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Articles by G. Rayman
Total Records ( 8 ) for G. Rayman
  P. J. Twomey , G. Rayman and D. R. Pledger
  Background  In 2003, a new General Medical Services (GMS) contract was agreed between UK general practitioners and the Department of Health. The three diabetes codes DM5–DM7 require glycated haemoglobin (HbA1c) testing and comprise 30 points in total, with 27 points being related to target glycaemic control. We compared two routinely used Diabetes Control and Complications Trial (DCCT)-aligned HbA1c methods to determine if different HbA1c methods could lead to postcode treatment to target across the UK.

Methods  A total of 164 specimens were randomly selected from diabetic patients attending the Diabetes Centre at the Ipswich Hospital. Samples were analysed on both a DCA 2000®+ Analyser and a Variant II analyser.

Results  Despite a mean difference of only 6.5% between the two methods, 32 (19.5%) and 63 (38.4%) patient samples had an HbA1c ≤ 7.4% with the Variant II analyser and DCA 2000®+ Analyser, respectively. Thus, the two methods differed according to the DM6 GMS target by 31 patients, or 18.9% of the total number of patients in this study. The difference between the two methods was statistically significant with P < 10−09 (McNemar's test).

Conclusions  DCCT-alignment has improved the transferability of HbA1c values; however, it is not perfect. It is important that the limitations of current DCCT-aligned HbA1c methods are understood by health-care professionals and policy makers, as these may have important financial and clinical implications.

  W. Jeffcoate , M. Edmonds , G. Rayman , C. Shearman , L. Stuart and B. Turner
  Not available
  M. W. Savage , K. K. Dhatariya , A. Kilvert , G. Rayman , J. A. E. Rees , C. H. Courtney , L. Hilton , P. H. Dyer and M. S. Hamersley
 

The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at:

(i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults;
(ii) http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance;
(iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf.

This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations.

The key points are:
Monitoring of the response to treatment
(i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter.
(ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response.
(iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers.
(iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only.

Insulin administration
(i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved.
(ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued.
(iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus®, Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir®, Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses.

Delivery of care
(i) The diabetes specialist team should be involved as soon as possible.
(ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.

  K. Dhatariya , N. Levy , A. Kilvert , B. Watson , D. Cousins , D. Flanagan , L. Hilton , C. Jairam , K. Leyden , A. Lipp , D. Lobo , M. Sinclair-Hammersley and G. Rayman
 

These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information.

This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report.

This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

  C. G. Taylor Jr , C. Morris and G. Rayman
  Aim  To evaluated whether a 1 hour, interactive, case-based programme could improve the quality of care and juniors' confidence.

Methods  We designed an educational programme using a patient's journey from admission to discharge in order to teach avoidance of common errors, while enhancing familiarity with local charts and protocols. The intervention was delivered in four hospitals, to doctors within 4 years of training following graduation. Feedback was received. The quality of care provided and the confidence of juniors' in its provision was evaluated before and after the intervention.

Results  Of the 242 trainees taught, 205 (85%) provided feedback. The programme was rated ‘very’ or ‘extremely’ easy to understand by 94.1%. The format was thought to improve attention and participation, ‘quite a lot’ or ‘extremely’ by 94.1% and was ‘highly’ or ‘extremely highly’ recommended for other areas of teaching by 93.1%. The mean confidence score increased from 17.6 (SD 4) to 24.9 (SD 2.7) (< 0.001), with Cronbach α coefficients of 0.81 and 0.86 for the questionnaires before and after the programme. Insulin prescription errors were reduced by 49% (15.4% before and 7.8% after, < 0.05).

Conclusion  The inpatient diabetes education programme, which is deliverable within 1 h, was liked by juniors, increased their confidence and improved the quality of inpatient diabetes care.

  C. Kerry , S. Mitchell , S. Sharma , A. Scott and G. Rayman
 

Aim

To determine whether diurnal temporal variations in hypoglycaemic frequency occur in hospitalized patients.

Methods

Hypoglycaemic events were identified in a snapshot bedside audit of capillary blood glucose results from diabetes charts of all inpatients receiving insulin or a sulphonylurea (with or without insulin) on 2 days separated by 6 weeks. Additionally, capillary blood glucose measurements were remotely captured over 2 months, in the same category of patients, and analysed for temporal patterns. Hypoglycaemia was defined as ‘severe’ when the capillary blood glucose was < 3.0 mmol/l and ‘mild’ when the capillary blood glucose was between 3.0 and 3.9 mmol/l.

Results

The bedside audit found that 74% of those audited experienced a hypoglycaemia event. Eighty-three per cent of all hypoglycaemic events and 70% of severe events were recorded between 21.00 and 09.00 h. This was confirmed in the longer duration remote monitoring study where 70% of all hypoglycaemic events and 66% of severe events occurred between 21.00 and 09.00 h.

Conclusion

Hypoglycaemia occurs more frequently between 21.00 and 09.00 h in hospitalized patients receiving treatments that can cause hypoglycaemia. This may be related to insufficient carbohydrate intake during this period, and is potentially preventable by changes in catering practice.

  W. Jeffcoate , N. Holman , G. Rayman , J. Valabhji and B. Young
  Not available
  S. Sharma , C. Kerry , H. Atkins and G. Rayman
 

Aims

The Ipswich Touch Test is a novel method to detect subjects with diabetes with loss of foot sensation and is simple, safe, quick, and easy to perform and teach. This study determines whether it can be used by relatives and/or carers to detect reduced foot sensation in the setting of the patient's home.

Methods

The test involves lightly and briefly (1-2 s) touching the tips of the first, third and fifth toes of both feet with the index finger. Reduced foot sensation was defined as ≥ 2 insensate areas. Patients due to attend clinic over a 4-week period were invited by post. The invitation contained detailed instructions and a sheet for recording the results. The findings were compared with those obtained in clinic using the 10-g monofilament at the same six sites.

Results

Of 331 patients (174 males), 25.1% (n = 83) had ≥ 2 insensate areas to 10-g monofilament testing. Compared with this, the Ipswich Touch Test at home had a sensitivity of 78.3% and a specificity of 93.9%. The predictive values of detecting ‘at-risk’ feet were positive at 81.2% and negative at 92.8%. The likelihood ratios were positive at 12.9 and negative at 0.23.

Conclusions

With clearly written instructions, this simple test can be used by non-professionals to accurately assess for loss of protective sensation. We believe that the Ipswich Touch Test may also be a useful educational adjunct to improve awareness of diabetes foot disease in patients and relatives alike and empower them to seek appropriate care if sensation was found to be abnormal.

 
 
 
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