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A 42 year-old Caribbean woman with, known type 2 diabetes, was admitted with worsening fatigue, arthritis and rashes. She was diagnosed with multisystem systemic lupus erythematosus and was initially treated with systemic steroids. During this admission, she had persistently elevated capillary glucose levels with insulin requirements over 8 U/kg/day that still did not control her blood glucose levels. Due to her profound hyperglycaemia, serum samples of fasting insulin, C-peptide, paired with blood glucose were analysed, which confirmed significant hyperinsulinaemia. Further analysis confirmed the presence of insulin receptor antibodies consistent with type B insulin resistance.She was started on intravenous cyclophosphamide (Euro-Lupus regimen) along with continuous glucose monitoring system. After completing her six cycles of cyclophosphamide, she no longer required insulin treatment. The goal of therapy for our patient with confirmed type B insulin resistance was to manage hyperglycaemia with high doses of insulin until autoantibodies were eliminated with immunosuppressive therapy.

Background: Adolescence is a challenging time for young people with Type 1 diabetes, associated with worsening glycaemia and disengagement with care. To improve support, we co-designed with young people a novel psychosocially modelled programme of diabetes education (the Youth Empowerment Skills [YES] programme). This study aimed to estimate the clinical impact and feasibility (recruitment, retention and participant experiences) of this programme. Methods: A pilot study using mixed-methods was conducted to assess process and outcomes, involving a pre- and post-exposure assessment of glycaemic control, programme participation data, service utilisation and qualitative semi-structured interviews (analysed using Framework Analysis). Participants were recruited from two hospital diabetes centres in Southeast London. The intervention was conducted in local community centres. Participants were young people with Type 1 diabetes aged 15–21 years. The YES programme involves contact with an outreach youth worker and attending a 3-day psychologically modelled course encompassing social learning, peer facilitation and simulation exercises. The primary outcome was change in HbA1c at 6 and 12-months post-intervention. Secondary outcomes included diabetes-related hospital admissions and incident diabetic ketoacidosis (DKA). Results: Twenty-six young people participated in the programme, mean age 18 (±1.7) years. Uptake was 34% (n = 26) of those approached, with 96% (n = 25) programme completion. Pre-exposure (12 month mean) HbA1c was 93.5 (±29.7) mmol/mol (10.7%), and at 12 months post-exposure, it was 85.1 (±25.4) mmol/mol (10%) (P = 0.01), with 46% (n = 12) of participants achieving a reduction in their HbA1c ≥5.5 mmol/mol (0.5%). Unplanned hospital admissions and DKA rates reduced by 38 and 30%, respectively. The qualitative data identified positive psychosocial impacts including increased diabetes engagement and activation. Active ingredients were social learning, peer support and experiential learning. Participants emphasised the importance of the youth worker in engaging with the programme. Conclusion: The evaluation indicates that the YES programme helps improve young people’s self-confidence in managing diabetes, enhances diabetes engagement and improves clinical outcomes.

OBJECTIVE The Hypoglycemia Fear Survey-II (HFS-II) is a well-validated measure of fear of hypoglycemia in people with type 1 diabetes. The aim of this study was to explore the relationships between hypoglycemia worries, behaviors, and cognitive barriers to hypoglycemia avoidance and hypoglycemia awareness status, severe hypoglycemia, and HbA1c. RESEARCH DESIGN AND METHODS Participants with type 1 diabetes (n = 178), with the study population enriched for people at risk for severe hypoglycemia (49%), completed questionnaires for assessing hypoglycemia fear (HFS-II), hyperglycemia avoidance (Hyperglycemia Avoidance Scale [HAS]), diabetes distress (Problem Areas In Diabetes [PAID]), and cognitive barriers to hypoglycemia avoidance (Attitudes to Awareness of Hypoglycemia [A2A]). Exploratory factor analysis was applied to the HFS-II. We sought to establish clusters based on HFS-II, A2A, Gold, HAS, and PAID using k-means clustering. RESULTS Four HFS-II factors were identified: Sought Safety, Restricted Activity, Ran High, and Worry. While Sought Safety, Restricted Activity, and Worry increased with progressively impaired awareness and recurrent severe hypoglycemia, Ran High did not. With cluster analysis we outlined four clusters: two clusters with preserved hypoglycemia awareness were differentiated by low fear/low cognitive barriers to hypoglycemia avoidance (cluster 1) versus high fear and distress and increased Ran High behaviors (cluster 2). Two clusters with impaired hypoglycemia awareness were differentiated by low fear/high cognitive barriers (cluster 3) as well as high fear/low cognitive barriers (cluster 4). CONCLUSIONS This is the first study to define clusters of hypoglycemia experience by worry, behaviors, and cognitive barriers to hypoglycemia avoidance. The resulting subtypes may be important in understanding and treating problematic hypoglycemia.

In our study of 187 patients with diabetes hospitalised with COVID-19 we observed a more than 5 fold increased risk of intubation in patients with diabetic retinopathy. Further studies are required to understand the mechanisms that explain the associations between retinopathy and other indices of microangiopathy with severe COVID-19.

Background: The transition from adolescence to young adulthood can be challenging for young people with type 1 diabetes. During this period many young people become disengaged from their health care and can experience increases in adverse diabetes events and diabetes distress. Study Aim: To deliver a novel psychoeducational programme called Youth Empowerment Skills (YES), using simulation based experiential learning and peer learning to increase diabetes knowledge and social confidence in young people with type 1 diabetes. Method: The YES programme was delivered in community settings with a youth worker supporting engagement. HbA1c and admission data were collected 12-months pre and post intervention. Follow-up qualitative questionnaires and semi-structured interviews were conducted 6 weeks post-intervention to elicit participant views of the programme. The study was conducted in a South London boroughs with high levels of socioeconomic disadvantage and ethnic diversity. Results: Data were collected from all participants (n=41), mean age 17.3±2.3 years. Mean HbA1c 12 month prior to attending the programme was (DDCT%) 10.4%±4.8%. There was a reduction of mean HbA1c at 12-months post-intervention to 9.7%± 4.6%m (Δ 0.7%) (p< 0.01). DKA admissions reduced by 55.6% (n=15) over the 12 month follow-up; saving £78,000 in admission avoidance. The programme successfully engaged young people from ethnic minorities (53%) and with high social deprivation (65%). Qualitative data showed perceived improvements in clinical knowledge and psychosocial health. Feedback highlighted active learning sessions and peer support as strengths of the programme. Conclusion: The study showed that the YES programme was beneficial in improving glycaemic control and reducing diabetes related admissions in adolescents with type 1 diabetes; and encouraged a more positive and accepting attitude towards living with diabetes. Disclosure D. Kariyawasam: None. K.A. Saqi: None. F. Dehzad: None. S. Pender: None. M. Jones: None. N. Yemane: None. R.H. Griffiths: None. T. Soukup: None. S.M. Singham: None. A. Forbes: None.

Problematic hypoglycemia complicates insulin therapy in >25% of adults with type 1 diabetes (T1D). Previous work has identified relationships between cognitive barriers to hypoglycemia avoidance and impaired awareness of hypoglycemia (IAH) with recurrent severe episodes (SH). We investigated fear of hypoglycemia in people with IAH and SH enrolling in a trial of interventions to restore hypoglycemia awareness (“HARPdoc” ClinicalTrials.gov NCT02940873) and compared their data with T1D clinic attenders not enriched for problematic hypoglycemia. Method: Adults with T1D (HARPdoc cohort; n=98, age 54±13 yr, 56% female, T1D duration 40±15 yr) and problematic hypoglycemia (Clarke score 5.5±1.0) completed the Hypoglycemia Fear Survey II (HFS), Hyperglycemia Avoidance Scale (HAS) and anonymous 12 month SH recall forms. The T1D clinic comparator group was n=467, age 46±14 yr, 50% female, T1D duration 30±13 yr. Results: In preliminary analyses, the HARPdoc cohort (n=88) reported higher scores on total HFS (p=0.018) and its worry subscale (p12 SH per yr). Worry scores increased with higher SH rates (p=0.004). Behavior scores increased (p=0.041) but not above the comparator 75th centile. In the ’maintaining high glucose’ subset of HFS behavior items, scores increased between the high SH rate groups (p=0.042) but not the lower rate groups. Conclusion: The majority of people with significant hypoglycemia problems show appropriately increased worry but not corresponding increases in behavior scores. A subgroup show inappropriately low worry. Inability to change behaviors, and worry about hyperglycemia, may be barriers to avoiding SH. Disclosure R.H. Maclean: None. P. Jacob: None. S. Haywood: None. P. Choudhary: Advisory Panel; Self; Abbott, Eli Lilly and Company, Insulet Corporation, Medtronic. Research Support; Self; European Union, JDRF. Speaker’s Bureau; Self; Dexcom, Inc., Novartis AG, Novo Nordisk A/S, Sanofi-Aventis. S.R. Heller: Advisory Panel; Self; Eli Lilly and Company, Novo Nordisk A/S, Zealand Pharma A/S. Speaker’s Bureau; Self; AstraZeneca, Novo Nordisk A/S. Other Relationship; Self; MannKind Corporation. E. Toschi: None. D. Kariyawasam: None. T.C. Anderbro: None. S.A. Amiel: Advisory Panel; Self; Medtronic, Novo Nordisk A/S, Roche Pharma. Other Relationship; Self; Diabetes UK. Funding JDRF (4-SRA-2017-266-M-N)

Background Multiplex bead assays, also known as addressable laser bead immunoassays (ALBIA) or Luminex® technology, have provided an alternative to enzyme-linked immunoassay, which is still the most widely utilized routine immunoassay for detection of specific autoantibodies. Our laboratory adopted the ALBIA technology early into its routine service. Methods We report the performance and utility of measurement of three different autoantibody types tested using the FIDIS (BMD, Marne La Vallee, France) ALBIA system. The analytes discussed are thyroid antibodies (thyroglobulin [TG], thyroid peroxidase [TPO]), anti-neutrophil cytoplasmic antibodies (ANCA), and ribonucleo-protein (RNP) antibodies. Results In single antibody analysis, TPO antibody testing was superior to TG antibody in identifying patients with Graves' disease and Hashimoto's thyroiditis. However, testing only TPO antibody would result in missing 8.6% of Graves' and 11.9% of Hashimoto's thyroiditis patients, hence demonstrating an advantage for the multiplex TG plus TPO assay. With respect to ANCA, the FIDIS ALBIA produced an overall similar level of performance to our comparator method, the Phadia fluorescent enzyme linked immunoassay. Sensitivity of the ALBIA for RNP antibodies was low in comparison to countercurrent immunoelectrophoresis, but performance was improved by altering the cutoff value for the assay. Conclusions ALBIA technology has many potential advantages in the routine laboratory, but as with any new assay, evaluation must be thorough and ongoing to ensure satisfactory clinical performance is obtained. Both false positive and false negative results have been reported in ALBIA studies. It may be necessary to re-evaluate assay performance and cutoff and consider further clinical correlation.

IntroductionSevere hypoglycaemia (SH), when blood glucose falls too low to support brain function, is the most feared acute complication of insulin therapy for type 1 diabetes mellitus (T1DM). 10% of people with T1DM contribute nearly 70% of all episodes, with impaired awareness of hypoglycaemia (IAH) a major risk factor. People with IAH may be refractory to conventional approaches to reduce SH, with evidence for cognitive barriers to hypoglycaemia avoidance. This paper describes the protocol for the Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc) study, a trial to assess the impact on hypoglycaemia experience of a novel intervention that addresses cognitive barriers to hypoglycaemia avoidance, compared with an existing control intervention, recommended by the National Institute of Health and Care Excellence.Methods and analysisA randomised parallel two-arm trial of two group therapies: HARPdoc versus Blood Glucose Awareness Training, among 96 adults with T1DM and problematic hypoglycaemia, despite attendance at education with or without technology use, in four centres providing specialist T1DM services. The primary outcome will be the SH rate at 12 and/or 24 months after randomisation to either course. Secondary outcomes include rates of SH requiring parenteral therapy, involving unconsciousness or needing emergency services; hypoglycaemia awareness status, overall diabetes control and quality of life measures. An implementation study to evaluate how the interventions are delivered and how implementation impacts on clinical effectiveness is planned as a parallel study, with its own protocol.Ethics and disseminationThe protocol was approved by the London Dulwich Research Ethics Committee, the Health Research Authority, National Health Service R&D and the Institutional Review Board of the Joslin Diabetes Center in the USA. Study findings will be disseminated to study participants and through peer-reviewed publications and conference presentations, including user groups.Trial registration numberNCY02940873; Pre-results.

We report a case of severe hypercalcaemia secondary to rhabdomyolysis in a woman with COVID-19 (SARS CoV-2) infection. The patient presented with myalgia and anuria with an acute kidney injury requiring haemodialysis. Creatine kinase peaked at 760 000 IU/L. A biphasic calcaemic response was observed with initial severe hypocalcaemia followed by severe, symptomatic hypercalcaemia, persistent despite haemodialysis. Control of the calcium levels was achieved by continuous haemofiltration.

Background: Diabetes management in primary care is becoming increasingly complex. Integrated working between primary and specialist care teams is important in addressing this complexity. Diabetes virtual clinics (DVC) provide an opportunity for the diabetes specialist team to work collaboratively with the primary care team.Aim: To evaluate the impact of a DVC on the clinical management and care outcomes of patients in primary care settings.Methods: A prospective clinical audit of DVC patients was performed in seven general practices comparing data, at baseline and at 6 months. The audit measured changes in care provision and clinical performance. The primary audit standard was that 50% of cases with a baseline glycated haemoglobin (HbA1c) ≥58 mmol/mol (7.5%) would optimise HbA1c by a clinical significant reduction of 6 mmol/mol (0.4%).Results: The audit examined 113 cases that were exposed to the DVC. Data were available on 73 cases at 6 months. The main theme for case discussion was treatment mod...

Aims/Introduction Monogenic diabetes accounts for approximately 1–2% of all diabetes, and is difficult to distinguish from type 1 and type 2 diabetes. Molecular diagnosis is important, as the molecular subtype directs appropriate treatment. Patients are selected for testing according to clinical criteria, but up to 80% of monogenic diabetes in the UK has not been correctly diagnosed. We investigated outcomes of genetic testing in our center to compare methods of selecting patients, and consider avenues to increase diagnostic efficiency. Materials and Methods We reviewed 36 probands tested for monogenic diabetes in the last 10 years in a large adult diabetes outpatient clinic, serving an ethnically diverse urban population. We compared published clinical criteria and an online maturity onset diabetes of the young calculator applied to these 36 patients, and presented the predictions together with the molecular results. Results The overall mutation detection rate was 42%, reflecting the strict clinical selection process applied before genetic testing. Both methods had high sensitivity for identifying patients with mutations: 88 and 89% for the clinical criteria and online calculator, respectively. Cascade testing in a total of 16 relatives led to diagnosis of a further 13 cases. Conclusions Existing patient selection criteria were effective in identifying patients with monogenic forms of diabetes, but the number of patients missed using these strict criteria is unknown. Because of the potential savings resulting from correct molecular diagnosis, it is possible that testing a larger pool of patients using less stringent selection criteria would be cost‐effective. Further evidence is required to inform this assessment.