hypoglycaemia documented with real-time continuous glucose sensing in a case of ‘dead in bed’...

P134

Vitamin B12 is lower in metformin treatedpatients but haemoglobin is unaffectedRP Narayanan1, SG Anderson2, E Onyekwelu3 and AH Heald1,3

1Vascular Research Group, University of Manchester, Manchester, UK,2Cardiovascular Sciences Group, University of Manchester, Manchester, UK,3Department of Medicine, Leighton Hospital, Crewe, UK

Introduction: Metformin treatment has recently been linked withvitamin 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 affectsvitamin B12 and haemoglobin (Hb) levels in primary care.

Methods: We used pseudo-anonymised data drawn from primarycare records in practices based in central and eastern Cheshire. We

compared vitamin B12 levels in 7,823 patients with Type 2 diabetestaking 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 inmetformin 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,mean419.1 ng/l, 95per centCI407.8430.3 ng/l),P < 0.001.There was no difference in folate levels (P = 0.17). Interestingly MCVwas 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 nodifference 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 metformintreated patients, there was no difference in circulating Hb. This has

implications for long-term monitoring requirements in metformintreated patients.

Clinical care and other categories posters: audit

P135

National Diabetes Audit (NDA): diabetes isunder-recorded on death certificates ofpeople with diabetesB Young1, D Eayres2, J Barrett3, C Buttery3 and J Henderson3

1Department 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 mostpeople with diabetes but death certificates may under-report diabetes as

a comorbidity.

Methods: The 20078 NDA included 1.42 million people withdiabetes, 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 werematched 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 2008to 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 peryear. 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 deathcertificate, 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 inEngland and its impact on total mortality is significantly under-

estimated by reliance on death certificates.

P136

National Diabetes Audit (NDA): comparisonbetween all-cause mortality in people withdiabetes and the general population inEngland; more than 20,000 excess deaths inpeople with diabetes and higher risks inType 1 diabetesD Eayres1, J Barrett2, C Buttery2, J Henderson2 and B Young3

1Public 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 isnot known.

Methods: The 20078 NDA included 1.42 million people withdiabetes.UsingNHSnumbers theOfficeofNationalStatistics identified

49,282 deaths in this cohort during the year beginning 1 November

2008. The diabetes cohorts mortality experience is compared with thegeneral 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 3,553per 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, comparedwith 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 than16,000 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 withdiabetes in England each year.

DIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: auditDIABETICMedicine Clinical care and other categories posters: audit

2012 The Authors.72 Diabetic Medicine 2012 Diabetes UK. Diabetic Medicine, 29 (Supp. 1), 30177

mimran74Typewritten TextRefer to page 80, poster 162

Conclusions: The contemporary risk of death in people with diabetesis substantially greater than in the general population and represents an

opportunity for improvingnational healthoutcomes.The risk inType 1is 1.7 times greater than in Type 2 diabetes.

P137

National Diabetes Audit (NDA):investigation by age and sex of excessdeaths in people with diabetes in England;greater effects in the young and in Type 1femalesD Eayres1, J Barrett2, C Buttery2, J Henderson2 and B Young3

1Public 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 indiabetes were investigated.

Methods: Using NHS numbers from the 20078 NDA the Office ofNational Statistics identified 49,282 deaths during the year beginning 1November 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 andfemales 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

femalebackground rate, inmales 4 times; for Type2diabetes 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 populationexcess 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 thecontemporary 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 appraisalof the AABC treatment paradigmK Al-Hourani1, T Mehrali2, A Murtaza2 and P De2

1Merton 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 T1end 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 percent 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. T168.3, P = 0.0002) and triglycerides (mean TG T0 2.33 vs. T1 1.7,

P = 0.05) occurred. TC levels remained unchanged (T0 4.08 vs. T14.05, 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 decreasesin blood pressure and triglycerides were observed during the audit

period with little change in HbA1c. A quarter of patients receivedstatins but prescription of aspirin remained comparatively low.

P139

Audit of the continuous subcutaneousinsulin infusion multidisciplinary service atthe University Hospitals Bristol NHSFoundation 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 recordsperformed 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 CSIIwas 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 percent) at 1 year. An improvement in hypoglycaemia awareness and

frequency was reported by 95 per cent. Currently 17 are not achieving

treatmentgoals.Eleven (12per cent)neverhave (nine startedpre-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 90per cent of patients who started post-2008 NICE guidelines, wereachieving 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 tohigher goal achievement through better patient selection. A written

contract enablingwithdrawal of CSII if treatment objectives are notmet

is essential, as patients are reluctant for it to be taken away. We do not

knowthe long-termeffectof engagementwithdiabetes services ifCSII iswithdrawn.

DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit

2012 The Authors.Diabetic Medicine 2012 Diabetes UK. Diabetic Medicine, 29 (Supp. 1), 30177 73

P140

Safer administration of insulin: using anaudit to get the basics right and reduce risksof patient harmAC 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 highlightedinsulin 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 eventslist. 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 anaudit, 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 notstock insulin syringes. Of 52 responses analysed, 50 (96 per cent)

separated insulin syringes from 1ml syringes, 45 (93 per cent) reportedthe 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 insulinand 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 andtwo (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) andopenedmultipacks in three (8 per cent).The risk of syringe

mis-selection was estimated to be low by 78 per cent, moderate by 10per cent, and significant by 12 per cent.

Summary: Eleven areas identified practice with moderate orsignificant risk of harm. Fifteen areas used needle lengths with

potential for IM injections. We will implement trust-wide policy toremove variation, improve practice and prevent potentially fatal errors.

P141

National Diabetes Audit (NDA): routine careis less effective and outcomes are poorer inyounger people compared with olderpeople who have diabetes in EnglandB Young1, A Uddin2, J Barrett2 and J Henderson2

1Diabetes 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 seewhether diabetes care and outcomes are age related.

Methods: In 200910 the NDA included 1.9 million people, 83 percent of those with diagnosed diabetes in England. The NDA usesprimary 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 than55 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 aged5584 years). Achieving the HbA1c < 7.5 per cent (58 mmol/mol)

treatment target was less likely in younger people (Type 1 diabetes, age

30per cent;Type 2diabetes, age

< 55 year, 70 year, >70 per cent). The

Methods: All the patients who had an OGTT requested between 1January 2010 and 30 September 2010 were included in this audit. All

OGTTs requested in pregnancy were excluded. The data source wasthe Pathology Laboratory in Furness General Hospital in Barrow-in-

Furness, which was checked for all plasma glucoses checked for the

patients in the preceding year. Early identification of people withType 2 diabetes Diabetes UK 2006 was used as the standard for this

audit.

Results: The total number of OGTTs requested was 354. Afterexcluding the OGTTs requested in pregnancy (n = 40), the totalnumber of patients selected for the audit was 314. The mean age of thepatients 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 forwhom 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 wouldprevent unnecessary investigation and wastage of time both for the

patients and the healthcare staff.

P144

Audit of inpatient management of diabetesin the elderlyA 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 atNorfolk 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, 13per cent elective, 38 per cent day admissions). Among EAs, 97 per centwere 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 centand 30 per cent admissions were diabetes and cardiovascular relatedrespectively. 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 in50per centwereguidelines followed.Dose

adjustment was not done in 50 per cent with consecutive day hypos. 30

per cent experienced hyperglycaemia (consecutive days glucoseconsistently >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 examinationdocumented. 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 wereglycaemic 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 elderlydiabetes inpatients. More focused education for staff is recommended.

P145

What proportion of patients fail NICEcriteria for continuing GLP-1 treatmentbeyond 6 months and whyL 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 2diabetes 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 percent.

Methods: We assessed the impact of NICE continuation criteria in 61patients, mean age (SD) 57 (10) years, diabetes duration 11 (6) years,

baseline median (range) weight 118kg (76192), body mass index42 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 lost7.2kg (2.926.3)andHbA1chad fallenby1.4 (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 lossafter 10 (639) months follow-up in those failing on HbA1c alone was

6.8kg (2.424.5) (similar to thosewhometNICEcontinuationcriteria).

Conclusions: We conclude that in our clinic most patients cancontinue GLP-1 treatment, but approximately 40 per cent fail to meetNICE continuation criteria, most as a result of poor HbA1c response

despite marked weight loss.

P146

The impact of the diabetes outreach teamon long-term glycaemic controlH Siddique1, AA Tahrani2, W Leong2, K Crowley1, G Wheatley1

and C Holmes1

1Diabetes, 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 serviceprovided by the dedicated Diabetes Outreach Team at Russells Hall

Hospital, Dudley, UK.

Methods: We performed a retrospective audit of all inpatients whowere 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 2,490patients, 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 Type1 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-upHbA1c 8.32 ( 2.03) (P < 0.001). Patients with new onset Type 1diabetes 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 patientsknown tohave diabetes alsodropped their HbA1c from 8.99 per cent to

DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit DIABETICMedicineClinical care and other categories posters: audit


8.46 per cent (P < 0.001 for all comparisons). When the samples wereanalysed based on their age (75), once again there was astatistically significant drop in HbA1c.

Conclusion: Byprovidingacomprehensive care, structurededucationand 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 servicein LanarkshireA 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 startingsubcutaneous 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 45individuals identified as using the insulin pump service at the Diabetes

Centre at Monklands Hospital. Audit standards were based on the

SIGN and NICE guidelines.

Results: The predominant reason for starting CSII therapy whichapplied 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 percent (n = 26), improving to 7.76 per cent (n = 24); it was 8.79 per centin thenon-DAFNEgroup(n = 15), improving to7.88per 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 withType 1 diabetes shown here to provide a 1 per cent improvement inHbA1c. 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 surveysare needed and are being implemented.

Clinical care and other categories posters: auto-immunity

P148

The evaluation of the utility of islet cellauto-antibody measurements in clinicalpracticeSA Nathwani1, D Kariyawasam2 and S Thomas2

1Medical 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 atypicalpresentations 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 auto-

antibody testing in an inner-city hospital serving a diverse ethnic

population.

Methods: The role of auto-antibody testing in affecting changes inmanagement, 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 theDiabeta3 database. Of these, 201 patients with either diagnosis under

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 testordered. Antibody testing predicted a change in management

(P = 0.003); 45 per cent (n = 49) of the tested population had one ormore changes in their diabetes management following the test. Themost 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); 22per 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 diagnosisand or management whether positive or negative. As classicalpresentations of diabetes change there may be a greater role for

testing and a need for awareness of the limitations of the test.


DIABETICMedicine Clinical care and other categories posters: auto-immunity

Clinical care and other categories posters: beta cells,

islets and stem cells

P149

Resolution of hypoglycaemia, improvementin glycaemic control and assessment ofmetabolic graft function in islet transplantrecipients in the UK islet transplantconsortium programmeAMS Brooks1, SA Amiel2, S Forbes3, P Johnson4, M Rosenthal5,M Rutter6, R Smith7 and JAM Shaw1

1Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne,

UK, 2Diabetes Research Group, Kings College London, London, UK,3Endocrinology 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 morphologywith cardiovascular disease and vascularrisk factors in older people with Type 2diabetes: the Edinburgh Type 2 DiabetesStudyCM Robertson1, MWJ Strachan2, L Nee3, J Morling1, S Masle1

and JF Price1

1Centre 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 cardiovascularmortality in people with Type 2 diabetes inScotlandC Jackson1, J Walker2, C Fischbacher3 and S Wild2

1Scottish 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


P152

Effect of exenatide on cardiovascularparameters: evidence from a small cohortstudyI Ramracheya

Centre for Diabetes and Endocrinology, Royal Berkshire NHS Foundation

Trust, Reading, UK

Aim: The glucagon-like peptide 1 (GLP-1) analogue exenatide isrecommended by the National Institute for Health and ClinicalExcellence 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 werecollected 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). Otherparameters were as follows: weight 124.8 4.0 kg; body mass index41.3 7.7 kg/m2; HbA1c 9.6 0.2 per cent. Twenty-five patientswere identified for comparisonbetween0and6 monthsand18patients

for 012 months. Blood pressure recordings at baseline were (mm Hg)

systolic 142 2.9; diastolic 80 1.6. Systolic readings at 6 monthsshowed 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 mmHg (baseline 146.6 6.2 vs. 140.5 5.5; P < 0.05). No change wasnoted in diastolic blood pressure. Triglyceride levels dropped by 9 per


DIABETICMedicineClinical care and other categories posters: beta cells, islets and stem cells

cent (P < 0.05) at 3 and 6 months and 10 per cent (P < 0.05) at12 months. There was a small reduction in total cholesterol levels at3 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 8per cent (3.9 0.1 vs. 3.6 0.1) respectively. LDL levels wereunaffected in this cohort.

Conclusions: Exenatide treatment can significantly and time-dependently improve cardiovascular risk factors. Further studies are

needed to assess the long-term cardiovascular benefits of exenetide.

P153

Frequency and characteristics of carotidartery plaque in older people with Type 2diabetes: the Edinburgh Type 2 DiabetesStudyCM Robertson1, MWJ Strachan2, L Nee3, J Morling1, S Masle1

and JF Price1

1Centre for Population Health Sciences, University of Edinburgh, Edinburgh,

UK, 2Metabolic Unit, Western General Hospital, Edinburgh, UK, 3Department

of Radiology, Western General Hospital, Edinburgh, UK

Introduction: Carotid plaque presence and characteristics may beimportant in cardiovascular risk prediction, in particular echolucent

and/or heterogeneous plaque. However, little is known about theprevalence and characteristics of carotid plaque in people with Type 2

diabetes.

Methods: In total, 939 subjects aged6176 years fromtheEdinburghType 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 wererepeated 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

(59.6vs. 61.7per cent), and least common in thecommon(31.9vs. 42.2per 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 43.0per cent had heterogeneous plaque. Plaque distributionat 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 withpredominantly 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 withType 2 diabetes, especially at the carotid bifurcation and internalcarotid 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 ofsubsequent events, is warranted.

P154

Sex differences in cardiovascular diseaserisk factor profiles in those with Type 1diabetes in ScotlandHM Colhoun

Population Health Sciences (PHS), University of Dundee, Dundee, UK

Aim: We previously reported that the relative risk for cardiovasculardisease (CVD) continues to be higher in women than men with Type 1

diabetes in Scotland compared with the general population. To explore

reasons for this we examined whether CVD risk factor profiles andachievement of treatment targets differ by sex in Type 1 diabetes.

Methods: We used clinical data and issued prescriptions data fromthe 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: Currentsmokingwasmorecommoninmenthanwomenatallages [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 aneGFR < 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) thanmen (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, glycaemiccontrol and renal function in women than men with Type 1 diabetesmay contribute to their greater elevation in CVD risk.

Acknowledgement: On behalf of the Scottish Diabetes ResearchNetwork.

P155

New onset hyperglycaemia in a multi-ethniccohort presenting with acute coronarysyndromeA Mathew and P De

Diabetes and Endocrine Unit, City Hospital, Birmingham, UK

Aim: Disturbancesofglucosemetabolismarewidelyprevalent inacutecoronary syndrome(ACS)andrelate toadverseoutcome, irrespectiveof

presence or absence of previously diagnosed diabetes. The aim of thisstudy 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 centAfro-Caribbean.52per centand38per centwere foundtohave

impaired glucose tolerance (IGT) and diabetes, respectively. Repeat

OGTT 2 weeks later showed 48 per cent now had normal glucosetolerance 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

wereSouthAsians,and25percentwereCaucasian (no familyhistoryof

diabetes in 62 per cent). Fifteen of 53 patients (28 per cent) with eitherIGT 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 andIGT 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.


DIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascularDIABETICMedicine Clinical care and other categories posters: cardiovascular

P156

Relieving the stress: the effect of primarypercutaneous coronary intervention onblood glucose levels in ST elevationmyocardial infarctionAK McGregor1, R Edwards1, H Thomas1, IF Purcell1 andNJ Leech2

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

Trust, Newcastle-upon-Tyne, UK, 2Diabetes and Endocrinology, Newcastle-

upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK

Aim: Studies demonstrating the benefit of insulin/dextrose infusion inpatients with hyperglycaemia and ST elevation myocardial infarction(STEMI) precede the widespreaduse 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/dextroseinfusion.

Methods: We measuredcapillarybloodglucoseonadmissionand1 hafter 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 admissionblood 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). Inthe 19 patients with admission glucose greater than 10 mmol/l,blood glucose fell from 13.3 3.1 mmol/L (mean SD, range10.420.0 mmol/l) to 10.8 4.6 mmol/l (mean SD, range5.324.4 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 themajority of patients. The benefits of insulin/dextrose infusions before

and after PCI therefore need further study.

P157

Estimating absolute cardiovascular riskreduction in young South Asians with newlydiagnosed glucose disordersDR Webb1, LJ Gray2, K Khunti2, A Farooqi2 and MJ Davies1

1Cardiovascular Sciences, University of Leicester, Leicester, UK, 2Health

Sciences, University of Leicester, Leicester, UK

Aims: Screening is recommended within groups at high risk of Type 2diabetes 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 modelledestimated absolute 10 year cardiovascular risk reduction (CVRR)

associatedwithpharmacological interventions in2540-year-oldSouth

Asians identified with impaired glucose regulation (IGR) or diabetes

through screening.

Methods: Effect estimates were derived from outcome trials ofindividual risk factors in established diabetes (additive model) and a

published randomised trial of multi-factorial intervention in screen-

detected cases (cumulative model). Baseline biomedical characteristicsrequired 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 screenedcohort of 359 with undiagnosed diabetes and IGR frequencies of 3.1

per cent (n = 11) and 12 per cent (n = 42) respectively. Calculatedbaseline 10 year cardiovascular risk was 4.91 per cent (SD 3.91) fordiabetesand4.44per cent (SD4.14) for IGR.The additive effects model

of lipid,bloodpressure,glucose loweringandaspirinresultedinaCVRR

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 intensivemulti-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 acrosspopulations is valid, clinically significant reductions in absolutecardiovascular 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.

Clinical care and other categories posters: case reports

P158

The first case of fetal genetic testing toguide insulin treatment in gestationaldiabetesAJ Chakera1,2, BA Knight1,2, RH Sturley3, S Ellard4 andAT Hattersley1,2

1Peninsula 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,4Department of Molecular Genetics, Royal Devon and Exeter NHS Foundation

Trust, Exeter, UK


P159

Important lessons from a rare case ofCharcot osteoarthropathy of the wrist indiabetesME Edmonds1, V Kavarthapu2, J Compson2, G Vivian3, D Elias4

and NL Petrova1

1Diabetic 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


DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports DIABETICMedicineClinical care and other categories posters: case reports


P160

Improved metabolic response to exercise onsulfonylurea drugs compared with insulin inHNF1A-MODYAN Lumb1, G Thanabalasingham2,3, IW Gallen1 andKR Owen2,3

1Diabetes 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 tohypomethylation of the maternal TND locus,is characterised by impaired insulinsensitivity and secretionYS Cheah1,2, T Evans3, L Docherty4, DJG Mackay4, IK Temple4

and SA Amiel1,2

1Diabetes Research Group, Kings College London, London, UK, 2Department

of Diabetes, Kings College Hospital NHS Foundation Trust, London, UK,3Paxton Green Group Practice, Lambeth Primary Care Trust, London, UK,4Faculty of Medicine, University of Southampton, Southampton, UK


P162

Hypoglycaemia documented withcontinuous glucose sensing in a case ofdead in bedN Waheed, MI Butt, E Jones, A Newton, S Wong and C Dayan

Diabetes Department, United Bristol Healthcare NHS Trust, Bristol, UK

We report a 41-year-old man who was found dead in his bed with acontinuous glucose monitoring device in situ. He had Type 1 diabetesdiagnosed at age 14 years. He had poor glycaemic control during his

teenage years and suffered from severe hypoglycaemic episodes andreduced 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 inJune 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 episodesover 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 remainedpersistently 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/sensorsystem. 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 havebeen the cause of death.

P163

Managing insulin and carbohydraterequirements for an athlete with Type 1diabetes: cycling from John OGroats toLands EndR Ritchie1, J Hadley2, S Woodman1 and R Holt3

1Nutrition 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 performinghigh intensity and long duration exercise, in particular preventing

hypoglycaemia and hyperglycaemia to optimise performance, is

challenging. To achieve this, a fine balance between carbohydrateintake and basal/bolus insulin is required.

Case report: A 28-year-old man with Type 1 diabetes was referredwith fluctuating blood glucose levels (BGL) ( 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 percent 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 consumingnumerous 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 orglucose 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 reductionsofup to60per centofrapid 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 levelconcentration during intensive exercise.

P164

Use of insulin pump therapy in patients withcystic fibrosis related diabetes: a case seriesS Gupta and R Canavan

Endocrinology and Diabetes Centre, St Vincents University Hospital, Dublin,

Ireland

Cystic fibrosis related diabetes (CFRD) is associated with 6-foldincrease 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 CFRDpatients 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 percent). 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

DIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reportsDIABETICMedicine Clinical care and other categories posters: case reports


mimran74Rectangle

required to manage complications of decompensated liver disease.

BMI improved minimally (19 kg/m2) and HbA1c fell (7.4 to 5.5 percent). 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 indicationsfor 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 thetinJT Cameron1, M Shepherd2, S Ellard2 and E Pearson1

1Diabetes, NHS Tayside, Perth, UK, 2Diabetes Genetics, Peninsular Medical

School, Exeter, UK

Background: Maturity-onset diabetes of the young (MODY) is oftenmis-diagnosed as Type 1 diabetes (T1D). The discovery of an HNF1Amutation 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 thesame 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. Anothercousin 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 offeringgenetic testing to all family members with diabetes. Dual diagnoses are

possible and a thorough assessment of each individual is required to

ensureanaccuratediagnosis ismadewhichwill also influence treatmentchoices.

P166

Insulin-type cutaneous amyloid from insulininjectionsIW Seetho1, A Coup2 and SA Olczak3

1Department 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

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 52mmin maximum dimension, which contained a firm, yellowish central

lesion on sectioning. Microscopy of this showed a nodular lesion

composed of amorphous eosinophilic material within fat, with a minorpatchy 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, indicatingamyloidosisof the insulin type.His serum amyloidP

component (SAP) scintigraphy scan showed no visceral amyloid

deposits. There was no evidence of systemic amyloidosis and plasmacell 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 inthe 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 canthen be investigated accordingly.

P167

GLIS3 mutations: a rare cause of neonataldiabetesO Ajala1, J Jones2, S Ellard3, C Shaw-Smith3 and BA Millward1

1Diabetes 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 byrecessive GLIS gene mutations (which encode a zinc finger

transcription factor) is rare; five families have been reported to date.Cardinal featuresareneonatal diabetesandcongenital hypothyroidism;

additional features include congenital glaucoma, hepatic fibrosis,

polycystic kidneys, developmental delay and facial dysmorphism. Wereport an unusual case with neonatal diabetes without thyroid

abnormalities.

Case history: SM, now 33 years, weighed 2,750 g at birth. She wasdiagnosed with diabetes at 1 week and treated with insulin. Choanalatresia was noted at 9 days and surgically corrected. By 4 years, she

failed to meet developmental milestones. Genetic screening of the

KCNJ11,ABCC8, INS,GCKand IPF1genes in20062008revealedno

abnormalities. DNA was retested in 2011 by array CGH revealing apaternally 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. Thyroidultrasound, function and autoantibodies were normal; she had no other

abnormalities and normal menstrual function.

Discussion: Genetic testing for PNDM is routine practice sinceidentification of a mutation in the KCNJ11 or ABCC8 genes (whichaccount for G50 per cent of cases) allowed better treatment withsulfonylureas 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.



P168

Ketoacidosis is not always due to diabetesO Ajala and DE Flanagan

Department of Diabetes and Endocrinology, Plymouth Hospitals NHS Trust,

Plymouth, UK

Background: Diabetic ketoacidosis (DKA) is anacute life-threateningcomplication 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-nourishedindividual. 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 foundunconscious 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 (capillaryglucose 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 madeand 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 ofcapillary glucose. Diabetes was excluded following normal capillary

glucose readings over a 24 h period ( 5 mmol/l), normal fastingglucose (4.9 mmol/l), normal HbA1c (4.8 per cent), C-

peptide > 500pmol/l and negative diabetes auto-antibodies (GADand islet cells).

Discussion: A possible explanation for initial hyperglycaemia mightbe the administration of intravenous dextrose prior to admission to

medical assessment (although this was not documented in the medicalnotes). 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 andpotentially reversible complication ofpoorly controlled diabetesB Paranandi1, J Hannah2, S Ashton-Cleary2, R Rea2 andA Austin1

1Hepatology, 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 uniquehistological 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 femalewith 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 liverscreening 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, mildsplenomegaly and patency of the portal and hepatic veins. Liver

biopsy showed a patchy lobular neutrophil infiltrate, extensive clearing

of hepatocyte cytoplasm and glycogenation of nuclei. There was no

evidence of fatty change, inflammation or fibrosis. A diagnosis ofglycogenic 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 impalpableliver and no other hepatic sequelae.

P170

Autoimmune pancreatitis and diabetesN Kaimal, A Kyriacou, C Babbs, S Taggart and B Young


Case history: A 68-year-old South Asian gentleman presented withreduced 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 yearsago, 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 wasconfirmed on CT.

Investigations: CT showed mediastinal and hilar lymphadenopathybut also showed bulky pancreas with peripancreatic oedema. Lymph

node aspirate was negative for tuberculosis but positive for silica. ESRwas 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 thecontext 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 clearimprovement in the inflammatory changes of the pancreas as well as the

hilar and mediastinal lymphadenopathy.

Conclusions: Pancreatic endocrine deficiency may rarely besecondary to autoimmune pancreatitis. Although uncommon, thisdisorder is usually treatable and hence merits consideration when the

presentation of diabetes is unusual.

P171

Acromegaly: a rare but important cause ofinsulin resistance in Type 1 diabetesJ Prague1, MSB Huda2, A McGregor1 and D Hopkins2

1Department of Endocrinology, Kings College Hospital, London, UK,2Department 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 withType 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 insulinrequirements; intravenous insulin at 3 units/h was required to

maintain fasting euglycaemia. Following basal insulin optimisation,



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 tocheiroarthropathy. 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 andprandial 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 ofinsulin 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 diabetesS 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 ofdiabetic 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 diabetespresented 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. Investigationsconfirmed 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 onintravenous 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 withclinical and symptomatic improvement.

Discussion: The source of air in the mediastinum orpneumomediastinum can be lungs, bronchial tree or oesophagus.

Spontaneous pneumomediastinum is uncommon; it results from

alveolar rupture, otherwise known as the Macklin phenomenon. Airmay 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 inwhom 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.

P173

Person with Type 1 diabetes andhypoglycaemia unawareness who regainedhypoglycaemia awareness and improvedglycaemic control post DAFNE course: a casereportKE 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 hewas 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 of7.5 mmol/l and toavoidhisbloodglucose level fallingbelow4.5 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 (8.2per cent) and in theprecedingyearhehadrequiredparamedicassistance

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 hisdriving 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 theprinciples 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 pregnancyF Le Neveu1, B Hywel2 and J Harvey1

1Department 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 ofdiscussion 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 beensuggested. 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 withher 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 requiredinotropic 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 compensatedmetabolic 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 counter-regulatory hormone levels rise causing free fatty acid release and ketone



production by the liver. With fasting, insulin levels are suppressed.

Euglycaemic ketoacidosis is more common in pregnancy probablybecauseof the insulin resistant stateand theeventsof 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.

P175

Eruptive xanthoma preceding acutepresentation of severehypertriglyceridaemia with new onsetdiabetes complicated by pancreatitis: a casereportR Ahluwalia1 and L Overend2

1Diabetes 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 pancreatitisaccounting 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 inducedpancreatitis. 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 withnew 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 managedconservatively. 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/molIFCC 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 fordiabetes. 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 wellas 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.

P176

Previously unrecognised HNF1B in adiabetes clinic: the value of systematictesting in patients with young-onsetdiabetesS Tiley1,2, M Shepherd1,2, UNITED Research Team1,2,TM McDonald3, S Ellard4 and AT Hattersley1,2

1Peninsula National Institute for Health Research (NIHR) Clinical Research

Facility, Peninsula College of Medicine and Dentistry, University of Exeter,

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-onsetdiabetes of the young (MODY) and is typically characterised by renalcysts 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 toproceed to genetic testing.

Case study: A 29-year-old man presented with a 6 months history ofpolyuria, polydipsia and loss of appetite; RBG 20.1 mmol/l, Hba1c

16.2 per cent (157 mmol/l), urinalysis 4 + glucose, 1 + ketones, bodymass 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 andprovided 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 wastested 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 leftkidney; the right kidney appeared entirely normal, renal function wasnormal, creatinine 87 lmol/l. Faecal elastase 106 mcg/g indicatedmoderate 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 young-onset diabetes can indicate individuals who may benefit from genetictesting and identify previously unrecognised cases of monogenic

diabetes. Recognising HNF1B is important as this allows

appropriate screening, follow-up and discussion of risk to otherfamily members.

P177

Dual onset of autoimmune hepatitis anddiabetes in an 18 year old patientM 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 ofautoimmune 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



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

Diabetic ketoacidosis was ruled out and subcutaneous insulin wascommenced. 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 andthyroid 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 withautoimmune 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 ifnecessary for, other potential coexisting autoimmune conditions.

P178

Does exercise preserve the honeymoonperiod in Type 1 diabetes? A presentation ofthree clinical casesA 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 (

Case 2: A 28-year-old primagravida with well-controlled Type 1diabetes of 18 years duration, microalbuminuria and previous

treatment of right-sided maculopathy presented with maculopathy at20 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 asudden deterioration in vision with a drop in VA to 6/9, 6/15. OCT

showeddiffusemacularoedema.Treatmentwithoral furosemide40mg

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. Thebenefit 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 birthweight.

P181

An insulin gene mutation presenting asmaturity-onset diabetes of the youngSA Mughal1,2, A Webster3, S Ellard4 and KR Owen1,2

1Oxford 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

Mostpatientswith insulingene (INS)mutationshaveneonataldiabetes.

However, a few patients present with clinical characteristics similar tomaturity-onset diabetes of the young (MODY). We present a family

clinicallydiagnosedas MODYwhoonfurther investigationwere found

to have a novel INS mutation. A 20-year-old lean woman was referred

to our monogenic diabetes clinic with symptoms of postprandialreactive 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 well-controlled 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 percent

hypoglycaemia documented with real-time continuous glucose sensing in a case of ‘dead in bed’...

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