Aim
To estimate the healthcare costs of diabetic foot disease in England.
Methods
Patient‐level data sets at a national and local level, and evidence from clinical studies, were used to estimate the ...annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014–2015.
Results
The cost of health care for ulceration and amputation in diabetes in 2014–2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration.
Conclusions
Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one‐third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.
What's new?
At least 2% of people with diabetes experience new foot ulcers annually, and one in 400 undergoes amputation.
The cost of diabetic foot disease in England is almost 1% of the health service budget.
More than 90% of these costs are for ulcer care.
It is hoped that knowledge of human and financial costs will increase research effort, clinical attention and compliance with national guidance, to improve ulcer healing rates and reduce amputations.
Population growth can be sensitive to changes in survival rates for many avian species. Understanding sources of mortality, and how to mitigate negative effects on survival, can give managers insight ...into factors contributing to population change. Harvest trends of eastern wild turkeys (Meleagris gallopavo silvestris) in northeastern South Dakota suggest a decline in abundance. We investigated factors influencing survival of wild turkeys to identify potential factors contributing to the decline. We monitored 122 female wild turkeys using VHF radio transmitters from February 2017 to April 2019. Annual survival was 0.52 (95% CI = 0.33–0.64) for juvenile and 0.49 (95% CI = 0.23–0.63) for adult females, respectively. Daily survival probability was significantly lower during the spring (log‐odds ratio LOR = −0.9; 95% CI = −1.5–−0.2) and while a juvenile female was incubating (LOR = −0.67; 95% CI = −1.23–−0.09) but not while an adult female was incubating (LOR = −0.35; 95% CI = −0.92–0.24). Mammalian predation was the leading cause of mortality, and female wild turkeys were most vulnerable to predation during the spring while engaging in nesting and rearing of young broods. Wild turkeys were at risk for additional sources of mortality while incubating nests that were not contributors to mortality during other periods of the year, as deaths caused by haying equipment—the second greatest cause of mortality—only occurred while a female was incubating. Reducing female mortality due to haying, by delaying cutting, installing flushing bars on haying equipment, or increasing availability of suitable nesting cover types to reduce the probability of nesting in hayfields, could improve female survival. Annual survival during our study was about 16–29% lower than survival estimates from northeastern South Dakota during the 1990s, suggesting that reduced female survival could be contributing to the apparent decline in wild turkey abundance.
We investigated factors influencing survival of female eastern wild turkeys to identify potential drivers of an apparent decline in abundance. Daily survival probability was significantly lower during the spring and while a juvenile female was incubating but not while an adult female was incubating. Mammalian predation and haying equipment were the leading causes of mortality. Mitigating negative impacts of haying or increasing availability of suitable nesting cover types to reduce the probability of nesting in hayfields could improve female survival.
Aims
Sustained engagement in type 1 diabetes self‐management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. ...Evaluations of self‐management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self‐management, their influences and relationships to each other.
Methods
A mixed‐methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self‐management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider‐generated ‘red flags’ and participant‐generated ‘frequently asked questions’) were analysed to identify and synthesise modifiable barriers and enablers to sustained self‐management. These were characterised according to the Capability‐Opportunity‐Motivation‐Behaviour (COM‐B) model.
Results
150 distinct behaviours were identified and organised into three self‐regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self‐management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty‐four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation.
Conclusions
Multiple behaviours within three self‐management cycles are involved in sustained type 1 diabetes self‐management. There are a wide range of barriers and enablers that should be addressed to support self‐management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self‐management programmes.
Obesity is difficult to reverse in older children and adults and calls have been made to implement obesity prevention strategies during the formative pre-school years. Childhood obesity experts ...suggest that prevention of overweight in the pre-school years should focus on parents, because parental beliefs, attitudes, perceptions and behaviours appear to contribute to children's development of excessive weight gain. While evidence suggests that parental variables may be instrumental in the development of obesity, there has been no systematic evaluation of whether intervening to change such variables will positively influence the development of excess adiposity during the pre-school years. This paper is a conceptual and methodological review of the literature on the parental variables targeted in interventions designed to modify risk factors for obesity by promoting healthy eating and/or physical activity and/or reducing sedentary behaviours in families of children aged 2-6 years. There were significant methodological limitations of existing studies and the scientific study of this area is in its infancy. However, the results suggest that the modification of parental variables known to be associated with obesity-promoting behaviours in pre-school children may show promise as an obesity prevention strategy; further research is needed.
Prevention of catheter related blood stream infections (CRBSI) and salvage of infected central venous catheters (CVC) are vital to maintaining long term venous access in patients needing home ...parenteral nutrition (HPN). It remains unclear as to whether patients are best trained for catheter care at home or in hospital or whether CRBSIs are lower if the patient self-cares for the CVC. Furthermore, there is minimal data on the longer term outcome following salvage of infected catheter and limited consensus on agreed protocols for catheter salvage.
We conducted a retrospective 5-year evaluation of CRBSI occurrence and CVC salvage outcomes in adult patients requiring HPN managed at a national UK Intestinal Failure Unit from 2012 to 2016. Prior to 2012, patients were primarily trained to administer PN in hospital; thereafter, patients underwent training at home.
A total of 134 CRBSI were recorded in 92 patients (62 patients with a single CRBSI and 30 patients with more than 1 CRBSI) in a cohort of 559 HPN patients, with a total of 1163 HPN years. The overall CRBSI rate was 0.31 per 1000 catheter days. CNS were the most common isolates (41/134 (30.5%)), followed by polymicrobial infections (14/134 (10.4%)), Klebsiella spp. (16/134 (11.9%)) and methicillin – sensitive Staphylococcus aureus (MSSA) 5/134 ((3.7%)). Salvage was not attempted in 34 cases due to methicillin – resistant (MRSA) infection (1/34), fungal infection (13/34) or clinical instability due to sepsis (20/34). Of the 100 cases where salvage was attempted, 67% were successful. 82.8% of CNS salvage attempts were successful; there was no difference in salvage rates between CNS CRBSIs salvaged with a 10-day (22/26) or 14-day protocol (7/9) (p = 0.4). CRBSI rate, in those cared for by trained home care nurses was the lowest at 0.270 (self care: 0.342 and non-medical carer (e.g. family member): 0.320) (p = 0.03).
We previously reported a sustained very low CRBSI rate in a large cohort of HPN patients in a national unit; we now further report that this is not influenced by training patients at home rather than in hospital but is influenced by the individual managing the catheter at home. CNS remains the primary cause of CRBSIs and can be successfully salvaged with a reduced duration of antibiotic therapy compared to our previous experience.
High‐temperature volcanic gas is widely considered to originate from ascending, mantle‐derived magma. In volcanic arc systems, crustal inputs to magmatic gases mainly occur via subducted sediments in ...the mantle source region. Our data from Merapi volcano, Indonesia imply, however, that during the April‐October 2006 eruption significant quantities of CO2 were added from shallow crustal sources. We show that prior to the 2006 events, summit fumarole gas δ13C(CO2) is virtually constant (δ13C1994–2005 = −4.1 ± 0.3‰), but during the 2006 eruption and after the shallow Yogyakarta earthquake of late May, 2006 (M6.4; hypocentres at 10–15 km depth), carbon isotope ratios increased to −2.4 ± 0.2‰. This rise in δ13C is consistent with considerable addition of crustal CO2and coincided with an increase in eruptive intensity by a factor of ∼3 to 5. We postulate that this shallow crustal volatile input supplemented the mantle‐derived volatile flux at Merapi, intensifying and sustaining the 2006 eruption. Late‐stage volatile additions from crustal contamination may thus provide a trigger for explosive eruptions independently of conventional magmatic processes.
Key Points
Carbon isotopes in CO2 at active Merapi show a positive spike from baseline levels
Crustal CO2 can be liberated by active volcanism
Crustal CO2 can intensify ongoing eruptions making it a factor in hazard assessment
Knowing the site of gamma-ray emission in active galactic nucleus jets will do much for our understanding of the physics of the source. In particular, if the emission region is close to the black ...hole then absorption of gamma-rays with photons from the broad-line region could become significant. Such absorption is predicted to produce two specific spectral breaks in the gamma-ray spectra of Flat Spectrum Radio Quasars (FSRQs). We test this hypothesis using three years of Fermi observations of nine bright FSRQs. A simple power-law fit to the spectrum of each source can be significantly improved by introducing a break, but the break energies are inconsistent with those predicted by the double-absorber model. In some cases the fit can be further improved by a log-parabola. In addition, by dividing the data from each source into two equal epochs we find that the best description of an object's spectrum often varies between a log-parabola and a broken power law.
Knockdown of the insulator factor CCCTC binding factor (CTCF), which binds XL9, an intergenic element located between HLA-DRB1 and HLA-DQA1, was found to diminish expression of these genes. The ...mechanism involved interactions between CTCF and class II transactivator (CIITA), the master regulator of major histocompatibility complex class II (MHC-II) gene expression, and the formation of long-distance chromatin loops between XL9 and the proximal promoter regions of these MHC-II genes. The interactions were inducible and dependent on the activity of CIITA, regulatory factor X, and CTCF. RNA fluorescence in situ hybridizations show that both genes can be expressed simultaneously from the same chromosome. Collectively, the results suggest a model whereby both HLA-DRB1 and HLA-DQA1 loci can interact simultaneously with XL9, and describe a new regulatory mechanism for these MHC-II genes involving the alteration of the general chromatin conformation of the region and their regulation by CTCF.
Kelut volcano, East Java, is an active volcanic complex hosting a summit crater lake that has been the source of some of Indonesia’s most destructive lahars. In November 2007, an effusive eruption ...lasting approximately 7 months led to the formation of a 260-m-high and 400-m-wide lava dome that displaced most of the crater lake. The 2007–2008 Kelut dome comprises crystal-rich basaltic andesite with a texturally complex crystal cargo of strongly zoned and in part resorbed plagioclase (An
47–94
), orthopyroxene (En
64–72
, Fs
24–32
, Wo
2–4
), clinopyroxene (En
40–48
, Fs
14–19
, Wo
34–46
), Ti-magnetite (Usp
16–34
) and trace amounts of apatite, as well as ubiquitous glomerocrysts of varying magmatic mineral assemblages. In addition, the notable occurrence of magmatic and crustal xenoliths (meta-basalts, amphibole-bearing cumulates, and skarn-type calc-silicates and meta-volcaniclastic rocks) is a distinct feature of the dome. New petrographical, whole rock major and trace element data, mineral chemistry as well as oxygen isotope data for both whole rocks and minerals indicate a complex regime of magma-mixing, decompression-driven resorption, degassing and crystallisation and crustal assimilation within the Kelut plumbing system prior to extrusion of the dome. Detailed investigation of plagioclase textures alongside crystal size distribution analyses provide evidence for magma mixing as a major pre-eruptive process that blends multiple crystal cargoes together. Distinct magma storage zones are postulated, with a deeper zone at lower crustal levels or near the crust-mantle boundary (>15 km depth), a second zone at mid-crustal levels (~10 km depth) and several magma storage zones distributed throughout the uppermost crust (<10 km depth). Plagioclase-melt and amphibole hygrometry indicate magmatic H
2
O contents ranging from ~8.1 to 8.6 wt.% in the lower crustal system to ~1.5 to 3.3 wt.% in the mid to upper crust. Pyroxene and plagioclase δ
18
O values range from 5.4 to 6.7 ‰, and 6.5 to 7.6 ‰, respectively. A single whole rock analysis of the 2007–2008 dome lava gave a δ
18
O value of 7.6 ‰, whereas meta-basaltic and calc-silicate xenoliths are characterised by δ
18
O values of 6.2 and 10.3 ‰, respectively. Magmatic δ
18
O values calculated from individual pyroxene and plagioclase analyses range from 5.7 to 7.0 ‰, and 6.2 to 7.4 ‰, respectively. This range in O-isotopic compositions is explained by crystallisation of pyroxenes in the lower to mid-crust, where crustal contamination is either absent or masked by assimilation of material having similar δ
18
O values to the ascending melts. This population is mixed with isotopically distinct plagioclase and pyroxenes that crystallised from a more contaminated magma in the upper crustal system. Binary bulk mixing models suggest that shallow-level, recycled volcaniclastic sedimentary rocks together with calc-silicates and/or limestones are the most likely contaminants of the 2007–2008 Kelut magma, with the volcaniclastic sediments being dominant.
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