.
NJ Robinson, J Mabrook and A Smith

Diabetes Centre, BSUH, Brighton and Haywards Heath, UK
Introduction: Maintenance of glycaemic control in severely insulin

resistant patients with Type 2 diabetes may be difficult to achieve
despite large doses of exogenous insulin. Our unit has successfully
treated such patients with U-500 insulin (Humulin R) since 2008,
resulting in improved HbA1c and reduced injection burden. We now
present our long-term follow-up data on those individuals receiving
Humulin R for 24 months.
Patients: Prior to initiation of U-500 insulin all patients had poor
glycaemic control (HbA1c > 8 per cent) despite total daily insulin
requirements of more than 150 units and maximum tolerated
metformin. Of the 33 patients so far initiated, 19 have now
completed 24 months follow-up. Nine patients have discontinued
therapy due to non-concordance (three), patient choice (two),
underwent bariatric surgery (two), reduced insulin requirements due
to illness (one), deceased (one).
140
P367
Optimising insulin therapy in patients with
Type 2 diabetes
M Ahmad, AY Laleye and A Ahmad
UK
Aim: Studies have shown that an intensive insulin regimen and

titration improves HbA1c and reduces diabetic complications. Our aim
was to assess whether patients were having their insulin doses titrated
according to their HbA1c levels to achieve optimum glycaemic control.
Method: Patients who attended the diabetes clinic in Royal Liverpool
University Hospital between January and March 2010 with Type 2
diabetes on insulin were included and retrospectively reviewed over
5 years. Data collected included patient age, sex, insulin regimen, total
insulin dose, HbA1c and number of hypoglycaemic episodes. Insulin
2012 The Authors.

regimen included conventional (one or two insulin doses a day) or

intensive therapy (four insulin doses a day).
Results: A total of 306 patients [180 men, 126 women; age 55 3.6
(mean SEM)] were included. In 2010 24 per cent of patients had
optimal HbA1c (< 7 per cent), 36 per cent had suboptimal HbA1c (78
per cent) and 40 per cent had poor HbA1c levels ( 8 per cent). Of all
patients 92 per cent had their insulin doses titrated; 64 per cent of these
showed an improvement in HbA1c whereas 32 per cent had
deteriorated and 4 per cent remained unchanged. 33 per cent of those
with HbA1c deterioration were on conventional therapy and 67 per
cent were on intensive therapy. 53 per cent with deteriorated HbA1c
had their insulin doses reduced suggesting recurrent hypoglycaemic
episodes.
Conclusion: A large proportion of patients had their insulin doses
titrated which improved HbA1c in the majority. However, a significant
proportion showed deterioration in HbA1c and required dose
reduction due to recurrent hypoglycaemic episodes suggesting
incorrect insulin regimens. Therefore, insulin regimen selection and
dose titration are important to improve glycaemic control in patients
with Type 2 diabetes.
P368
Study of Once-daily LeVemir (SOLVE): UK
results from a 24-week international
observational study
K Khunti1 and J Vora2
1

Department of Diabetes and Endocrinology, Royal Liverpool University
Hospitals NHS Trust, Liverpool, UK
2
Aims: SOLVE (Study of Once-daily LeVemir) was a 24-week,

international, multicentre, non-interventional study across 10
countries. The primary objective of the trial was to determine the rate
of serious adverse drug reactions in individuals with Type 2 diabetes
initiating once-daily insulin detemir therapy. In this subanalysis, the
safety and efficacy outcomes within the UK cohort of the study were
examined.
Methods: Patients with Type 2 diabetes initiating treatment with
once-daily insulin detemir were included in the study. The UK cohort
consisted of 761 insulin-nave subjects, and baseline data were recorded
upon enrolment.
Results: Mean (SD) glycated haemoglobin (HbA1c) level at baseline
in the UK cohort was 9.8 per cent (1.8 per cent) [84 (4)mmol/mol] and
0.9 per cent of subjects had HbA1c levels < 7 per cent. This decreased
significantly to 8.4 per cent (1.5 per cent) [68 (7)mmol/mol] (P < 0.001)
by the end of the study. Furthermore, fasting plasma glucose levels
declined from 8.3 to 7.9 mmol/l between weeks 12 and 24 of the trial.
2012 The Authors.

DIABETICMedicine
Weight increased by 0.5kg (P = 0.017). Only 2.4 per cent of patients

experienced a major hypoglycaemic event and/or serious adverse drug
reaction; of these only 10 (1.7 per cent) people experienced a major
hypoglycaemic event by study end. Insulin detemir was initiated at a
daily mean dose of 0.12U/kg, and by study end this had increased to
0.47U/kg (P < 0.001).
Conclusion: Insulin detemir initiated once daily in insulin-nave
patients with Type 2 diabetes in the UK improved glycaemic control and
was well tolerated.
Acknowledgement: SOLVE Study Group.
P369
Metabolic response to insulin initiation in
patients with Type 2 diabetes in a clinical
setting
RW Jones1,2, AE Denver1,2 and M Barnard1
1
Diabetes, Whittington Health NHS, London, UK, 2Research Department of
Clinical Physiology, University College London, London, UK
Aim: Tight glycaemic control with insulin in Type 2 diabetes (T2DM)

can improve HbA1c. In clinical practice there appears to be a cohort of
insulin treated patients who fail to achieve this. We evaluated the impact
of insulin therapy on patients with T2DM, assessing cardiovascular
disease (CVD) risk factors.
Methods: A hundred patients with T2DM starting insulin at
Whittington Hospital diabetes clinic were identified. Data were
collected retrospectively from medical records, followed over 5 years
from insulin initiation. The outcome measures were change in HbA1c,
body mass index (BMI), CVD risk, and diabetes-related complications.
Results: We retrieved records for 91 patients (50 men, 41 women),
mean age 58.7 11.4 years. At 5 years there was a significant decrease
in HbA1c (10.4 1.7 vs. 8.9 2.1 per cent, P = 0.000), eGFR
(78 20 vs. 71 28 ml/min, P = 0.025), systolic blood pressure
(145 27 vs. 134 23mm Hg, P = 0.010), cholesterol (5.1 1.0 vs.
4.3 1.1 mmol/l, P = 0.000) and coronary heart disease (CHD) risk
(24.7 14.4 vs. 21.3 11.4 per cent, P = 0.014). There was a
significant increase in BMI (29.6 6.0 vs. 31.7 5.1 kg/m2,
P = 0.001) and stroke risk (12.6 12.4 vs. 20.5 16.0 per cent,
P = 0.000). Risk of fatal CHD and fatal stroke were unchanged.
Conclusion: Insulin treatment improved HbA1c and some CVD risk
factors, but increased BMI and stroke risk. These effects should be
considered when an individual patient starts insulin. Studies are needed
to determine the long-term impact of insulin initiation on health.
141
DIABETICMedicine
Clinical care and other categories posters: insulinotropic agents and enteroinsular hormones
Clinical care and other categories posters: insulinotropic

agents and enteroinsular hormones
P370
An observational study of the effect of
incretin therapies upon cardiovascular risk
in Type 2 diabetes
P372
Projected cost-effectiveness of exenatide
once weekly versus exenatide twice daily for
the treatment of Type 2 diabetes in the UK
CJ Smith and RS Drummond
BP Wilson1, A Beaudet2, J Caputo3 and L Timlin1
Diabetes and Endocrinology, NHS Greater Glasgow and Clyde, Glasgow, UK
P371
Projected long-term clinical and economic
outcomes of exenatide once weekly versus
sitagliptin for the treatment of Type 2
diabetes in the UK
BP Wilson1, A Beaudet2, J Caputo3 and L Timlin1
1
Eli Lilly and Company Ltd, Windlesham, UK, 2IMS Consulting Group, Basel,
Switzerland, 3IMS Consulting Group, London, UK
Aims: To estimate long-term incremental clinical and cost outcomes

associated with exenatide once weekly (EQW) vs. sitagliptin therapy in
UK patients with Type 2 diabetes (T2D). Data from DURATION-2, a
phase 3, multinational, randomised, double-blind trial in 491 patients
with T2D previously treated with metformin, were used. After
26 weeks, patients receiving EQW (n = 160) had a significantly
greater reduction (LS mean) in HbA1c (1.6 per cent vs. 0.9 per
cent, respectively) and weight (2.3kg vs. 0.8kg, respectively) than
patients on sitagliptin (n = 166).
Methods: A published validated model (IMS CORE Diabetes Model)
was used to make 50-year projections of clinical and cost outcomes
using DURATION-2 baseline patient characteristics and treatment
effects. Costs were derived from published sources and expressed in
2010 UK pounds. Costs and outcomes were discounted by 3.5 per cent.
Sensitivity analyses were performed.
Results: EQW treatment was projected to improve quality-adjusted
life expectancy by 0.22 quality-adjusted life-years (QALYs) [95 per cent
confidence interval (CI) 0.120.32] vs. sitagliptin. Total direct medical
costs associated with EQW were projected to be higher over patient
lifetimes than with sitagliptin (difference 1,405, 95 per cent CI 444
1,982) due to higher drug acquisition costs, but were partially offset by
lower costs of treating diabetes-related complications. The projected
incremental cost effectiveness ratio (ICER) was 6,418 per QALY
gained. Results of the sensitivity analysis showed that the ICER was
influenced by reduction in time horizon, decrease in EQW benefits on
HbA1c and increased time on EQW.
Conclusion: Projected from DURATION-2 data, EQW appears cost
effective vs. sitagliptin from the UK National Health Service
perspective. Results were robust to sensitivity analyses.
142
Eli Lilly and Company Ltd, Windlesham, UK, 2IMS Consulting Group, Basel,
Switzerland, 3IMS Consulting Group, London, UK
Aim: To estimate the cost-effectiveness of exenatide once weekly

(EQW) vs. exenatide twice daily (ExBID) in patients with Type 2
diabetes in the UK. Pooled data from DURATION-1 and DURATION5, phase 3, randomised, open-label clinical trials in 295 and 252 patients
respectively, were used. EQW was associated with greater reductions
(LS mean) in HbA1c (1.7 per cent vs. 1.2 per cent, P < 0.001) and
weight (2.9kg vs. 2.4kg, P = 0.126) than ExBID.
Methods: A published, validated model (IMS CORE Diabetes
Model) was used to make 50-year projections of clinical and cost
outcomes based on pooled DURATION-1 and DURATION-5 baseline
patient characteristics and treatment effects. Costs were derived from
published sources and expressed in 2010 UK pounds. Costs and
outcomes were discounted by 3.5 per cent. Sensitivity analyses were
performed.
Results: EQW treatment was projected to improve quality-adjusted
life expectancy by 0.18 quality-adjusted life-years (QALYs) [95 per cent
confidence interval (CI) 0.100.25] and life expectancy by 0.16 years
(95 per cent CI 0.070.26) vs. ExBID. EQW was associated with
delayed onset (almost 6 months on average) of any diabetes-related
complication vs. ExBID. Due to the lower incidence of diabetes-related
complications during EQW treatment and hence reduction in treatment
costs, EQW was associated with direct medical cost savings (difference
305, 95 per cent CI 715 to 35). EQW was therefore projected to
be dominant vs. ExBID. Results were robust to most sensitivity analyses.
Conclusion: Based on data from DURATION-1 and DURATION-5,
EQW was projected to be less costly and more effective than ExBID
over a lifetime horizon in the UK setting.
P373
Adding exenatide to insulin in Type 2
diabetes: benefits to glycated haemoglobin
and body mass index in clinical practice
RM Manikandan, P Miles and MG Masding
Trust, Poole, UK
Introduction: Although only licensed to be used with oral

hypoglycaemic agents, exenatide often seems a logical choice in
addition to insulin in the management of Type 2 diabetes. We looked at
off-licence use of the addition of exenatide to insulin therapy in
everyday practice in our clinic.
Method: This was a retrospective observational study assessing how
adding exenatide in patients on insulin affects weight, body mass index
(BMI), HbA1c and insulin doses over a 12-month period. Intention-totreat analysis was used.
Results: In 49 patients [27 male; median age 57 years (range 3274);
median duration of diabetes 12 years (336)], the mean baseline insulin
2012 The Authors.

Clinical care and other categories posters: insulinotropic agents and enteroinsular hormones
daily dose was 118.6 units (SD 67.6); it dropped by 17.6 units (14.8 per
cent fall) at 3 months (P = 0.004), stayed at a similar level at 6 months
and rose to 106.8 units (SD 65.2; P = NS) at 912 months. BMI fell
from baseline [mean (SD) 41.8 kg/m2 (6.3); 912 months 39.6 kg/m2
(6.0); P < 0.05]. At baseline, average HbA1c was 81.9 mmol/mol (SD
14.3), dropped to 68.6 mmol/mol (SD 15.4) at 3 months (P < 0.0001)
and continued to be lower than baseline at 6 months [71.3 mmol/mol
(SD 19.1); P = 0.027] and 912 months [70.6 mmol/mol (SD 19.5);
P = 0.007]. Exenatide treatment was stopped in nine patients (three due
to intolerance; six did not achieve targets)
Conclusion: Adding exenatide in patients with Type 2 diabetes
already on insulin therapy resulted in a reduced HbA1c and BMI, which
was maintained at 12 months. However, whilst daily insulin dose
initially fell, the amount of insulin used returned to baseline to maintain
these benefits.
P374
An observational analysis of the combined
use of insulin and incretin therapies in Type
2 diabetes
CJ Smith1, SE Sneddon2, N Roe2 and RS Drummond1
1
Glasgow Royal Infirmary, Diabetes and Endocrinology, NHS Greater Glasgow
and Clyde, Glasgow, UK, 2University of Glasgow Medical School, Glasgow,
UK
Aims: Glucagon-like peptide 1 (GLP-1) analogues not only lower

blood glucose but they promote weight loss, and liraglutide has been
associated with blood pressure reduction. DPP4 inhibitors are licensed
to prescribe with insulin; GLP-1 analogues are not. We sought to
examine the effect of insulin treatment with either GLP-1 analogues or
DPP4 inhibitors in a large diabetes centre in Glasgow.
Methods: We analysed the effect on HbA1c, weight, systolic blood
pressure and daily insulin dose over 12 months of combination therapy.
A Students t test determined statistical significance.
Results: Forty-twopatientsusedinsulinandliraglutideincombination.
Mean HbA1c fell from 9.9 per cent to 9.0 per cent (P = 0.001). Weight
decreased from 109.2kg to 106.8kg (P = 0.003). Systolic blood pressure
did not change (142.7mm Hg to 136.6mm Hg; P = 0.23). Mean daily
insulin dose reduced from 101.0 units to 94.7 units (P = 0.04). Thirty
patientsusedthecombinationofinsulinandexenatide.MeanHbA1cdid
not change (9.5 per cent to 9.4 per cent; P = 0.21). Weight fell from
112.9kg to 106.4kg (P = 0.003). There was no effect on systolic blood
pressure (133.9mm Hg to 129.1mm Hg; P = 0.166) nor mean daily
insulin dose (83.1 units to 77.5 units; P = 0.363). Twelve patients used a
combinationofinsulinandsitagliptin.Therewasnosignificantchangein
HbA1c(9.9percentto9.5percent;P = 0.28),weight(97.9kgto96.1 kg;
P = 0.16) or systolic blood pressure (136.5mm Hg to 136.3mm Hg;
P = 0.793). Daily insulin dose rose significantly, from 62.8 units to 76.0
units over 12 months (P = 0.009).
Conclusions: Our study confirmed the beneficial effect of
combination treatment of insulin and GLP-1 analogues but not DPP4
inhibitors. Specifically liraglutide and insulin reduced HbA1c and
weight and decreased insulin requirements, whereas exenatide and
insulin demonstrated weight loss only.
2012 The Authors.

DIABETICMedicine
P375
Is the effect of exenatide on diabetes
control sustained in patients not on insulin
therapy?
I Ramracheya
Royal Berkshire NHS Foundation Trust, Reading, UK
Aims: The glucagon-like peptide 1 (GLP-1) analogue exenatide is

recommended by NICE as an add-on therapy for patients with poorly
controlled diabetes. There is evidence to suggest that the drug improves
HbA1c and weight control. This study examined whether the beneficial
effects of exenetide are sustained in patients with diabetes.
Methods: Retrospective data were collected from notes and a local
diabetes database. Follow-ups were done over 612 months. Data were
analysed using Excel 2010.
Results: Forty patients were identified (65 per cent males; 35 per cent
females) with an age range of 3575 years. Duration of diabetes varied
between 1 and 19 years (average SEM 9.2 0.7). Four patients had
to discontinue treatment due to intolerable side-effects or lack of
response to the drug. A remarkable 12 per cent reduction in HbA1c was
noted at 3 months (9.6 0.2 vs. 8.4 0.2 per cent; P < 0.0001)
followed by a negligible drop at 6 months (8.3 0.2 per cent) and
12 months (8.1 0.2). There was a significant reduction in weight at
3 months (124.2 3.9 vs. 121.7 3.9 kg; P < 0.001) with a
sustained drop at 6 months (125.5 4.3 vs. 121.1 4.5 kg;
P < 0.0001) and 12 months (125.2 5.9 vs. 119.2 6.6 kg;
P < 0.01). Body mass index was significantly improved at all time
points (3 months, 41.2 1.2 vs. 40.4 1.2 kg/m2; P < 0.001;
6 months, 41.6 1.6 vs. 40.1 1.4 kg/m2; P < 0.0001; 12 months,
41.7 1.7 vs. 39.6 1.2 kg/m2; P < 0.05).
Conclusions: Consistent with published reports this study shows that
exenatide is effective at reducing HbA1c levels, weight and body mass
index. Interestingly these data show that maximal improvement in
HbA1c occurs during the first 3 months of treatment. The effect on
weight reduction and body mass index is sustained over time. Exenatide
may be better used as a weight reduction therapy than as an antidiabetic
medication.
P375A
Clinical effectiveness of concomitant
therapy with exenatide twice daily and
basal insulin in patients with Type 2
diabetes: a real-world analysis
M Pawaskar1, Q Li2, LJ Lee1, M Reynolds2 and BJ Hoogwerf1
1
Eli Lilly & Company and Lilly USA LLC, Indianapolis, USA, 2United BioSource
Corporation, Lexington, MA, USA
Aim: Concomitant use of exenatide twice daily (exenatide) and insulin

for Type 2 diabetes (T2D) has resulted in HbA1c reduction and weight
loss in clinical trials. This retrospective study examined the real-world
clinical effectiveness of this concomitant therapy in the ambulatory care
setting.
Methods: Adult patients with T2D were selected from the General
Electric Electronic Medical Record Database. Concomitant therapy
was defined as prescription order of basal insulin (neutral protamine
Hagedorn/glargine/detemir) within 6 months before or after exenatide
prescription from May 2005 to April 2009. The initiation date of
concomitant therapy is the first date of treatment with both
medications. Clinical effectiveness was measured as change in
HbA1c, weight, body mass index (BMI), blood pressure (BP) and
lipids from the 6-month baseline to mean adjusted follow-up value in a
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DIABETICMedicine
12-month post-index period, using a bootstrapping test. Generalised

linear regressions were conducted to estimate outcomes, controlling for
the baseline demographics, clinical and utilisation variables.
Results: In total, 1,752 patients initiated the concomitant therapy
(n = 1,320 adding exenatide to insulin and n = 432 adding insulin to
exenatide), 46 per cent male with mean age 57 years. Patients achieved
significant reductions in mean HbA1c (0.5 per cent), weight (4kg), BMI
(0.6 kg/m2) and diastolic BP (DBP) (0.7mm Hg) (all P < 0.05). There
Clinical care and other categories posters: IT
were significant reductions in lipid parameters, including total

cholesterol, triglycerides, high-density lipoproteins (HDL) and lowdensity lipoproteins and non-HDL (all P < 0.05).
Conclusion: Initiation of concomitant therapy with exenatide and
basal insulin in a large, diverse, real-world patient population was
associated with reductions from baseline in several clinical biomarkers,
including HbA1c, weight, BMI, DBP and lipid levels.
Clinical care and other categories posters: IT

P376
Electronic prescription data is useful in
validating discharge diagnostic codes for
patients with diabetes
K Nirantharakumar1,2, T Marshall1, K Hemming1,
P Narendran2,3 and JJ Coleman2,3
1
Department of Public Health, Epidemiology and Biostatistics, University of
Birmingham, Birmingham, UK, 2Queen Elizabeth Hospital, Edgbaston,
Birmingham, UK, 3School of Clinical and Experimental Medicine, University of
Birmingham, Birmingham, UK
Aim: To estimate under-reporting of diabetes in secondary care using

electronic prescription (EP) data for diabetic medication in a single UK
hospital.
Methods: Administrative data containing discharge diagnostic codes
(DDCs) were linked to EP data at the University Hospital of
Birmingham (20072010). A missed diabetes DDC was defined as a
prescription for insulin or oral hypoglycaemic agents (excluding
prescriptions that could be for other clinical needs) but no diabetes
DDC. Characteristics of patients without a diabetes DDC were
investigated using logistic regression. Adjusted odds ratios with 95
per cent confidence intervals were calculated.
Results: Among 171,067 admissions (77% linkage) there were
22,411 admissions with a diabetes DDC. An additional 2,707 had a
missed DDC, increasing in-patient prevalence of diabetes from 13% to
15%. Missed DDCs were associated with female gender (OR 1.12; CI
1.031.21). Patients with reduced length of stay (OR 0.996; CI 0.993
1.0) and those with higher Charlson co-morbidity score (>1) (OR 0.66;
CI 0.600.71) were less likely to have a missed diabetes DDC. No
association was noted with age, ethnicity, social class, admission type
and insulin use.
Conclusion: Missing diabetes DDCs add 30 per cent to the total
number of discharges with diabetes. Admissions with comorbid
diabetes have important implications for healthcare planning and
have financial consequences for the hospital. Using EP data to
investigate and correct missing diabetes DDCs would be a simple
solution.
Acknowledgement: This work was funded by the National Institute
for Health Research (NIHR) through the Collaborations for Leadership
in Applied Health Research and Care for Birmingham and Black
Country (CLAHRC-BBC) programme.
Disclaimer: The views expressed in this abstract are not necessarily
those of the NIHR, the Department of Health, NHS Partner Trusts,
University of Birmingham or the CLAHRC-BBC Theme 9
Management/Steering Group.
144
P377
Hospital-wide diabetic nephropathy
monitoring: an IT-facilitated
multidisciplinary team based approach
SR Page1, L Evans2, A Archer1, CE Bebb2, M Hall2, V Oguntolu1
and C Byrne2
1
Diabetes, Nottingham University Hospitals, Nottingham, UK, 2Nephrology,
Nottingham University Hospitals, Nottingham, UK
Background: Approximately one in three people with diabetes

develop nephropathy. Patients typically report few symptoms until
severe impairment has developed. Therefore, identifying patients with
early-stage nephropathy requires regular urinalysis and measurement of
serum creatinine. As renal function declines, anaemia and renal bone
disease develop which may also benefit from early identification and
active management. We describe an innovative systems-based
approach to improve the identification and clinical management of
patients attending the Nottingham University Hospitals diabetes
service.
Methods: Nottingham has both diabetes (Diamond) and renal
(Proton) databases which receive daily electronic uploads from the
central laboratory computer. Each month an electronic search of the
Diamond database identifies patients whose eGFR is less than 35 ml/
min (approximately 80120 males and 60100 females). Patient
demographics are collated with the Proton database to generate a list of
patients for monthly multidisciplinary team (MDT) review. Diabetes
colleagues are sent the patient list with a request to comment on any
patients known to them in advance. At the MDT serial laboratory data
(renal function, haematology, bone chemistry) are reviewed in patients
with CKD4 (eGFR 30 ml/min or less) and recommendations are made
(where necessary) to colleagues (GP or consultant) with the objective of
optimising nephropathy management.
Results: To date in 2011 the MDT has discussed 166 cases, of which
24 (14 per cent) were not previously known to renal services. Some 21
per cent of cases discussed required a letter with recommendations
regarding further investigations, management changes or referral to
renal services.
Conclusion: An integrated approach using IT systems combined with
MDT based discussions between diabetes and renal specialists can
improve the monitoring and enhance the care of patients with diabetes
and progressive renal impairment.
2012 The Authors.

Clinical care and other categories posters: lay involvement
DIABETICMedicine
Clinical care and other categories posters: lay

involvement
P378
Patient input is crucial in designing,
implementing and monitoring clinically and
cost-effective diabetes services
P379
Redesigning an intensive insulin service for
patients with Type 1 diabetes: a patient
engagement exercise
JPG Grumitt1, J Medhurst2, A Goodchild1 and S Lucas1
S Ozcan1, A Forbes1, H Rogers2, P Choudhary1, SA Amiel1 and

A Cox2
Bexley Community Diabetes Team, NHS South East London, Bexleyheath,

UK, 2Bexley Care Trust, NHS South East London, Bexleyheath, UK
Aims: Faced with fragmented and incomplete care, we investigated

whether coordinated patient centred care could deliver improved health
outcomes and be cost effective for 11,048 people with diabetes in
Bexley.
Methods: A diabetes network was re-established including five
patients (one being the chair) and representatives from all service
providers and commissioners. It met monthly to redesign the service and
monitor performance. This ensured a coordinated approach and
patient representation on practice audits, patient education and further
engagement via patient surveys and regular attendance at the patient
group with 727 members.
Results: The new service specification was agreed by all stakeholders
specifically addressing the explicitly solicited patient needs. Fourteen
lay and 14 healthcare professionals trained as X-PERT Educators. In
total, 1,031 patients completed courses in eight venues at four different
times and achieved the UKs largest mean reduction in HbA1c of 15.5
per cent (to 7.1 per cent). 61 per cent of all patients have obtained
HbA1c below 7 per cent, the highest percentage in London. The Year
of Care care planning initiative was launched in 25 out of 28
practices. Referrals to secondary care reduced from 51 per month in
January 2010 to 20 in March 2011. Patient satisfaction is reported at
91 per cent.
Conclusions: Patient centred integrated care improves the health,
wellbeing and satisfaction of people with diabetes. We have
demonstrated that a coordinated and audited patient centred diabetes
service designed by a network of patients, clinicians and commissioners
has the potential to save NHS costs from reduced referrals to secondary
care and the prevention and effective treatment of diabetes
complications.
1
DENOVaRS, Kings College London, London, UK, 2Diabetes Centre, Kings
College Hospital NHS Foundation Trust, London, UK
Aim: To explore the perspectives of adult Type 1 patients on their

current diabetes care in order to generate ideas for creating a new
patient centred intensive insulin clinic.
Methods: A multi-method approach was used, comprising an
observational exercise of current clinical care; three focus groups
(n = 17); and a survey of service users (n = 380) to test the ideas
generated from the observational exercise and focus groups (rating 1 to
5 in terms of importance).
Results: The observational exercise and focus groups generated a
number of ideas for service enhancement. These ideas were organised
thematically into the following areas. (1) Clinic visits: continuity of
professional; book and view appointment schedule online; electronic
reminders; an explicit visit agenda; space for social interaction;
educational and technology resources available in the waiting area.
(2) Self-management support: increased emphasis on shared care
planning; technology choice and review; choice over mode of
communications (letter or email or text); a website (for information,
and interaction with patients/professionals); more educational support.
(3) Care system: care feedback (how well am I doing?); care integration
(primary and secondary care); emergency support; psychological
support; social welfare support. The findings from the patients
survey indicate high preferences for most of the areas for service
enhancement identified in the focus groups and observational exercise.
Clinical feedback and professional continuity (median = 5, IQR = 1)
were the most highly rated.
Conclusions: Patients can generate important ideas on how to
improve care. These ideas are being used to improve clinic visits, for
self-management support, and for the overall care system.
Clinical care and other categories posters: lifestyle issues

P380
The impact of lifestyle interventions and
dietary weight loss on obstructive sleep
apnoea (OSA): a meta-analysis and
implications for diabetes care
M Hosseini Araghi1, YF Chen1, D Banerjee2, AC Cartwright1,
S Choudhury1, D Jenkinson1, GN Thomas1 and S Taheri1
1
School of Health and Population Sciences, University of Birmingham, UK,

Sleep and Ventilation Academic Department, Birmingham Heartlands
Hospital, NHS, Birmingham, UK
2
Aims: Obstructive sleep apnoea (OSA) is common in patients with

diabetes where it can impinge on diabetes control and complications.
2012 The Authors.

We conducted a meta-analysis assessing the effects of weight loss

through diet and physical activity on the apnoeahypopnoea index
(AHI) and oxygen desaturation index (ODI).
Methods: A systematic search was performed to identify publications
using Medline (19482011), EMBASE (from 1988) and CINAHL
(from 1982). The review included randomised controlled trials (RCTs)
and uncontrolled before-and-after studies. RCTs were assessed using
the rapid critical appraisal of RCTs checklist, and uncontrolled beforeand-after studies were assessed using the STROBE checklist. Data were
extracted using a standardised data extraction form that captured
details of study design, population, intervention and outcomes. The
inverse variance method was used to weight studies and the random
effects model was used to analyse data.
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Results: Three RCTs of fair quality with 386 participants showed that
weight reduction programmes were associated with a decrease in AHI
(11.46 /hr [95 per cent confidence interval 1.69 to 21.23] compared
with controls. Seven uncontrolled before-and-after studies with 172
participants also showed significant decrease in AHI [5.17/h (95 per
cent confidence interval 2.05, 8.28)] post intervention. In addition,
uncontrolled before-and-after studies with 86 participants showed a
significant decrease in ODI4 [19.16/h (95 per cent confidence interval
14.23 to 24.09)].
Conclusions: Although studies are limited, lifestyle interventions
have been shown to produce clinically relevant improvements in OSA.
These results need confirmation in patients with diabetes, but suggest
that lifestyle change should remain a cornerstone of diabetes care.
Clinical care and other categories posters: lipids and fatty liver
fibrosis were less consistent with only one study showing a significant
reduction. The majority of studies also reported improvements in
glucose control/insulin sensitivity following intervention. However,
study design, definition of disease, assessment methods and
interventions varied considerably across studies.
Conclusion: Lifestyle modifications leading to weight reduction and/
or increased physical activity consistently reduced liver fat and
improved glucose control/insulin sensitivity.
P382
Systematic literature review on weight
training and glycaemia
J Chisholm1, L Kilbride1 and J McKnight2
P381
A systematic review of lifestyle
modification in adults with non-alcoholic
fatty liver disease
C Thoma1, CP Day2 and MI Trenell1
1
Physical Activity and Exercise Research Group, Newcastle University,
Newcastle-Upon-Tyne, UK, 2Medical School, Newcastle University,
Aims: Non-alcoholic fatty liver disease (NAFL) is an independent risk

factor for Type 2 diabetes affecting 2030 per cent of the population.
Prevalence increases with obesity and is highest in those with Type 2
diabetes. Reversing NAFL is likely to reduce the incidence of its sequelae
including Type 2 diabetes. In the absence of approved
pharmacotherapy, lifestyle modification is the only currently
recommended treatment option. Our aim was to update the first
systematic review of lifestyle interventions in the treatment of NAFL.
Methods: Medline (Pubmed), Scopus and the Cochrane Controlled
Trials Register were searched for diet, physical activity and/or exercise
interventions in adults with NAFL. Effects on liver fat and indicators of
liver damage and glucose control were extracted.
Results: We identified 28 studies for inclusion; 11 had control groups,
but only eight were randomised. Sixteen groups received diet-only
interventions, three exercise-only, and 20 diet and physical activity/
exercise. Studies consistently showed reductions in liver fat and/or liver
aminotransferase concentration, with the strongest correlation being
with weight reduction. Of the five studies reporting changes
in histopathology, all showed a trend toward reduction in
inflammation; in two this was statistically significant. Changes in
1
School of Nursing, Midwifery and Social Care, Edinburgh Napier University,
Edinburgh, UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK
Aim: The purpose of this review was to analyse current research

relating to the effects that weight training exercise has on glycaemia in
people with Type 1 diabetes. Organisations such as the American
College of Sports Medicine, as well as healthcare professionals,
promote the use of exercise as an effective therapy in diabetes
management. However, the acute response to weight training for
Type 1 diabetes is less clear. Anecdotal findings indicate that weight
training may cause acute episodes of hyperglycaemia to occur in Type 1
diabetes; however, research thus far in this area is far from conclusive
and is lacking. The overall aim of this literature review was to determine
the acute effects that weight training has on glycaemia in people with
Type 1 diabetes.
Methods: A comprehensive search of the major databases was
undertaken (Medline, Cochrane Systematic Reviews Database,
CINAHL and SPORTDiscus). Publications were selected from the
last 20 years and included keywords and MeSH terms commonly
related to Type 1 diabetes, weight training, glycaemia, interventions
and clinical outcomes and were limited to human subjects.
Results: The search yielded 44 papers; 38 were excluded after not
meeting the inclusion criteria. Six were retrieved, examined and
included after fulfilling the set inclusion criteria.
Conclusion: Findings from the current review are inconclusive
regarding the acute glycaemic response to weight training exercise.
Intervention studies revealed that weight training may increase or
decrease post exercise glycaemia in Type 1 diabetes. It is likely that the
variety in training methods used in these studies have impacted the
findings.
Clinical care and other categories posters: lipids and fatty

liver
P383
Thiozolidinedione use in people with Type 2
diabetes is associated with regression of
hepatosteatosis: the Edinburgh Type 2
Diabetes Study
J Morling1, MWJ Strachan2, RM Williamson2, L Nee3,
CM Robertson1, S Glancy3, R Reynolds4 and JF Price1
1
UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK, 3Radiology
Department, Western General Hospital, Edinburgh, UK, 4Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
146
Background: Increasing evidence suggests that some antidiabetic

medications may improve markers of abnormal liver structure and
function in people with non-alcoholic fatty liver disease. We
investigated this association in older people with Type 2 diabetes.
Methods: A total of 755 participants, aged 6075 years (at
recruitment), from the Edinburgh Type 2 Diabetes Study, a large,
randomly selected population of patients with Type 2 diabetes,
underwent assessment on two occasions. At baseline, liver
ultrasonography was undertaken and antidiabetic medications
(metformin, sulfonylureas, thiazolidinediones and insulin) were
recorded. Liver ultrasonography was repeated approximately
3 years later. Hepatosteatosis was graded as either normal, mildly
2012 The Authors.

Clinical care and other categories posters: lipids and fatty liver
fatty or significantly fatty, and the change between examinations as

1 or 2 grades of regression, no change or 1 or 2 grades of
progression. Chi-squared for trend was used to analyse the
association.
Results: Mean follow-up was 2.7 years. 14.4 per cent (n = 109) of
participants progressed, 20.4 per cent (n = 154) regressed and 65.2
per cent (n = 492) remained the same. Thiazolidinedione use during
the study (13.4 per cent, n = 101) was significantly higher amongst
participants whose hepatosteatosis regressed (P < 0.001). Metformin
(71.3 per cent, n = 39.6 per cent), sulfonylurea (39.6 per cent,
n = 299) and insulin use (99.6 per cent, n = 752) were not associated
with change in hepatosteatosis (P = 0.08, P = 0.12 and P = 0.18
respectively).
Conclusion: In a large sample of patients with Type 2 diabetes
representative of Type 2 diabetes in general, thiazolidinedione use was
associated with regression of hepatosteatosis. This is consistent with
emerging evidence from clinical trials suggesting a role for
thiazolidinediones beyond glucose control in patients with Type 2
diabetes. Further analyses are warranted to explore the potential
mechanism underlying this association.
DIABETICMedicine
change in hepatosteatosis and aminotransferase levels for both ALT and

AST with the highest reductions in aminotransferases associated with
higher proportions of regression and the higher increases in
aminotransferases associated with higher proportions of progression
(P = 0.001 and P < 0.001 respectively).
Conclusions: Alterations in aminotransferase levels are associated
with change in levels of hepatosteatosis; however, alone they are
insufficient to accurately predict changes in hepatosteatosis. Further
work is needed to investigate simple marker panels that can be used in
clinical practice to assess changes in hepatosteatosis.
P385
A new national clinical service for patients
with severe insulin resistance or
lipodystrophy
AJ Stears1,2, J Harris1,2, C Hames2, C Jenkins Liu2, D Dunger3,
D Savage1,2, R Semple1,2 and S ORahilly1,2
1
Institute of Metabolic Science, University of Cambridge, Cambridge, UK,

Wolfson Diabetes and Endocrine Clinic, Addenbrookes Hospital, Cambridge
University Hospitals NHS Foundation Trust, Cambridge, UK, 3Department of
Paediatrics, Addenbrookes Hospital, Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK
2
P384
Aminotransferases indicate changes in
hepatosteatosis in people with Type 2
Study.
J Morling1, MWJ Strachan2, RM Williamson2, L Nee3,
CM Robertson1, S Glancy3, R Reynolds4 and JF Price1
1
UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK, 3Radiology
Department, Western General Hospital, Edinburgh, UK, 4Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
Background: Recent data have suggested that plasma

aminotransferases may be of limited use in the diagnosis of nonalcoholic fatty liver disease. However, data on the use of
aminotransferases to monitor change in hepatosteatosis are lacking.
Methods: A total of 723 participants, aged 6075 years (at
recruitment), from the Edinburgh Type 2 Diabetes Study, a large,
randomly selected population of patients with Type 2 diabetes, were
assessed on two occasions approximately 3 years apart. Liver
ultrasonography was undertaken and both plasma alanine
aminotransferase (ALT) and aspartate aminotransferase (AST) were
measured. Hepatosteatosis was graded as normal, mild or moderate/
severe according to findings on ultrasound. Change in steatosis was
classified as regression, no change or progression between categories.
Chi squared (with trend) analysis was used to assess the association
between change in aminotransferase levels and hepatosteatosis.
Results: Mean follow-up was 2.7 years. 14.8 per cent of participants
showed a reduction in ALT of 20 per cent, 67.4 per cent remained
largely unchanged and 17.8 per cent had an ALT increase of 20 per
cent. For AST the figures were 16.5 per cent, 77.0 per cent and 6.5 per
cent respectively. There was a statistically significant trend between
2012 The Authors.

Background: Severe insulin resistance (SIR) and lipodystrophy are

rare disorders associated with severe morbidity and early mortality.
Research in our centre has produced a database of more than 900
affected patients and has contributed to identification of nine novel
genetic syndromes, allowing successful trials of leptin and rhIGF-1
therapy in selected subgroups. More recently integrated biochemical
and genetic diagnostic algorithms have been established in our NHS
laboratories, and in April 2011 this was recognised through
commissioning of a national multidisciplinary service for patients in
England with SIR by the National Specialist Commissioning Team
(NSCT).
Service aims: The service aims to provide diagnostic, therapeutic and
educational support for patients with lipodystrophy and/or SIR and
their local carers, and to establish and disseminate evidence-based
recommendations for their clinical management.
Service structure: The service accepts referral of patients with (1)
clinical suspicion of insulin receptor defects, from neonatal Donohue
syndrome to adult type A insulin resistance; (2) clinically diagnosed
lipodystrophy (generalised or partial); and (3) unexplained SIR with
body mass index < 30 kg/m2 and acanthosis nigricans and/or severe
hyperinsulinaemia. The core elements are a weekly multidisciplinary
clinic, customised diagnostic evaluation of patients in liaison with
genetic and biochemical laboratories, and close contact with local
specialists and primary carers. For selected subgroups of patients
treatment with agents such as leptin and rhIGF-1 is supervised directly.
Conclusions: The National Severe Insulin Resistance Service is a new
NSCT-funded multidisciplinary service aiming to improve
management and clinical outcomes for patients with lipodystrophy
and/or SIR, and is now open for referrals.
147
DIABETICMedicine
Clinical care and other categories posters: MODY
Clinical care and other categories posters: MODY

P386
Urine C-peptide creatinine ratio is a noninvasive tool to identify MODY and Type 2
diabetes in children
REJ Besser1, TG Barrett2, M Shepherd1, BM Shields1,
TJ McDonald1,3, S Hammersley1, BA Knight1, S Ellard1,4 and
AT Hattersley1
1
Facility, Peninsula College of Medicine and Dentistry, Exeter University, Exeter,
UK, 2Wellcome Trust CRF at BCH School of Clinical and Experimental
Medicine College of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK, 3Department of Clinical Biochemistry, Royal Devon and
Exeter NHS Foundation Trust, Exeter, UK, 4Department of Molecular
Genetics, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
P387
Stopping insulin following genetic testing:
the importance of making the correct
diagnosis
M Shepherd1,2, UNITED research team1,2, S Ellard3 and
AT Hattersley1,2
1
Exeter, UK, 2Research and Development, Royal Devon and Exeter NHS
Foundation Trust, Exeter, UK, 3Department of Molecular Genetics, Royal
Devon and Exeter NHS Foundation Trust, Exeter, UK
Aim: Some 90 per cent of patients with monogenic diabetes are

initially mis-diagnosed with Type 1 or Type 2 and are inappropriately
treated. Most patients with HNF1A MODY and HNF4A MODY can
be successfully managed on low dose sulfonylureas and those with GCK
MODY require no treatment. The UNITED project aims to improve
diagnosis and identify patients with a molecular genetic diagnosis who
may benefit from treatment change. Our aim was to determine success
of treatment change following detection of a mutation in HNF1A,
HNF4A or GCK in patients referred via the UNITED project.
Methods: We studied a consecutive series of 26 patients diagnosed
with monogenic diabetes within a 12-month period who may benefit
from treatment change. Patients were diagnosed < 30 years and
currently aged < 50 years.
Results: At the time of genetic testing 22 (85 per cent) were on insulin
(16 HNF1A, two HNF4A, four GCK) and four (15 per cent) on
metformin (all HNF1A). Eighteen (69 per cent) changed treatment with
as good or better glycaemic control. All four patients with GCK stopped
treatment completely. Eleven (42 per cent) patients successfully
transferred to sulfonylureas (10 HNF1A, one HNF4A); three (11 per
cent) patients with long duration of HNF1A diabetes were able to
reduce insulin to a once-daily dose in combination with sulfonylureas.
The only patient unable to change treatment had coexisting Type 1 and
HNF4A. The remaining seven patients are either in the process of
transferring (four) or have not attempted transfer (three).
Discussion: Confirming monogenic diabetes enables the most
appropriate treatment to be commenced and this is successful in the
vast majority of cases even many years after diagnosis.
Clinical care and other categories posters: monitoring

P388
Capillary glucose measurements in a district
general hospital: overview of all tests
carried out over one year
AV Macklin
Diabetes and Endocrinology, Dorset County Hospital NHS Trust, Dorchester,
UK
Background: Our hospital uses a central computer server to record

the capillary blood glucose (CBG) test results carried out throughout the
hospital. With increasing interest in inpatient diabetes care and its role
in better outcomes it is important to estimate the level of service need
and to plan the targets for specialist intervention. The CBG database
provides a different perspective from the National Diabetes Inpatient
Audit (NDIA).
Methods: All CBG results from 20 September 2010 to 20 September
2011 were analysed. Results were divided into control and patient tests
before analysis.
148
Results: In our hospital (450 beds) 144,774 CBG tests were carried
out over 1 year: 29,611 control samples and 115,161 patient samples.
The number of tests per day ranged from 191 to 395 (mean 315). The
patient tests were attributed to departments in the following
frequencies: elderly care (17,966), medicine (38,721), surgery
(28,543) and other (29,931). The glucose distribution for all patient
tests was [centile (glucose in mmol/l)] 2.5 (3.2), 25 (5.7), 50 (7.6), 75
(10.7), 97.5 (20.6). There was no significant departmental effect on the
distribution. For hypoglycaemic (< mmol/l) values (5.6 per cent of
patient tests), 50 per cent were 3.3 mmol/l, with 6 per cent < 2 mmol/
l. For glucose values 11 mmol/l (22.4 per cent of patient tests), 50 per
cent were < 14.2 mmol/l, with 20 per cent 18 mmol/l.
Conclusions: Very large numbers of CBGs are carried out annually.
28 per cent of unselected patient tests fall outside the desirable range.
The database contains patients without diabetes, implying that the
percentage of undesirable test results in patients with diabetes is even
higher. This information supplements the NDIA snapshot and supports
increased specialty input into inpatient diabetes.
2012 The Authors.

Clinical care and other categories posters: nephropathy
DIABETICMedicine

P389
Use of complementary markers in assessing
glycaemic control in patients with diabetes
and chronic kidney disease undergoing iron
or erythropoiesis stimulating agent
treatment
J Konya1, JM Ng1, H Kahal1, N Lewis2, SL Atkin1, ES Kilpatrick2
and MM Aye1
1
Diabetes, Endocrinology and Metabolism Department, University of Hull,
Kingston-upon-Hull, UK, 2Department of Biochemistry and Blood Sciences,
Hull and East Yorkshire Hospitals NHS Trust, Kingston-upon-Hull, UK
P390
Intensive diabetic nephropathy
management is associated with sustained
clinical improvements and favourable
outcomes over 10 years
SV OBrien, S Nair and KJ Hardy
Diabetes Centre, St Helens Hospital, St Helens, UK
P391
Impaired but improving outcomes for those
with diabetes related foot ulceration and
renal failure
RB Paisey1, M Waterson2, J Davis3, J Zeng4, A Rys1 and
R Gornall5
1
Department of Diabetes, Torbay Hospital, Torbay, UK, 2Department of
Biochemistry, Torbay Hospital, Torbay, UK, 3Department of Orthopaedics,
Torbay Hospital, Torbay, UK, 4Nuffield Bursary, Torbay Hospital, Torbay, UK,
5
Department of Podiatry, Torbay Care Trust, Torbay, UK
Aim: Survival and limb preservation has been reported to be poor in

patients with diabetes with renal impairment and foot ulceration. Our
aim was to assess the effects of renal dysfunction on outcome in persons
with diabetes presenting with foot ulceration in South Devon
Healthcare district.
Methods: Demographic details, Texas wound score, chronic kidney
disease stage, minor and major amputations and cause of death have
been analysed from August 2009 to July 2011.
Results: Of the 250 subjects over 2 years 20 have died: eight sudden
deaths; seven heart failure; six ischaemic heart disease; two renal failure.
There were 14 major amputations. Major amputation and death were
more common outcomes in group 1 patients with CKD4, CKD5 (five
and 10 of 34 total patients in the group respectively) compared with
group 2 patients CKD13 (10 and 15 of 216 total patients). These
differences were significant by Fishers exact test and not explained by
differences in age (64.2 and 68.8 years), percentage neuroischaemic
(45.8 and 40.5 per cent), nor gender (32.1 and 32.8 per cent female), all
group 1 vs. group 2. However, 24 of the 34 group 1 subjects with severe
renal dysfunction survived 15 years from presentation of foot
ulceration, only two of whom required major amputation.
2012 The Authors.

Conclusions: Although severe renal disease is associated with worse

outcome for diabetic subjects treated for foot ulceration in the past
2 years the majority survive for more than 1 year and avoid major
amputation.
P392
Combined diabetesrenal clinic: an
evaluation of management indicators
E Knight, VN Cherukuri, L Varadhan, GI Varughese and
AB Walker
Diabetes and Endocrinology, University Hospitals North Staffordshire NHS,
Stoke-on-Trent, UK
Aim: Proteinuria is an early marker of diabetic nephropathy and

requires aggressive multifactorial management. Combined diabetes
renal clinics could help to streamline holistic diabetes care. The aim of
our project was to ascertain whether a combined clinic is achieving
national standards identified by NICE guidelines.
Methods: A retrospective analysis was carried out of data collected
from 71 patients attending the combined clinic between 2010 and 2011.
Records were collected based on clinical letters and computer records.
Results: Median age was 67 years, and 82 per cent had Type 2
diabetes. HbA1c was recorded in 70 patients (99 per cent); median
HbA1c 8.0 per cent. Eighteen patients (26 per cent) achieved HbA1c
between 6.5 and 7.5 per cent. Median blood pressure was 138/72mm
Hg. The median serum total cholesterol was 4.0 mmol/l; 54 patients (76
per cent) were prescribed a lipid lowering agent. Fifty-three patients (84
per cent) were classified as chronic kidney disease (CKD) 3 or 4.
Albumin/creatinine ratio (ACR) was measured in 38 patients (54 per
cent). 26 per cent of men and 8 per cent of women had proteinuria. Of
these, 33 per cent achieved a target blood pressure of < 125/75mm Hg.
78 per cent were prescribed an ACE inhibitor or angiotensin receptor
blocker; 84 per cent required at least two anti-hypertensives.
Conclusion: This audit suggests that overall control of blood pressure
and cholesterol, in patients with diabetes and renal disease in the
context of a specialist joint diabetic renal clinic, is good. The presence of
albuminuria/overt proteinuria and a low glomerular filtration rate may
predict poor renal prognosis. Intensive multifactorial intervention and
appropriate monitoring of cardiovascular parameters including
proteinuria should be encouraged to prevent progression of
nephropathy.
P393
Secondary hyperparathyroidism and
vitamin D deficiency are common in people
with Type 2 diabetes and modest renal
impairment
I Tullo1, S Winship1, M Bilous1, J Ellis1, R Mukhtar1, A Phillips1,
V Arutchelvam1, S Nag1, S Jones1 and RW Bilous1,2
1
Diabetes Department, James Cook University Hospital, South Tees NHS
Trust, Middlesbrough, UK, 2Institute of Cell Science, Newcastle University,
Aims: Renal impairment is common in people with Type 2 diabetes

(T2DM) and is associated with increased cardiovascular (CV)
mortality. Secondary hyperparathyroidism and vitamin D deficiency
are frequent concomitants of renal impairment and are associated with
149
DIABETICMedicine
CV death. For this reason guidelines recommend measurement of

parathyroid hormone (PTH) and vitamin D in all with an eGFR of
< 60 ml/min/1.73m2.
Methods: We measured PTH in 285 people with T2DM with an
eGFR of 3090 ml/min/1.73m2 who were recruited into a 5-year trial of
intensive CV risk factor modification. All those with a raised
PTH 72 ng/l also had vitamin D measured.
Results: Their mean age was 64 years, and duration of diabetes
13 years. Mean eGFR was 66 ml/min/1.73m2. 11 per cent had an
elevated PTH and of these 62 per cent had a low vitamin D
(< 40.4nmol/l). Serum calcium levels were normal in all. 41 per cent
of those with a raised PTH and 31 per cent of those with a low vitamin D
had an eGFR 60 ml/min/1.73m2.
Conclusions: Secondary hyperparathyroidism and vitamin D
deficiency are relatively common in people with T2DM and
moderate renal impairment but not confined to those with an eGFR
< 60 ml/min/1.73m2. Routine PTH and vitamin D measurement
should be considered more often in such patients. The impact of
corrective therapy will be explored in the trial.
P394
An audit of the multidisciplinary diabetic
follow-up of patients with end-stage
diabetic nephropathy attending the dialysis
centre at Ealing Hospital in West London
P Behary1, FWD Tai1, O Najam1, A Saso2 and K Baynes1
1
2
Diabetes and Endocrinology, Ealing Hospital NHS Trust, London, UK,

Imperial Medical School, Imperial University, London, UK
Background: Diabetic nephropathy is a major cause of end-stage

renal disease (ESRD) in the UK. Such patients are at increased risk of
developing retinopathy and foot ulceration. NICE guidelines
recommend a multidisciplinary approach to diabetic care. We looked
at the follow-up of ESRD patients at Ealing Hospital Dialysis Unit with
a focus on the degree of specialist diabetic physician, ophthalmological
and podiatric intervention.
Methods: Patients receiving dialysis secondary to diabetic
nephropathy were identified from the hospital database. Patients
were interviewed using a questionnaire assessing multidisciplinary
follow-up and foot ulceration risk. As per NICE guidelines, increased
foot risk was defined as the presence of neuropathy, active or previous
ulceration, or amputations.
Results: We identified 49 patients with diabetic nephropathy of whom
78 per cent had Type 2 diabetes. Forty-four (91 per cent) were seen as
having adequate retinal follow-up. However, 26 (53 per cent) were not
regularly followed up in a specialist diabetic clinic. Fifteen (30 per cent)
of all diabetic ESRD patients with an increased foot risk had no follow-
150
up in a podiatric service, including three with active ulcers. All patients

with active or previous ulcers had diabetes for over 10 years and over
half for more than 20 years. Seven patients with increased foot risk were
cutting their own toenails.
Conclusion: Foot risk increases with duration of diabetes. Foot care in
this high risk group was poor whereas ophthalmic follow-up was
adequate. People possibly value their eyes more than their feet. This
study has outlined the possible need for a similar national survey to
understand whether such issues are apparent nationwide.
P395
Use of the direct renin inhibitor aliskiren in
a mixed ethnic clinical practice: an
observational audit
E Mozdiak and P De
Diabetes and Endocrine Unit, City Hospital, Birmingham, UK
Aim: Aliskiren is a selective direct renin inhibitor. In the AVOID study,

aliskiren reduced albuminuria in diabetic nephropathy (despite
losartan), independent of its blood pressure (BP) lowering effect. The
aim of this audit was to evaluate efficacy and safety of aliskiren in
proteinuria and BP lowering and effects on renal function.
Method: Twenty-one patients with diabetic nephropathy started
aliskiren between January 2008 and October 2009 in our diabetic renal
clinic. Data on proteinuria, creatinine, eGFR, HbA1c and BP was
collected pre- and post-aliskiren initiation. Aliskiren was prescribed
where BP and ACR continued to be high despite ACEi and /or ARB
(eGFR 3060 ml/min).
Results: Mean age was 64 years, HbA1c 7.6 per cent. 73 per cent were
males; 46 per cent Asian, 36 per cent Caucasian and 18 per cent AfroCaribbean. Mean duration of treatment was 11.8 months. 62 per cent
were already on ACEi, 42 per cent on ARB. Aliskiren significantly
lowered systolic BP (162 to 145mm Hg, P < 0.0009), the highest
reductions being in Caucasians. Mean ACR reduced from 232 to 125
(P = 0.0001). However, mean creatinine and potassium levels were
significantly increased and eGFR significantly reduced from 59 to
52 ml/min/m2, P = 0.0012. Ten patients discontinued treatment: two
adverse events, three hyperkalaemia, two worsening renal function, and
three unknown.
Conclusion: In this single-centre audit, treatment with aliskiren had
mixed effects on renal function decreased ACR and systolic BP, but
also mean eGFR. Aliskiren also effectively lowered BP in Asian and
Caucasian patients. However, nearly half discontinued treatment for a
variety of reasons. Aliskiren use should only be considered in selected
patients with resistant proteinuria, but with strict renal function
monitoring.
2012 The Authors.

Clinical care and other categories posters: new technologies, therapies and treatment
DIABETICMedicine
Clinical care and other categories posters: new

technologies, therapies and treatment
P396
Insulin degludec has less hypoglycaemia
and improves long-term glycaemic control
compared with insulin glargine in a
randomised basalbolus trial in patients
with Type 2 diabetes
AJ Garber1, AB King2, AMO Francisco3, L Endahl4 and
PA Hollander5
1
Department of Medicine, Baylor College of Medicine, Houston, USA,

Department of Endocrinology, Diabetes Care Center, Salinas, USA, 3Medical
and Science Degludec, Novo Nordisk A/S, Sborg, Denmark, 4Biostatistics,
Novo Nordisk A/S, Sborg, Denmark, 5Department of Endocrinology, Baylor
Endocrinology Center, Dallas, USA
2
P397
Basalbolus therapy with insulin degludec
improves long-term glycaemic control with
less nocturnal hypoglycaemia compared
with insulin glargine in Type 1 diabetes:
results of a one year trial
S Heller1, AMO Francisco2, H Pei3 and D Russell-Jones4
1
School of Medicine and Biosciences, University of Sheffield, Sheffield, UK,

Medical and Science Degludec, Novo Nordisk A/S, Sborg, Denmark,
Department of Biostatistics and Statistical Programming, Novo Nordisk Inc.,
Princeton, USA, 4Department of Diabetes and Endocrinology, Royal Surrey
County Hospital, Guildford, UK
2
3
P398
Sitagliptin in the real world
MD Feher1,2,3, N Munro1,2,3, K Jeyaraman1, H Nizar1, Z
Mickute1 and K Watters1,2,3
1
Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, UK,
Clinical Sciences Research Institute (CSRI), Warwick Medical School,
Warwick, UK, 3Diabetes Therapies Evaluation Network, London, UK
2
Introduction: DPP-4 inhibitors are a new class of incretin therapies

which have an expanding role in diabetes management. Registration
data for these drugs were derived from clinical trial subjects who often
do not reflect real world practice. There are few studies evaluating
sitagliptin, first-to-market in class, in routine clinical practice.
Methods: This was a phase 4 evaluation using a systematic case note
audit of patients from a specialist diabetes centre. Subjects were treated
with combination oral therapy following initiation of sitagliptin 100mg
once daily.
Results: The database comprised 196 Type 2 diabetes cases, with
mean baseline HbA1c 9.2 per cent, creatinine 91, eGFR 72, body mass
index (BMI) 31 kg/m2 and blood pressure 135/76. Six months
treatment effects of sitagliptin on HbA1c were greater in those with
mean baseline HbA1c 10 per cent (1.8 per cent) compared with
HbA1c < 8 per cent (+0.1 per cent). There was a gradient of HbA1c
effects according to baseline weight: BMI 30 (0.5 per cent), BMI
< 27 (1.0 per cent) and BMI < 25 (1.7 per cent). Durability of effect
was demonstrated in those on sitagliptin for 2 years; there was a 1.2 per
cent reduction in HbA1c at 1 year, maintained at 2 years with no
change in BMI.
Conclusions: Real world clinical practice indicates a greater clinical
benefit than that reported in pre-registration data. In addition to initial
lowering of HbA1c, a sustained glucose lowering effect was evident at
2 years. The enhanced response in those with low compared with high
BMI suggests that tailoring therapy to the individual may produce
important gains in improving diabetes control. New glucose lowering
drugs should have efficacy assessed according to baseline parameters in
order to inform clinical practice.
Clinical care and other categories posters: pregnancy

P399
Predictors of birth weight in singleton
offspring of mothers with pre-gestational
diabetes
R Bell1, SV Glinianaia1, PWG Tennant1, RW Bilous2 and
J Rankin1
1
Institute of Health and Society, Newcastle University, Newcastle-Upon-Tyne,
UK, 2James Cook University Hospital, South Tees NHS Trust, Middlesbrough,
UK
2012 The Authors.

P400
Diabetes in pregnancy: mode of delivery
and pregnancy outcome: Diabetes in
Pregnancy Mother and Baby 3
O Ajala1, E Stenhouse2, I Montague3 and BA Millward1
1
Diabetes Clinical Research Centre, Peninsula College of Medicine and
Dentistry, Plymouth, UK, 2School of Nursing and Midwifery Faculty of Health,
Education and Society, Plymouth University, Plymouth, UK, 3Department of
Maternal and Child Health, Plymouth Hospitals NHS Trust, Plymouth, UK
151
DIABETICMedicine
P401
Benefit of metformin in reducing weight
gain and insulin requirement in pregnancies
complicated by gestational diabetes
RA Iftakhar1, K Cheer1, S Wylie2, SJ Howell1 and K Kaushal1
1
Diabetes and Endocrinology, Lancashire Teaching Hospitals NHS Foundation
Trust, Preston, UK, 2Obstetrics and Gynaecology, Lancashire Teaching
Hospitals NHS Foundation Trust, Preston, UK
P402
Maternal efficacy and safety outcomes, and
perinatal outcomes, in a randomised trial
comparing insulin detemir with neutral
protamine Hagedorn insulin in 310 pregnant
women with Type 1 diabetes
D McCance1, M Hod2, M Ivanisevic3, S Duran-Garcia4,
L Jovanovic5, ER Mathiesen6 and P Damm7
1
Metabolic Unit, Royal Victoria Hospital, Belfast, UK, 2Obstetrics and
Gynecology, Rabin Medical Center, Petah Tiqva, Israel, 3Department of
Obstetrics and Gynecology, University Hospital of Zagreb, Zagreb, Croatia,
4
Hospital Universitario De Valme, Sevilla, Spain, 5Sansum Diabetes Research
Institute, Santa Barbara, USA, 6Endocrine Department, Copenhagen
University Hospital, Copenhagen, Denmark, 7Center for Pregnant Women
with Diabetes, Department of Obstetrics, Rigshospitalet, Copenhagen,
Denmark
P403
Incidence of gestational diabetes in an
obese population using the International
Association of Diabetes and Pregnancy
Study Groups (IADPSG) criteria in the UK
Pregnancies Better Eating and Activity Trial
(UPBEAT) pilot study
RA Maitland1, S Barr1, A Briley2, P Seed1 and L Poston1
1
Womens Health Academic Centre KHP, Kings College London, London,
UK, 2Guys and St Thomas NHS Foundation Trust, London, UK
Aims: UPBEAT is a randomised controlled trial (RCT) which aims to

improve glucose homeostasis and reduce macrosomia in obese pregnant
women through a strategy based on dietary advice and increased
physical activity. Our primary aim was to establish whether the
intervention was associated with changes in dietary and physical
activity. Secondary aims included evaluation of the incidence of
gestational diabetes (GDM) to determine the sample size of the RCT.
Methods: Inclusion body mass index (BMI) was 30 kg/m2. Healthtrainers delivered the intervention over eight structured sessions (19
28 weeks gestation). GDM was diagnosed following oral glucose
tolerance test (28 weeks) if fasting plasma glucose 5.1 mmol/l, 1 h
glucose 10.0 mmol/l or 2 h plasma glucose 8.5 mmol/l. Dietary
data were obtained using triple pass 24 h recall and analysed using
WISP software.
152
Results: In all, 117 women were randomised (control n = 59, mean

BMI 36.4 kg/m2; and intervention n = 58, mean BMI 37.11 kg/m2). 58
per cent were White and 36 per cent Black. GDM incidence was 30 per
cent with eight women diagnosed on the 1 h glucose value alone.
Application of the World Health Organisation criteria for GDM
confirmed substantially fewer cases [12 (12 per cent) vs. 29 (30 per
cent), WHO vs. IADPSG]. One woman was positive by WHO
definition and negative by IADPSG. Dietary GL was significantly
reduced in the intervention group (110 vs. 150, P < 0.001).
Summary: Data on the prevalence of GDM in the obese population
using the IADPSG criteria are sparse. CEMACE reported 8 per cent of all
pregnancies in women with BMI 35 kg/m2 were complicated by
GDM. The 30 per cent incidence in this pilot illustrates the potential
influencethatadoptionofthesenewcriteriamayhaveonclinicalservices.
Acknowledgement: On behalf of the UPBEAT study.
P404
PROCEED (Preconception Care for Diabetes
in Derby): a teams without walls approach
P King1,3, C Westcott1, S Ruston2, K Gale1,3, S Ashton-Cleary1,3
and G Tan3
1
Diabetes and Endocrinology, Derby Hospitals NHS Foundation Trust, Derby,
UK, 2Derbyshire County PCT, Derby, UK, 3Intercare Health, Derby, UK
Aims: Effective preconception care (PCC) is fundamental to

improving pregnancy outcomes in women with diabetes. A service
reorganisation in 2009 reduced the capacity of our secondary care PCC
clinic, and women were becoming pregnant before receiving PCC.
Pregnancy outcomes worsened, in particular the stillbirth rate increased
from 0 (20068) to 6 per cent (200910). We piloted an innovative
teams without walls approach to PCC aiming to increase user choice,
service capacity and PCC rates and improve pregnancy outcomes.
Methods: Specialist resources in primary and secondary care were
utilised according to competencies rather than location. PCC was
delivered in hospital and community based settings using groups and
individual sessions according to user choice and need. Quality was
maintained through regular consultant led case discussions.
Results: After 6 months, activity more than doubled (38 new patients
compared with 17 in the previous 6 months), but the median waiting
time reduced from 13 to 5 weeks. Only 3 per cent of women failed to
attend their appointments compared with 17 per cent in the traditional
clinic. The PCC rate has increased from 48 per cent in 2010 to 66 per
cent of deliveries in 2011 and 78 per cent of women who are currently
pregnant. The congenital abnormality rate remains at 2 per cent but the
stillbirth rate has fallen from 6 per cent to 0. This project saves over
70,000 annually through service reconfiguration, reduction in
outpatient activity and reducing maternal and neonatal length of stay.
Conclusions: Our teams without walls model has increased service
capacity, user choice and PCC rates and reduced stillbirths while saving
money.
2012 The Authors.

P405
Effect of ethnicity on conversion to
impaired glucose regulation and/or Type 2
diabetes following gestational diabetes
KJ Ly1, D Todd2, S Nolan3, SA Mostafa4, MJ Davies4 and
IG Lawrence5
1
Department of Diabetes and Endocrinology, University Hospitals of Leicester
NHS Trust, Leicester, UK, 2Department of Womens and Childrens Services,
University Hospitals of Leicester NHS Trust, Leicester, UK, 3Department of
Health Sciences, University of Leicester, Leicester, UK, 4Department of
Cardiovascular Sciences, University of Leicester, Leicester, UK, 5Department
of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust,
Leicester, UK
Aim: Conversion to impaired glucose regulation [impaired fasting

glucose (IFG) and/or impaired glucose tolerance (IGT)] or Type 2
diabetes following gestational diabetes increases soon after delivery.
Early postpartum screening with the oral glucose tolerance test (OGTT)
identifies women with persisting glucose intolerance. However,
conversion rates have not been well reported across different ethnic
groups. Our aim was to ascertain conversion rates with postpartum
OGTT screening among different ethnic groups in a multi-ethnic
population attending a large UK teaching hospital between 2006 and
2010.
Methods: Retrospective analysis undertaken from clinical databases.
Demographic details, body mass index and glycaemic data were
recorded.
Results: In all, 592 patients were identified as having gestational
diabetes (46.8 per cent White European, 28.4 per cent South Asian, 13
per cent Afro-Caribbean and 11.8 per cent other ethnic minority
groups). The mean maternal age at 2428 weeks screening was 31.7
(SD 5.6) years and mean body mass index was 29.5 kg/m2. Of the 281
patients (47.5 per cent) who attended postpartum screening at 6 weeks,
216 (76.8 per cent) were detected as having a normal glucose tolerance,
10 (3.6 per cent) isolated IFG, 24 (8.5 per cent) isolated IGT, 10 (3.6 per
cent) combined IFG and IGT and 21 (7.5 per cent) developed Type 2
diabetes . Conversion rates among the different ethnic groups were 9.0
per cent in White Europeans, 12.5 per cent in South Asians, 14.3 per
cent in Afro-Caribbeans and 11.4 per cent in other ethnic minority
groups (P = 0.457).
Conclusions: One in five women with GDM have persisting glucose
intolerance or develop Type 2 diabetes at 6 weeks post-delivery. NonWhite Europeans appeared to show higher conversion rates but
differences were not significant.
P406
Diabetes antenatal care at a large district
general hospital: an audit from 1997 to 2010
FK Kavvoura1, D Graham2, R Crowley2, H Simpson1, P Street2
and M Elsheikh1
1
Centre for Diabetes and Endocrinology, Royal Berkshire Hospital, Reading,
UK, 2Department of Obstetrics, Royal Berkshire Hospital, Reading, UK
Aims: In our hospital, pregnant women with diabetes are seen in a

joint antenatal diabetes clinic run by an endocrinologist, an
obstetrician and a diabetes midwife. We audited the increasing
demand of the service and the improvement in obstetric outcomes
since its initiation.
Methods: We did an annual collection of data pertaining to number
of pregnancies complicated by diabetes (Type 1, Type 2 and gestational
diabetes) along with outcomes related to antenatal, perinatal and
postnatal care from 1997 to 2010. Chi-squared tests were calculated for
differences across the years.
2012 The Authors.

DIABETICMedicine
Results: There was an increasing trend in pregnancies requiring

specialist diabetes care (33 in 1997 vs. 152 in 2010), primarily due to the
increase of gestational diabetes (4 vs. 103 in 1997 and 2010,
respectively; P = 0.0009) and Type 2 diabetes (0 vs. 21 in 1997 and
2010, respectively). The number of miscarriages has reduced over the
years (15.2 per cent vs. 7.2 per cent in 1997 and 2010, respectively;
P = 0.26). The number of stillbirths and neonatal deaths has improved
(1 vs. 0 in 1997 and 2010, respectively). There was a significant
reduction in the number of macrosomic babies born (16 vs. 13 in 1997
vs. 2010, respectively; P < 0.0001), and those admitted to special care
post delivery (19 vs. 27 in 1997 and 2010, respectively; P < 0.0001).
Conclusions: There is a considerable increase in the number of
pregnancies complicated by diabetes in our hospital in the last 14 years.
The presence of the joint antenatal clinic has significantly improved
outcomes in pregnant women with diabetes.
P407
The National Diabetes in Pregnancy Audit:
lessons from a prospective proof of concept
pilot in England
N Lewis-Barned1, R Bell2, N Holman3, H Murphy4,
HJ Stephens5, R Young6 and L Allen7
1
Diabetes and Endocrinology Service, Northumbria Healthcare NHS
Foundation Trust, Northumbria, UK, 2Institute for Health and Society,
Newcastle University, Newcastle-Upon-Tyne, UK, 3Diabetes Health
Intelligence, Yorkshire and Humber Public Health Observatory, York, UK,
4
Metabolic Research Laboratories and National Institute for Health Research
(NIHR) Biomedical Research Centre, Cambridge University, Cambridge, UK,
5
Diabetes Information, NHS Diabetes, Manchester, UK, 6National Diabetes
Information Service, NHS Diabetes, Salford, UK, 7Diabetes Information, NHS
Diabetes, Newcastle-Upon-Tyne, UK
Aim: To develop and test a dataset and audit process to support

improvements in care for women with pre-gestational diabetes across
England.
Methods: The National Diabetes in Pregnancy Dataset Group was
established in 2009 by NHS Diabetes. A dataset was agreed and
retrospectively tested in three established regional audits. Eleven
individual sites and one region volunteered to test the feasibility of
embedding the dataset and processes into routine care in a prospective
proof of concept pilot between 1 June 2010 and 31 May 2011. Each
centre completed a State of Readiness Questionnaire before
participation. Data were collected from paper and electronic records,
entered locally onto an Access template, anonymised and transferred to
Yorkshire and Humber Public Health Observatory for analysis.
Telephone interviews explored the experience of participating centres.
Results: In all, 529 pregnancies were recorded (approximately half
predicted). No centres were able to provide full data reporting. The
main reasons given for this were time (each pregnancy taking 2045min
to review and collect data); data access (multiple sources/security
permissions); incomplete records; lack of local organisational support/
infrastructure (including IT for database setup). Some data items lacked
clear value to participants.
Conclusions: Despite demonstrating the value of the data, and high
levels of individual motivation, it became clear that sites require local
support and infrastructure for success. Some data items could be
simplified and some are already being collected as part of the National
Maternity Dataset and NDAA. This will reduce the burden for data
collection.
153
DIABETICMedicine
P408
An audit on gestational diabetes reflecting
on the changes in NICE guidance (2008)
DJ Martin1, EP Birdsall1, S Murray1, JM Roland2, and S Oyibo2
1
Diabetes Care Team, Peterborough Community Services, Peterborough, UK,

Department of Endocrinology, Peterborough and Stamford Hospitals
Foundation Trust, Peterborough, UK
2
Aims: The aim of this audit was to identify how many women with a
raised glucose tolerance test would require medication, metformin,
gliblenclamide or insulin, during their pregnancy. NICE (2008) suggest
that 1020 per cent of women will need oral hypoglycaemia agents or
insulin if diet and exercise are not effective in controlling diabetes.
Methods: Data were collected from 230 pregnant women who were
referred to the community diabetes team between January 2010 and
December 2010. They were divided into three groups: diet controlled
gestational diabetes post glucose tolerance test (GTT) of between
7.8 mmol and 8.9 mmol; gestational diabetes had a GTT of over
9 mmol; women with previous gestational diabetes. At the initial
consultation all women received dietary and lifestyle advice and there
was weekly telephone contact. Data were collected on weeks of
gestation when medication was started and the age of the woman.
Results: In total there were 125 women with diet controlled
gestational diabetes with a GTT between 7.8 mmol and 8.9 mmol of
whom 84 required medication, 79 women with gestational diabetes
with a GTT over 9 mmol of whom 60 required medication, and 33
previous gestational diabetes pregnancies of whom 23 required
medication. They commenced diabetes medication as follows: under
10 weeks, two; 1019 weeks, 33; 2029 weeks, 113; 3034 weeks,
six; 35 weeks, 15. A hundred and thirty women were over 30 years of
age.
Conclusion: The audit found the number of women requiring
medication was significantly more than NICE suggested in 2008. This
has had an impact on the workload of the community diabetes team and
the hospital antenatal clinics.
P409
Abstract withdrawn.
P410
How do professionals decide whether to
introduce medication in gestational
diabetes?
MH Charlton
Department of Diabetes, Heart of England Foundation Trust, Birmingham, UK
Aims: NICE guidance CG63 (2008) for management of gestational

diabetes (GDM) anticipates that up to 20 per cent women with GDM
will need hypoglycaemic medication, but the percentage at our hospital
is much higher, 72 per cent. Our aims were to examine (1) factors
involved in deciding whether women with GDM require antidiabetic
medication and (2) how consistent such decision-making is across
healthcare professionals.
Methods: Fifty-seven multidisciplinary professionals attending a
regional diabetes and pregnancy meeting were given six diaries of
self-monitored blood glucose (BG) from women with GDM following
diet and lifestyle advice and asked whether they would recommend
154
medication. They then reviewed their decisions in the light of clinical

information such as estimated fetal weight.
Results: Respondents included diabetologists, obstetricians,
midwives and specialist nurses from eight centres. The number
recommending medication was most strongly related to the frequency
of readings above target rather than the height of BG. When < 4 or 7
readings were above target in 7 days (maximum 28 readings) there was
over 80 per cent agreement (four cases of six). There was less agreement
(60/40) with four high readings. In only one case did clinical data (large
for dates, HbA1c 6.2 per cent at 36 weeks) alter decision-making with a
26 per cent rise in those (mostly obstetricians and midwives) who would
recommend medication or earlier delivery.
Conclusions: There is consistency of decision-making in GDM in all
but borderline cases. Professionals use medication in GDM much more
frequently than predicted by NICE and make that decision primarily on
frequency of maternal hyperglycaemia rather than fetal parameters.
P411
The effect of body mass index on pregnancy
outcomes in gestational diabetes
AW Tang1, S Ballal1, N Goenka2, D MCaulay2, J Davies1 and
F Joseph2
1
Women and Childrens Division, Countess of Chester NHS Foundation Trust,
Chester, UK, 2Department of Diabetes and Endocrinology, Countess of
Chester NHS Foundation Trust, Chester, UK
Aims: To determine the effect of booking body mass index (BMI) on

glycaemic management and pregnancy outcomes in women with
gestational diabetes (GDM).
Methods: Data on BMI at booking, demographic characteristics,
antenatal care, pregnancy and neonatal outcomes were retrospectively
collected on all women diagnosed with GDM (fasting blood
glucose 5.1 mmol/l, 2 h glucose 7.8 mmol/l) over a 7-month
period. The outcomes were compared between women who were
obese (BMI 30 kg/m2) and those with a BMI < 30 kg/m2.
Results: Seventy-four women (mean age 31 5.5 years, mean BMI
30 7.0 kg/m2) were diagnosed with GDM. Forty-one women (55 per
cent) had a BMI 30 kg/m2. Obese women required more
pharmacological intervention with metformin (46 per cent vs. 29 per
cent) and insulin (17 per cent vs. 9 per cent) for glycaemic control than
non-obese women. Nine (22 per cent) babies from obese women were
macrosomic on growth scans compared with three (9 per cent) babies
from women with a BMI < 30 kg/m2, but there were equal numbers of
babies with birth weight 4kg in each group (two each). Five (12 per
cent) babies were born preterm (<37 weeks gestation) to obese women,
compared with two (6 per cent) babies in women with a BMI < 30 kg/
m2. A greater proportion of obese women required caesarean sections
(51 per cent vs. 37 per cent). Pregnancy complications of pre-eclampsia
and postpartum haemorrhage were similar in both groups. There was
an increased incidence of neonatal hypoglycaemia, however (7.3 per
cent vs. 3 per cent), and admission to the special care baby unit (17 per
cent vs. 6 per cent) in obese women.
Conclusions: In women with GDM, those with a raised BMI required
more pharmacological therapy and had a higher rate of pregnancy
complications and adverse perinatal outcomes.
2012 The Authors.

P412
Metformin in gestational diabetes: a
retrospective analysis of its introduction
into an insulin-based protocol of care
C Cheyette, V Deprez and S Ramasamy
DIABETICMedicine
Conclusion: Annual screening provides a continuing window of

opportunity for early detection and prevention of Type 2 diabetes.
However, low uptake and the high incidence of Type 2 diabetes
amongst the patients who did undergo screening highlights the need for
antenatal education and raising awareness amongst primary healthcare
professionals of the importance of screening.
Diabetes, Kings College Hospital, London, UK
Background: Metformin is increasingly accepted as part of the

routine management of gestational diabetes (GDM). We conducted a
pilot of incorporating metformin into an insulin-based protocol for
managing diabetes currently delivering good outcomes in a multi-ethnic
population in southeast London (treatment targets pre-meal blood
glucose 3.55.5 mmol/l; post-meal 47 mmol/l at 1 h).
Methods: A case note review was performed for women attending the
diabetic antenatal clinic at our hospital from January 2011 when
metformin was started in consenting women with 2 h blood
glucose 8.9 mmol/l on glucose tolerance testing (n = 18) and the
data were compared with those from a matched cohort from 2009
2010 immediately prior to metformin use (n = 16).
Results: The groups were matched for age, body mass index and
HbA1c at diagnosis of GDM. 72 per cent in the metformin group
commenced insulin compared with 62.5 per cent in controls. Mean
insulin doses were less with metformin (32.2 27.2 units vs.
62.9 47.5 units, P = 0.01) and the women gained less weight
(8.3 8.8kg vs. 12.4 7.8kg, P = 0.01). Mean birth weights were
not different (3.32 0.30kg vs. 3.33 0.55kg, NS), but four babies
were considered macrosomic in the control women vs. none in the
metformin group.
Conclusion: The data suggest that metformin is safe and effective in
managing glycaemic control in GDM. Its use is not associated with a
higher risk of maternal or neonatal complications. Furthermore our
data show reduced maternal weight gain with metformin use.
Metformin has now been included in the standard treatment protocol
for our GDM population.
P413
Annual screening for Type 2 diabetes in
women with a history of gestational
diabetes: an opportunity for prevention and
early diagnosis
A Schlesinger and JM Bissell
Mid Yorks NHS Trust Diabetes Centre, Pontefract, UK
Aim: Gestational diabetes (GDM) affects 314 per cent of pregnancies

depending on the population screened. Following pregnancy most
women return to a euglycaemic state yet up to 70 per cent develop Type
2 diabetes. Our aim was to determine using the WHO criteria the
number of women with Type 2 diabetes at 1 year postpartum following
a diagnosis of GDM.
Method: This was a retrospective audit of 38 women with GDM who
had attended a diabetic antenatal clinic at a district general hospital and
delivered between April 2009 and April 2010. Pathology results for
fasting plasma glucose were obtained 6 weeks postpartum and 1 year
following delivery.
Results: All women had been advised to undergo a fasting plasma
glucose (FPG) test at 6 weeks postpartum and then annually, which
their GPs had been advised to arrange. None of the women had been
diagnosed with Type 2 diabetes at 6 weeks postpartum. Fifteen (39.5
per cent) women had undergone screening of whom six (40 per cent)
were found to have Type 2 diabetes.
2012 The Authors.

P414
Identifying women with persistent
abnormal glucose metabolism following
gestational diabetes: what was NICE once
may not be NICE anymore
V Photiou1, A Verma2, D MCaulay1, N Goenka1, DL Ewins1,
J Davies3, M Clement-Jones4, IF Casson5 and F Joseph1
1
Department of Diabetes and Endocrinology, Countess of Chester NHS
Foundation Trust, Chester, UK, 2Manchester Urban Collaboration of Health,
School of Translational Medicine, Manchester Academic Health Sciences
Centre, Manchester, UK, 3Department of Obstetrics and Gynaecology,
Countess of Chester NHS Foundation Trust, Chester, UK, 4Department of
Obstetrics and Gynaecology, Liverpool Womens Hospital, Liverpool, UK,
5
NHS Foundation Trust, Liverpool, UK
Objectives: An oral glucose tolerance test (OGTT) 6 weeks after

delivery is considered the gold standard test to identify persistently
abnormal glucose metabolism in women with gestational diabetes
(GDM) but the National Institute for Health and Clinical Excellence
(NICE) recommends fasting plasma glucose (FPG) alone. This study
aimed to identify the percentage of women with diabetes and impaired
glucose tolerance (IGT) that would be missed using this strategy.
Methods: Data were collected on all women with GDM attending the
joint diabetes and pregnancy clinic over a 7-year period. Fishers exact
test was used to demonstrate differences between OGTT and FPG and a
receiver operating characteristic curve was used to try and identify an
FPG concentration that would predict a post glucose load abnormality.
Results: Fifty-two of the 147 women had a persistent abnormality in
glucose metabolism. Twenty-three had impaired fasting glycaemia
(IFG), 21 had IGT and eight women had diabetes. Only seven of the
eight women with diabetes had an FPG 7.0 mmol/l and hence one
out of eight women with diabetes (12.5 per cent) and all 21 women with
IGT would have been missed if an FPG alone was used (P < 0.001). No
cases of diabetes would have been missed if an OGTT were performed
for FPG 6.0 mmol/l; however, 16 (76 per cent) cases of IGT would
have been missed (P < 0.001).
Conclusion: Postnatal FPG alone is inadequate to identify all women
with diabetes and an OGTT for FPG 6.0 mmol/l would miss a
significant proportion of women with persistent IGT. An OGTT in all
women with GDM remains the gold standard test.
P415
Comparison of pregnancy outcomes of first
and second pregnancies in women with
Type 1 diabetes
J Berry, D Rajasingham and A Brackenridge
Diabetes and Endocrine, Guys and St Thomas NHS Foundation Trust,
London, UK
Aims: Anecdotally we feel that women with Type 1 diabetes engage

less well with our multidisciplinary antenatal clinic during second and
155
DIABETICMedicine
subsequent pregnancies. The aim is to establish any differences in

outcomes in this group.
Methods: Data were collected from the in-house database for 15
women with Type 1 diabetes (mean age 35, range 3240) who delivered
first and second babies in the last 5 years at our hospital.
Results: HbA1c was higher in the second pregnancy in nine women in
the first trimester, eight women in the second trimester and 12 women in
the third trimester. Second babies were significantly heavier than first
babies: first babies, mean 3340 g (range 3050 4320 g); second babies,
mean 3945 g (range 33805180 g). There was no significant difference
in gestation at delivery between first and second babies (37.7 weeks and
37.6 weeks). All but two second babies were bigger than the first-born
(one delivered at 32 weeks). All nulliparous women had assisted
Clinical care and other categories posters: psychological health
delivery (seven emergency sections, one elective section, four ventouse

and four forceps). In second pregnancies seven had spontaneous
deliveries, two emergency sections, five elective sections and one
ventouse. One woman who had a caesarean for her first delivery went
on to have vaginal delivery subsequently. In conclusion, although
HbA1c was increased in non-index pregnancies and babies were bigger
they required less intervention at delivery. Strategies targeting this
group of women may improve macrosomia rates.
Clinical care and other categories posters: psychological

health
P416
Type 2 diabetes and memory impairment:
findings from the Guangzhou Biobank
Cohort Study
AC Cartwright1, CQ Jiang2, GN Thomas1, WS Zhang2,
KK Cheng1, S Taheri3 and TH Tam4
1
Public Health, Epidemiology and Biostatistics, University of Birmingham,

Birmingham, UK, 2Guangzhou Occupational Diseases Prevention and
Treatment Centre, Guangzhou Number 12 Peoples Hospital, Guangzhou,
China, 3School of Medicine, University of Birmingham and Heartlands
Hospital, Birmingham, UK, 4School of Public Health, University of Hong Kong,
Hong Kong, China
P418
Design and development of
mydiabetesliving.com: data and designs
from phases 1 and 2 of the Psychological
Online Support for Diabetes study
CS McKenzie1, A Montgomery1, K Bennert1, D Kessler1 and
P Gregor2
1
2
School of Social and Community Medicine, University of Bristol, Bristol, UK,

School of Computing, University of Dundee, Dundee, UK
P417
The effect of GLP-1 agonist therapy on
hospital anxiety and depression score,
compared with insulin treatment
L Kockum, K Adamson, J Walker and A Dover
Department of Diabetes, St Johns Hospital, Livingston, UK
P419
The sensitivity and specificity of the PHQ-9
as a screening tool for depression in
individuals with newly diagnosed Type 2
diabetes
K Twist1, D Stahl2, SA Amiel1, K Winkley3 and K Ismail3
1
Diabetes and Nutritional Science Division, Kings College London, London,
UK, 2Department of Biostatistics, Institute of Psychiatry, London, UK,
3
Academic Department of Psychological Medicine, Institute of Psychiatry,
London, UK
156
2012 The Authors.

P420
Association between N-terminal pro B-type
natriuretic peptide (NT-proBNP) and
depressive symptoms in elderly patients
with Type 2 diabetes: the Edinburgh Type 2
Diabetes Study
I Feinkohl1, N Sattar2, P Welsh2, R Reynolds6, IJ Deary3,4,
MWJ Strachan5 and JF Price1
1
UK, 2Institute of Cardiovascular and Medical Sciences, University of Glasgow,
Glasgow, UK, 3Psychology in the School of Philosophy, Psychology and
Language Sciences, University of Edinburgh, Edinburgh, UK, 4Centre for
Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh,
Edinburgh, UK, 5Metabolic Unit, Western General Hospital, Edinburgh, UK,
6
Centre for Cardiovascular Sciences, Queens Medical Research Institute,
University of Edinburgh, Edinburgh, UK
Background: Depression is a major determinant of quality of life in

people with diabetes but can be difficult to detect. Depression appears to
have a bidirectional relationship with vascular disease, which itself is
more prevalent in diabetes. Plasma NT-proBNP is raised in both clinical
and subclinical vascular disease. We hypothesised that NT-proBNP
might be a useful marker for depressive symptoms in people with Type 2
diabetes.
Method: A cross-sectional analysis was carried out of 1,066 people
aged 6075 years with Type 2 diabetes participating in the populationbased Edinburgh Type 2 Diabetes Study. Plasma NT-proBNP was
measured using fasting blood samples. The depression subscore of the
Hospital Anxiety and Depression Scale (HADS-D) was used to screen
for current symptoms of depression. NT-proBNP and HADS-D values
were highly skewed and were log transformed.
Results: HADS-D scores were associated with raised NT-proBNP (age
and sex adjusted r = 0.13, P < 0.001) and increased gradually across
NT-proBNP quintiles (geometric means 2.8. 2.9, 3.2, 3.3 and 3.6
respectively, P = 0.012). Patients with possible clinical depression
(score 8 on HADS, n = 78) had higher NT-proBNP levels compared
with those with a HADS-D score below 8 (geometric means 107.8 vs.
79.8 pg/ml, Cohens d = 0.28; P = 0.034). Following adjustment
for age, sex and diabetes and lifestyle-related factors, NT-proBNP
accounted for only 1 per cent of variance in depression scores (P = 0.002).
Conclusion: In elderly patients with Type 2 diabetes, raised NTproBNP is associated with higher levels of current depressive symptoms.
Further investigation of the clinical relevance of this finding is
warranted, including confirmation in patients with clinically
diagnosed depression.
Acknowledgement: On behalf of the ET2DS investigators.
P421
Alcohol associated risks for young adults
with Type 1 diabetes: a narrative review
KD Barnard1, R Holt1, AJ Young1, J Lawton2 and JMA Sinclair3
1
Faculty of Medicine, University of Southampton, Southampton, UK, 2Social
Sciences, University of Edinburgh, Edinburgh, UK, 3Wessex Alcohol Research
Collaborative, University of Southampton, Southampton, UK
Aim: To undertake a narrative review of the impact and levels of

alcohol consumption in young adults with Type 1 diabetes.
Methods: The data sources were MEDLINE, EMBASE, PsycINFO,
The Cochrane Library, Web of Science, meeting abstracts of EASD,
2012 The Authors.

DIABETICMedicine
ADA and Diabetes UK, current controlled trials, ClinicalTrials.gov, UK

CRN, bibliographies of retrieved papers and contact with experts in the
field. Relevant studies of any design of alcohol consumption and young
adults with Type 1 diabetes were included. The key outcomes were the
levels and impact of alcohol consumption, the effect on diabetes
control, and the impact of interventions to minimise the risks of alcohol
for this population.
Results: Five papers met the inclusion criteria. There were two crosssectional studies, one a review, one qualitative study and one withinsubjects design study. The quality of the studies was variable. Alcohol
use amongst young adults with Type 1 diabetes was reported to be
common. There was a paucity of evidence on interventions to minimise
the risks of alcohol in this target group.
Conclusions: Research is required to understand the social context of
alcohol consumption in this population with a view to developing
appropriate interventions to minimise the risks associated with its use.
P422
Fear of hypoglycaemia: is there an
association with glycaemic control,
hypoglycaemic symptoms and diabetes
emotional distress in people with Type 1
diabetes?
E Sheils, J Knott, D Cavan and C Shaban
Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital,
Bournemouth, UK
Aim: This study aimed to determine the magnitude of fear of

hypoglycaemia (FOH) in a sample of people with Type 1 diabetes
and to explore any association with glycaemic control, diabetes
emotional distress, and experience of hypoglycaemia.
Methods: Consecutive patients attending clinic completed self-report
questionnaires: Hypoglycaemia Fear Scale, Problem Areas in Diabetes
Scale (PAIDS) and the Clark Questionnaire to assess hypoglycaemia
symptom awareness. Demographic and biochemical data were
accessed from the clinic database.
Results: A total of 108 sets of completed questionnaires were obtained
[49 men, mean + SD age 44.0 + 12.9 years, duration of diabetes
23.6 + 12.9 years, HbA1c 8.8 + 1.5 per cent (73.1 + 16.3 mmol/
mol)]. There was no association between HbA1c and FOH
(rho = 0.04, P = 0.71), nor between HbA1c and PAID (rho = 0.07,
P = 0.48). FOH was greater in patients who reported reduced hypo
awareness (n = 17) (49.06 + 31.46, 34.99 + 22.20, P = 0.08) and in
those who experienced at least one severe hypo during the last year
(n = 14) (55.50 + 25.93, 34.47 + 22.93, P = 0.003). There were no
differences in HbA1c between any of these groups. PAID and FOH
were highly correlated (rho = 0.72, P = 0.01).
Conclusion: The finding that neither FOH nor PAID scores were
associated with HbA1c is not consistent with the literature. The strong
association between FOH and PAID is due to both being an indication
of diabetes distress. The FOH score indicates worries and protective
behaviours adopted to manage fear of hypoglycaemia and it is
counterintuitive that these are not correlated with HbA1c. The
findings suggest a complex relationship between the study variables
which merits further analysis.
157
DIABETICMedicine
P423
Predictors of fear of hypoglycaemia in UK
children and adolescents with Type 1
diabetes and their families
P Tah1, CE Lloyd2, L Gonder-Frederick3, K Vajda3 and
KA Matyka1
1
Division of Metabolic and Vascular Health, Warwick Medical School,
Coventry, UK, 2Faculty of Health and Social Care, Open University, Milton
Keynes, UK, 3Behavioral Medicine Center, University of Virginia Health
System, Virginia, USA
Aim: Clinical experience suggests that fear of hypoglycaemia (FOH) is

an important barrier to good glycaemic control, and yet there is little
research in this area. This study aimed to identify physiological and
psychological factors that contribute to the development of FOH in
childhood.
Method: Data on measures of FOH, state and trait anxiety,
hypoglycaemia frequency, quality of life (QOL), self-efficacy and
HbA1c were collected from 206 children and young people (CYP) aged
318 years. At least one parent was invited to participate (n = 189, 137
mothers). Parents provided data on children less than 5 years.
Results: In CYP FOH was positively correlated with prior severe
hypoglycaemia (rs = 0.205, P < 0.01) and trait anxiety (r = 0.469,
P < 0.01) and negatively correlated with QOL (rs = 0.525, P < 0.01)
and self-efficacy (r = 0.183, P < 0.05). Multiple regression analyses
demonstrated that trait anxiety in CYP predicted 21.8 per cent of the
variance in FOH total score (R2 = 0.218, P < 0.001). Parents displayed
a high level of trait anxiety: 51 per cent of mothers and 46 per cent of
fathers scored greater than the 70th centile on the Spielberger
questionnaire. In mothers there was a positive correlation between
FOH and trait anxiety (r = 0.226, P < 0.05) and prior severe
hypoglycaemia (r = 0.173, P < 0.05) and a negative correlation with
QOL (rs = 0.410, P < 0.01).
Summary: Trait anxiety and prior episodes of severe hypoglycaemia
are significant predictors of FOH in CYP and their parents. Recognising
significant anxiety in families may lead to improvements in both QOL
and diabetes care in this vulnerable group of individuals.
P424
Reflection: a benchmark for future audits of
counselling services for people with
diabetes
A Archer1, T Cooper1, S Marks2, K Ackroyd2, M Wan2,
B Bullock2, H Begg2, C Jones2, M Hall2, S Winterburn2,
E Jackson2, J Forrest2, J Stone2, K Hubbard2 and J Newstead2
1
Diabetes and Endocrinology, Nottingham University Hospitals, Nottingham,
UK, 2Department of Diabetes City Hospital Campus, Nottingham University
Hospitals, Nottingham, UK
Background: Psychological services for people with diabetes are

substandard. Standards 3 and 5 of the 1999 diabetes NSF addressed
this, yet the 2000 and 2006 ABCD Survey of Consultant-led Services
reported fewer than50 per cent of diabetes units with access to
psychology services. The Diabetes UK Professional Advisory Council
has recommended that psychological wellbeing be assessed annually
and that initiatives, eg psychological support services not delivered by
psychologists, be explored. In 2005 our humanistic counselling service
began and now provides 21 weekly therapy sessions. It is advertised
within the diabetes centre via consultations, education packs, our
intensive Type 1 diabetes education course and the web-based Diabetes
Directory of Services accessible to primary care. In the first 5 years of the
service 124 people completed therapy.
158
Method: Pre and post therapy scores from four questionnaires

(number completed): PAIDS (70) diabetes-related stress, HADS (58)
anxiety/depression, W-BQ12 (70) wellbeing and ADDQOL (70)
impact of diabetes on quality of life have been compared (Mann
Whitney U test, one tailed).
Results: Significant differences in pre and post therapy scores were
demonstrated in the PAIDS (m 37 vs. 27, P = 0.025), HADS (anxiety m,
13 vs. 9.6, P < 0.001; depression m, 9 vs. 6.8, P = 0.005) and the WBQ12 (m 12 vs. 18, P < 0.001); pre and post ADDQOL scores were not
significantly different (m 2.63 vs. 2.10, P = 0.06).
Conclusion: Our counselling service is an important addition to the
diabetes care portfolio provided by the hospital diabetes department to
our local health community, enabling an improvement in wellbeing and
reducing both diabetes-related distress and the negative impact that
diabetes can have on a persons quality of life.
P425
The influence of genetic explanations of
Type 2 diabetes on patients attitudes to the
efficacy of preventative behaviours and
treatment and personal responsibility for
the condition
LE Davies and K Thirlaway
Applied Psychology, University of Wales Institute Cardiff, Cardiff, UK
Aim: To investigate whether perceiving the cause of Type 2 diabetes as

either genetic or environmental has any effect on attitudes that may
influence the perceived efficacy of preventative behaviours and
treatment and personal responsibility for the condition.
Method: A between-participants experimental survey design was
utilised. In total, 200 patients aged 40 years and above were recruited
from a GP surgery. Allocation to experimental groups was achieved by
alternate vignette allocation. The independent variable, perceived
aetiology, had two experimental conditions: genetic and
environmental. In both conditions participants read a vignette
describing how Type 2 diabetes might affect an individual. The
vignettes were identical other than the explanation of aetiology.
Patients attitudes to prevention, treatment and personal responsibility
in each experimental group were measured using an attitude
questionnaire. A two-way independent ANOVA was used to
compare means for perceived aetiology and family history for each
measure.
Results: A significant perceived aetiology by family history interaction
effect on attitude to treatment indicated that participants with a family
history perceived treatment as less effective when a genetic aetiology
was implied [F(1, 193) = 5.34, P < 0.05]. Significant main effects of
perceived aetiology [F(1, 193) = 7.7, P = 0.006] and family history
[F(1, 193) = 4.33, P < 0.05] were found for attitude to responsibility.
Conclusions: This study indicates that it is important that patients
understand the multifactorial nature of Type 2 diabetes and that health
professionals present information in a balanced way to ensure that
explanations of aetiology do not undermine patients beliefs about
treatment efficacy and reduce their perceived responsibility for its
development.
2012 The Authors.

P426
Recognition of being overweight and obese
in young adults
E Stenhouse1, T Lander2, R OSullivan2, M Moore2 and G Rees3
1
School of Nursing and Midwifery, Faculty of Health, Education and Society,
Plymouth University, Plymouth, UK, 2School of Health Professions, Faculty of
Health, Education and Society, Plymouth University, Plymouth, UK, 3School of
Biomedical and Biological Sciences, Faculty of Science and Technology,
Plymouth University, Plymouth, UK
Aim: Obesity is a significant risk factor for the development of Type 2

diabetes and cardiovascular disease. However, there is limited research
related to recognition of being overweight/obese in the general
population and less in young adults. Non-recognition of overweight/
obesity may affect health behaviours. Our aim was to explore how
young adults perceive weight, height and body mass index compared
with their actual weight and height.
Methods: Self-reported weight and height (SR W,H) were gained
from 109 students aged 1825 years (56 males); actual weight and
height (A W,H) were measured. Body mass index (BMI) was calculated
using SR W,H and A W,H. Comparisons between the two
measurements were made via correlations and BlandAltman plots.
Results: Of the 109 respondents 103 completed both parts of the
study. There was a significant difference between SR W and A W and
between genders [mean difference 1.95kg (SD 4.35), range 21.4kg to
7.2kg, P = 0.008] with a greater number of women underestimating
weight, and between SR H and A H and between genders with men
overestimating height [mean difference 0.58cm (SD 2.67), range 5.0 to
14cm, P = 0.04]. For the BMI comparison between SR W,H and A
W,H the mean difference was 0.82 kg/m2 (SD 1.51), range 7.6 to 2.1.
Conclusions: This small study showed the more obese/overweight the
greater the difference in SR W,H and BMI and the difference is
associated with gender. Failure to recognise overweight/obese has
potential to affect health in this cohort and non-recognition of being
overweight/obese may have an impact on health behaviours.
P427
Investigating the relationship between
positive affect and health outcomes in
people living with diabetes
MR Patel, M Harrison, A Jackson and S Williams
School of Pharmacy and Biomolecular Sciences, University of Brighton,
Brighton, UK
Aims: Accumulating research suggests that positive affect (PA) is

beneficial in determining health outcomes. PA has been associated with
lower HbA1c in women without diabetes and better health practices.
This study sought to assess the role that PA has on people living with
diabetes independently of negative affect (NA) and other factors.
Methods: This cross-sectional study recruited people with Type 1 and
Type 2 diabetes in southeast England. Individuals completed a selfreport questionnaire (n = 147) and, if known, reported their HbA1c
(n = 87). Measures included demographics, mood, coping style and
diabetes-specific variables such as HbA1c, health practices and diabetes
quality of life (DQOL).
Results: People with higher PA scores were twice as likely to follow a
healthy eating plan (odds ratio 1.8; 95 per cent confidence interval
2012 The Authors.

DIABETICMedicine
1.063.00) after controlling for exercise, avoiding high fat foods and
engaging in active coping strategies. This was not independent of
NA (P = 0.089). Individuals who followed a healthy diet (U = 625;
z = 2.69; P < 0.01; r = 0.29) or avoided high fat foods (U = 617.5;
z = 2.77; P < 0.01; r = 0.30) had lower HbA1c levels. No direct link
was found between PA and HbA1c; however, following a healthy diet
acted as a moderator in this relationship [F(1,82) = 0.4.65; P < 0.05].
PA predicted DQOL satisfaction after controlling for age, body mass
index, NA, marital status, engaging in instrumental coping strategies
and DQOL impact [R2 change 0.02; change in F(1,113) = 5.10;
P < 0.05].
Conclusion: Diabetes self-care has been shown to improve glucose
control and consequently reduce the onset of complications. This study
suggests that individuals high in PA are more likely to follow such selfcare activities and have better DQOL. Further studies are needed to
elucidate the directional nature of this relationship.
P428
The importance of measuring diabetes
distress in young people with Type 1
diabetes
S Brierley1,2, B Johnson1,2, V Young1,2, C Eiser1,2, S Heller1,3,
Diabetes Theme Research Group and CLAHRC South Yorks1
1
National Institute for Health Research (NIHR) CLAHRC for South Yorkshire,
Sheffield, UK, 2Child and Family Research Group, Department of Psychology,
University of Sheffield, Sheffield, UK, 3Academic Unit of Diabetes,
Endocrinology and Metabolism, School of Medicine and Biomedical Sciences,
University of Sheffield, Sheffield, UK
Aims: The present study is the first to examine the prevalence of

diabetes distress in young people with Type 1 diabetes and its use in a
clinical setting. In addition, this study aims to determine the prevalence
of anxiety and depressive symptoms in this group. The relationship
between these psychological measures and HbA1c is assessed.
Methods: Young people (1621 years) were recruited from two
transition clinics in Sheffield (n = 101). Participants completed the
Hospital Anxiety and Depression Scale (HADS), and the Diabetes
Distress Scale (DDS28). Demographic characteristics and HbA1c were
collected from medical records.
Results: In all, 17 per cent of the sample reported borderline abnormal
levels of anxiety, 11 per cent abnormal levels of anxiety, and 8 per cent
reported borderline and above levels of depressive symptoms. 30 per
cent reached levels of distress worthy of clinical attention. There was no
relationship between HbA1c and anxiety or depressive symptoms.
HbA1c for those above threshold for diabetes distress was significantly
higher than for those scoring below threshold. Females were more likely
to be distressed than males.
Conclusions: Although efforts have been made to encourage
screening for anxiety and depression within diabetes clinics, this study
found these symptoms to be similar to published norms and to be
unrelated to HbA1c. Heightened diabetes distress is prevalent within
this group and importantly those with higher diabetes distress have
poorer HbA1c. Clinics may benefit from screening for diabetes distress
especially given that comorbid conditions can lead to issues with selfmanagement. Future interventions should consider diabetes distress as a
separate condition to depression or anxiety.
159
DIABETICMedicine
P429
Quality and Outcomes Framework (QOF)
screening questions for depression in
patients with diabetes: effective but
non-efficient
SR Abu-Roomi1, S Javed2, SC Bain3, DE Price1 and
JW Stephens1,3
1
Department of Diabetes and Endocrinology, Morriston Hospital, Swansea,
UK, 2General Practice, The Robert Street Practice, Pembrokeshire, UK,
3
Diabetes Research Group, Institute of Life Science, Swansea University,
Swansea, UK
Aim: Diabetes is associated with depression. Depression screening is

included in the Quality and Outcomes Framework (QOF) 2006. Recent
concerns had been raised regarding QOF screening in depression,
resulting in NICE recommending the suspension of the QOF depression
indicators. Our aim was to evaluate the prevalence of depression and
the accuracy of the two recommended QOF screening questions in
patients with diabetes attending a routine secondary care follow-up
clinic.
Methods and results: Patients were asked the QOF screening
questions and then assessed further using a Patient Health
Questionnaire (PHQ-9) depression assessment tool as the gold
standard. This was performed by a researcher not involved in patient
care. A total of 40 patients were interviewed (20 males, 20 females) with
a mean age of 60 (3583) years and duration of diabetes of 13 years. Of
these 29 (73 per cent) were insulin treated. Prior to interview 13/40
patients declared a past history of depression and a further three patients
were under active treatment. The QOF questionnaire was positive for
depression in 14 patients, but only seven of these screened positive with
PHQ-9 (two with suicidal ideation). A total of 26 patients screened
negative with both QOF and PHQ-9.
Conclusions: Depression is prevalent in diabetes and a screening tool
is valuable. QOF screening has a high sensitivity (100 per cent) but
lower specificity (78 per cent). The positive predictive value of QOF
screening was 50 per cent and negative predictive value 100 per cent.
This small study supports that QOF screening questions do not provide
accuracy in screening for depression in patients with diabetes.
P430
Emotional wellbeing and diabetes control
prior to hospital admission for diabetic
ketoacidosis in Type 1 diabetes: a service
evaluation
KY Matheson1,2, AJA Keen1 and AE Gold1
1
Diabetes Centre, NHS Grampian, Aberdeen, UK, 2Clinical Psychology,

University of Edinburgh, Edinburgh, UK
Aim: To explore whether adults with Type 1 diabetes admitted for

diabetic ketoacidosis (DKA) were significantly more emotionally
distressed before admission than the adult Type 1 diabetes clinic
population in Grampian.
Methods: We obtained a range of information collected routinely by
clinicians from medical notes and the diabetes database (SCI-DC) on
adults with Type 1 diabetes who had been admitted for DKA between 1
June 2010 and 31 May 2011 (n = 66). This information included
standard demographics; pre- and post-admission HbA1c levels; the
reason medical staff noted for the DKA presentation; and pre-admission
anxiety and depression scores [measured by the Hospital Anxiety and
Depression Scale (HADS) during routine annual screening at the
160
secondary care diabetes centre]. Post-discharge HbA1c and HADS data

were available for 55 and 33 cases, respectively.
Results: People with Type 1 diabetes admitted for DKA had
significantly higher levels of anxiety (P < 0.001) and depression
(P < 0.001) than a consecutive sample of the clinic population
(n = 396). Furthermore, they more frequently had clinically significant
levels of anxiety (36.4 vs. 11.9 per cent; P < 0.001) and depression (24.2
vs. 6.6 per cent; P < 0.001). Pre- and post-admission HbA1c values were
strikingly similar [11.31 per cent (100 mmol/mol) and 11.36 per cent
(101 mmol/mol); not significant], andthe most common reason for DKA
was chronically poor control (33.8 per cent of cases).
Conclusions: Further larger scale prospective research is required to
confirm these initial results. If robust, there may be scope for
multidisciplinary interventions targeting this specific group of adults
with Type 1 diabetes, who appear vulnerable to psychological
problems, chronic poor control, and therefore substantial health
problems in the future.
P431
Predictors of quality of life gains among
people with Type 1 diabetes participating in
the Irish Dose Adjustment for Normal Eating
(DAFNE) study
MC OHara1, M Byrne2, J Newell3,4, N Coffey4, D OShea5,6,
D Smith7, C McGurk8, CH Courtney9, S Heller10, SF Dinneen1,11
1
Diabetes and Endocrinology Centre, University Hospital Galway, Galway,
Ireland, 2School of Psychology, National University of Ireland (NUI), Galway,
Ireland, 3HRB Clinical Research Facility, National University of Ireland (NUI),
Galway, Ireland, 4School of Mathematics, Statistics and Applied Mathematics,
National University of Ireland (NUI), Galway, Ireland, 5Diabetes and
Endocrinology, St Vincents University Hospital, Dublin, Ireland, 6Diabetes and
Endocrinology, St Columcilles Hospital, Dublin, Ireland, 7Diabetes, Beaumont
Hospital, Dublin, Ireland, 8Diabetes, St Lukes General Hospital, Kilkenny,
Ireland, 9Regional Endocrinology and Diabetes Centre, Royal Victoria
Hospital, Belfast, UK, 10Academic Unit of Diabetes, Endocrinology and
Metabolism, School of Medicine and Biomedical Sciences, University of
Sheffield, Sheffield, UK, 11School of Medicine, National University of Ireland
(NUI), Galway, Ireland
Aims: To examine whether baseline characteristics of participants

enrolled in the DAFNE programme can predict improvements in
quality of life (QOL).
Methods: Clinical and questionnaire data [the Problem Areas in
Diabetes scale (PAID) and the Diabetes-Specific Quality of Life Scale
(DSQOLS)] were collected at baseline and at 6, 12 and 18 months postDAFNE training. Participants (n = 437) received either structured
group follow-up or individual clinic follow-up. Linear mixed models
were conducted to identify predictors of changes in psychosocial
outcomes. Predictor variables included age, gender, marital status,
smoking status, years since diagnosis, body mass index, blood pressure,
HbA1c, anxiety and depression (measured using the Hospital Anxiety
and Depression Scale, HADS).
Results: Participants experienced significant improvements in
psychosocial measures (PAID and DSQOLS). Individuals with
higher baseline levels of diabetes-related distress experienced a
greater improvement in QOL scores (DSQOLS) than those with
lower levels of diabetes-related distress (P = 0.05). There was a
positive correlation between levels of educational attainment and
change in DSQOLS, with individuals with higher baseline levels of
educational attainment experiencing more improvement in DSQOLS
than those with lower levels of educational attainment. Individuals
with poorer baseline glycaemic control and those with higher baseline
levels of depression (HADS) experienced significantly greater
2012 The Authors.

reductions in diabetes-related distress (PAID) than those with better

glycaemic control (P = 0.04) or those with lower levels of depression
(P = 0.03).
Conclusions: These data suggest that certain baseline characteristics
may predict improved psychosocial outcomes following structured
education for Type 1 diabetes.
Acknowledgement: The Irish DAFNE Study Group.
P432
The My Hypo Compass psycho-educational
intervention: design of a novel curriculum
to aid the prevention of severe
hypoglycaemia
S Little1, SM Barendse2, D Kyne3, J Speight2, RM Thomas1,
ML Evans4 and JAM Shaw1
1
Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne,
UK, 2AHP Research, Hornchurch, UK, 3Newcastle Diabetes Centre,
Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Newcastle-UponTyne, UK, 4Institute of Metabolic Science, University of Cambridge, UK
Aims: People with Type 1 diabetes can be reluctant to discuss

hypoglycaemia, despite it necessitating behavioural changes and
having distressing consequences including seizures, coma and,
infrequently, sudden death. Few structured education programmes
exist with the sole objective of preventing severe hypoglycaemia (SH).
Our objectives were to design a brief person-centred psychoeducational intervention addressing theoretical and practical
principles of SH prevention.
Methods: Initial design involved development of four key messages
based around points of a compass to aid recall and maintain visual
simplicity. The curriculum was driven by findings from semi-structured
interviews with people with Type 1 diabetes/history of SH and learnings
from the Blood Glucose Awareness Training (BGAT) programme.
Content was refined through an iterative design process, including (1)
review by health psychologists, diabetes specialist clinicians and nurse
educators, and (2) debriefing by patient experts.
Results: The Hypo COMPaSS Trial afforded an opportunity to pilot
the intervention at five diabetes centres (96 participants), demonstrating
that it is understandable, acceptable (completed within 1 h), and meets
pre-intervention expectations of both people with Type 1 diabetes and
professionals.
Conclusions: A comprehensive and iterative design process generated
a person-centred intervention which elicits individual preferences for
hypo treatment and enables the formulation of individual action plans.
My Hypo Compass provides a much needed, brief tool to support the
goal of avoiding SH whilst continuing to aim for optimal blood glucose
levels.
Acknowledgement: The Hypo COMPaSS Study Writing Group.
DIABETICMedicine
Aim: To pilot a mindfulness-based cognitive therapy (MBCT) group

intervention for treating anxiety and depression in adults with Type 1
and 2 diabetes.
Methods: Fifteen adults with diabetes participated in the MBCT
intervention (participants self-selected by responding to posters and
leaflets in the local secondary care diabetes clinic). The intervention
consisted of eight weekly 2 h meetings and a participant workbook.
The meetings covered educational topics pertinent to the target
population (eg the nature of stress and its impact on blood glucose),
along with standard mindfulness exercises (eg the body scan).
Participants were also expected to complete mindfulness exercises at
home. Measures of anxiety and depression (the Hospital Anxiety and
Depression Scale, HADS), diabetes-related distress (Problem Areas in
Diabetes) and mindfulness (Cognitive and Affective Mindfulness Scale
Revised) were collected pre- and post-intervention.
Results: Participants reported significantly lower levels of anxiety
(z = 2.77, P = 0.006), depression (z = 3.24, P = 0.001) and
diabetes-related distress (z = 3.4, P = 0.001). They also reported
significantly greater levels of mindfulness (z = 3.15, P = 0.002). The
effect sizes were all large: d = 1.1 for anxiety; d = 1.5 for depression;
d = 0.9 for diabetes-related distress; and d = 1.5 for mindfulness. Of
the 13 participants scoring in the clinical range for anxiety (HADS
anxiety score 10) at baseline, only one did so post-intervention. None
of the three participants who scored in the clinical range for depression
(HADS depression score 10) did so post-intervention.
Conclusions: MBCT is a promising intervention for adults with
diabetes. Further research is required to establish if there are lasting
effects on emotional wellbeing and diabetes control.
P434
Implementation and review of a preconsultation checklist within a young
persons diabetes service
C Darbyshire, D Pearson, E Stewart, S Copland, A Mayo and
SC McGeoch
Diabetes Service, NHS Grampian, Aberdeen, UK
Diabetes Centre, NHS Grampian, Aberdeen, UK, 2Health Services Research

Unit, University of Aberdeen, Aberdeen, UK
Aim: To review the use of a pre-consultation checklist designed to

encourage young people aged 1621 years with Type 1 diabetes to take
a more active role in negotiating the topics discussed during routine
outpatient consultations. This is important because this time of life can
be characterised by a deterioration in control and disengagement with
diabetes services.
Method: A checklist, detailing 26 potential topics of discussion during
routine clinic visits, was developed in a young persons diabetes clinic.
Young people completed the checklist in the waiting area and presented
it to the clinician at the beginning of their appointments. Fifty-four
checklists were gathered retrospectively from medical notes.
Results: In all, 88.9 per cent of young people selected one or more
item(s) on the checklist (mean 4.8 items). The most popular items were
My blood results from the lab today (glucose, HbA1c) (61.1 per cent);
Current insulin doses and adjusting my insulin (40.7 per cent) and
Managing and avoiding high blood glucose levels and calculating
correction doses (35.2 per cent). A minority also indicated that they
wanted to discuss some of the more sensitive issues, including Diabetes
and pregnancy (5.6 per cent) and Diabetes and drugs (3.7 per cent).
Conclusion: A pre-consultation checklist appears acceptable to the
vast majority of young people with diabetes. A checklist may facilitate
the foundation for patient-centred consulting and give permission for
young people to discuss some of the more sensitive issues. Further
research should assess young peoples and professionals perspectives of
2012 The Authors.

161
P433
The effectiveness of a mindfulness-based
cognitive therapy intervention specifically
designed for adults with diabetes
experiencing significant levels of anxiety
and/or depression: a pilot clinical service
AJA Keen1, E Duncan2 and AE Gold1
1
DIABETICMedicine
the use of the pre-consultation checklist in routine diabetes clinics and

changes in responses over time.
P436
Abstract withdrawn.
P435
Evaluating the effectiveness of a rapid
response psychotherapy initiative in the
young persons diabetes clinic
S Singham
Diabetes and Endocrine Centre, Guys and St Thomas NHS Foundation Trust,
London, UK
Aim: Young people with diabetes may experience psychological and

emotional difficulties but can be ambivalent about engaging with
diabetes services. Psychological care is part of the routine package of
care offered in a multidisciplinary young persons diabetes clinic in
secondary care, providing immediate and accessible care for a difficult
to engage population. The aim of the study was to determine the
effectiveness of a rapid response brief psychotherapy intervention for
young people with diabetes who seek autonomy and independence
from authority figures and resist engaging in long-term relationships.
Method: Assessment was followed by four weekly sessions. Analysis
of data over a 12-month period using the CORE (Clinical Outcomes in
Routine Evaluation) questionnaire was administered pre and post
therapy to measure outcome in four dimensions: wellbeing, problems,
functioning and risk. A reduction in scoring indicated improved
outcome.
Results: The total clinic population was 60. Thirty regular attendees
agreed to participate in psychological screening as part of their routine
diabetes visit. Eighteen of these (55 per cent) were identified as scoring
moderate to high and were offered psychological intervention. The age
range was 1623, mean age 19. There were 14 patients with Type 1
diabetes and four with Type 2; 10 females, 8 males; nine Black British,
four Asian and five White Europeans. Fourteen of the 18 (78 per cent)
attended therapy. Ten completed (56 per cent), two dropped out, two
completing therapy. In the 10 who completed therapy there was an
improvement in outcomes in all four dimensions indicating a global
reduction in distress (mean score pre-intervention 61/136; mean score
post-intervention 17/136).
Conclusion: Early intervention using brief psychotherapy improves
psychological wellbeing in young people with diabetes. Further work is
necessary to evaluate the impact of early psychological intervention on
the long-term engagement of young people with diabetes services.
162
P437
Disordered eating in young adults with Type
1 diabetes: predictors of disordered eating
behaviour
V Young1,2, C Eiser1,2, B Johnson1,2, S Brierly1,2 and S Heller2,3
1
Psychology, University of Sheffield, Sheffield, UK, 2National Institute for
Health Research (NIHR) CLAHRC for South Yorkshire, Sheffield, UK, 3School
of Medicine and Biosciences, University of Sheffield, Sheffield, UK
Aims: This cohort study is one of the first to explore predictors of

disordered eating in young adults with Type 1 diabetes using a diabetesspecific measure of eating.
Methods: A cohort of young adults (1621 years) with Type 1
diabetes recruited from specialist young adult clinics at Sheffield
Teaching Hospitals (n = 103, 85 per cent of population) completed
the Diabetes Eating Problems Scale revised (DEPS-r). Body mass index
(BMI), HbA1c and demographic data were obtained from medical
records.
Results: The prevalence of disordered eating behaviour was 36.9 per
cent (mean score on DEPS-r 1.25). Medical and demographic data
were regressed on DEPS-r scores using a stepwise method. Variables
predictive of DEPS-r scores were female gender (b = 0.37) and higher
HbA1c (b = 0.39) (P < 0.001). Age and BMI were not predictive of
disordered eating behaviour (P 0.05).
Conclusions: Disordered eating was common in this cohort of young
adults with Type 1 diabetes. Although in previous work (using selfreport measures) overweight was predictive of disordered eating
behaviour, in this study BMI was not. This implies that perceptions
of weight are more important than actual BMI in predicting disordered
eating. Since female gender and higher HbA1c were predictive of
disordered eating behaviour, screening of females with suboptimal
glycaemic control for disordered eating behaviour and developing
appropriate interventions may be beneficial in addressing problematic
eating in young adults with Type 1 diabetes.
Acknowledgement: The CLAHRC-SY Diabetes Clinical Research
Team who collected the data.
2012 The Authors.

Clinical care and other categories posters: retinopathy
DIABETICMedicine

P438
Severity of diabetic retinopathy predicts a
four year decline in verbal fluency in older
people with Type 2 diabetes: the Edinburgh
Type 2 Diabetes Study (ET2DS)
I Feinkohl1, J Ding2, M Keller1, CM Robertson1, J Morling1,
S Masle1, IJ Deary3,4, MWJ Strachan5 and JF Price1
1
UK, 2Singapore Eye Research Institute, Singapore National Eye Centre,
Singapore, 3Psychology in the School of Philosophy, Psychology and
Language Sciences, University of Edinburgh, Edinburgh, UK, 4Centre for
Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh,
Edinburgh, UK, 5Metabolic Unit, Western General Hospital, Edinburgh, UK
Background: Diabetes is associated with accelerated age-related

cognitive decline but the underlying risk factors are largely unknown.
We previously reported cross-sectional associations between diabetic
retinopathy (DR), an indicator of cerebral microvascular disease, and
cognitive ability in elderly Type 2 diabetes patients participating in the
ET2DS. This association was investigated further in the follow-up of the
cohort.
Method: This was a prospective study of 1,066 men and women aged
6075 years with Type 2 diabetes. Seven-field digital retinal
photographs were graded at baseline and categorised as no, mild
and moderate/severe DR. Seven neuropsychological tests were
administered at baseline and after 4 years, including a test of verbal
fluency for executive function. To determine cognitive change analyses
of follow-up test scores were adjusted for baseline scores.
Results: Absolute changes in mean test scores were small for all
groups. The DR category was associated with verbal fluency after
controlling for age, sex and baseline scores (P = 0.057). Both no DR
(n = 705; adjusted mean 36.9; 95 per cent CI 36.3, 37.5) and mild DR
groups (n = 292; adjusted mean 37.3; 95 per cent CI 36.3, 38.3)
outperformed the moderate/severe DR group (n = 47; adjusted mean
34.0; 95 per cent CI 31.5, 36.5; Cohens d = 0.23, P = 0.03; Cohens
d = 0.26, P = 0.02, respectively). DR was not associated with change in
other cognitive tests.
Conclusion: DR severity predicts decline in executive function in
older people with diabetes, suggesting a role for cerebral microvascular
disease in this aspect of diabetes-related cognitive decline. Lack of
association in other cognitive domains requires further exploration as
this may have been affected by the short period of follow-up.
Acknowledgement: On behalf of the ET2DS investigators.
P439
Relationship between retinopathy grade
from digital retinal screening, age and
visual acuity: when does retinopathy impact
on the vision of the patient with diabetes?
IM Stratton1, SJ Aldington1, M Histed2, S Chave3 and PH
Scanlon3
1
English National Screening Programme for Diabetic Retinopathy,
Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT), Gloucester, UK,
2
Gloucestershire Diabetic Eye Screening Service, Gloucestershire Hospitals
NHS Foundation Trust (GHNHSFT), Gloucester, UK, 3Department of
Ophthalmology, GHNHSFT, Gloucester, UK
Aims: To investigate the relationship between diabetic retinopathy

(DR) grade and age with visual acuity (VA).
2012 The Authors.

Methods: Data were from a programme of the English National

Screening Programme for Diabetic Retinopathy on all patients screened
between 2005 and 2010. Retinopathy was graded as R0, no
retinopathy; R1, background; R2, pre-proliferative; and R3,
proliferative retinopathy. Diabetic maculopathy was graded as M0,
no maculopathy; or M1, maculopathy present. Analysis of variance was
carried out to assess the contribution of age and retinopathy grade to
visual acuity as measured by the LogMAR score.
Results: Data were available on 28,773 patients, 56.4 per cent men,
age at screening 68 (59, 77) years [median (25th, 75th centile)]. Data
were analysed by eye, n = 186,303. VA increased with patients age
from 0 (0.00, 0.02) in those under 24 to 0.34 (0.22 to 0.56) in those aged
95 and above. VA was 0.06 (0.0, 0.22) in R0M0, 0.06 (0.00, 0.20) in
R1M0, 0.08 (0.0, 0.22) in R2M0, 0.12 (0, 0.32) in R3M0, 0.22 (0.02,
0.40) in R1M1, 0.18 (0.02, 0.40) in R2M1, 0.22 (0.02, 0.42) in R3M1.
In eyes that had undergone laser treatment VA was 0.24 (0.08, 0.44)
and eyes with unassessable images VA was 0.46 (0.24, 1.00). Analysis
of variance showed that the affects of age and DR grade were highly
significant (both P < 0.0001); however, using Duncans multiple range
test R0M0, R1M0, R2M0 were not significantly different and R1M1,
R2M1 were not significantly different.
Conclusions: Patients may remain symptomless with no visual loss
with background or more advanced proliferative DR unless the macula
is affected.
P440
Obstructive sleep apnoea (OSA) is
associated with the development and
progression of diabetic retinopathy,
independent of conventional risk factors
and novel biomarkers for diabetic
retinopathy
S Rudrappa1, G Warren2 and I Idris1,3
1
Diabetes and Endocrinology, Sherwood Forest Hospitals Foundation Trust,
Nottinghamshire, UK, 2Trent Research Design Services for East Midlands,
University of Nottingham, Nottingham, UK, 3School of Graduate Entry
Medicine, University of Nottingham, Nottingham, UK
Aim: The aim of this study was to investigate the relationship between
OSA, the apnoeahypopnoea index (AHI) and diabetic retinopathy
(DR) independent of clinical parameters and serum biomarkers
implicated in the development and progression of DR.
Methods: Thirty-one patients underwent a standard in-hospital sleep
study. Details of their diabetes, clinical parameters, retinopathy grading
and HbA1c levels were recorded. Assessment of serum biomarkers
included levels of vascular endothelial growth factor, interleukin-6,
tumour necrosis factor a, hsCRP, monocyte chemoattractant protein 1
and matrix metalloproteinases levels.
Results: Seventeen patients were identified to have OSA; mean age
54.9 11.3 years, body mass index 35.3 4.8 kg/m2, HbA1c
9.2 2.4 and diabetes duration 11.0 8.3 years. All clinical and
biochemical parameters were equally matched between OSA and nonOSA patients, except for the Epworth score (11.0 vs. 6.8, P = 0.008)
and the AHI score (23.4 17.1 vs. 3.1 1.0, P < 0.0001), which by
definition were increased in patients with OSA. Retinopathy score
(P = 0.04) but not maculopathy score (P = 0.15) were significantly
worse in the OSA group. The proportion of patients with proliferative
DR (R3) was significantly higher in the OSA group (chi-squared 4.8;
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DIABETICMedicine
P = 0.03). Stepwise multiple regression analysis showed only OSA to be

an independent significant predictor of the total retinopathy scores
(P = 0.008) and remained in the regression model after stepwise forced
exclusion of other covariates. Diabetes duration was marginal in
predicting retinopathy scores (P = 0.08).
Conclusion: This study confirms recent observation of a strong
association between DR and OSA. Our observation suggests that this
association persists even after adjustment of conventional and novel risk
factors for the development of DR.
P441
Progression of diabetic retinopathy to
referable or sight threatening retinopathy?
Does it matter whether there is background
retinopathy in either or both eyes?
SJ Aldington1, PH Scanlon2, M Histed3, S Chave2 and IM Stratton2
1
English National Screening Programme for Diabetic Retinopathy, Gloucester
Hospitals NHS FT, UK, 2Ophthalmology, Gloucester Hospitals NHS FT, UK,
3
Gloucestershire Diabetic Eye Screening Service, Gloucester, UK
Aims: To investigate progression to referable and to sight threatening

retinopathy in patients in a programme of the English National
Screening Programme for Diabetic Retinopathy with no or background
retinopathy only.
Methods: People with diabetes screened with mydriatic digital retinal
photographs who were screened between 2005 and 2010 with no
diabetic retinopathy (DR) or background DR at the first of these screens
and who were screened on at least two occasions were included.
Patients were classified at first screening as no DR (NDR), background
DR in one eye (B1) or background DR in both eyes (B2). Times to
detection of proliferative retinopathy (PR) and to referable retinopathy
(RR) (maculopathy or pre-proliferative or proliferative retinopathy)
were analysed using survival models.
Results: Data were available on 19,044 patients, 56 per cent men; age
at screening 66 (5774) years [median (25th, 75th centile)]. Of these
65.6 per cent had NDR, 19.6 per cent had B1, 14.5 per cent had B2.
Progression to PR within 5 years was 0.12 per cent for NDR, 0.23 per
cent for B1 and 1.6 per cent for B2. Progression to RR within 2 years
was 0.9 per cent for NDR, 3.1 per cent for B1 and 14.7 per cent for B2.
The Cox hazard ratio for progression to PR from B2 was 13.4 (6.9
25.6), and to RR from B1 was 2.82 (95 per cent CI 2.433.27) and from
B2 10.77 (9.5512.15).
Conclusions: The risk of progression is significantly higher for those
with background DR in both eyes than those with background
retinopathy in one eye only or in neither eye. High sensitivity when
grading microaneursyms and other lesions of background retinopathy
will optimise algorithms for extended screening intervals.
P442
High prevalence of diabetic retinopathy at
first eye screening due to delayed inclusion
into the diabetic retinopathy register
L Sellahewa1, C Simpson2, J Duffy2, P Maharajan2 and I Idris1,3
1
Nottingham, UK, 2North Notts Diabetic Retinopathy Screening Programme,
Sherwood Forest Hospitals Foundation Trust, Nottingham, UK, 3School of
Graduate Entry Medicine, University of Nottingham, Nottingham, UK
Background: The advent of the national diabetic retinopathy

screening programme in the UK facilitates the immediate screening of
164
eyes once patients are diagnosed with Type 2 diabetes. These screening
programmes rely on GP practices to inform the screening offices of such
patients. We have recently identified a cohort of patients whose
inclusion into the retinopathy screening register was delayed by more
than 1 month. We report the prevalence of retinopathy and their ocular
outcomes following their first screening within an optometry based
screening programme.
Methods: Data were obtained and audited from the diabetic
retinopathy screening database and hospital based clinical
information record.
Results: A total of 36 patients were identified, mean age
62.2 17.1 years, of whom 19 were female. Mean delay of their
first retinopathy screening from diagnosis of diabetes was
12.9 25.8 months. Prevalence for any retinopathy at presentation
was 44.4 per cent (n = 16) and for any maculopathy was 8.3 per cent
(n = 3). Two patients required urgent referrals to the hospital
ophthalmology service for suspected proliferative retinopathy (R3)
although both gradings were downgraded following slit-lamp and
fluorescein angiogram assessments. Two patients had sight threatening
maculopathy (M1) requiring ophthalmology referral. Neither the
duration of delay from diagnosis to first retinopathy screening nor age
of patients influenced the development of sight threatening disease.
Conclusion: The observed prevalence of retinopathy at presentation
appears to be slightly higher than that observed from the UKPDS.
Delayed referral to the screening programme may contribute to the high
prevalence of any retinopathy at first presentation to the screening
programme.
P443
Evaluating digital diabetic retinopathy
screening in people aged 90 years and over
AS Tye1, HM Wharton1, JM Gibson1,2, M Clarke1, A Wright1
and PM Dodson1,2
1
Departments of Diabetes and Ophthalmology, Heartlands Hospital,

Birmingham, UK, 2School of Health and Life Sciences, Aston University,
Birmingham, UK
Aims: The English National Screening Programme determines that all

people with diabetes aged 12 and over should be screened annually for
diabetic retinopathy (DR) until they die. This study aimed to evaluate
digital DR screening in patients aged 90 and over to establish whether it
is appropriate to cease screening at age 90.
Methods: A retrospective analysis was carried out of 200 randomly
selected patients with diabetes aged 90 and over within the Birmingham
and Black Country Screening Programme.
Results: In all, 179 (90 per cent) patients attended screening at least
once after turning 90 years of age. To date, the mean number of screens
per person of 90 + is two (range 16) and the mean age of the first of
these screens is 91 years (range 9098 years). A total of 133 (74 per cent)
were put on annual recall after their first screen in their 90s, of whom 58
per cent had no visible DR bilaterally. Thirty-eight (21 per cent) were
referred to ophthalmology, including 30 (80 per cent) for other lesions,
two for DR and one for both. Of the 133 patients put on annual recall, 75
(56 per cent) were screened at least once more. Seven improved, 36
remained stable, three became unsuitable and 29 deteriorated. Of the
latter, 17 were referred to ophthalmology (all non-DR reasons).
Conclusions: Patients with diabetes aged 90 and over are at low risk
of sight threatening DR and annual screening in this age group may be
unnecessary. However, annual screening does provide opportunistic
identification of non-DR eye conditions which may improve patient
care, but is this a duty of the screening programme?
2012 The Authors.

Clinical care and other categories posters: screening and pre-diabetes
DIABETICMedicine
P444
An audit of current screening practice for
diabetic retinopathy in Type 1 and Type 2
diabetes patients
P445
Diabetic retinopathy screening: is there a
link between number of images graded and
grading accuracy?
A Varma1, K Patel1 and J Barraclough2
W Gatling1,2, RM Manikandan2, C Wallis1,2 and PW Thomas3
School of Medicine, University of Birmingham, Birmingham, UK, General

Practice, Village Surgery, Cheswick Green, Solihull, UK
Aim: Retinopathy screening amongst patients with diabetes has been

established as an integral part of diabetic care since 2003. The intent of
this practice is to allow early identification of retinal damage so
allowing prompt treatment and thereby preventing sight loss. National
Institute for Health and Clinical Excellence guidelines recommend that
all patients with diabetes be offered retinopathy screening annually;
however, this has not been met as exemplified by 2009 Department of
Health data indicating that of the approximately 2.3 million patients
with diabetes in England only 70.2 per cent have received screening.
The objective of this retrospective audit was to assess how effectively
these guidelines are being implemented within the general practice
setting.
Method: This audit used patient data collected from the EMISTM
patient record system and central screening records as provided by the
Heart of England Diabetic Retinopathy Screening Centre of Excellence
(HEDRSCE). Of 184 patients with diabetes studied, we aimed to
identify what proportion were part of the formal screening programme,
and the reasoning behind those who are not.
Results: Of the 184 patients, only 150 (84 per cent) had been screened
within the past 15 months. Of the remaining 34 unscreened patients,
only 32 per cent were true non-attenders; the remaining had either been
screened or were deceased.
Conclusions: This audit illustrates that the true values of screening
non-attendance may be lower than initially estimated. Out-of-date
practice records and poor communication between HEDRSCE and the
general practice may be partly responsible, as a large amount of
discordance in screening dates was seen to exist between the two
registers.
Dorset Diabetic Eye Screening Programme, NHS Dorset, Ferndown, UK,

Trust, Poole, UK, 3Clinical Research Unit, Bournemouth University,
Bournemouth, UK
2
Aim: The English National Screening Programme for Diabetic

Retinopathy quality assurance standards recommend optometrist
graders grade a minimum of 500 patient image sets annually. In the
Dorset Diabetic Eye Screening Programme (DDESP), optometrist
graders participated in local online tests to assess grading accuracy. We
investigated the relationship between grading accuracy and number of
images graded for DDESP over a 12-month period.
Methods: In total the online test consists of 250 image sets: five 50
image sets (25 per cent sight threatening retinopathy, STR). All the
graders were required to participate; they received assessment and
feedback. The aim is to prevent missing STR: sensitivity 90 per cent
for identifying STR; specificity 95 per cent. The total number of
images graded for DDESP was obtained from Orion software.
Results: Forty-six of 49 optometrists participated. Median sensitivity
(minimum, maximum) for identifying STR was 89 per cent (64 per cent,
98 per cent). Using 99 per cent confidence intervals only 4/46 did
significantly worse than 90 per cent sensitivity. Median specificity was
91 per cent (78 per cent, 99 per cent). Using 99 per cent confidence
intervals 11/46 did significantly worse than 95 per cent specificity.
There was no correlation between number of images graded per year
and graders test results. Average number of images graded 622 (range
1002646); correlation coefficient of 0.09 (P = 0.56).
Summary: Graders participated enthusiastically in local quality
assurance tests and only 9 per cent failed to achieve required
sensitivity. Although the graders achieved excellent results in the
online test, there was no correlation between this and the number of
actual patient sets graded.
Clinical care and other categories posters: screening and

pre-diabetes
P446
Association of Type 2 diabetes with
polycystic ovary syndrome: analysis of a
large cohort of patients with polycystic
ovary syndrome
H Mani1,2, MJ Davies1,2, TA Howlett1,2, MJ Levy2, LJ Gray3,
MJ Bankart3, H Blackledge3 and K Khunti3
1
Cardiovascular Sciences, University of Leicester, Leicester, UK, 2Diabetes and
Endocrinology, University Hospitals of Leicester, Leicester, UK, 3Health
Introduction: The reported incidence and prevalence of diabetes in

women in the UK is 2.82/1,000 person-years and 3.7 per cent
respectively. The reported prevalence of Type 2 diabetes in polycystic
ovary syndrome (PCOS) is up to four times higher; however, data on the
incidence of diabetes in this group are lacking.
2012 The Authors.

Methods: A retrospective analysis was carried out of a PCOS patients

database (n = 2,353) at an endocrine unit (19772009). Data linkage
was made with the local hospital admission database. For the incidence
study people without diabetes at registration (n = 2,228) were followed
up to 2009 unless they emigrated, died or were diagnosed with diabetes
(date confirmed using medical notes or earliest abnormal blood test).
Results: There were 188 (8 per cent) patients with diabetes; 139 (5.9
per cent) Type 2 diabetes and 25 (1 per cent) gestational diabetes
(GDM). Mean age of the total cohort and for diagnosis of Type 2
diabetes and GDM was 35.9 years (SD 9.8), 33.5 years (11.2) and
27.3 years (7.8) respectively. Ethnic groups were 60.1 per cent White,
26.3 per cent South Asians, 1.1 per cent Afro-Caribbean and 12.5 per
cent other. Age-specific prevalence of Type 2 diabetes was 2.5 per cent
(1524 years), 3 per cent (2534 years), 6.3 per cent (3544 years),
10.8 per cent (4554 years), 15.5 per cent (5564 years) and 45.5 per
cent (65 years). Corresponding numbers in the general female
population (Health Survey for England, 2006) are 0.3 per cent, 0.5
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DIABETICMedicine
per cent, 0.8 per cent, 2.3 per cent, 5.9 per cent and 10.4 per cent. The
cumulative continuous observation period was 16,687 person-years in
which 99 people developed diabetes (80 Type 2 diabetes, 13 GDM).
The cumulative incidence of Type 2 diabetes was 4.8/1,000 personyears. Using Cox regression analysis, age and body mass index (BMI)
were significant predictors of incident diabetes (P < 0.01);
hyperandrogenism reduced the risk of diabetes (P < 0.01).
Conclusions: Women with PCOS have a higher prevalence/incidence
of Type 2 diabetes which increases with age and BMI. Screening for
diabetes and early lifestyle intervention should be considered at a
younger age.
P447
Understanding of the risks of Type 2
diabetes by women with polycystic ovary
syndrome
J Tomlinson1, G Letherby2, J Pinkney1 and E Stenhouse2
1
University Medicine, Peninsula College of Medicine and Dentistry, Plymouth,
UK, 2Faculty of Health Education and Society, Plymouth University, Plymouth, UK
Aim: Research has shown that women with polycystic ovary

syndrome (PCOS) have an increased risk of developing impaired
glucose tolerance (IGT) and Type 2 diabetes and this risk can be reduced
by lifestyle interventions such as weight loss and physical exercise. The
aim was to explore womens (with polycystic ovary syndrome)
understanding of the risk of IGT and Type 2 diabetes and their
response to this risk, and to explore womens lived experience of PCOS.
Methods: Data were collected via focus groups. The interview
schedule was semi-focused allowing the respondents to introduce
themes and issues of concern to them. The focus groups were
transcribed verbatim and the transcripts were analysed using a
grounded theory approach. Key themes and issues were identified and
key similarities and differences considered.
Results: All respondents were aware of the risks of IGT and Type 2
diabetes and what they should do to minimise their risk. But future
health concerns were less significant to them than the here and now
identity concerns. The main theme to emerge from the data was a focus
on the effect of PCOS on identity which can be further subdivided thus:
feminine identity; reproductive identity; un/healthy identity. A
secondary theme to emerge from the data was lack of information
from specialised health professionals. Women reported that they
obtained most of their information about PCOS from the internet.
Conclusion: Further training is needed to enable specialised healthcare professionals to support women in living with PCOS and understanding and minimising future ill health, including Type 2 diabetes .
Clinical care and other categories posters: structure of care
P448
Screening for diabetes in acute medical
admissions in Ireland using guidelines from
the American Diabetes Association (ADA),
the US Department of Veterans Affairs/
Department of Defense (VA/DoD) 2010 and
WHO 2006
KT OBrien1, FM Ali1, DB Moore1, IM Stratton2, SE Manley3
and GA Roberts1
1
Endocrinology and Diabetes Research Group, Waterford Institute of
Technology, Waterford, Ireland, 2English National Diabetic Retinopathy
Screening Programme, Gloucestershire Hospitals NHS Foundation Trust,
Cheltenham, UK, 3Clinical Biochemistry, University Hospitals Birmingham NHS
Foundation Trust, Birmingham, UK
Objective: To compare screening for diabetes using the above

guidelines in emergency medical admissions to a regional hospital.
Methods: Over 2 years, 2,061 (14 per cent) unselected patients out
of 14,432 were studied with the 75 g oral glucose tolerance test
(OGTT) performed on 407 (20 per cent), aged 18 years, with
symptoms or complications of diabetes but no known diagnosis of
hyperglycaemia. HbA1c was measured within a week of the OGTT in
164 (40 per cent) patients by IE HPLC (Menarini 8160) with reference
interval IFCC 2042 mmol/mol, DCCT 4.06.0 per cent.
Results: The 164 patients were White Caucasian, aged 69 (5979)
years [median (IQ range)], with 62 per cent male. Their HbA1c was 39
(3442) mmol/mol, fasting plasma glucose (FPG) 5.2 (4.85.7) mmol/l
and 2 h plasma glucose 8.9 (7.311.2) mmol/l. By WHO 2006, 52 (32
per cent) had diabetes and 62 (38 per cent) impaired glucose tolerance;
of these only 11 (7 per cent) had FPG in the diabetes range, whereas 51
(31 per cent) had 2 h plasma glucose in the diabetes range. Applying the
ADA diagnostic criteria for HbA1c of 48 mmol/mol (6.5 per cent)
categorised 19 (12 per cent) patients as diabetic. However, use of the
VA/DoD HbA1c diagnostic criteria of 53 mmol/mol (7.0 per cent)
and FPG 7.0 mmol/l categorised 12 (7 per cent) as diabetic with 11
(6.7 per cent) in the diabetes range on 2 h plasma glucose and eight (5
per cent) in diabetes range on FPG.
Summary: Both ADA and VA/DoD 2010 guidelines identified fewer
acute hospital medical admissions with diabetes by 63 per cent and 77
per cent, respectively, than WHO 2006, with FPG alone missing 79 per
cent. As reliance on these criteria would miss considerable numbers of
patients with diabetes, the OGTT performed according to WHO 2006
may still be needed to detect stress hyperglycaemia in these
circumstances.
Clinical care and other categories posters: structure of

care
P449
Delivering large-scale change in diabetes care
M Roshan1, R Gregory2, C Richardson3 and S Frost4
1
Corporate Medical, NHS Leicestershire County and Rutland, Leicestershire,
UK, 2Metabolic Medicine, University Hospital of Leicester, Leicestershire, UK,
3
Commissioning, NHS Leicestershire County and Rutland, Leicestershire, UK,
4
Quality Improvement, Lilly UK, Basingstoke, UK
Background: We carried out a pilot to assess the feasibility of

providing primary care based diabetes care for patients needing level 3
166
care. New commissioning arrangements and QIPP (Quality

Innovation, Productivity and Prevention) delivery plans stipulate the
need for provision of level 3 diabetes care in the primary care. There is
little reported experience in up-skilling primary care to implement this.
The service was commissioned to deliver primary care service with
specialist input in one GP locality. The pilot aims included up-skilling
primary care, providing level 3 services in primary care, demonstrating
patient satisfaction, care integration and patient satisfaction.
Method: Educational input and specialist support was provided to
up-skill primary care. A selected proportion of secondary care patients
2012 The Authors.

were discharged to primary care. Follow-up was provided by own

general practitioner/practice nurse supported by a diabetes consultant
and diabetes specialist nurse.
Results: Nine of 11 practices in the locality participated. The cohort
was 128 patients (35 per cent of patients under secondary care). The
number seen in joint clinics was 105, and suitable for care in a primary
care setting 114. The main reasons for unsuitability included control
and regime issues, clinical complications, patient considerations and
complex needs. 92 per cent of patients reported being given advice to
completely self-care for their diabetes; 86 per cent reported increased
convenience. Potential cost savings of 55 per cent (69,000) were
identified. There was no difference in clinical quality outcomes.
Conclusion: Primary care can be up-skilled to provide level 3 diabetes
care with specialist support resulting in good patient feedback.
Significant cost savings can be made with improvement in integration
and equivalent clinical quality outcomes.
P450
Diabetes care provision in UK general
practices: patients and healthcare
professionals perspectives
G Hawthorne1, MP Eccles2, E Stamp2, S Hrisos2, N Steen2,
M Elovainio3, JJ Francis4, JM Grimshaw5, M Hunter2,
M Johnston6 and J Presseau2
1
Newcastle Diabetes Centre, Newcastle-Upon-Tyne Hospitals NHS
Foundation Trust, Newcastle-Upon-Tyne, UK, 2Institute of Health and Society,
Newcastle University, Newcastle-Upon-Tyne, UK, 3National Institute for
Health and Welfare, Health Services Research Unit, Helsinki, Finland, 4Health
Services Research Unit, University of Aberdeen, UK, 5Clinical Epidemiology
Program, Ottawa, Canada, 6College of Life Sciences and Medicine, University
of Aberdeen, Aberdeen, UK
Aims: To understand the structure, functions and perceptions of

diabetes care by clinicians and people with diabetes delivered by UK
general practices.
Methods: GPs and nurses from practices from the UK Medical
Research Council General Practice Research Framework completed a
telephone interview and postal questionnaire for practice attributes and
individually reported measures of clinical behaviour at baseline. A
random sample of people with diabetes attending the participating
practices completed an anonymised postal questionnaire.
Results: All practices scored highly in the Quality and Outcomes
Framework (QOF). Ninety-nine practices completed the telephone
interview; 326/331 (90.3 per cent) doctors, 163/186 (87.6 per cent)
nurses and 3,591 patients (41.8 per cent) returned a questionnaire.
Forty-three of the 99 practices had a healthcare professional trained in
diabetes and 17/99 had routine access to a dietitian. Clinicians reported
giving advice about lifestyle behaviours (eg 88 per cent would routinely
advise about calorie restriction; 99.6 per cent about increasing exercise)
more often than patients reported having received it (43 per cent and 42
per cent), and correlations between clinician and patient report were
low. Reported patient levels of confidence were modest with between 3
and 25 per cent of patients reporting being Not at all confident about
areas of diabetes self-management.
Conclusion: The QOF demonstrates that primary care is successfully
recording the delivery of the physical checks for diabetic complications.
Lifestyle advice is a key component of diabetes care and is recognised as
important by healthcare professionals but patient report suggests this is
happening less often than clinicians report.
2012 The Authors.

DIABETICMedicine
P451
Testing multiple theories of behaviour
across multiple health professional
behaviours in primary care: an investigation
of diabetes care provision in the UK
J Presseau1, M Johnston2, JJ Francis3, S Hrisos1, E Stamp1,
IN Steen1, G Hawthorne4, JM Grimshaw5, M Elovainio6,
M Hunter1 and MP Eccles1
1
Institute of Health and Society, Newcastle University, Newcastle-Upon-Tyne,
UK, 2College of Life Sciences and Medicine, University of Aberdeen,
Aberdeen, UK, 3Health Services Research Unit, University of Aberdeen,
Aberdeen, UK, 4Diabetes Centre, Newcastle-Upon-Tyne Hospitals NHS
Foundation Trust, Newcastle-Upon-Tyne, UK, 5Clinical Epidemiology, Ottawa
Hospital Research Institute, Ottawa, Canada, 6Health Services Research Unit,
National Institute for Health and Welfare, Helsinki, Finland
Aims: The aim of this prospective predictive study was to inform the
design of interventions to improve quality of diabetes care by identifying
theory-based predictors of six professional behaviours related to Type 2
diabetes management in primary care. The objective was to test
constructs from social cognitive theory, learning theory, the theory of
planned behaviour, and action and coping planning separately as
predictors of prescribing (to reduce blood pressure and for glycaemic
control), advising (about weight, self-management and general
education) and examining feet.
Methods: GPs and practice nurses (n = 427) from 99 UK primary
care practices completed postal questionnaires at baseline (including
measures of theoretical constructs and scenario-based simulations) for
each behaviour, and then self-reported their behaviour 12 months later.
The main predicted outcomes were intention strength, direct estimation
of intention, simulated behaviour and self-reported behaviour.
Results: For all behaviours, mean scores on all theoretical constructs
exceeded the midpoint on measurement scales. Self-efficacy and coping
planning mean scores were lower than for other constructs. Intention/
proximal goals, self-efficacy and habit predicted all six behaviours.
Over all behaviours, each theory accounted for significant variance in
self-reported behaviour (median R2 = 0.15), behaviour simulation
(median R2 = 0.05), intention strength (median R2 = 0.66) and direct
estimation of intention (median R2 = 0.34).
Conclusions: Theories that include constructs which consistently
predict intention and behaviour for all six clinical behaviours (ie social
cognitive theory, learning theory, planning) and with lower mean scores
and higher variability (ie self-efficacy, habit, coping plans) should
inform interventions to change clinical behaviours to enhance quality of
diabetes care.
P452
Introducing a new style of patient
consultation within the diabetes clinic in
North Cumbria
K Vithian1, A Routledge1, N Higgins1, J Redgate1, E Simpson1
and C Hay2
1
Cumbria Diabetes, Cumbria Partnership NHS Foundation Trust, Carlisle, UK,

Cumbria Diabetes, Cumbria Partnership NHS Foundation Trust, Barrow-inFurness, UK
2
Aims: Healthcare professionals across Cumbria are starting to

incorporate the Year of Care planning model endorsed by NICE
(National Institute for Health and Clinical Excellence) and the
Department of Health. A key component of this process focuses on
moving from a target-oriented consultation towards a patient priority
oriented approach. The North Cumbria multidisciplinary specialist
care diabetes team have been moving away from standardised annual
167
DIABETICMedicine
reviews towards patient-centred consultations. This survey assesses

patient satisfaction towards this new style of consultation.
Methods: Data were collected from all patients attending successive
diabetes clinics at Cumberland Infirmary, Carlisle, Cumbria, between
25 August 2011 and 8 September 2011. They were given questionnaires
at the end of the clinic visit that assessed their satisfaction with the
content and style of the consultation.
Results: Twenty-three patients (13 men, 10 women) completed the
questionnaires. The mean age was 54 years (2672). The majority had
Type 1 diabetes (65 per cent). The overall assessment of the new
consultation method was very positive with a mean satisfaction score of
8.5/10.
Conclusion: The overall positive endorsement from the patients has
been encouraging. However, in key areas such as diet and exercise
(mean satisfaction scores 8 and 7 respectively) further input would have
been beneficial. The next step is to send out blood results (and their
interpretation) prior to clinic and invite patients to set out their own
agendas for consultation. We plan to reassess our performance once all
components of shared care planning are fully implemented.
P453
The GAPPTM (Global Attitudes of Patients
and Physicians in Insulin Therapy) study:
identifying risk factors associated with
injection omission/non-adherence in insulin
treated patients with Type 1 and Type 2
diabetes
AH Barnett1, LF Meneghini2, P-M Schumm-Draeger3 and
M Peyrot4
1
Diabetes Centre, Heart of England NHS Foundation Trust and University of
Birmingham, Birmingham, UK, 2Miller School of Medicine, University of
Miami, Miami, USA, 3Clinic for Endocrinology, Diabetology and Angiology,
Academic Teaching Hospital Munich Bogenhausen, Munich, Germany,
4
Sociology and Medicine, Loyola University of Maryland and Johns Hopkins
University, Baltimore, USA
Aims: The GAPP (Global Attitudes of Patients and Physicians in

Insulin Therapy) study identified, through telephone interviews, the
frequency and correlates of insulin omission/non-adherence in 1,530
adults with Type 1 (12 per cent) or insulin treated Type 2 (88 per cent)
diabetes.
Methods: Respondents from eight countries (USA, UK, China,
France, Spain, Turkey, Germany and Japan) participated in the study
(mean age 60.1 years, diabetes duration 14.7 years, insulin duration
8.6 years). Regression analysis, which controlled for country and
participant characteristics, was used to assess the independent
associations of treatment-related beliefs/perceptions with the number
of days in the past month that an insulin injection was missed or not
taken as prescribed.
Results: In all, 34.6 per cent of respondents reported one or more days
(mean 3.41 days) of insulin omission/non-adherence in the previous
month. Insulin omission/non-adherence was highest in Turkey,
followed by the USA, UK, China and Japan, and lowest in Germany,
followed by Spain and France. Insulin omission/non-adherence was
more frequent among respondents who were younger, had frequent
hypoglycaemia, were less successful with non-medication regimens,
regarded insulin adherence as less important, had practical/logistical
barriers and were concerned that insulin required lifestyle changes.
Satisfaction with insulin therapy, especially administration flexibility,
was associated with less frequent insulin omission/non-adherence.
168
Conclusions: The results of this large-scale study suggest that insulin

omission/non-adherence is common and associated with several
modifiable risk factors, including practical barriers, lifestyle burden
and regimen inflexibility. Developing strategies to manage these risk
factors may reduce the frequency of insulin omission/non-adherence
and lead to improved clinical outcomes.
P454
Enhancing DiabetesE to help general
practices implement the NICE quality
standard for diabetes (adults)
K Moore, B Wright and H Seymour
DiabetesE, Innove, Manchester, UK
Aims: To enable practices to assess whether structures and processes

are in place to deliver the quality standard.
Methods: DiabetesE is an online self-assessment tool, designed to
measure and benchmark the quality of diabetes services and drive
continuous improvement. A new practice questionnaire was developed,
based on the 13 NICE quality statements. A total of 138 questions were
written, grouped into nine modules, including an optional Insulin
Initiation module. A clinical reference group ranked the questions/
modules to enable generation of scores and prioritised
recommendations for improvement. Users can upload evidence to
validate answers and select peers to benchmark against. High level
results are available publicly, increasing transparency.
Results: The questionnaire was launched in June 2011. Within
6 weeks, 89 practices had assessed: over 90 per cent have a clinical
lead and a multidisciplinary practice team possessing the required
competencies. Most GPs and practice nurses have undertaken a
recognised diabetes education programme. However, gaps remain: 37
per cent of practices do not provide patients with a copy of their agreed
care plan. Only 72 per cent can demonstrate that people with diabetes/
carers are offered structured education; less than half monitor its
uptake. Just 66 per cent take action to reduce the number of preventable
diabetes-related emergency admissions. Only 65 per cent can
demonstrate activity to reduce the variation between diagnosed
diabetes and predicted prevalence.
Conclusions: Over time, DiabetesE has enabled organisations to
demonstrate improvement. Practices reassessing will be able to
demonstrate improvement towards meeting the quality standard.
P455
Diabetes redesign in Her Majestys Prison
Wakefield: tackling the challenges
R Jenkins1, T Kadis1, J Wilson2, T Celliers3 and D Nagi1
1
Edna Coates Diabetes Centre, Pinderfields Hospital, Mid Yorks Health Trust,
Wakefield, UK, 2Long Term Conditions Team Public Health, NHS Wakefield
District, Wakefield, UK, 3MY Therapies, Mid Yorks Health Trust, Wakefield,
UK
Aims: There is evidence to support that diabetes care for the prison
population remains suboptimal. An innovative service redesign to
support primary care and reduce inequalities by delivering high quality
diabetes care was implemented in the Wakefield District. This model
was then replicated in HMP Wakefield (high security) with the aim of
improving clinical outcomes for prisoners.
Methods: The intervention included one session per month by a
diabetologist and diabetes specialist nurse to initially undertake
2012 The Authors.

individual case note reviews (CNRs) and organise specialist clinics with
diabetes dietitian input. However, after the initial CNR it became clear
that more specialist sessions were needed to ensure a thorough initial
review of all patients. The model also includes inpatient ward rounds in
the hospital wing, together with education of appropriate staff.
Results: The prevalence of diabetes is currently 8.8 per cent (66/745) of
prisoners(10percent Type 1,90percent Type 2).Since2010, 90 percent
ofthepatientshavebeenreviewedandappropriatemanagementinitiated
including annual reviews. There has been a significant increase in the
uptake of retinal screening, HbA1c recording and foot examination.
Sincethisnewinitiativetodelivercareclosertohome,therehavebeenno
prisonerswhohaveneededtobeseeninthehospitalbaseddiabetesclinics
and a dramatic reduction in hospital attendances for hypoglycaemia and
diabetes related admissions with significant associated cost savings.
Conclusion: This innovative approach addresses the quality
improvement, productivity and prevention agenda and brings benefits
to the prisoners and healthcare staff.
P456
Pursuing perfection in the diabetes review
clinic
PS Grant1 and DW Lipscomb2
1
2
Department of Diabetes, Pembury Hospital, Tunbridge Wells, UK,

Department of Diabetes, Eastbourne District General Hospital, UK
Objectives: We wished to prospectively assess how successful we

were at asking about and accurately recording data relating to three
important aspects of ongoing diabetes: neuropathy symptoms such as
erectile dysfunction (in men), pregnancy plans (in women of childbearing age) and obstructive sleep apnoea (OSA) in all patients.
Methods: We collected anonymised information about the content of
the diabetes review consultation through two main processes: first, a
post-consultation screening questionnaire which was given to patients
in the manner of an exit poll; second, data from the diabetes database
DIABETA 3 was mined to reveal whether young females had their
pregnancy intentions discussed.
Results: With regard to neuropathy, erectile dysfunction, OSA
symptoms and pregnancy we discovered that patients with diabetes
attending the annual review clinic were infrequently asked about the
above and overall that diabetologists fared poorly in enquiring about
these different issues. With regard to pregnancy intentions and arranging
follow-up pre-conception planning, only 23 per cent of female patients
(of child-bearing age, 1645 years) were asked about this.
Discussion: It would appear that the diabetes review clinic is
suboptimal in its ability to explore and screen for signs and symptoms
of OSA in all patients, neuropathy, such as erectile dysfunction in men,
and crucially finding out about pregnancy plans in young females. We
shall explore ways of improving such an important aspect of ongoing
diabetes care.
P457
Survey of diabetes care in university
healthcare centres in the UK
KS Myint1, P Coathup2, C Jensen1 and MJ Sampson1
1
Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS
Foundation Trust, Norwich, UK, 2University of East Anglia Health Care Centre,
Norwich, UK
Aim: We aimed to identify the pattern of diabetes care for UK

university students (UUS) by conducting a pilot survey (20102011) of
healthcare professionals (HCPs) in university medical centres.
2012 The Authors.

DIABETICMedicine
Method: Twenty-nine questions were generated via the

SurveyMonkey web system (with advice from Diabetes UK Health
Policy team). An email invitation was sent to members of the British
Association of Health service for students in Higher Education
(BASHE), HCP affiliated with 58 university institutions.
Results: Thirty-four members responded (58 per cent), and 18 (31 per
cent) completed all questions. Practices were spread across the UK, 82.4
per cent in the university campus, 64.7 per cent dedicated solely to
students and university staff. Each practice had a median of 33 UUS.
Only 50 per cent had written full guidelines and 73 per cent had annual
review arrangements. Written protocols were available in only 17 per
cent for insulin dose titration, 31 per cent for emergency management,
18 per cent for diabetes and pregnancy. 30 per cent indicated that core
diabetes services, ie access to diabetes specialist nurses, dietitians and
education programmes were not available/inadequate. 13.5 per cent
rated the frequency of review by diabetes specialist teams as poor/very
poor, and 31.7 per cent felt specialists were not available when needed.
Practices used letters, telephone calls, text messages and email to engage
students. The availability of essential written educational materials
(hypoglycaemia, driving, contraception, pregnancy care, alcohol,
ketone testing, and sickness advice) varied from 44 to 65 per cent per
item. The HCP concerns included missed appointments, difficulty
engaging, keeping up with high volume turnover, poor shared care
arrangements and communication.
Conclusion: There are substantial gaps in diabetes service delivery for
these at risk UUS. More detailed evaluation is needed.
P458
Patients views on nurse:patient diabetes
consultations in a community care setting
R Priharjo1, A McVicar2 and J Smith3
1
Primary and Public Health, Anglia Ruskin University, Peterborough, UK,

Mental Health, Anglia Ruskin University, Chelmsford, UK, 3Research Degree,
Anglia Ruskin University, Peterborough, UK
2
Aims: This is the second phase of a mixed methods study (qualitative

followed by quantitative) to explore the experience of patients and
diabetes specialist nurses (DSNs) with diabetes consultations. The aim
was to determine patients views on their consultations with DSNs.
Methods: Patients with diabetes (n = 150) were purposively selected
from a database within a healthy living centre in the east of England.
Inclusion criteria were adults who recently attended a consultation with
the DSN. An adopted questionnaire from Consultation Quality Index
(CQI-2) was sent to all patients. Statements were used to measure
partnership (1 point), empathy (10 points) and consultation outcomes
(6 points).
Results: In all, 40 (26.6 per cent) patients responded. There was an
equal number of males (47.5 per cent) and females (57.5 per cent); age
group from 18 to 65 or higher; White British (66.7 per cent); Type 1
diabetes (42.5 per cent); Type 2 diabetes (45 per cent); others (12.5 per
cent); living with diabetes for more than 5 years (66.7 per cent).
Bivariate correlation was used to measure the correlation of the three
variables in the form of a three-by-three symmetric metric. The
relationships between empathy/partnership and outcomes are not
statistically significant. However, there is a significant correlation
between partnership and empathy at the 0.01 level (two-tailed).
Conclusions: This study revealed the relationship between empathy
and partnership working within nurse/patient consultations. Larger
studies are required to measure how empathy and partnership may
contribute to consultation outcomes.
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DIABETICMedicine
Clinical care and other categories posters: systems of care

P459
Coding accuracy of secondary care diabetes
related admissions, and cost implications
M Greig and AR Scott
Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK
P460
Are we missing an opportunity in the
diabetic retinopathy clinic?
PS George1,2, G Leese1 and J Ellis2
1
2
Department of Diabetes and Endocrinology, NHS Tayside, Dundee, UK,

Department of Ophthalmology, NHS Tayside, Dundee, UK
Introduction: Good control of blood glucose and blood pressure are

essential components in managing diabetic retinopathy. In an
epidemiological study of diabetic eye disease done in Tayside, fear of
visual loss is pre-occupying and intense for a substantial proportion of
the diabetic population.
Methods: We analysed data from 108 patients who attended the
diabetic retinopathy clinic over a 3-month period. Seventeen and 91
patients had Type 1 and Type 2 diabetes respectively. Twenty-eight
patients were managed for routine diabetes care in the primary care
setting, 64 in the secondary care, and 16 (15 per cent) were defaulters of
secondary care.
Results: Mean HbA1c in the primary care group was 7.41 (SD 1.31),
in the secondary care group 8.66 (SD 2.36) and in the defaulters from
the secondary care group 9.70 (SD 1.78). The differences between each
of the groups reached statistical significance (P < 0.05). There was no
statistical difference between the groups for blood pressure and
cholesterol. Of the patients in primary care and those defaulting, 54
per cent and 94 per cent respectively failed to reach an HbA1c target < 7
per cent, and 25 per cent and 38 per cent had no estimation of
microalbuminuria in the last 2 years recorded. Of the 28 patients
managed in primary care, 29 per cent had clinically significant
retinopathy ( mod NPDR); 7 per cent had clinically significant
macular oedema.
Conclusions: This audit has shown that even though patients default
from attending their secondary care diabetes follow-up, they still attend
the retinopathy clinic. The main difference between the groups is
glycaemic control. We may be missing an opportunity to influence
medical management of this group of patients.
P461
Management of diabetes in the Queen
Elizabeth Central Hospital, Blantyre,
Malawi: a comparison with the UK
A Hide
Medical Education, University of Liverpool, Liverpool, UK
covering 9,800 people with a prevalence of diabetes of 4.3 per cent; and
(2) QECH in Blantyre, the sole teaching hospital in the country
providing care to six million people in South Malawi. Management of
diabetes within the UK was taken from national and local guidelines.
Management of diabetes at QECH was observed during attendance at
diabetes clinics.
Results: The prevalence of diabetes in Malawi is currently estimated
at 5.6 per cent. Medication is expensive and stocks often run out.
Prescribing may depend on where the patient lives and how far they
are able to travel for medication rather than nationally agreed
prescribing guidelines. Investigations taken for granted in the UK, such
as HbA1c, cholesterol and lipid profiles, are not available. Patients felt
that their diabetes had a bigger impact on their lives than patients in
the UK and they had fewer opportunities for education about their
disease.
Conclusions: Management of diabetes in Malawi is affected by the
low income resource setting. Limited availability of investigations and
medications taken for granted in the UK mean that clinicians have extra
considerations when deciding on appropriate management. Patient
education and understanding about diabetes was a large factor in
suboptimal blood glucose control.
P462
Doseresponse relationship between HbA1c
and inpatient cost in Cambridgeshire:
preliminary results
D Yu1, A Aggarwal2 and D Simmons1
1
Institute of Metabolic Science, Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK, 2Rainbow Surgery, Ramsey, Huntingdon,
Cambridge, UK
Aim: This study aimed to explore the doseresponse relationship

between HbA1c level and inpatient costs across Cambridgeshire.
Methods: The HbA1c of diabetes patients was collected from 16
practices across three Cambridgeshire regions (n = 4,704) in 2008
2009. Inpatient cost data at all hospital admissions were collected from
the Secondary Uses Service (SUS) dataset, January 2010 to May 2011.
Results: 43.6 per cent of patients had at least one admission during the
time period. The mean annual inpatient cost across all patients with
diabetes was 1,989.58 (95 per cent CI 1,862.532,116.62) overall and
4,553.96 (95 per cent CI 4,303.404,804.52) among the patients who
were admitted. Linear models achieved comparable goodness of fit
statistics to the more complex spline and threshold models. A linear
doseresponse curve for HbA1c and inpatient cost was observed both
overall and among patients with at least one admission (both
P < 0.001) after adjusting for confounders (eg age, gender, body mass
index, blood pressure). The inpatient cost increased 13.02 per cent (95
per cent CI 12.9813.06), 6.41 per cent (95 per cent CI 6.376.45) with
every 1 per cent (11mml/mol) increment of HbA1c for the overall
diabetes population and patients with at least one admission,
respectively.
Conclusion: A linear doseresponse relationship exists between
HbA1c and inpatient cost among diabetes patients in Cambridgeshire.
Aims: To investigate and evaluate management of diabetes at the

Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi, and to
compare with management and current guidelines in the UK.
Methods: A detailed analysis was carried out of four case studies from
two centres: (1) the Elms Medical Centre, Chester, UK, a GP surgery
170
2012 The Authors.

P463
Diabetes local enhanced service in
Birmingham East and North Primary Care
Trust
SM Choudhury1, S Hussain1, GL Yao1, J Hill2, W Malik2 and
S Taheri1,3
1
College of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK, 2Community Diabetes Team, Birmingham Community
Healthcare NHS Trust, Birmingham, UK, 3Heartlands Biomedical Research
Centre (HBMRC), Heart of England Foundation Trust, Birmingham, UK
Background: Birmingham East and North Primary Care Trust

(BENPCT) invested in a diabetes Local Enhanced Service (LES).
Participating GP practices provided all essential and additional services
for patients with diabetes, including management of patients with Type
2 diabetes on diet and/or tablets, patients with Type 1 diabetes, and
more complex Type 2 patients.
Aims: (1) To explore the difference between LES and non-LES
practices for Quality and Outcomes Framework (QOF) indicator
outcomes for DM12 (percentage with diabetes in whom the last blood
pressure is 145/85 or less), DM17 (percentage whose last measured
total cholesterol within the previous 15 months is 5 mmol/l or less) and
DM23 (percentage with diabetes in whom the last HbA1c is 7 or less).
(2) To explore whether there is a significant difference between LES and
non-LES practices for hospital first and follow-up appointments.
Results: DM12 and DM17: The difference in achievement of these
targets by LES and non-LES practices was not statistically significant.
DM23: The probability of achieving DM23 targets by an LES and nonLES practice is 53 per cent and 43 per cent respectively and this is
statistically significant. LES practices referred fewer patients (0.10
compared with 0.20 for non-LES practices) for a first hospital
appointment and had fewer patients attending hospital for a followup than non-LES practices (0.16 and 0.39 respectively). Both results are
statistically significant.
Conclusion: LES practices perform better in achievement of DM23
targets and also refer fewwer patients to hospital, for both first and
follow-up appointments. However, there may be confounding factors
that need to be explored further.
P464
Use of diabetes care pathways and
ThinkGlucose toolkit in adult inpatients
ZJ Cousland, N Phelan, N Patel, A Ososanya, K DuckworthBrown, S Dissanayake and E Jude
Department of Diabetes and General Medicine, Tameside General Hospital,
Ashton-Under-Lyne, UK
Aims: The ThinkGlucose toolkit is an NHS Institute for Innovation

and Improvement programme, designed to improve care and the
experience of patients with diabetes through the implementation of a
clinical pathway. Diabetes care pathways have been recommended by
the Audit Commission and Tameside Hospital has developed a local
pathway, in use since 2006. Our aim was to audit the diabetes
documentation of all adult inpatients in medical and surgical wards,
namely ThinkGlucose stickers in current medical records and diabetes
care pathway in nursing notes.
2012 The Authors.

DIABETICMedicine
Method: The diabetes team (consultants, junior doctors and specialist

nurses) developed a documentation proforma, and one of these was
completed for every ward in the medicine, surgery and orthopaedic
departments (14 wards in total). This data collection took place over
2 days to give a snapshot picture of all people with diabetes in the
hospital at that time.
Results: All inpatients (343 patients) in 14 wards were surveyed.
Prevalence of diabetes was 24.8 per cent (n = 85). Of these patients 62.4
per cent (n = 53) had care plans in their records. Only 9.4 per cent
(n = 8) of patients had ThinkGlucose stickers in their notes.
Conclusions: The prevalence of diabetes was 24.8 per cent which is at
the high end of the range estimated by the NHS Institute for Innovation
and Improvement (1025 per cent). The documentation of diabetes
using care plans and ThinkGlucose stickers was not satisfactory, as our
target is 100 per cent. Education of medical and nursing staff and reauditing should be considered.
P465
An evaluation of Diabetes Virtual Clinic
(DVC): a collaborative and integrated
service to improve diabetes care in Lambeth
RR Atkinson1,3, M Chamley1, D Karuyawasam2 and A Forbes3
1
Diabetes, Intermediate Care Team, London, UK, 2Diabetes, Guys and St

Thomas NHS Trust, London, UK, 3Primary and Intermediate Care, Kings
College London, London, UK
Aims: The Diabetes Virtual Clinic (DVC) aims to improve the

management of Type 2 diabetes in primary care by systematically
identifying cases with poor glycaemic control for a joint clinical
discussion between the primary and specialist diabetes team to develop
an optimal clinical management strategy to inform patient care. Our
aim was to evaluate the impact of the DVC on care processes and
patient outcomes.
Method: A comprehensive audit of nine practices in a defined
geographical area over a 6-month period. The audit included an
analysis of the structure and process of the DVC; a before and after
analysis of metabolic outcomes; and an assessment of participating
clinicians satisfaction.
Results: Seven practices participated; 113 cases were discussed at
baseline and 74 cases had 6 months analysis data. Sixty-one (58 per
cent) treatment plans were implemented in general practice and five (4
per cent) cases resulted in a new referral to secondary care. Glycated
haemoglobin at baseline was 8.79 per cent, at follow-up 8.33 per cent, a
reduction of 0.46 per cent (SD 1.12, CI 0.20.72; P = 0.0001). Systolic
blood pressure decreased from 132.05mm Hg to 130.44mm Hg (a
reduction of 1.17 mm Hg; P = 0.478), and cholesterol from
4.42 mmol/mol to 4.34 mmol/mol (a reduction of 0.06 mmol/mol;
P = 0.51). All care pathways optimised control. Clinicians were very
satisfied.
Conclusion: Glycaemic reduction was clinically and statistically
significant independent of gender, age, ethnicity, reason for referral,
care pathway and practice characteristics. DVC provides an effective
model for integrated working between primary and diabetes specialist
services. Recommendations for continued enhancement of the DVC
were identified.
171
DIABETICMedicine
Clinical care and other categories posters: therapies

P466
Inpatient hypoglycaemia management: one
year in effect
CM Sobajo and P Rao-Balakrishna
Department of Medicine, Central Manchester University Hospitals NHS
Foundation Trust, Manchester, UK
P467
Factors which might influence the success of
GLP-1 agonist therapy in Type 2 diabetes
L Kockum, SA Ritchie, J Walker and K Adamson
Department of Diabetes, St Johns Hospital, Livingston, UK
Aim: Insulin therapy in Type 2 diabetes may be complicated by weight

gain and hypoglycaemia. Glucagon-like peptide 1 (GLP-1) agonists
offer an alternative without these side-effects. The aim of this study was
to explore factors which may influence the success of this therapy.
Methods: A total of 174 patients were included in the study and data
were obtained using patients case notes. Anxiety and depression levels
were assessed using the Hospital Anxiety and Depression (HAD) Scale.
Results: 81.6 per cent of the patients lost weight, and females lost on
average 2.71kg more than males (P < 0.05). The data suggest a positive
correlation between C-peptide levels and body mass index (BMI)
(P = 0.05). Furthermore, patients who felt better reported lower
anxiety and depression levels at follow-up. Another finding was that
patients on GLP-1 agonists and insulin did not do worse than those on
single therapy.
Conclusion: Predictors of GLP-1 agonist success were not entirely
distinguished, although a link between C-peptide levels and BMI was
found. The data suggest that females on GLP-1 agonists lose
significantly more weight than men. Patients who reported that they
felt better had a lower HAD score at follow-up. This opens up
potential for further discussions with regard to holistic care focusing on
lowering anxiety and depression levels.
P468
Exenatide treatment with insulin has less
improvement in glycaemic control than
without insulin but the same reduction in
weight
A Bowes, V Field, J Haviland and D Kerr
and Christchurch Hospitals NHS Trust, Bournemouth, UK
Aims: Currently, exenatide in combination with insulin is not licensed

in the UK but increasing numbers of patients are being prescribed this
combination. Here we compared, retrospectively, the outcomes
between two treatment groups: (1) exenatide in combination with
insulin (E+I) and (2) exenatide without insulin (E) in patients with Type
2 diabetes.
Methods: Our electronic database identified patients started on
exenatide between December 2006 and November 2010. Weight,
body mass index (BMI) and HbA1c were collected at baseline and 3, 6,
172
9 and 12 months. Longitudinal analyses using generalised estimating

equations was used to obtain estimates of change in HbA1c and weight
over time and the significance was assessed by the Wald test. Spearman
rank correlation was used to estimate the association between HbA1c
and weight.
Results: In all, 209 patients (115 men, 59.3 10.5 years, HbA1c
9.5 1.7 per cent, BMI 41.1 7.5 kg/m2) were treated with
exenatide for an average of 16.9 9.5 months with 47 per cent on
E + I. With time HbA1c fell by 0.49 per cent (CI 1.030.05) per year in
the E+I group (P < 0.001) and by 1.37 per cent (CI 1.850.89) per year
for the E group with greater reduction for the E group (P < 0.05). The
decrease in weight over time was 7.6kg (CI 12.542.58) (P < 0.001)
and 7.6kg (CI 13.861.24) (P < 0.001) per year for I+E and E
respectively, without no difference between groups. There was no
association between change in HbA1c and change in weight.
Conclusions: Exenatide treatment with insulin compared with
treatment without insulin for obese subjects with Type 2 diabetes
leads to similar significant weight loss but less significant improvement
in HbA1c.
P469
Resource use in patients with Type 2
diabetes who initiated exenatide twice
daily or insulin therapy: six month data
from CHOICE
B Guerci1, H Sapin2, C-G Ostenson3, T Krarup4,
M Theodorakis5, M Reaney6, J Kiljanski7, C Salaun2,
S Matthaei8 and C Mathieu9
1
Diabetology, Nutrition, Metabolic Disorders, Brabois Hospital and Center of
Clinical Investigation, Yandoeuvre-Les-Nancy, France, 2Eli Lilly GmbH, Paris,
France, 3Department of Molecular Medicine and Surgery, Karolinska
Institutet, Stockholm, Sweden, 4Department of Endocrinology, Bispebjerg
Hospital, Copenhagen, Denmark, 5Department of Clinical Therapeutics,
University of Athens School of Medicine, Athens, Greece, 6Eli Lilly and
Company Ltd, Windlesham, UK, 7Eli Lilly, Warsaw, Poland, 8Diabetes-Centre
Quakenbruck, Quakenbruck, Germany, 9Department of Endocrinology, UZ
Gasthuisberg, Leuven, Belgium
Aims: CHOICE is an ongoing European, six-country, prospective,

observational study assessing time to make, and reasons for, a
significant change in therapy among adults with Type 2 diabetes
(T2D) initiating their first injectable glucose-lowering therapy, and
clinical outcomes over 24 months.
Methods: We present resource use data from 6 months pre- and postinitiation of first injectable therapy for T2D [exenatide twice daily
(ExBID) or insulin].
Results: Baseline differences between the two cohorts prevent direct
comparison of outcome data. In the ExBID cohort (baseline/6 months,
n = 1,177/1,073), 78.8 per cent of patients self-monitored blood
glucose at baseline; 81.6 per cent at 6 months. Mean (SD) tests per week
(past 4 weeks) were 9.28 (7.93) and 8.24 (6.41), respectively. Mean
(SD) number of oral anti-hyperglycaemia medications used was 1.20
(0.75) and 1.42 (0.73), respectively. 93.4 per cent patients had at least
one contact with a healthcare professional (HCP) in 6 months preExBID initiation [mean (SD) 7.75 (7.49) visits]; 89.1 per cent postinitiation [7.55 (7.41)]. In the insulin cohort (baseline/6 months,
n = 1,315/1,235), 79.8 per cent of patients self-monitored blood
glucose at baseline; 92.4 per cent at 6 months. Mean (SD) tests per week
were 9.91 (8.58) and 13.08 (8.46), respectively. Mean (SD) number of
oral anti-hyperglycaemia medications used was 0.96 (0.76) and 0.98
2012 The Authors.

(0.77), respectively. 93.8 per cent patients had at least one contact with
an HCP in 6 months pre-insulin initiation [mean (SD) 8.45 (9.19)
visits]; 93.2 per cent post-initiation [11.11 (16.75)]. Mean doses of both
treatments increased during the first 6 months post-initiation.
Conclusions: Mean resource utilisation increased following initiation
of injectable therapy. Increases in mean test strip use per week (+ 32 per
cent) and mean contacts with HCPs (+ 31 per cent) were observed in the
insulin cohort. Respective observations for the ExBID cohort were
12.7 per cent and 2.7 per cent.
P470
Exenatide therapy: proven to be effective in
weight reduction and improving glycaemic
control in people with Type 2 diabetes on
insulin
H Rachabattula1, R Mukhtar2 and T Robinson3
1
Diabetes and Endocrinology, Guys and St Thomas Hospital, London, UK,

Diabetes and Endocrinology, James Cook University Hospital,
Middlesbrough, UK, 3Diabetes and Endcorinology, Royal United Hospital,
Bath, UK
2
Aim: Exenatide, a glucagon-like peptide 1 (GLP-1) analogue, is

licensed for use with oral agents for the management of Type 2
diabetes. Evidence for its use with insulin is limited but implies benefits
in HbA1c reduction and weight loss. Our aim was to assess the weight
reduction and glycaemic control in individuals with Type 2 diabetes, on
insulin, at the Royal United Hospital between 2007 and 2010. This was
a retrospective audit.
Results: A total of 183 subjects were identified to be on exenatide
therapy of which 101 were on a combination of both insulin and
exenatide. Average age was 58.2 years. The mean duration of diabetes
was 15 years. The mean length of exenatide treatment was
10.5 months. Baseline weight and HbA1c were 120kg and 9.4 per
cent respectively. A constant decline was noted in both measurements
over the 12-month period following initiation. Weight changes were
118.7 and 116kg with HbA1c readings of 8.5 and 8.1 per cent at 6 and
12 months respectively. Overall insulin requirements dropped from
135 to 114 units. Seventy-eight individuals were on metformin in
addition to insulin and exenatide therapy. No significant dose changes
were seen for oral hypoglycaemic agents. Exenatide was discontinued in
17 subjects, usually within the first 6 months. Four subjects
discontinued due to lack of response, 10 discontinued due to
gastrointestinal side-effects such as nausea, vomiting and abdominal
cramps and three for other reasons.
Conclusion: Exenatide therapy can be efficacious in weight reduction
and improving glycaemic control when used in combination with
insulin in Type 2 diabetes. Our group appear to experience fewer
gastrointestinal side-effects than in previous reports (10 per cent vs. 35
per cent).
P471
Replacing insulin with exenatide in a South
Asian population group with Type 2
diabetes
R Agha-Jaffar and KA Steer
Diabetes and Endocrinology, Northwick Park Hospital, Northwest London
Hospitals NHS Trust, London, UK
DIABETICMedicine
glycaemic control and long-term complications. Cultural attitudes to

insulin therapy in this and other ethnic groups may render it an
ineffective treatment modality and in part account for the difficulties
encountered in achieving health equality with Caucasian patients. We
reviewed the efficacy of exenatide as an adjunct and alternative to
insulin therapy in this ethnic group.
Methods: Insulin treated patients of South Asian descent who had
exenatide added to their therapy were retrospectively reviewed. Data
regarding weight, body mass index (BMI), HbA1c and insulin
independence was collected at two distinctive points: prior to starting
exenatide and at 12 months following the onset of treatment.
Results: Twenty-three of the 44 patients (52.3 per cent) had insulin
therapy successfully withdrawn at a mean period of 11 months.
Compared with the baseline, those who had insulin successfully
withdrawn demonstrated reductions of 10 per cent in weight (kg), 8.1
per cent in BMI (kg/m2) and 7.1 per cent in HbA1c. In contrast, those
who remained on insulin therapy had a 7.2 per cent reduction in weight,
a 6.1 per cent reduction in BMI and a 10.1 per cent reduction in HbA1c.
Conclusions: The effects of exenatide seen in this South Asian group
are encouraging not only by showing an improvement in areas which
would modify risk factors, but also by demonstrating the potential for
insulin independence. When considering recently published qualitative
data reflecting cultural reluctance to use insulin therapy, the latter point
is particularly important.
P472
High prevalence of vitamin B12 deficiency in
patients on metformin based treatment:
data from the Teesside Anaemia in Diabetes
Study
S Nag, M Bilous, S Winship, R Bilous and S Jones
Diabetes and Endocrinology, James Cook University Hospital, Middlesbrough,
UK
Aims: Metformin is an effective oral hypoglycaemic agent but has

been implicated as a cause of vitamin B12 deficiency by inducing
malabsorption. The role of screening non-anaemic diabetic patients on
metformin for B12 deficiency is unclear. We assessed the prevalence of
B12 deficiency in metformin treated patients in a population-based
cohort of diabetic subjects and estimated the risk of deficiency
compared with patients not taking the drug.
Methods: Data from the Teesside Anaemia in Diabetes Study were
analysed. The study cohort comprised 243 patients (male 57.2 per cent).
B12 status was available for 58 patients. Vitamin B12 deficiency was
defined as serum B12 180 ng/l.
Results: 48.7 per cent of the cohort (n = 114) was on metformin based
therapy. Mean metformin group haemoglobin was 13.7 g/dl. Mean
serum B12 was 332 ng/l (SD 262.8). The prevalence of B12 deficiency
in the metformin therapy group was 8.7 per cent. Patients taking
metformin were four times more likely to have B12 deficiency than
patients not taking the drug (odds ratio 4.4; 95 per cent CI 1.216.3).
The relative risk of developing B12 deficiency in patients taking
metformin was 3.1 per cent (95 per cent CI 1.18.7).
Conclusion: Patients taking metformin are at significant risk of
developing vitamin B12 deficiency. B12 deficiency may be subclinical
and not associated with overt anaemia. The role of routinely screening
patients taking metformin for vitamin B12 deficiency needs to be
explored further.
Background: Type 2 diabetes is more common in people of South

Asian descent; additionally, they are more likely to have poorer
2012 The Authors.

173
DIABETICMedicine
Clinical care and other categories posters: Type 1 diabetes

P473
Can continuous subcutaneous insulin
infusion effectively maintain glycaemic
stability in patients requiring renal
support?
G Morrison, TS Purewal and PJ Weston
Diabetes Centre, Royal Liverpool University Hospital, Liverpool, UK
P474
Characteristics of patients surviving
50 years or more with diabetes
S Mehmet and S Ibrahim
Diabetes Centre, Queen Marys Hospital, South London Healthcare NHS
Trust, London, UK
Aim: Despite advances in our understanding of diabetes the precise

reasons why some patients with Type 1 diabetes live longer with fewer
complications than others remains unclear. Our aim was to assess both
clinical and biochemical features in a cohort of 37 patients who have
lived with diabetes for 50 years or more.
Methods: The last recorded relevant data were extracted from our
diabetes database and are presented as the mean standard
deviation.
Results: The group was 69.2 9 years old, 38 per cent female, nonobese (body mass index 25.6 4.6 kg/m2), and the age at onset of
diabetes was 16 8 years (range 230). Total daily insulin dose was
low (0.53 0.13 Units/kg) and the HbA1c = 7.37 0.78 per cent
(normal < 6.2 per cent). Retinopathy was common (51 per cent had
past laser treatment). Cardiovascular and cerebrovascular disease was
uncommon affecting 24 per cent and 16 per cent of the group,
respectively. Three had a major amputation. Two were on dialysis and
this had happened after 48 and 47 years of diabetes. Nephropathy was
absent in 59 per cent. Lipid results (mmol/l) were total cholesterol
4.44 0.87, triglycerides 1.13 0.31, HDL-cholesterol 1.5 0.38,
LDL-cholesterol 2.44 0.75. Lipid lowering and anti-hypertensive
drugs were prescribed in 43 per cent and 75.7 per cent, respectively.
Conclusions: Macrovascular complications are uncommon and lipid
profiles are cardioprotective. Although diabetic nephropathy is
uncommon, end-stage renal disease can develop after 40 years of
diabetes.
P475
Responders to insulin therapy at 18 months
among adults with newly diagnosed Type 1
diabetes: which insulin regimen should we
start?
H Tate1, A Pillai1, G Thomson1,2, DJ Fernando1,2 and I Idris1,3
1
UK, 2Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield,
UK, 3School of Graduate Entry Medicine, University of Nottingham,
Nottingham, UK
Background: This study aimed to determine baseline parameters

including insulin regimen that might predict achievement of glycaemic
174
target (HbA1c < 7.5 per cent) at 18 months following a diagnosis of

Type 1 diabetes.
Methods: This was a retrospective UK population-based study
derived from 479 general practices electronic dataset. We included all
adult patients (age 18 years) with newly diagnosed Type 1 diabetes.
Predictors were stratified for insulin regime during the study (L, longacting only; P, premixed insulin only; BB, basalbolus insulin regime),
baseline body mass index (BMI), age, HbA1c, serum lipids, blood
pressure (BP), lipids and BP lowering treatment. Multiple imputations
analysis was performed to adjust for missing data.
Results: In all, 1,492 patients (aged 1993 years) were analysed.
HbA1c and BMI at baseline were 10.3 per cent (2.6) and 29.6 kg/m2
(7.0) respectively. There was a significant difference between the insulin
regimes that predicted achievement of HbA1c target at 18 months: the
response rates for P, L and BB were 57.3 per cent, 49.0 per cent and 46.4
per cent (P = 0.0007). Following logistic regression analysis, HbA1c
(<0.0001), treatment regime (P BB, P = 0.006; P L, P = 0.03) and
lipid-lowering therapy were significant predictors of responders. Those
on lipid-lowering therapy were shown to have a lower response rate.
Mean weight gain was 2.4kg and was not influenced by treatment
regime.
Conclusion: The use of a premixed insulin regime among newly
diagnosed patients with Type 1 diabetes appears to be effective in
reaching HbA1c target values, independent of other confounders. The
poor HbA1c outcome among BB regimen users may indicate
inadequate delivery of a structured education programme among
patients with Type 1 diabetes during the first 18 months of their
diagnosis.
P476
Audit on the acute management of diabetic
ketoacidosis in adults at Scunthorpe
General Hospital
V Singh, A Modi, P Dromgoole, M Malik and A Elmalti
Department of Diabetes and Endocrinology, Scunthorpe General Hospital,
Scunthorpe, UK
Background: Diabetic ketoacidosis (DKA) consists of the

biochemical triad of ketonaemia, hyperglycaemia and acidaemia.
DKA remains a significant clinical problem in spite of improvements in
diabetes care.
Method: This was a retrospective audit looking at the acute
management of DKA in patients admitted to Scunthorpe General
Hospital over a 12-month period.
Results: Twenty-seven patients were audited. Fifteen patients (56 per
cent) were females. The average age was 35 years. 59 per cent of
patients had previous admission with DKA and 26 per cent had DKA in
the previous 12 months. In our cohort poor compliance with insulin
therapy was the leading cause of DKA constituting 47 per cent of
patients. The majority of patients (67 per cent) spent less than 3 h in
A&E prior to transfer to the medical admission unit. 44 per cent of
patients received intravenous fluids within 30min of admission and 52
per cent received insulin within 60min; only 48 per cent had adequate
potassium monitoring. 74 per cent of patients stayed less than 5 days,
and only 78 per cent of patients were reviewed by the diabetes team
prior to discharge.
Conclusions: Management of DKA in our hospital is still suboptimal
despite the regular conventional staff training and dissemination of
guidelines. We recommend an alternative mode of education to front-
2012 The Authors.

line medical and nursing staff using compulsory e-learning modules

with one face to face taught session. In addition we propose a monthly
review by the diabetes team for management of all patients admitted
with DKA during this period, who have the responsibility to account for
any training or facilities gaps identified.
P477
The impact of continuous subcutaneous
insulin infusion in patients with Type 1
diabetes
M Shanmugasundaram1, MA Karamat1, J Hand2, A Field2,
MH Charlton2 and P Dyer2
1
Medical School, University of Birmingham, Birmingham, UK, 2Diabetes
Centre, Heart of England NHS Foundation Trust, Birmingham, UK
Aims: The aims of this audit were to investigate the impact of

continuous subcutaneous insulin infusion (CSII) initiation on glycaemic
control, rate of hypoglycaemia, and hypoglycaemia awareness in
patients with Type 1 diabetes (T1DM).
Methods: We performed a retrospective audit of 72 patients with
T1DM using CSII in our clinic at Heartlands Hospital, Birmingham.
Information on glycaemic control and hypoglycaemia were recorded
DIABETICMedicine
before and after initiation of CSII therapy, from hospital records and
Clarks questionnaires respectively.
Results: Mean age of the patients was 41.7 12.6 years, duration of
diabetes was 23.2 11.6 years, and 36 per cent of the patients were
male. Thirty-one (43 per cent) patients were initiated on CSII due to
hypoglycaemia, 32 (44.5 per cent) for poor glycaemic control and nine
(12.5 per cent) for both. The average number of years on CSII was
3.4 2.6. There was significant improvement in glycaemic control
before and after CSII therapy initiation (8.7 1.74 per cent vs.
8.1 1.4 per cent respectively, P = 0.02). Sub-analysis showed
patients with worse glycaemic control (HbA1c 8.5 per cent) did
best, with a mean HbA1c of 10.4 1.38 per cent before and
9.3 1.43 per cent after CSII therapy initiation (P = 0.02). Clark
questionnaires were available for 30 patients before and 53 after CSII
therapy. We found a trend towards improvement in hypoglycaemia
awareness (9 per cent vs. 17 per cent), and a reduction in the rate of
moderate hypoglycaemia (40 per cent vs. 24.5 per cent) before and after
CSII initiation respectively. These did not reach significance.
Conclusion: This audit found a significant improvement in glycaemic
control with use of CSII therapy. Initiation of CSII also led to reduced
rates of moderate hypoglycaemia and improved hypoglycaemia
awareness. We would like to improve our services further and reaudit after a year.

P478
Early initiation or intensification of insulin
therapy is important for patients with Type
2 diabetes in achieving glycated
haemoglobin targets without weight gain
or hypoglycaemia in PREDICTIVE
P480
Complication status of patients with a new
diagnosis of Type 2 diabetes in South
London, UK
K Winkley1, S Sivaprasad2, D Stahl3, S Thomas4, K Ismail1 and
SA Amiel5
Department of Metabolic Medicine, Imperial College London, London, UK,

Department of Endocrinology, Connolly Hospital, Dublin, Republic of
Ireland, 3Center for Diabetes and Metabolism, Fachklinik Bad Heilbrunn, Bad
Heilbrunn, Germany, 4Novo Nordisk A/S, Sborg, Denmark
1
Psychological Medicine, Kings College London and Institute of Psychiatry,
London, UK, 2Opthalmology, Kings College Hospital NHS Foundation Trust,
London, UK, 3Biostatistics, Kings College London and Institute of Psychiatry,
London, UK, 4Diabetes, Guys and St Thomas NHS Foundation Trust,
London, UK, 5Diabetes and Nutritional Sciences, Kings College London,
London, UK
A Dornhorst1, S Sreenan2, A Liebl3 and JB Hansen4

1
P479
Changes in early drug treatment for Type 2
diabetes in Scotland
HC Looker
Population Health Sciences, University of Dundee, Dundee, UK
P481
Clinical inertia in people with Type 2
diabetes before insulin initiation in routine
clinical practice in the UK versus a global
cohort: baseline data from the SOLVETM
study
J Vora1, K Khunti2, J-F Yale3 and LF Meneghini4
1
Department of Diabetes and Endocrinology, Royal Liverpool University
Hospitals NHS Trust, Liverpool, UK, 2Department of Health Sciences,
University of Leicester, Leicester, UK, 3McGill Nutrition and Food Science
Centre, Royal Victoria Hospital, Montreal, Canada, 4Diabetes Research
Institute, University of Miami Miller School of Medicine, Miami, USA
2012 The Authors.

175
DIABETICMedicine
P482
Investigation of the effects of bariatric
surgery on the microvascular complications
of Type 2 diabetes
LL Chuah, A Mohite, S Faruq, P Shah, A Miras and C Le Roux
Background: Bariatric surgery is effective in improving glycaemia in

morbidly obese patients with difficult to control diabetes, but little is
known about its effects on microvascular complications. There are no
data on the impact of bariatric surgery on the progression of
retinopathy. This study aimed to evaluate the effect of bariatric
surgery on Type 2 diabetes nephropathy and retinopathy.
Methods: A retrospective study was performed on patients with Type
2 diabetes who underwent bariatric surgery between June 2007 and
August 2010. The primary outcome was changes in retinopathy and
nephropathy 1 year postoperatively. Standard retinal screening
photography and urine albumin creatinine ratio (ACR) results were
obtained and compared preoperatively and 1 year postoperatively.
Results: Complete retinal data were obtained for 63 patients.
Postoperatively, 19.1 per cent showed an improvement, 12.7 per cent
showed deterioration, and 68.2 per cent showed no change. In 28
patients (44 per cent) with pre-existing retinopathy, there was a
statistically significant improvement (decrease) in retinopathy grading
after surgery (P = 0.004). There were 70 patients with complete renal
data, and 27 had pre-existing nephropathy. In the group with preexisting nephropathy, median urine ACR improved from 7.9mg/mmol
(IQR 4.348.1) to 2.6mg/mmol (IQR 1.123.5) (P = 0.002).
Conclusion: Bariatric surgery was shown to stabilise and even reverse
the progression of Type 2 diabetes retinopathy and nephropathy. The
results of this study will need to be confirmed in a larger randomised
controlled clinical trial.
P483
A cross-sectional audit into insulin
prescription and concordance with National
Institute of Health and Clinical Excellence
(NICE) guidance for Type 2 diabetics on longacting analogue insulin
TJ Fox and DE Flanagan
Aims: NICE guidance from 2009 (Clinical Guidance 87) specifies that
patients with Type 2 diabetes should be treated with natural protamine
Hagedon (NPH) insulin initially. Long-acting insulin analogues
(detemir and glargine) should be used second-line in specific
circumstances only. We undertook a cross-sectional audit of 100
patients to establish the degree to which we are adhering to the NICE
guidelines for Type 2 diabetes with regard to analogue insulin
prescribing. In those cases in which an analogue insulin was
prescribed we aimed to establish if there was a justifiable reason
documented for non-concordance.
Methods: Clinic correspondence for the last 100 patients was
examined and patients with Type 2 diabetes on long-acting insulin
were identified. Patients on pre-mixed insulin were excluded following
the discontinuation of Mixtard since the publication of the guidance.
Data on age, gender, body mass index (BMI), duration of diabetes and
treatment were recorded.
Results: A hundred patients (43 female, 57 male) with a mean age of
59.2 years, mean BMI of 33.7 kg/m2 and mean duration of diabetes
13 years were studied. 17 per cent were treated with NPH insulin in
176
line with NICE guidance. 37 per cent were treated with insulin
glargine and 46 per cent with detemir. Of those treated with analogue
insulin 16/73 (19 per cent) had no documented reason for nonconcordance.
Conclusion: Although our use of analogue insulin was high the
majority of patients had a recognised indication for this such as frequent
hypoglycaemia or need for once-daily insulin or a basalbolus regimen.
This may reflect the complex nature of the patients managed in
secondary care.
P484
Conversion time to insulin in patients with
Type 2 diabetes
M Ahmad, M Jabeen and A Ahmad
UK
Aim: The average time taken to convert Type 2 diabetes patients with
HbA1c 7 per cent from oral hypoglycaemic agents (OHGAs) to
insulin therapy was reported to be 9.6 years, increasing risk of
complications. Our aim was to investigate and improve the time
taken to initiate insulin and improve HbA1c.
Method: In 2007 (JanuaryMarch), we selected 100 consecutive
Type 2 diabetes patients on insulin referred to the Royal Liverpool
University Hospital diabetes clinic within the last 10 years. The data
collected were the times taken to initiate insulin from the date of
referral. Recommendations were then put in place in 2007 to reduce
the time to initiate insulin. In 2011 (JanuaryMarch) another sample
of 100 patients on one OHGA referred to the clinic after 2007 was
reviewed.
Results: The time taken to initiate insulin in patients reviewed in 2007
was 7.6 1.1 (mean SEM) years. The recommendation made was
to add and maximise OHGAs every 4 months if HbA1c remained 7
per cent aiming to initiate insulin within 1824 months. From 2007 to
2011, 70 per cent were initiated on insulin within 2 years with 60 per
cent of these showing a mean HbA1c reduction of 1.3 per cent over
2 years. 10 per cent had optimal glycaemic control on two or more
OHGAs while the remaining 20 per cent had HbA1c 7 per cent
awaiting insulin start.
Conclusion: Although the time to convert patients to insulin therapy
before the recommendations were put in place was better than previous
reports, it was not optimal. After the recommendations were
implemented patients were converted to insulin three times faster
with the majority showing improvement in HbA1c over a shorter
period.
P485
Barriers to insulin therapy in people with
Type 2 diabetes: a qualitative exploration of
attitudes in a multi-ethnic population
N Patel1, MA Stone1, H Eborall1, C McDonough1, MJ Davies2
and K Khunti1
1
Health Sciences, University of Leicester, Leicester, UK, 2Cardiovascular

Aims: Research has identified under-prescribing of insulin for South

Asians (SAs) with Type 2 diabetes (T2DM). We aimed to explore
attitudes to accepting insulin amongst people with T2DM in an
ethnically diverse (SA, mainly Indian) UK community.
2012 The Authors.

Method: We conducted 19 semi-structured interviews with people

with T2DM (14 SAs). Analysis was conducted using a thematic,
interpretive approach.
Results: Participants attitudes to accepting insulin could be mapped
into four main typologies. These fitted with an attitudinal analysis based
on the necessityconcerns framework, described in the medication
adherence literature, comprising four attitudes: accepting, sceptical,
ambivalent and indifferent. Decisions about accepting insulin involved
balancing concerns (such as needle size) against perceived necessity of
insulin (generally, inadequacy of oral medication). SAs and White
Europeans had similar concerns. However, these were sometimes
2012 The Authors.

DIABETICMedicine
enhanced because the high prevalence of T2DM in SAs provides the

opportunity to be influenced by negative views and experiences of other
insulin users. This could lead, for example, to the perception that insulin
causes complications.
Conclusions: When discussing insulin with people with T2DM,
healthcare providers need to ensure that concerns are identified and
explored, along with fully explaining necessity. Furthermore, they
should be aware of the influence of people in the social networks of SAs.
There is a need to identify ways of promoting positive messages about
insulin at community level.
177

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DIABETICMedicine

Clinical care and other categories posters: audit

Refer to page 80, poster 162

Vascular Research Group, University of Manchester, Manchester, UK,

Introduction: Metformin treatment has recently been linked with

Clinical care and other categories posters: audit

Background: Diabetes is implicated in the cause of death for most

Background: The present impact of diabetes on overall mortality is

2012 The Authors.

Clinical care and other categories posters: audit

Conclusions: The contemporary risk of death in people with diabetes

P = 0.05) occurred. TC levels remained unchanged (T0 4.08 vs. T1

D Eayres1, J Barrett2, C Buttery2, J Henderson2 and B Young3

Background: The effects of age and sex on excess mortality in

2012 The Authors.

Aim: To audit the UHB continuous subcutaneous insulin infusion

Aim: In 2010 the National Patient Safety Association highlighted

Clinical care and other categories posters: audit

Aim: The National Diabetes Inpatient Audit (NaDIA) was established

Background: The latest NDA data have been investigated to see

Department of Medicine, Furness General Hospital, Barrow-in-Furness, UK,

Introduction: The oral glucose tolerance test (OGTT) is one of the

2012 The Authors.

Clinical care and other categories posters: audit

Methods: All the patients who had an OGTT requested between 1

Aim: We evaluated elderly (> 70 years) inpatient diabetes care at

2012 The Authors.

Aims: Glucagon-like peptide 1 (GLP-1) agonist treatment in Type 2

Aim: This audit aimed to identify (1) indications for starting

Clinical care and other categories posters: auto-immunity

Centre at Monklands Hospital. Audit standards were based on the

Clinical care and other categories posters: auto-immunity

Medical School, Kings College London University, London, UK, 2Diabetes

Aim: The earlier onset of Type 2 diabetes and increasing atypical

40 years of age (n = 176) or above 40 years of age with ketones

2012 The Authors.

Clinical care and other categories posters: beta cells,

Refer to Oral number A15

Clinical care and other categories posters: cardiovascular

Centre for Population Health Sciences, University of Edinburgh, Edinburgh,

Refer to Oral number A81

Refer to Oral number A82

2012 The Authors.

Aim: The glucagon-like peptide 1 (GLP-1) analogue exenatide is

Introduction: Carotid plaque presence and characteristics may be

Aim: We previously reported that the relative risk for cardiovascular

Clinical care and other categories posters: cardiovascular

diabetes in Scotland compared with the general population. To explore

Aim: Disturbances of glucose metabolism are widely prevalent in acute

2012 The Authors.

Clinical care and other categories posters: case reports

AK McGregor , R Edwards , H Thomas , IF Purcell and

Cardiothoracic Services, Newcastle-upon-Tyne Hospitals NHS Foundation

Aim: Studies demonstrating the benefit of insulin/dextrose infusion in

Aims: Screening is recommended within groups at high risk of Type 2

Clinical care and other categories posters: case reports

Diabetic Foot Clinic, Kings College Hospital, London, UK, 2Department of

Refer to Oral number A18

Refer to Oral number A17

2012 The Authors.

Diabetes Centre, Wycombe Hospital, Buckinghamshire Healthcare NHS

Refer to Oral number A19