Introduction
The COVID‐19 pandemic has transformed lives across the world. In the UK, a public health driven policy of population “lockdown” has had enormous personal and economic impact.
Methods
We ...compare UK response and outcomes with European countries of similar income and healthcare resources. We calibrate estimates of the economic costs as different % loss in Gross Domestic Product (GDP) against possible benefits of avoiding life years lost, for different scenarios where current COVID‐19 mortality and comorbidity rates were used to calculate the loss in life expectancy and adjusted for their levels of poor health and quality of life. We then apply a quality‐adjusted life years (QALY) value of £30,000 (maximum under national guidelines).
Results
There was a rapid spread of cases and significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non‐COVID‐19 was 79.1 and 11.4 years, respectively, while COVID‐19 were 80.4 and 10.1 years; including adjustments for life‐shortening comorbidities and quality of life plausibly reduces this to around 5 QALY lost for each COVID‐19 death. The lowest estimate for lockdown costs incurred was 40% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimations they were over 5 times higher. Future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst‐case £3.7m (125xNICE guideline) was needed to justify the continuation of lockdown.
Conclusion
This suggests that the costs of continuing severe restrictions are so great relative to likely benefits in lives saved that a rapid easing in restrictions is now warranted.
With sustained growth of diabetes numbers, sustained patient engagement is essential. Using nationally available data, we have shown that the higher mortality associated with a diagnosis of T1DM/T2DM ...could produces loss of 6.4 million future life years in the current UK population. In the model, the ‘average’ person with T1DM (age 42.8 years) has a life expectancy from now of 32.6 years, compared to 40.2 years in the equivalent age non diabetes mellitus population, corresponding to lost life years (LLYs) of 7.6 years/average person. The ‘average’ person with T2DM (age 65.4 years) has a life expectancy from now of 18.6 years compared to the 20.3 years for the equivalent non diabetes mellitus population, corresponding to LLY of 1.7 years/average person. We estimate that for both T1DM and T2DM, one year with HbA1c >58 mmol/mol loses around 100 life days. Linking glycaemic control to mortality has the potential to focus minds on effective engagement with therapy and lifestyle recommendation adherence.
Introduction
Vaccination against the COVID‐19 virus began in December 2020 in the UK and into Spring 2021 has been running at 5% population/week. High levels of social restrictions were implemented ...for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education and provision of non‐Covid‐19 healthcare.
Methods
Weekly and monthly officially published data for 2020/21 were used to estimate the influence of seasonality and social restrictions on the spread of COVID‐19 by age group, on the economy and on healthcare services. These factors were combined with the estimated impact of vaccinations and immunity from past infections into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. The model was applied prospectively to the next 6 months to evaluate the impact of different speeds of easing social restrictions.
Results
The results show vaccinations as significantly reducing the number of hospitalisations and deaths. The central estimate is that relative to rapid easing, the avoided loss of 57 000 life‐years from a strategy of relatively slow easing over the next several months comes at a cost in terms of GDP reduction of around £0.4 million/life‐year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting the spread of the virus give significantly different trade‐offs between costs and benefits of different speeds of easing. Disruption of non‐Covid‐19 Healthcare provision also increases in times of higher levels of social restrictions.
Conclusion
In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies.
Introduction
We previously demonstrated in both a longitudinal study and in meta‐analysis (pooled relative‐risk RR, 2.45) that all‐cause mortality is significantly higher in people with diabetes foot ...ulceration (DFU) than with those without a foot ulcer. In this prospective study, we looked at the factors linked to mortality after presentation to podiatry with DFU.
Methods
Ninety‐eight individuals recruited consecutively from the Salford Royal Hospital Multidisciplinary Foot Clinic in Spring 2016 were followed up for up to 48 months. Data concerning health outcomes were extracted from the electronic patient record (EPR).
Results
Seventeen people (17) had type 1 diabetes mellitus, and 81 had type 2 diabetes mellitus. Thirty‐one were women. The mean age (range) was 63.6 (28–90) years with maximum diabetes duration 45 years. Mean HbA1c was 72 (95% CI: 67–77) mmol/mol; 97% had neuropathy (International Working Group on the Diabetic Foot (IWGDF) monofilament); 62% had vascular insufficiency (Doppler studies); 69% of ulcers were forefoot, and 23% of ulcers were hind foot in location.
Forty of 98 (40%) patients died in follow‐up with 27% of death certificates including sepsis (not foot‐related) and 35% renal failure as cause of death. Multivariate regression analysis indicated a 6.3 (95% CI: 3.9–8.1) fold increased risk of death with hind foot ulcer, independent of age/BMI/gender/HbA1c/eGFR/total cholesterol level.
Conclusion
This prospective study has indicated a very high long‐term mortality rate in individuals with DFU, greater for those with a hind foot ulcer and shown a close relation between risk of sepsis/renal failure and DFU mortality, highlighting again the importance of addressing all risk factors as soon as people present with a foot ulcer.
Bariatric surgery improves dyslipidaemia and reduces body weight, but it remains unclear how bariatric surgery modulates gene expression in fat cells to influence the
and
gene expression. The ...expression of the
gene in adipose tissue was measured in two groups of Zucker Diabetic Sprague Dawley (ZDSD) rats after Roux-en-Y gastric bypass (RYGB) surgery or 'SHAM' operation. There was lower
(
= 0.02) and higher
gene expression (
= 0.02) in adipose tissue in rats after RYGB. Weight change did not correlate with
gene expression (r = -0.5,
= 0.08) or
gene expression (r = -0.4,
= 0.1).
gene expression was positively correlated with
gene expression (r = 0.7,
= 0.001) but not correlated with
expression (r = -0.3,
= 0.3). Circulating triglyceride levels were lower in RYGB compared to the SHAM group (1.1 (0.8-1.4) vs. 1.5 (1.0-4.2),
= 0.038) mmol/L with no difference in cholesterol levels.
gene expression was increased post-bariatric surgery with the potential to reduce the number of circulating LDL particles.
gene expression and
gene expression were positively correlated after RYGB in ZDSD rats, suggesting that the modulation of pro-inflammatory pathways in adipose tissue after RYGB may partly relate to
and
gene expression.
Testosterone (T), the principal androgen secreted by the testes, plays an essential role in male health. Male hypogonadism is diagnosed based on a combination of associated clinical signs and ...symptoms and laboratory confirmation of low circulating T levels. In this review, we have highlighted factors, both biological and analytical, that introduce variation into the measurement of serum T concentrations in men; these need to be considered when requesting T levels and interpreting results. There is an ongoing need for analytical standardisation of T assays and harmonisation of pre- and post-analytical laboratory practices, particularly in relation to the laboratory reference intervals provided to clinicians. Further, there is a need to share with service users the most up-to-date and evidence-based action thresholds for serum T as recommended in the literature. Estimation of free testosterone may be helpful. Causes of secondary hypogonadism should be considered. A comprehensive approach is required in the management of male hypogonadism, including lifestyle modification as well as medication where appropriate. The goal of treatment is the resolution of symptoms as well as the optimisation of metabolic, cardiovascular, and bone health. The advice of an endocrinologist should be sought when there is doubt about the cause and appropriate management of the hypogonadism.
Primary hypothyroidism affects about 3% of the general population in Europe. Early treatments in the late 19
Century involved subcutaneous as well as oral administration of thyroid extract. Until the ...early 1970s, the majority of people across the world with hypothyroidism were treated with natural desiccated thyroid (NDT) (derived from pig thyroid glands) in various formulations, with the majority of people since then being treated with levothyroxine (L-thyroxine). There is emerging evidence that may account for the efficacy of liothyronine (NDT contains a mixture of levothyroxine and liothyronine) in people who are symptomatically unresponsive to levothyroxine. While this is a highly selected group of people, the severity and chronicity of their symptoms and the fact that many patients have found their symptoms to be alleviated, can be viewed as valid evidence for the potential benefit of NDT when given after careful consideration of other differential diagnoses and other treatment options.
The COVID-19 pandemic, and the focus on mitigating its effects, has disrupted diabetes healthcare services worldwide. We aimed to quantify the effect of the pandemic on diabetes diagnosis/management, ...using glycated haemoglobin (HbA1c) as surrogate, across six UK centres.
Using routinely collected laboratory data, we estimated the number of missed HbA1c tests for 'diagnostic'/'screening'/'management' purposes during the COVID-19 impact period (CIP; 23 March 2020 to 30 September 2020). We examined potential impact in terms of: (1) diabetes control in people with diabetes and (2) detection of new diabetes and prediabetes cases.
In April 2020, HbA1c test numbers fell by ~80%. Overall, across six centres, 369 871 tests were missed during the 6.28 months of the CIP, equivalent to >6.6 million tests nationwide. We identified 79 131 missed 'monitoring' tests in people with diabetes. In those 28 564 people with suboptimal control, this delayed monitoring was associated with a 2-3 mmol/mol HbA1c increase. Overall, 149 455 'screening' and 141 285 'diagnostic' tests were also missed. Across the UK, our findings equate to 1.41 million missed/delayed diabetes monitoring tests (including 0.51 million in people with suboptimal control), 2.67 million screening tests in high-risk groups (0.48 million within the prediabetes range) and 2.52 million tests for diagnosis (0.21 million in the pre-diabetes range; ~70 000 in the diabetes range).
Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for, diabetes. For people with diabetes, missed tests will result in further deterioration in diabetes control, especially in those whose HbA1c levels are already high.
Introduction
Recent prescribing policies in England and Wales have imposed significant restrictions on liothyronine prescribing in general practice driven by the prohibitive costs and uncertain ...benefits of liothyronine in the management of hypothyroidism. However, the impact of these policies on liothyronine usage and costs is still unclear.
Methods
Data were downloaded from the NHS monthly General Practice Prescribing Data in England and from the Comparative Analysis System for Prescribing Audit (CASPA) in Wales for 2011–2020. Trends over the period in amount and costs of levothyroxine and liothyronine prescribing were analysed.
Results
The total medication costs per year for England Wales for hypothyroidism rose from £60.8 million to £129.8 million in 2015–16 and have since reduced to £88.4 million. Levothyroxine prescriptions have been growing above the population growth rate at 0.7%/annum in England and 1.1% in Wales. The costs/patient/year for liothyronine rose from £550 to £3000 in 2015–16 and has since fallen to £2500. Use of liothyronine as a percentage of levothyroxine started to fall in 2015–16 at 7%/annum in England and 3% in Wales. Nevertheless, 0.5% of levothyroxine‐treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019–20.
Conclusion
In spite of strenuous attempts to limit prescribing of liothyronine in general practice, a significant number of patients continue to receive this therapy. The price differential of liothyronine vs levothyroxine should be examined again in light of the continuing use of liothyronine.
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