We investigated the prevalence and characteristics of 'brittle diabetes', defined as insulin-dependent diabetes mellitus associated with glycaemic instability of any type, leading to life disruption with recurrent and/or prolonged hospitalizations. A questionnaire was sent to all physicians and paediatricians running diabetic clinics in the UK, from lists held at the British Diabetic Association. A total of 414 brittle patients were reported (72% questionnaire return). Most were young (mean age +/- SD was 26 +/- 15 years), though there was a small peak at ages 60-70 years. There was an excess of females (66%) and overall clinic prevalence was 1.2 per 1000 diabetic patients and 2.9 per 1000 insulin-treated diabetic patients. On average, there was 1.0 brittle patient per diabetic clinic. The most common form of brittleness was recurrent ketoacidosis (59%), with 17% having predominant hypoglycaemia, and 24% mixed instability. Female excess was highest and mean age lowest in the recurrent ketoacidosis group, whilst the reverse was true for those with recurrent hypoglycaemia. Causes of brittleness were offered by 58% of consultants, and most (93%) considered various psychosocial problems as likely underlying factors. We conclude that brittle diabetes is a small but significant problem, currently affecting about 1 per 1000 diabetic patients. Most, but by no means all, are young females--often with recurrent ketoacidosis. Older age groups are more likely to have recurrent hypoglycaemic or mixed types of brittleness. Perceived causes of brittleness are usually psychosocial.

Planned future work will develop an updated questionnaire tool to access self-care behaviours. This will enable assessment of the effectiveness of existing structured education programmes at producing desired changes in behaviour. It will also help people with diabetes and their healthcare team identify areas where additional support is needed to initiate or maintain changes in behaviour. Provision of such support may improve glycaemia and reduce diabetes-related complications and severe hypoglycaemia.

Insulin-taking African Americans with a high likelihood of limited FHL are approximately 6 times more likely to have an A1C ≥ 8% compared to patients with a possibility of limited FHL, or adequate FHL, demonstrating the need for focused interventions tailored to FHL needs.

Sickle cell trait (SCT) has a UK urban population rate estimated at 3.2%. The condition may remain unrecognised, but sudden death is a recognised feature. The sudden death of a 51-year-old man with SCT who presented with hyperosmolar non-ketotic acidosis (HONK) as his first presentation of diabetes is reported here. After admission to hospital, a rapid deterioration was seen in his condition, with loss of cardiac output, leading to death. He was found to have had acute-chest syndrome and hepatosplenic infarction on postmortem examination. The pathophysiology of sudden death in patients with SCT and the role of HONK in the patient’s demise is discussed here.

This paper examines the evolution of diabetes education from a time when it was viewed as an ad hoc event or even as an optional extra to one when it is now accepted as essential and central to successful self‐management. During the last 20 years there has been a transition from didactic teaching practices towards problem‐solving models which are based on modern principles of adult learning, and from one‐to‐one teaching towards group learning. The evolving role of the diabetes nurse specialist over the last two decades has been crucial in enabling these changes. The evidence base for different educational models needs further strengthening, but structured programmes for life‐long learning are now being developed. Important decisions are still needed on the provision and content of the training programmes for educators and on the mechanisms for the provision of quality assurance. Copyright © 2004 John Wiley & Sons, Ltd.