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\"The issue of difference sits at the core of many of the world's crises. Large corporations are a microcosm of the globalized world we live in, and hold significant power in shaping our lives and ideas. Despite decades of work in the area, little progress has been made because current approaches focus on specific contexts, short-term results and commercial return rather than taking into account what we know about human behaviour and addressing culture. Here, the authors, who have worked in a number of leading organizations, including Caterpillar, American Express, HSBC and the NHS, put forward a new approach, based on years of experience of what works in individual and organizational change.\" -- Provided by publisher.

Early-onset type 2 diabetes (defined as type 2 diabetes diagnosed in people aged <40 years) is an increasingly prevalent condition with a more aggressive disease trajectory than late-onset type 2 diabetes. It is associated with accelerated microvascular and macrovascular complications, reduced life expectancy, and adverse pregnancy outcomes. Despite its rising incidence, global management strategies have mostly been extrapolated from studies in older adults with limited evidence specific to younger populations. In this Series paper, we aim to highlight the unique challenges in the management of early-onset type 2 diabetes and why current models of care are inadequate. We emphasise that early-onset type 2 diabetes necessitates proactive and combination treatment strategies to address weight, faster β-cell decline, worse insulin resistance, and rapidly progressing hyperglycaemia compared with late-onset type 2 diabetes. However, there is minimal evidence on how best to address these factors and clinical inertia risks contributing to glycaemic burden. Cardiovascular risk assessment tools underestimate long-term risk, contributing to low use of statin and antihypertensive therapy. Reproductive health remains a key concern, yet preconception and pregnancy care are inadequate, with low adherence to recommended interventions. Health-care systems are not optimised to address the distinct needs of young adults, and gaps in transitional care (from paediatric to adult services) contribute to disengagement and adverse outcomes. Addressing these challenges requires tailored management strategies that consider the unique metabolic and psychosocial factors in this population. In this Series paper, we summarise the evidence base for the management of early-onset type 2 diabetes, key evidence gaps, and discuss the multisectoral and transdisciplinary elements needed to achieve population-level prevention to reverse these concerning trends.

BackgroundThe prevalence of type 2 diabetes mellitus (T2DM) in children and young people (CYP) is increasing in the UK and worldwide. Little is known about the experience young people and their families have when attending for their diabetes care. The aim of this study is to analyse the responses to the Parent and Patient Reported Experience Measures (PREM) survey 2021–2022 for patients with T2DM and their families to inform care.MethodsAs part of the National Paediatric Diabetes Audit (NPDA) (2022), the NPDA PREM survey was open online between August 2021 and January 2022. The data have previously been analysed collectively for all diabetes; however, we specifically analysed the data for patients living with T2DM.Results9.2% (105/1144) of young people living with T2DM in England and Wales responded to the NPDA PREM survey, mostly aged 12–16 years (61.9%) and the majority were female (67.6%). 87% of patients and 95% of carers said that they would recommend their diabetes team, and 73% of patients felt happy after appointments. Only just over half of the patients and parents felt well prepared for transferring to adult care. Only 38% of patients felt that their school or college often had the necessary information to support them with their diabetes.ConclusionsThis analysis describes the experience of CYP and their parents/carers of T2DM care and highlights areas for improvement. These findings may help to inform recommendations about the development of better patient-centred care for young people with T2DM.

Background Few treatments exist for adolescents living with severe obesity. This qualitative study explored the experiences of severely obese adolescents and their families who participated in the BOB study. Methods Twelve adolescents (5 males;7 females; mean age 15 years; BMI > 3.5 s.d; puberty stage 4 +) who were engaged with the research study BOB (a non-randomised, pilot novel obesity treatment programme that involved the insertion of an intra-gastric balloon coupled with a family lifestyle behavioural support programme). Adolescents attended weekly lifestyle sessions before, during and post balloon insertion. All participants were interviewed at 3 months, (halfway through intra-gastric balloon insertion) and at 12 months follow-up (6 months post intra-gastric balloon removal, 3 months post lifestyle intervention). Results All BOB participants had exhausted all treatment options deeming this study their final option. Many alluded to feelings of desperation and referred to a sense of hope that this intervention would be effective. Family involvement and attendance within the structured sessions differed significantly. Adolescents and parents perceived support from the research study ceased when the intra-gastric balloon was removed at 6-months despite attendance post balloon removal being poor. All participants emphasised a need for further support longer term with the integration of the family a critical factor. Conclusions Further research is needed to explore the specific role families play within treatment to optimise health and wellbeing outcomes. Adolescents perspectives should be integrated within treatment to inform and improve the effectiveness of future treatment programmes for severely obese adolescents and their families.

ObjectivesAttaining optimal glycaemic control in paediatric patients with T1DM is challenging, with reports that only 11.8% of paediatric patients achieve a target HbA1c (<48mmol/mol) (Anon., 2022). It is well established that good glycaemic control is key to reducing long-term diabetic complications, and is the underlying principle of diabetic management.2 Paediatric patients most commonly present in two different ways at diagnosis- osmotic symptoms without diabetic ketoacidosis (DKA) or in DKA. Previous studies have reported that DKA at diagnosis is a predictor of poorer long-term glycaemic control irrespective of demographics and socio-economic factors.3, 4The aims of this project were to explore whether there was an association betweenPresenting HbA1c in patients with DKA compared with patients who did not present in DKAMode of presentation and long-term glycaemic control (using HbA1c values)MethodsData was collected from 114 paediatric patients diagnosed with T1DM between January 2015 and March 2019 at Nottingham Children’s Hospital. Final HbA1c was regarded as the 6-month average of HbA1c values last recorded, before March 2020 (pre-pandemic). Data was analysed using SPSS software.ResultsThis audit included 114 patients, of which 33 initially presented in DKA. 59.6% of patients were male; mean age at diagnosis was 9.62 years (SD±4.50). There was no significant difference between the final HbA1c value and the DKA status at diagnosis: p=0.166, (independent samples test). There was no difference between the initial HbA1c at presentation in the DKA patients compared with the patients not in DKA (p=0.072) (figure 1). Age, duration of diabetes, gender and length of preceding symptoms before diagnosis of T1DM also did not show a difference between the DKA at presentation versus non-DKA at presentation group. However DKA patients diagnosed with T1DM were significantly younger at diagnosis than those that did not present initially in DKA (p=0.041) (table 1).Abstract 770 Figure 1Initial HbA1c compared with DKA status of the patient at presentation (non-significant result)[Figure omitted. See PDF]ConclusionOur results did not show any statistically significant difference between DKA status at presentation and glycaemic control between 1–5 years later, which contrasts with other studies. This mirrors the findings from a similar audit from our centre in 2007. Other significant factors, which influence glycaemic control in the paediatric population, include family support, socioeconomic status, pubertal status, ethnicity and access to technology.5–7 Comprehensive research into these factors is required as well as greater effort to implement evidence-based, targeted screening programs and psychosocial interventions to reduce the incidence of DKA at presentation and improve long-term glycaemic control.ReferencesAnon., 2022. National Paediatric Diabetes Audit Annual Report 2020–21: Care Processes and Outcomes. Royal College of Paediatrics and Child Health.Watts WH. Lamabadusuriya, and J Edge. Targeting glycaemic control in children and young people with type 1 diabetes: Getting it right from day one. Diabetes Care for Children & Young People 2014;3(3):89–95.Duca LM, et al. Diabetic ketoacidosis at diagnosis of type 1 diabetes predicts poor long-term glycemic control. Diabetes Care 2017;40(9):1249–1255.Shalitin S, et al. Ketoacidosis at onset of type 1 diabetes is a predictor of long-term glycemic control. Pediatr Diabetes 2018;19(2):320–328.Sherwood Z. What factors influence glycaemic control in children aged under 11 years with type 1 diabetes? A literature review. Journal of Diabetes Nursing 2016;20:213–7.Viklund G, Örtqvist E. Factors predicting glycaemic control in young persons with type 1 diabetes. International Diabetes Nursing 2014;11(3):75–78.Mazarello Paes V, et al. Factors predicting poor glycemic control in first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models. Pediatr Diabetes 2020;21(2):288–299.

BackgroundThe COVID-19 pandemic led to changes in patterns of presentation to emergency departments. Child health professionals were concerned that this could contribute to the delayed diagnosis of life-threatening conditions, including childhood cancer (CC) and type 1 diabetes (T1DM). Our multicentre, UK-based service evaluation assessed diagnostic intervals and disease severity for these conditions.MethodsWe collected presentation route, timing and disease severity for children with newly diagnosed CC in three principal treatment centres and T1DM in four centres between 1 January and 31 July 2020 and the corresponding period in 2019. Total diagnostic interval (TDI), patient interval (PI), system interval (SI) and disease severity across different time periods were compared.ResultsFor CCs and T1DM, the route to diagnosis and severity of illness at presentation were unchanged across all time periods. Diagnostic intervals for CCs during lockdown were comparable to that in 2019 (TDI 4.6, PI 1.1 and SI 2.1 weeks), except for an increased PI in January–March 2020 (median 2.7 weeks). Diagnostic intervals for T1DM during lockdown were similar to that in 2019 (TDI 16 vs 15 and PI 14 vs 14 days), except for an increased PI in January–March 2020 (median 21 days).ConclusionsThere is no evidence of diagnostic delay or increased illness severity for CC or T1DM, during the first phase of the pandemic across the participating centres. This provides reassuring data for children and families with these life-changing conditions.

ObjectiveTo determine the incidence and describe the presentation and management of unexpected symptomatic glucocorticoid-induced adrenal suppression (AS) in children and young people aged 0–15 years.Setting and designSurveillance study of symptomatic glucocorticoid (GC)-induced AS with supportive biochemical evidence or presenting as an adrenal crisis, reported via the British Paediatric Surveillance Unit (BPSU) from September 2020 to September 2022.ResultsOver a 25-month period, 190 reports of symptomatic GC-induced AS/adrenal crisis were made, of which 22 were confirmed cases: 18 AS and 4 adrenal crises. This translates to an incidence rate of 0.09 new cases of GC-induced AS per 100 000 children aged 0–15 per year in the UK. There was a broad range of underlying diagnoses requiring GC prescription (16) and GC preparations (13). Of the 22 patients, 7 had more than 1 type of GC prescribed. The administration of oral GC occurred in 19 of the cases, inhaled GC use in 7, topical use in 5 and 1 case occurred after a single intramuscular injection of GC. All patients were discussed with a paediatric endocrinology team.ConclusionsThe incidence of AS from this UK-based BPSU study is lower than a similar Canadian study. This may indicate that paediatricians in the UK and Ireland are becoming more aware of the potential for GC-induced AS and thus are more proactive to prevent its occurrence. The clinical cases still highlight the need to educate families and healthcare professionals with a view to further reducing the morbidity and potential mortality associated with GC-induced AS.

We present a non-consanguineous family of three siblings who presented with diabetes mellitus (DM), two of whom had genetically confirmed cystic fibrosis (CF), with one pancreatic-sufficient mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene (ΔF508/R117H;IVS8-5T). A detailed history revealed family members from three successive generations diagnosed with ‘type 1’ or ‘type 2’ diabetes, leading to genetic investigations for monogenic DM. A heterozygous frameshift mutation in the hepatocyte nuclear factor 1 homeobox alpha (HNF1A) gene (c.404delA) was subsequently confirmed in all three siblings, which is known to cause monogenic diabetes and is exquisitely sensitive to sulfonylurea therapy. Following this diagnosis, both siblings with CF and HNF1A monogenic diabetes were started on gliclazide therapy, while their older brother who had been wrongly diagnosed with type 1 diabetes was switched from insulin to gliclazide, all with excellent therapeutic responses.

ObjectiveIn 2021, centres across all seven NHS-England regions were selected to develop pilot clinics with the aim of treating children and young people (CYP) living with complications relating to excess weight (CEW). We led a process to develop core outcomes to enable the evaluation of these clinics.MethodsA two-round Delphi process, virtual steering group meetings and two patient representation workshops were used to agree the most important outcomes for both clinicians/allied professionals and representative prospective service users.ResultsA total of 119 clinicians/allied professionals were invited to contribute to the Delphi process: 62 (52%) agreed and completed round 1 and 47 of these (76%) went on to complete round 2. Six young people (age range 13–17 years) and six parents were involved in two patient representation workshops and their experiences fed into virtual steering group meetings, via a representative.There were 44 outcomes assessed in round 1 and 21 outcomes assessed in round 2. There were 16 core outcomes selected: anthropometric, glucose tolerance/insulin resistance/type 2 diabetes, blood pressure, lipid profile, breathing problems, identification of aetiology, non-alcoholic fatty liver disease, idiopathic intracranial hypertension, anxiety, depression, self-esteem, quality of life, school attendance, dietary habits including disordered eating, exercise and activity habits.ConclusionsUse of an online Delphi process, patient representation workshops and virtual steering group meetings has enabled the development of core outcomes for clinical obesity services with eight physical health, five mental health and three self-management outcomes. Further work is needed to develop outcome measures to complete a core outcome set. These will be used to guide the evaluation of novel regional clinics for the treatment of complications of excess weight.