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01 - DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial
Original DAFNE trial outcomes - UK
The original trial paper showing an HbA1c improvement of 1% at 6 months, and 0.5% at 12 months. No reductions in severe hypoglycaemia (numbers too small).
02 - Substantial reduction in episodes of diabetic ketoacidosis and savings in emergency treatment costs following structured education in patients with Type 1 diabetes
Elliott J, Jacques R, Kruger J, Campbell M, Amiel S, Mansell P, Brennan A, Heller S.
Reduction in DKA / emergency treatment costs
An analysis of the research database showing that DAFNE reduces DKA by 62% and severe hypoglycaemia events requiring emergency treatment by 82%, therefore saving on average £92 per patient.
03 - Twice- rather than once-daily basal insulin is associated with better glycaemic control in Type 1 diabetes mellitus 12 months after skills-based structured education in insulin self-management
Hopkinson HE, Jacques RM, Gardner KJ, Amiel SA, Mansell P.
Evidence for twice-daily basal insulin
An analysis of the research database and data from Glasgow showing that only patients on twice a day, as opposed to once a day NPH, levemir, or glargine significantly decrease their HbA1c at 1-year post-DAFNE
04 - Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes
Hopkins D, Lawrence I, Mansell P, Thompson G, Amiel S, Campbell M, Heller S.
Real-world audit data
The first published audit of real-world data showing a decrease in HbA1c of 0.3% at 1 year, severe hypoglycaemia reduction of 64%, and improvements in quality of life measures.
05 - Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)
Writing committee on behalf of the study group: Simon Heller (Department of Oncology and Metabolism, University of Sheffield), Stephanie Amiel (Kings College, University of London), Michael Campbell (School of Health and Related Research, ScHARR, University of Sheffield), Pratik Choudhary (Kings College, University of London), Cindy Cooper (Sheffield Clinical Trials Research Unit, University of Sheffield), Munya Dimairo (Sheffield Clinical Trials Research Unit, University of Sheffield), Jackie Elliott (Department of Oncology and Metabolism, University of Sheffield), Peter Hammond (Harrogate and District Foundation Trust), Ellen Lee (Sheffield Clinical Trials Research Unit, University of Sheffield), Robert Lindsay (University of Glasgow), Peter Mansell (Nottingham University Hospitals NHS Trust), Norman Waugh (Warwick Medical School, University of Warwick) and David White (Sheffield Clinical Trials Research Unit, University of Sheffield).
Insulin pump vs. MDI
06 - Bicentric evaluation of a teaching and treatment programme for type 1 (insulin- dependent) diabetic patients: improvement of metabolic control and other measures of diabetes care for up to 22 months
Mühlhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L et al.
Original trial outcomes - Germany
The original German publication showing the outcomes from the ITTP which was the course from which DAFNE originated. The German team have continued to publish their outcomes since then.
De Zoysa N, Gianfrancesco C, Beveridge S, Britneff E, Choudhary P, Elliott J, Heller S, Amiel S.
Restoring hypo awareness
A pilot study in 24 patients showing that by using group psychological/educational interventions hypoglycaemia unawareness can be improved without glycaemic control deteriorating, baseline HbA1c 7.8% and at 1 y unchanged at 7.8%. So improving unawareness is about avoiding hypoglycaemia, not raising the BG targets above the upper end of the DAFNE target range.
08 - The experiences, views and support needs of family members of people with Hypoglycaemia Unawareness: Interview study
Lawton J, Rankin D, Elliott J, Heller S, Rogers H, De Zoysa N, Amiel S.
Hypoglycaemia unawareness – family experiences
A must-read for all healthcare professionals looking after patients with hypoglycaemia unawareness. By providing real quotes it describes very effectively the immense burden this condition puts on family members (and has no p values!).
09 - Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients' experiences and views
Rankin D, Cooke DD, Elliott J, Heller SR, Lawton J
Support after DAFNE
Most patients say they need tailored and individualized support from DAFNE trained HCPs following a DAFNE course. Free access through NCBI.
10 - Assessing the cost-effectiveness of Type 1 Diabetes Interventions: The Sheffield Type 1 Diabetes Policy Model
Thokala P, Kruger J, Brennan A, Basarir H, Duenas A, Pandor A, Gillett M, Elliott J, Heller S.
A paper explaining how a model of Type 1 diabetes has been created in order to evaluate DAFNE and other structured education programmes. No free access. People will need to request a copy from their library.
11 - Perceptions and experiences of using automated bolus advisors amongst people with type 1 diabetes: a longitudinal qualitative investigation
Lawton J, Kirkham J, Rankin D, Barnard K, Cooper CL, Taylor C, Heller S, Elliott J.
Bolus advisors are useful but patients may forget their ratios and not know how to change them. So without support, they may hinder the process of reflection on glucose readings, and subsequent dose adjustments.
12 - Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes
Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J, Emery C, Baird W, Basarir H, Beveridge S, Bond R, Campbell M, Chater T.
Analysis of DAFNE
For those with a lot of spare time on their hands / or thinking of doing a PhD around DAFNE then this monograph details all the research undertaken in the first DAFNE programme grant. Free access through NCBI.
13 - The Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE): study protocol for a cluster randomised controlled trial
White D, Waugh N, Elliott J, Lawton J, Barnard K, Campbell M, Dixon S, Heller S.
Study protocol: REPOSE
It describes in detail the methods for the DAFNE pump vs DAFNE MDI RCT
14 - Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled Type 1 diabetes
Speight J. Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C, Thompson G. L
Sustained quality of life
A follow-up of patients from the original trial showing that quality of life improvements following DAFNE are sustained for at 4 years, whilst the mean HbA1c improvement had decreased to 0.36%.
15 - Do high fasting glucose levels suggest nocturnal hypoglycaemia? The Somogyi effect-more fiction than fact?
Choudhary P, Davies C, Emery CJ, Heller SR.
Myth-busting the Somogyi effect
This is not a paper about DAFNE, but does explain the reasoning behind some of what we teach around hypoglycaemia. Its an analysis of 89 CGM traces showing that nocturnal hypos are followed by low fasting glucoses (average 5.5mmol/l); only on 2/89 occasions was the fasting level >10mmol/l (likely following hypo treatment). When fasting glucoses were <5mmol/l there was evidence of nocturnal hypoglycaemia in 94% of cases. Therefore DAFNE does not teach the rebound theory, evidence shows it does not exist, and fasting glucose levels ought to be 5.5mmol/l.
16 - Glycaemic control and weight 7 years after Dose Adjustment for Normal Eating (DAFNE) structured education in Type 1 diabetes
Gunn D, Mansell P.
Impact of DAFNE on weight
An audit of outcomes in Nottingham showing that benefits in HbA1c of 0.3% are maintained for at least 7 years, without any excess weight gain.
17 - Experiences of hypoglycaemia unawareness amongst people with type 1 diabetes: a qualitative investigation
Rankin D, Elliott J, Heller S, Amiel S, DeZoysa N, Lawton J for the UK NIHR DAFNE Study Group
Hypo unawareness – experiences of people with type 1 diabetes
Real-life quotes of how patients with hypoglycaemia unawareness perceive their condition.
18 - A cluster-randomized trial comparing a 5-day DAFNE course delivered over 1 week against DAFNE training delivered over 1 day a week for 5 consecutive weeks
Elliott J, Rankin D, Jacques R, Emery C, Campbell M, Lawton J, Heller S.
Standard DAFNE vs. 5x1 DAFNE
The results of an RCT showing that DAFNE delivered over one day a week for 5 weeks is as effective as 5 days in one week in terms of HbA1c, severe hypoglycaemia and quality of life outcomes.
19 - Self-treating hypoglycaemia: a longitudinal qualitative investigation of the experiences and views of people with type 1 diabetes
J Lawton , Rankin D, Cooke DD, Elliott J, Amiel S, Heller S.
Whilst knowledge around hypos is increased post DAFNE some patients need psychological one-to-one help to overcome their fears of hypoglycaemia not just DAFNE training.
20 - Experiences of using blood glucose targets when following an intensive insulin regime: a qualitative longitudinal investigation involving patients with Type 1 diabetes
D. Rankin, D.D. Cooke, S. Heller, J. Elliott, S. Amiel, J. Lawton
After DAFNE BG targets often drift, and we as HCPs do not revisit them often enough in clinic visits, hence glycaemic control may worsen.
Using BG targets
No free access. People will need to request a copy from their library. Copy provided by inter-library loan. Can print/save through our subscriptions (follow link below, should recognise our IP and allow access).
21 - Dose Adjustment for Normal Eating: A qualitative longitudinal exploration of the food and eating practices of type 1 diabetes patients converted to flexible intensive insulin therapy in the UK
J. Lawton, D. Rankin, D.D. Cooke, M. Clark, J. Elliott, S. Heller for the UK NIHR DAFNE Study Group.
Eating habits after DAFNE
Food choices post-DAFNE often do not change as much as one might expect because patients usually continue to eat the same kinds of foods, whilst some choose to avoid carbohydrate at certain meal times to avoid an injection. No free access. People will need to request a copy from their library.
22 - Incorporating psychological predictors of treatment response into health economic simulation models: a case study in Type 1 diabetes
Kruger J, Pollard D, Basarir H, Thokala P, Cooke D, Clark M, Bond R, Heller S, Brennan A.
Psychological assessment before education– yes or no?
Assessing a patients psychological status prior to DAFNE does not reliably predict who will do well, and therefore this is not a cost-effective way in which to target education. No free access. People will need to request a copy from their library.
23 - Group follow-up compared to individual clinic visits after structured education for type 1 diabetes: A cluster randomised controlled trial
Dinneen SF, O’Hara MC, Byrne M, Smith D, Courtney CH, McGurk C, Heller SR, Newell J, Coffey N, Breen C, O’Scannail M, O’Shea D; Irish DAFNE Study Group.
Group vs. individual follow-up
Group follow-up is as effective as individual clinic visits in relation to outcomes in this study. No free access. People will need to request a copy from their library.
Lawton J, Rankin D, Elliott J.
Patient choice re: standard or 5x1 DAFNE
When we asked patients what arm they would want to be randomized to in the 5x1 trial the spilt was 50:50, usually citing reasons around work or childcare etc. However, when we asked them after the course they virtually all said that if given the choice again they would opt for the course they got, i.e., patients rationalize the outcome to make them feel better. So is asking patients what they want in the future a worthwhile thing to do? No free access. People will need to request a copy from their library.
25 - What are the characteristics of the best Type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective? Diabetic Med. 2020
S. Heller, C. Gianfrancesco, C. Taylor, J.Elliott.
What makes a good education course?
Explores the components and outcomes of courses, and goes on to discuss barriers, and future avenues of research aimed to improve structured education in type 1 diabetes.
26 - Follow-up support for effective type 1 diabetes self-management (The FUSED Model): A meta-ethnography of the barriers, facilitators and recommendations for sustaining self-management skills after attending a structured education programme. BMC Health Services Research
F Campbell, J Lawton, D Rankin, M Clowes, E Coates, S Heller, N de Zoysa, J Elliott, J Brenckenridge.
What kind of follow-up support do people with type 1 need?
Some people struggle to maintain the benefits of DAFNE course in the longer-term. This paper explores the evidence around effective follow-up and helped inform the design of the DAFNEplus intervention arm.
27 - A deep neural network application for improved prediction of HbA1c in type 1 diabetes. IEEE Journal of Biomedical and Health Informatics Jan 2020
A. Zaitcev, MR Eissa, Z Hui, M. Benaissa, T.Good, J.Elliott, M. Benaissa.
Can you accurately predict HbA1cs from finger-pricks?
Yes, if you’re good at machine learning, read this article to find out how it can be done.
28 - Intelligent data-driven model for diabetes diurnal patterns analysis. IEEE Journal of Biomedical and Health Informatics Feb 24 2020
M. Eissa, T. Good, J. Elliott and M. Benaissa.
Bolus advisors use time-blocks, but how do you assess the best timings for these?
Answer – use a computer program, much quicker than 12 diabetes experts!
29 - Mobilising knowledge between practitioners and researchers to iteratively refine a complex intervention (DAFNEplus) pre-trial: protocol for a structured, collaborative working group process. Pilot and Feasibility Studies (2018)
Breckenridge JP, Gianfrancesco C, de Zoysa N, Lawton J, Rankin D, Coates E.
When re-designing DAFNE for the DAFNEplus trial we had to decide which ideas to test
This paper describes the process we went through to gather everyone's ideas and feedback from pilot DAFNEplus courses, in order to agree what the final DAFNEplus intervention should be.