An unusual presentation of thyroid storm with cardiac failure in a young female Aisha Rummaan, Yagoub Abdelgader Pilgrim HospitalWe present a case of thyroid storm with cardiovascular manifestations, an unusual clinical presentation.

Aims: This study sought to evaluate retrospectively how switching from dulaglutide to oral semaglutide affected glycaemic control and clinical parameters in patients with well-controlled type 2 diabetes (T2DM). Methods: The study included 18 patients with well-controlled T2DM (mean HbA1c 6.99%) who were taking dulaglutide. HbA1c levels and clinical parameters were measured at baseline and two, four and six months later. Changes in these parameters during the study period were assessed retrospectively. Results: HbA1c levels at two months from baseline were significantly higher than at baseline (7.43 ± 0.72 vs. 6.99 ± 0.39%, p = 0.003), whereas no significant change was observed at four or six months from baseline. Subjects with improved glycaemic control at six months from baseline (n = 5) had significantly lower gamma-glutamyl transferase levels at baseline compared to those who did not show improvement (n = 13) (13.8 ± 3.0 vs. 47.9 ± 53.6 IU/L, p = 0.026). Notably, high-density lipoprotein cholesterol levels at six months were significantly higher than at baseline (p = 0.006). Conclusion: Glycaemic control worsened temporarily after switching from dulaglutide to oral semaglutide, but no significant difference was observed between baseline and six months later.

The management of type 2 diabetes (T2DM) has undergone significant changes in recent years, with a shift away from the hospital setting towards community–based teams. This study aimed to investigate changes in clinical acuity and complexity of patients with T2DM referred to the Sutton Community Diabetes Service. This retrospective audit of patients with T2DM compared the first hundred patients referred in 2017, when local guidelines for referral were first introduced, with the first hundred patients referred in 2023. Demographic data, treatment modalities, diabetic complications and co- morbidities were retrieved from our EMIS database. Compared to the 2017 cohort, patients referred in 2023 were more ethnically diverse (35% South Asian vs. 18%; p<0.01), had higher mean (SD) HbA1c levels (mmol/mol at referral 90.8 [20.6] vs. 81.5 [19.9, p <0.01), higher rates of microalbuminuria (47% vs. 28%, p=0.02),and were more likely to have three or more significant co-morbidities such as co-existent cancers or cardiovascular disease. This study highlights the growing complexity of patients referred to the community diabetes service, which impacts on the entire multidisciplinary team. Commissioners and care planners need to consider the increasing complexity of patients managed in these settings.

A 34-year-old Ghanaian woman with a complex obstetric history, including seven miscarriages, recurrent pre-eclampsia, placental abruption, a neonatal death at 18 months and a baby with a neural tube defect, presented 11 weeks into her 11th pregnancy.Her medical history also included hypertension, type 2 diabetes and chronic kidney disease (CKD) secondary to diabetes and hypertension.At her booking appointment, her blood pressure was poorly controlled at 187/90 mmHg, her HbA1c was elevated at 76 mmol/mol, creatinine was 258 nmol/L, estimated glomerular filtration rate (eGFR) was 18 ml/min, and her urinary protein-tocreatinine ratio (UPCR) was 579.31 mg/mmol.During her initial consultation, the team discussed the risks posed to both mother and baby by her poorly controlled diabetes, hypertension and CKD.These included risks of stillbirth, accelerated decline in renal function requiring dialysis, and escalated hypertension with the potential for an intracranial bleed.The option of a termination was offered, but the patient chose to proceed with the pregnancy.She was managed in a multidisciplinary team (MDT) clinic, involving a diabetologist, renal physician, obstetrician, midwife and diabetes specialist nurse (DSN).Her blood pressure was optimised using pregnancy-safe antihypertensive medications, and her diabetes was managed with insulin.She was also started on aspirin to reduce the risk of pre-eclampsia, a renal-appropriate dose of venous thromboembolism (VTE) prophylaxis and erythropoietin (EPO) injections.Although she did not require dialysis during pregnancy, she developed pre-eclampsia at 32 weeks: serial growth scans demonstrated intrauterine growth restriction (IUGR) and polyhydramnios.An MDT-recommended plan for early delivery by Caesarean section at 34 weeks, along with tubal ligation and possible dialysis around delivery, was discussed.Despite detailed counselling, the patient declined an early delivery.She went into spontaneous labour at 33 weeks and 1 day, with the baby requiring neonatal intensive care for respiratory distress but ultimately making an uneventful recovery.Following delivery, the patient required further blood pressure optimisation.Her eGFR had dropped further to 8 ml/min, prompting a referral to the renal clinic.Four months postpartum, she presented with acute pulmonary oedema and was subsequently started on dialysis.Conclusion: In England, chronic kidney disease affects an estimated 15,000 to 20,000 pregnancies each year, a number that is expected to rise.CKD significantly increases the risk of adverse outcomes in pregnancy for both mother and baby.Managing pregnancy in women with CKD requires a sensitive, multidisciplinary approach, shared decision-making, close monitoring in a supportive environment and effective preconception counselling.

Diabetic foot disease is one of the most costly complications of diabetes in the UK, and frequently co-occurs with chronic kidney disease (CKD), including end-stage renal disease, in people with diabetes. In addition to the common pathologies underlying each complication of diabetes it is not clear whether each may have an influence on the other. Those with end- stage renal disease are at particular risk of the development of diabetic foot disease, and this risk increases dramatically when renal replacement therapy commences. However, it is now also recognised that the presence of a diabetes-related foot ulcer may accelerate decline in renal function, such that the commencement of renal replacement therapy may be advanced. Potential mechanisms for this include chronic inflammation with circulating inflammatory cytokines and/or repeated episodes of acute kidney injury, particularly in those who have hospital admissions for their diabetic foot disease. Given the poor outcome of foot disease and CKD in this patient cohort, renal units and diabetes foot services should work closely together to ensure that patients are seen regularly by preventative podiatry services, and to ensure that pathways are in place for rapid referral should new foot disease be noticed.

Background: Injectable insulin formulations exhibit a notable propensity for errors and can cause significant patient harm when used inappropriately. Aims: The aim was to conduct a second audit on insulin prescribing, administration and glucose monitoring practices in Galway University Hospitals since the initial audit in 2022. Methods: This audit was conducted over one day in June 2023, approved by the local Clinical Audit Committee, piloted on four inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Independent analysis was conducted by three researchers to confirm reliability of results. Results: Five hundred and fifty-seven inpatients were reviewed, of whom 21% (116) had diabetes and 10% (56) were prescribed insulin. In total, 94% (265) insulin brand names and 94% (266) dose units were clearly prescribed, 90% (254) administration times were clearly specified by a prescriber, 80% (227) orders were signed, 70% (39) prescribers clearly documented their registration number/bleep/name at least once for contact purposes, 80% (210) administrations were double-checked by a second person, 58% (152) administration times documented by a nurse, and 24% (9) inpatients administered insulin by a nurse when not prescribed. Conclusion: Results have identified an overall practice improvement. High-leverage strategies such as electronic prescribing are a current consideration to standardise practices. All aspects of this review are transferable to other hospitals. Disseminating results and promoting transferable benefits should encourage participation of all Irish hospitals to conduct a standardised national annual insulin audit to improve patient care.

Aims: To assess the safety and efficacy of duodenal-jejunal bypass liner (DJBL) implantation for 9 months or 12 months in patients with obesity and sub-optomally controlled type 2 diabetes (T2DM). Methods: Over 4.25 years DJBLs were implanted in 90 adult patients with obesity and sub-optimally controlled T2DM at a single centre in England. The liners remained in situ for up to 12 months and outcomes were monitored in a registry. Results: Of the 90 patients (BMI 41.5±7.1kg/m2, HbA1c 79.3±20 mmol/mol), 53% were insulin-treated. During DJBL treatment, there was no difference between the mean±SD fall in HbA1c at 9 months (20.5±18.8mmol/mol) vs. 12 months (20.5±19.4mmol/mol) (p=0.95). The mean±SD weight loss at 9 months (13.8±7.7kg) was 1.6±3.6kg less than that at 12 months (15.4±8.4kg) (p<0.001). By 12 months, 15.6% of patients had had early DJBL removal due to serious adverse events (SAEs), from which they all recovered. Of these SAEs, 43% would have been avoided by DJBL removal at 9 months. Conclusion: DJBL is effective in people with intractable diabesity. To reduce the incidence of SAEs, our data support reducing the recommended/conventional implantation period for DJBL from 12 months to 9 months.

Objectives: Globally, 40% of people receiving peritoneal dialysis have a diagnosis of diabetes.High-quality data on the potential impact of improving glycaemic control are needed to inform the KDIGO recommendation to individualise HbA1c targets.Methods: The association between first HbA1c and all-cause mortality in people on peritoneal dialysis (PD) for kidney failure recruited into PDOPPS1(2014-2017) and PDOPPS2(2018-2022) identified as diabetic was estimated using Cox proportional hazards models adjusted for age, sex, race, country, albumin, haemoglobin and co-morbidities.To inform HbA1c individualisation, subgroup analyses drawn from these adjustment variables were performed.Results: From 24,259 individuals recruited into PDOPPS, 13,646 were identified as diabetic.Of these, 9,722 had HbA1c performed after a mean of 11.2 months' PD therapy, mean follow-up 17.2 months.Mean HbA1c was 6.9%.Mean HbA1c ranged from 6.4% in Japan to 7.3% in Canada.In people with type 2 diabetes (T2DM), relative to HbA1c 6.0-7.0%,there was weak evidence for increased all-cause mortality for HbA1c >9% (HR 1.18, p=0.067), becoming more robust in those aged <65 years (HR 1.4, p=0.01).In individuals with albumin >3.0g/dL, or those with no previous coronary artery disease (CAD), the threshold for significantly increased mortality dropped to >8% (HR ~1.2 ).The hazard ratio for mortality for the >8% threshold climbed to 1.92 for those aged <65 years, with both serum albumin >3.0g/dL and no previous CAD.Conclusions: In diabetic adults receiving PD for kidney failure, the associations seen between HbA1c and mortality argue for tighter individualised targets for particular patient subgroups (younger, non-inflamed and without established CAD) than clinical practice guidelines have previously suggested.

Background: Obesity and type 2 diabetes (T2DM) can both profoundly impact health and wellbeing. Their prevalence largely follows a social gradient. The National Health Service Low Calorie Diet programme in England aims to support people to achieve T2DM remission while also reducing health inequalities. We aimed to explore the experiences of local health service leads and identify barriers and facilitators in relation to the equitable mobilisation of the Low Calorie Diet programme. Methods: Twenty semi-structured interviews were completed with 24 locality leads across the first two years of the Low Calorie Diet programme. Interviewees were purposively sampled from the 10 localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest, including referrals, training, communication, incentivisation, governance and engagement, before being subjected to a thematic analysis. Results: From the data, seven core themes were identified: COVID-19 and primary care capacity and engagement; methods of communication; approaches to training; approaches to incentivisation; approaches to referrals; barriers to referrals; and the importance of collaboration. COVID-19 presented a specific challenge to the mobilisation and delivery of the Low Calorie Diet programme; however, our findings demonstrate the large variation and differences in the approaches taken when delivering the programme across 10 geographically and demographically distinct pilot sites. We also identified a lack of a recognised approach or strategy to mobilisation and delivery support for the Low Calorie Diet programme, such as proportionate universalism, which is a social policy response to tackling health inequalities by ensuring that service delivery is equitable. Conclusions: Health inequalities remain a significant challenge, and health service leads have the potential to adopt an equity perspective from the start of programme mobilisation. In doing so, resources at their disposal can be managed equitably and can therefore contribute to efforts to reduce the potential occurrence of intervention-generated inequalities.