Thursday: Diabetes professionals day
Diabetes professionals day opened with a special symposium on diabetic ketoacidosis (DKA) covering recommendations and proposed revisions to the BSPED guidelines. This was followed by sessions covering nutrition and eating disorders, the management of diabetes in various groups (socially deprived, Black and ethnic minority, sporting participants and type 2 diabetes [T2D]), and enhancing care through social media (covered in a recent editorial [Ng, 2019]). The afternoon included a lively debate between Anuja Natarajan and Rachel Besser about whether continuity of care with doctors underpins optimal diabetes management in children with diabetes or whether multidisciplinary care is more important. Justin Davies wrapped up the day by presenting the James M Tanner Award. BSPED members were then invited to attended the 2019 AGM.
The evening provided delegates with the opportunity to catch up with colleagues and unwind in the memorable setting of the National Museum Cardiff. A drinks reception held in the art galleries followed by dinner in the Grand Hall with Dippy, the Diplodocus, was enjoyed by all who attended.
Friday: Diabetes main meeting
Diabetes trials and quality improvement (QI) were the focus points of the main meeting. Tim Barrett provided an overview of novel therapies for T2D in children and young people – an issue touched upon by several presenters the day before. The presentations on immunotherapy in type 1 diabetes (T1D) and the role of the environment in T1D pathogenesis were interesting but generated more questions than answers in many cases. Various studies are ongoing and the next 5 years should hopefully provide greater insight into who is at risk of T1D, how disease progress can be slowed/halted and, indeed, possibly prevented through immunomodulation.
The oral communications covered a wide range of topics, from alcohol-related hospital admissions in young people with T1D to the impact of continuous glucose monitoring on sleep quality. Several communications reflected talks given during the meeting, including the increasing prevalence of T2D and impact of deprivation in T1D.
Exhibition and posters
The exhibition hall provided the opportunity for delegates to take a tour the diabetes posters and, in many cases, learn more from the authors. Posters covered a broad selection of topics, from QI initiatives to unusual case studies. Delegates were also able to wander among stands in the exhibition hall and speak to representatives from patient groups and the pharmaceutical industry.
Special DKA session
Rum Thomas (Sheffield) and Neil Wright (Sheffield) set the stage for the proposed revision of the BSPED DKA guidelines and sought views and comments from the BSPED membership. Since the introduction of the 2015 guidelines, there have been a number findings from joint audits:
- More children with DKA have been treated for cerebral oedema
- More patients have required renal replacement therapy
- More patients have needed vasoactive drugs for shock
- It generally takes longer to recover from DKA (2–3 hours if mild and 12–18 hours if severe)
- There is frequent deviation from the guidelines.
Due to small numbers of patients, the statistical significance of these findings could not be determined. The two deaths in the past 2 years at Sheffield have prompted an urgent review of national guidelines to balance the risks of developing cerebral oedema and its prevention versus treating dehydration and/or shock and its consequences.
The symposium focused on key potential mechanisms of cerebral oedema (osmotic changes, vasogenic oedema and hypoperfusion) and clarified that the administration of intravenous fluids is unlikely to be the sole cause of cerebral oedema (as emphasised by the 2015 BSPED guidelines). It also highlighted some potential flaws in interpretation leading to the recommendation of restricted fluid administration. Apparently four studies linked cerebral oedema to increased fluids, while nine studies did not; and the more recent PECARN study (Kuppermann et al, 2018) has shown no relationship to fluid volumes (and a trend towards brain injury in individuals receiving less or slower fluid administration).
Key revisions
The symposium provided a list of key revisions for the forthcoming BSPED guidelines, including: restoring circulation and avoiding excessive fluid restriction; de-emphasising the use of inotropes; not subtracting bolus fluid administration during resuscitation from total fluid requirements; and using long-acting insulin analogues along with DKA management. The updated guidelines will probably be published later this year.
It is difficult to opine whether the 2015 guidelines are too fluid restrictive due to the small numbers of patients; however BSPED has been proactive in recognising the possible flaw in the current guidelines and making urgent attempts to provide well-researched, more robust and evidence-based guidelines to improve safety for children and young people with diabetes across UK.
Diabetes trials update
The symposium on diabetes research consisted of talks on immunotherapy, environment and T1D parthenogenesis, and T2D.
Colin Dayan (Cardiff) kick-started the symposium with a very robust argument of why and how targeted, low-risk immunotherapy might preserve some residual beta-cell activity in newly-diagnosed patients. He informed us that even a small amount of residual insulin secretion (c-peptide levels >200 nmol/L) has shown improved outcomes in T1D patients (fivefold fewer hypos, >50% achieve target HbA1c levels, reduced insulin requirements and reduced long-term complications). He informed us about the ongoing USTEKID trial in adolescents with new-onset T1D. This phase 2, double-blind randomised controlled trial is assessing the safety and efficacy of ustekinumab (Stelara) – a specific monoclonal antibody that halts cytokine-mediated destruction of beta-cells (IL-12 and IL-23 pathways) – in the preservation of residual beta-cell function. Ustekinumab is currently licensed for other conditions, notably psoriasis, but has not been used for this indication previously.
Susan Wong (Cardiff) discussed the role of environment, in particular gut microbiota, in the evolution of diabetes. She highlighted various studies showing that the gut microbiome subtly changes prior to the start of diabetes, with lower microbial diversity noted. A high fibre diet, probiotics and prebiotics may be helpful in maintaining the gut microbiome, but their significance is uncertain. She highlighted that regular vaccinations and antibiotics use have no effect on the causation of T1D and informed delegates that the role of genetics in the causation of T1D is more important at a young age.
Tim Barrett (Birmingham) highlighted that T2D in youth is a completely different disease compared to adults. It has a faster progression, higher rate of complications, reduced survival and higher predisposition to DKA. There is higher beta-cell stress and higher insulin secretion than in adults with the same degree of obesity.
Early metformin is helpful; however, over 50% fail to respond and reduce their HbA1c levels by 3 years of treatment. (Metformin needs circulating insulin to be effective.) Of the newer therapies available:
- GLP-1 inhibitors consistently lower HbA1c by >11 mmol/mol (>1%) in children, with >60% attaining target HbA1c levels of <58 mmol/mol (<7.5%); but the drug has important gastrointestinal side effects
- DPP-4 inhibitors, which raise GLP-1 levels, are not yet licensed in children
- SGLT2 inhibitors cause dehydration, in particular euglycaemic DKA, and thus caution is warranted.
In severe cases of obesity, the role of bariatric surgery should not be ignored; as this improves both T2D and obesity outcomes.
Enhancing diabetes care though social media
In 2008, the King’s Fund highlighted the increasing use of technologies in the NHS and their potential to transform patient care (Liddell et al, 2008). Internet use continues to grow, with four out of five people in the UK having access at home. Social media is rapidly growing in importance and its impact on health is expected to grow. The major social media platforms are listed in Box 1. It is clear that the internet is changing the relationships between health and professionals and service users.
Reasons to participate in social media: #SoMe
Digital advocacy for diabetes via social media is on the rise. This creates opportunities for improvements in healthcare, research, peer support and advocacy. The main Twitter handles used for diabetes are #GBDOC (the UK Diabetes Online Community handle) and #DOC. Twitter is one of the main platforms that enables the rapid dissemination, curation and sharing of information. It can enable us to elicit learner reflections, engage with the community, be part of the conversation, crowd-source ideas, provide patient and public health education, build relationships, network, collaborate and perform research.
There are, however, barriers to the adoption of social media by healthcare professionals. Barriers include unfamiliarity, lack of time, knowledge, skills, trust, access and organisational support. Social media opens us up to some risks, so we should adhere to the rules accordingly. We should not be so risk adverse that we do not participate in social media, but be mindful that technology on its own is no substitute for face-to-face care (Ng, 2019).
Social media can improve clinical practice, outcomes, consistency of messaging and patient engagement and satisfaction. It can also be used as a tool to disseminate education and knowledge. We now have readily available technology and should aim to adopt it within our clinical practice.
BSPED 2020
For details about this year’s meeting in Belfast, visit the BSPED website
NHSEI National Clinical Lead for Diabetes in Children and Young People, Fulya Mehta, outlines the areas of focus for improving paediatric diabetes care.
16 Nov 2022