Dear Editor, the launch of the FreeStyle Libre intermittently scanned continuous glucose monitoring system (also known as Flash or isGCM) on prescription in November 2017 and subsequently Libre 2 has brought about a paradigm shift in the widespread availability of CGM for people living with type 1 diabetes (T1D) in the UK.1 Libre has been available for self-funding since 2014 and real-time (rt) CGM has been around commercially for a decade or so before this.2 Strong clinical leadership from Professor Partha Kar and colleagues from the Diabetes Technology Network along with campaigning from patient organisations have undoubtedly accelerated and catalysed this change with over 69% of the English population of people living with T1D being prescribed a Libre, and – with the exception of two (out of 42) integrated care systems – all other systems have at least half of their population of people living with T1D on Libre from almost zero five years earlier.3 This growth occurred prior to the publication of 2022 NICE guidance (NG17)4 recommending all forms of CGM be offered to all people living with T1D. Previous NHS England guidelines suggested about 20% of the T1D population would be eligible for FreeStyle Libre and funding for sensors up to this number of patients was available centrally for a limited time. National Diabetes Audit data for rtCGM from 2020–215 (until recently rtCGM was not available on prescription at all) show that the majority of specialist adult diabetes care providers in England had none or a miniscule percentage of their patients using rtCGM; many of these same units had large numbers of people using FreeStyle Libre. (See Figure 1.) These data would suggest that there were (and still may be) large parts of the country where, for adults with T1D, rtCGM was (or still may be) either not available or difficult to access. The data would further suggest that there is an even greater variation in the use of rtCGM than there is with FreeStyle Libre. The recent update to NG174 on the use of all forms of CGM has undoubtedly encouraged companies to include some of their rtCGM products on prescription, but not all. At present there appears to be inconsistent, non-transparent and often complicated local schemes for providing access to many rtCGM systems. This makes delivery on the promise of NG17 unnecessarily difficult -- especially in terms of giving people with T1D a genuine choice in the device they use to monitor their glucose levels. If we are to fully meet the glucose monitoring needs of our adult population of people with T1D, surely the time has come for all CGM systems to be available on prescription. This would create a level playing field for people living with diabetes and those who provide their care, thereby affording access based on NICE 2022 criteria in keeping with the founding principles of the NHS. There are no conflicts of interest declared.

The 2022 Mary MacKinnon lecture reminds us of some of the history of the development of out of hospital specialist diabetes services in the United Kingdom. There have been multiple clarion calls across the years to collaborate, share information and values and break down traditional boundaries in the pursuit of improved patient care and outcomes. Along with this, we note the roles of clinical and managerial leadership, followership and partnership in working together with people living with diabetes to co‐produce a model of diabetes care and then to ensure through good stewardship of shared resources that the expectations of that change are delivered for our population. We go on to discuss how the Diabetes Care for You team has continued to innovate and provide care during the pandemic and conclude with a vision of the future and a challenge for decision makers to put the needs of the population at the forefront of future planning. Copyright © 2023 John Wiley & Sons.

Background Sub-optimal control of diabetes is a significant cause of complications during pregnancy. One of the aims of diabetes management should be to ensure that all women of child-bearing age with diabetes should be regularly screened with regard to their plans for pregnancy to ensure that their overall diabetic control and fitness for pregnancy can be maximized. Methods We analysed the electronic patient records of a target population of young women of child-bearing age (16–45) with both type 1 and type 2 diabetes who were attending the diabetes review clinic over a period of three years from 2007 to 2010. The Diabeta 3 software program which is commonly used has a query builder function which allows immediate recall and analysis of data. Results Of 1808 patients within the fertile range, only a small number appeared to have had information accurately documented with regard to any of the following: pregnancy plans, preconception counselling, contraception and also the recording of whether patients with diabetes were pregnant or not and enrolled in the ante-natal diabetes clinic. Conclusions The main inference from the data is its paucity and inaccuracy. It would appear that we are failing to enquire and/or record the fertility intentions of young female patients with diabetes. This is important because it means that we subsequently then miss those patients who need to be targeted for preconception counselling/optimization, which has implications for the morbidity and mortality associated with diabetes in pregnancy.

This case describes for the first time a de novo chromosomal abnormality (46, XX, inv dup del(12)(qter-p13.3::p13.3-p12.3:)dn.ish inv dup del(12)(TEL-ETV6++) which produced the phenotype of a female with primary ovarian failure and subsequent osteopenia in early adult life. This warranted treatment with oestrogen replacement therapy and close supportive monitoring.

AimsUsing psychological and quality of life assessment tools, we prospectively studied changes in health-related quality of life and emotional well-being in patients who had commenced GLP-1 analogue therapy (exenatide) and compared them with new insulin starters.MethodsTwo matched groups of patients with type 2 diabetes who had suboptimal glycaemic control on oral medication were assessed using a battery of well-validated psychological and quality of life tests at baseline, prior to commencement of treatment and then again after 6 months of continuous therapy, along with body mass index (BMI) and hemoglobin A1c (HbA1c) measurements.ResultsIn the exenatide-treated patient group (n=71), treatment satisfaction was greater (P<.05), as was the well-being score, at 6 months (P<.05), and the Hospital Anxiety and Depression Scale scores were significantly reduced (P<.05) when compared with the insulin-treated group (n=67). This was also found to be independent of changes in BMI in an analysis of covariance calculation. The effect size (using Cohen's d) of these changes was however relatively small.ConclusionsAlthough exenatide and insulin appear to have similar efficacy for the treatment of type 2 diabetes mellitus, there are several differences between them that could influence outcomes from a patient's perspective. Exenatide affects both physiological and psychological parameters. ‘Well-being’ generally tends to improve in exenatide-treated patients and could be used as an adjunctive therapy for depression in the context of diabetes. A larger study is required to confirm these interesting findings.

We describe the rare condition of emphysematous pyelonephritis (EPN) in a non-diabetic patient who had previously undergone gender reassignment surgery. The report discusses the acute management and treatment and then provides background to the aetiology and historical aspects of the condition.

Recent developments in the field of diabetes and endocrinology have led to greater understanding of the body's complex hormonal axes. This article reviews the latest significant treatments which have the potential to impact greatly on a wide variety of disease states in the not too distant future.

Sir, Obesity is both a disease in itself and a risk factor for cardiovascular death, diabetes and cancer. As an issue of local and national concern we wished to establish if patients in our hospital trust are being correctly identified as being obese. This is in order that the condition may be highlighted, potential causes (endocrine or otherwise) identified and treatment options considered (dietary, pharmacological or surgical). We were interested in whether obese patients are being formally ‘diagnosed’ and appropriately clinically coded.1 Data were collected over a one-month period in April 2008. All inpatients admitted to the trust were included, from all specialties. Information from discharge summaries, computer records and clinical notes was used. We wanted to attempt to quantify how often we are accurately measuring and documenting patient body mass index (BMI) using height and weight measurements. Obesity was defined as having a BMI > 30 and morbid obesity > 40. Also noted was whether the term obesity was used in any diagnosis or problem list, examination findings or clinical coding record. The clinical code for obesity is E66 (0–9). There were a total of 4672 patients discharged from Eastbourne District General Hospital in April 2008. Of these, only 32 had a clinical code of E66 (0–9 in any position). Twenty-two were obese and 10 morbidly so. The majority were known to either diabetes or endocrine services. Of the remaining 4640, we analysed 280 sets of notes and 182 discharge summaries (10% of the total). In this subgroup, 58% of patients had their bodyweight measured at some point during their hospital admission, either as part of the initial nursing assessment or later. Eight percent had their heights measured at any time. Only 6% had their BMIs calculated. This roughly equates to only 280 patients over the course of the whole month. Forty-two percent of these would fulfil the criteria for being obese but were not coded or ‘diagnosed’ as such. BMI calculation is very easy to perform. We are significantly sub-optimal in measuring and acting on it. By attempting to identify patients with obesity as an ‘official’ clinically coded problem we can then focus on the condition as a distinct clinical entity that warrants investigation and management.2 We know there are evidence-based treatments for this condition (that is associated with a great deal of morbidity and mortality) and until we establish the extent of the problem we cannot begin to manage it effectively. We conclude that it is essential that all patients admitted to hospital have a BMI documented as part of their nursing or medical assessment and that it is recorded on the patient's discharge summary. There are no conflicts of interest.

Diabetic neuropathy is a significant complication of chronic diabetes. We wished to discover whether we were successfully identifying patients who had developed neuropathic problems. Specifically, Diabetologists are traditionally poor at asking about erectile dysfunction (ED) and patients themselves are not always forthcoming as it an embarrassing medical problem. We targeted all patients attending diabetes review clinics over a 4-month period in two hospitals and asked them to complete an anonymous, self-reported questionnaire after their consultation with the diabetologist or diabetes specialist nurse. Whilst most aspects of diabetic neuropathy are routinely screened for in the diabetes clinic we found that the neuropathic symptoms of both ED and gastroparesis were not commonly enquired about, and that erectile failure was found to be more prevalent than previously. Diabetologists need to be more thorough in their assessment of diabetic neuropathy. This is especially of import with regards to ED because we often shy away from enquiring into such a personal area and male patients rarely highlight the issue due to embarrassment. Our post consultation questionnaire has now been modified to form a useful preconsultation neuropathy screening tool and this is undergoing validation.