Vitamin E refers to a group of compounds that are essential to the diet of animals, where its primary function is an antioxidant. Excessive vitamin E supplementation can cause a reversible coagulopathy in the setting of compromised vitamin K absorption or function. We describe the case of a woman in her mid-80s treated for micronutrient deficiencies following a biliopancreatic diversion as a bariatric procedure 14 years previously. Her coagulation tests were normal until she commenced vitamin E and accidentally over-administered the prescribed dose. This resulted in a coagulopathy, characterised by a prolonged international normalised ratio (INR) and activated partial thromboplastin time (APTT). The patient never had any signs of active bleeding. Both coagulation parameters normalised after stopping the vitamin E and with vitamin K supplementation. This case signifies the importance of careful instruction and monitoring of vitamin replacement, in particular vitamin E supplementation, which in excess leads to coagulopathy.

There is growing interest in metabolic dysfunction-associated steatotic liver disease (MASLD), given its increasing prevalence and our developing understanding of the disease. People living with type 2 diabetes or obesity have a greater risk of developing significant hepatic steatosis and a greater risk of more rapid progression to steatohepatitis, advanced hepatic fibrosis and hepatocellular carcinoma. As such, various international bodies now advocate for routine screening for MASLD-related hepatic fibrosis in people with such risk factors. This would permit earlier targeted lifestyle interventions and the use of pharmacotherapies, which may reverse earlier stages of MASLD-associated fibrosis. This may improve both liver-related and cardiovascular outcomes in these higher-risk groups. Nonetheless, the identification of MASLD-related hepatic fibrosis is frequently limited to liver enzyme tests, given the lack of a systematic approach to investigation and screening. In this article, we discuss the potential to screen for advanced fibrosis in people with MASLD using various blood-based biomarkers, such as the Fibrosis-4 score, non-alcoholic fatty liver disease fibrosis score and enhanced liver fibrosis test, amongst other available patented and non-patented tests. We discuss the relative benefits and limitations of each and the potential for future research in this evolving area of clinical interest.

FreeStyle Libre (FSL) monitoring is available for all patients in Wales with insulin-treated diabetes. English guidance permits FSL in patients with type 1 diabetes mellitus (T1D) and type 2 diabetes mellitus (T2D) requiring multiple daily insulin doses (MDI) (National Institute for Health and Care Excellence 2023). The literature suggests benefits from using FSL, specifically improved glycaemic control and reduced hypoglycaemia. Patients aged >18 years with insulin-treated T2D using FSL for ≥ 3 months were identified from Libreview. Those with pre- and post-FSL HbA1c were included. Days 1–14 of FSL data were taken as baseline. Patients were categorised by insulin regime (OD basal, premixed, basal bolus). 236 patients were identified and 189 patients included. The median follow-up duration was 14.6 [10.3–15.0] months. There were significant reductions in median HbA1c [8 mmol/mol, p < 0.001], time below range [< 4.0 mmol/L](1.2 ± 3.4 vs 0.6 ± 1.5

Starvation ketoacidosis represents one of the three forms of metabolic acidosis caused by the accumulation of ketone bodies within the blood stream. It can be easily missed in patients who present acutely and are found to have an unexplained or profound metabolic acidosis. Here, we present a life-threatening case of severe ketoacidosis in a breast-feeding mother without diabetes who was on a strict ketogenic diet. Although a ketogenic diet has been previously considered to be safe in non-pregnant individuals, its safety in breast-feeding mothers in the post-partum period is less known and may be associated with greater harm. Health professionals and mothers should be aware of the potential risks associated with a strict ketogenic diet when combined with breast-feeding, especially in the earlier stages of the post-partum period. Prompt investigation, diagnosis and immediate management is vital to avoid life-threatening complications. We report a case admitted on the acute medical take with starvation ketoacidosis associated with ketogenic diet and adequate calorie consumption who was breast-feeding at the time of admission.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Oral semaglutide improves cardiovascular risk factors in people with type 2 diabetes (T2D) in clinical trials, though real-world evidence is limited. We aimed to determine the real-world impact of oral semaglutide on routinely collected clinical data in our practice. People with T2D initiated on oral semaglutide in secondary care diabetes clinics at two hospital sites in Wales (United Kingdom) were included. Data were collected on reasons for oral semaglutide initiation and changes in bodyweight, blood pressure, glycemic control, and lipid profiles over follow-up at 3–6 months, and at 6–12 months. Data were collected to determine the safety of oral semaglutide. Seventy-six patients were included, with a median age 59.3 [51.4–67.6] years, and 38 (50.0

Aims: To evaluate real -world outcomes in people with Type 1 Diabetes (PwT1D) initiated on Omnipod DASH (R) Insulin Management System. Methods: Anonymized clinical data were submitted to a secure web -based tool within the National Health Service network. Hemoglobin A1c (HbA1c), sensor -derived glucometrics, total daily dose of insulin (TDD), and patientreported outcome changes between baseline and follow-up were assessed. Individuals were classified to "new -topump" (switched from multiple daily injections) and "established -on -pump" (switched from a tethered insulin pump) groups. Results: 276 individuals from 11 centers [66.7 % female; 92 % White British; median age 41 years (IQR 20-50); diabetes duration 20 years (IQR 11-31); 49.3 % within "new -to -pump" group] were included. Baseline HbA1c was 8.0 +/- 1.3 % (64 +/- 14 mmol/mol). At follow-up [3 years (IQR 1.5-3.2)], HbA1c reduced by 0.3 % [(3 mmol/ mol); p = 0.002] across the total population, 0.4 % [(5 mmol/mol); p = 0.001] in those "new -to -pump" and remained unchanged in those "established -on -pump". TDD decreased in the "new -to -pump" cohort (baseline:44.9 +/- 21.0units vs follow-up:38.1 +/- 15.4units, p = 0.002). Of those asked, 141/143 (98.6 %) stated Omnipod DASH had a positive impact on quality of life. Conclusions: Omnipod DASH was associated with improvements in HbA1c in PwT1D "new -to -pump" and maintained previous HbA1c levels in those "established -on -pump". User satisfaction in all groups and TDD reduction in those "new -to -pump" were reported.

Introduction Type 2 diabetes (T2D) and metabolic dysfunction-associated steatotic liver disease (MASLD) have shared pathophysiology. We aim to explore associations between these diseases and the impact of T2D therapies on MASLD-related outcomes in a real-world population. Methods A retrospective cohort study included 153 patients with biopsy-proven MASLD. Health records were reviewed for biochemical or radiological changes over follow-up and compared by T2D status. The rate of incident T2D was determined, and in those with T2D, the changes over follow-up were compared by prescribed treatment. The statistical significance of changes over follow-up was evaluated by Student's t-test, and logistic regression was undertaken to determine the impact of variables on T2D development. Results One hundred and fifty-three patients were included with a mean follow-up of 48.0±22.0 months. Patients with T2D (n=73) were older than patients without T2D (n=80; 56.3 vs 51.9 years, p<0.05). Patients with T2D had a greater stage of hepatic fibrosis (2.6 vs 1.7, p<0.001). Nine (12.3%) patients with T2D and four (5.0%) without T2D died during follow-up (p=0.10). Patients without T2D had greater glycosylated haemoglobin (HbA1c) over follow-up (3.0 mmol/mol, p<0.01), and 21 (26.3%) developed T2D. Patients with T2D treated with sodium-glucose transporter-2 inhibitors (SGLT-2i) and/or glucagon-like peptide-1 receptor analogues (GLP-1RA) had a reduction in FibroScan®-controlled attenuation parameter (-33.7dB/m, p<0.001) but not liver stiffness measure. There were no significant FibroScan® changes in those receiving other treatments. Conclusions Patients with T2D had greater hepatic fibrosis, and one in four patients with MASLD developed T2D over four years. Treatment with SGLT-2i and/or GLP-1RA in patients with T2D is associated with improved measures of steatosis but not fibrosis.

GLP-1 receptor agonists were first launched as glucose-lowering therapies for people with type 2 diabetes in 2005. GLP-1 receptor agonists are peptides, initially available as twice-daily injections but later formulated for once-weekly subcutaneous administration and more recently once-daily oral dosing. In phase 3 clinical trials, GLP-1 receptor agonists were associated with weight loss independent of glucose-lowering. This led to clinical trial programmes of once-daily liraglutide and once-weekly semaglutide at higher doses than those licenced for diabetes management and their subsequent approvals for weight management.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Dear Editor, We read with great interest the article by Asbach et al., ‘Prevalence of Primary Aldosteronism in Newly Diagnosed Hypertensive Patients in Primary Care’, published in Experimental and Clinical Endocrinology & Diabetes [1]. The authors reported that of 200 patients with newly-diagnosed hypertension in 27 primary care centres, 42 (21.0 %) had an elevated aldosterone-to-renin ratio (ARR), of which 11/33 (33.3 %) were subsequently confirmed to have primary aldosteronism (PA). This gave a 5.5 % prevalence of PA in people with newly-diagnosed hypertension. Curiously, none of the patients with confirmed PA were hypokalaemic at screening, and hypokalaemia prevalence did not differ at screening between those with normal or pathological ARR.

Introduction Type 2 diabetes mellitus (T2D) is associated with poor health outcomes whilst tight glycaemic targets are questionable in those aged over 70 years with increased frailty. Our aim was to examine whether people with T2D admitted to hospital with a fall, were more likely to have greater frailty, increased mortality and co-morbidity burden, or risk factors for falls than people without T2D, and whether these differences were associated with medications used for the treatment of T2D. Methods The Older Persons Assessment Service (OPAS) is a local emergency department (ED) service, which accepts patients on frailty criteria. The OPAS accepts patients primarily aged over 70 years who present with frailty and geriatric syndromes such as falls, with retrieval from the ED department directly to the service from triage. The OPAS databank was analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS). Results 1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (+/- 15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0 +/- 2.2 vs 5.9 +/- 2.1, p < 0.001). Of those people with T2D, 175 (59.5%) and 240 (81.6%) had a HbA1c = 53 mmol/mol [7.0%] and = 64 mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0 mmol/L on admission to the ED. At 12 months' follow-up, 831 ( 76.9%) patients were alive and 250 (23.1%) had died. People with T2D treated with insulin and/or gliclazide had a greater 1-year mortality (36.6% vs 23.6%, p < 0.05), greater frequency of hypoglycaemia ( 35.4% vs 11.8%, p < 0.001), and greater HbA1c (65.5 +/- 17.2 mmol/mol [ 8.2] vs 48.9 +/- 12.1 mmol/mol [6.6%]) compared to those who used other agents. Logistic regression confirmed a diagnosis of T2D was associated with 1-year mortality, but mortality was not significantly associated with hypoglycaemic-inducing agents. People with T2D were not more likely to live in deprived areas. Conclusions A diagnosis of T2D is associated with greater 1-year mortality, and may be influenced by use of hypoglycaemiainducing diabetes medications. Clinician awareness can support de-prescribing for patients with frailty and HbA1c < 64 mmol/ mol.

Descriptions of the hierarchical ladder of evidence used to inform health-care practices have developed over the last half-century, from a relatively simplistic original description by the Canadian Task Force in 1979 [1], to the more familiar hierarchical ‘pyramid’ of clinical evidence that many are now accustomed with [2]. Originally, the Canadian Task Force described three levels of evidence: level 1 (e.g. well-designed randomized controlled trials (RCT)), level 2 (e.g. well-designed cohort or case-control studies), and level 3 (expert opinions) [1]. This has now expanded to a 5-tiered pyramid, with some tiers having additional sub-levels of evidence: level 1A-C (e.g. RCTs), level 2A-C (e.g. cohort studies), level 3A-B (e.g. case-control studies), level 4 (e.g. case series), and level 5 (expert opinion) [2]. However, with the growing complexity of health-care systems, rapid proliferation of innovative health technologies coupled with extensive granular data derived from clinical practice, it is now time to challenge the historical paradigm of evidence hierarchy with respect to informing health-care practices.