The Effects of Bariatric Surgery on the Requirement for Antihypertensive Treatment in Type 2 Diabetes: Insights from a Long-Term Follow-Up Study

INTRODUCTION

Bariatric surgery (BS) has emerged an effective intervention in achieving significant and sustained weight loss in patients with type 2 diabetes (T2D). However, comprehensive data on the long-term impact of BS on hypertension is scarce. We aimed to investigate the long-term impact of BS on blood pressure management in individuals within a T2D cohort.

METHODS

This retrospective cohort study was conducted on 119 patients who underwent BS between 2009 and 2012. Baseline and follow-up observations, including blood pressure, HbA1c, BMI, and antihypertensive medication use were obtained from electronic patient records at regular intervals up to and beyond 10-year follow-up.

RESULTS

The median follow-up period for the 119 patients was 11.5 years. Mean fall in BMI 4-8 weeks post-surgery was 12%. A sustained reduction in systolic BP was observed up to 10 years post-surgery (154.5 mmHg pre-op vs. 132.8 mmHg at 10 years; p < 0.0001. From 5 years onwards, there were increases in mean glycated hemoglobin (HbA1c) and body mass index (BMI). At latest follow-up (> 5 years after bariatric surgery), the number of individuals prescribed an antihypertensive agent started to increase. This is in the context of the number of the number of individuals on 2-3 antihypertensive agents declining up until 5 years post-BS. Specifically, there was a reduction in the number of prescriptions of an antihypertensive agent over time from 164 prescriptions pre-operatively to 81 at 8 weeks post-operatively, 78 at 6 months, 72 at 1 year, 66 at 5 years before rising at 10 years to 95 prescriptions.

CONCLUSIONS

Our study shows an overall benefit in the years after bariatric surgery in terms of blood pressure and requirement for antihypertensive medication. However, at 5 years and beyond after surgery, the beneficial effect of bariatric surgery diminishes with respect to an increase in number of antihypertensive medication prescriptions, BMI, and HbA1c.

Enhancing type 2 diabetes treatment through digital plans of care - a randomized controlled trial: evaluation of change in patient reported outcome measures

BACKGROUND

We investigated how a personalized care-planning software and linked mobile-app may aid people to self-manage their type 2 diabetes (T2D) more effectively.

RESEARCH DESIGN AND METHODS

People with T2D and glycated hemoglobin (HbA1c) greater than 58 mmol/mol (7.5%) were randomized to either an intervention group receiving a personalized care plan, or the control group receiving usual care. Quality of life (QoL) was measured for both groups using validated questionnaires and one-on-one interviews with a subset of 12 participants from each group.

RESULTS

QoL for the active treatment group increased, by their EQ -5D-5 L score increasing on average by 0.046, whereas it decreased for the control group on average by 0.009. The EQ Visual Analogue Score (VAS) of the intervention group also increased by 8.2%, whereas the control group had a reduction in EQ VAS score of 2.8% (p = 0.008 for difference).

CONCLUSION

In this prospective RCT, the findings point to how the provision of personalized care plans can result in an improvement in individuals' self-rated QoL. This may lead to longer term health benefits.

Macroprolactin over time: Is there any point in rechecking it in people with a persistently elevated serum prolactin?

OBJECTIVE AND DESIGN

Macroprolactinemia may influence the interpretation of serum prolactin levels-a recognised phenomenon since 1981. The degree of macroprolactinaemia over time is less well described. We determined how macroprolactin status (based on polyethylene glycol (PEG) precipitation) varied by analysing serial measurements in hyperprolactinaemic individuals over a period of 9 years.

PATIENTS AND MEASUREMENTS

Results from 1810 individuals were included. All serum total prolactin results (measured using Roche Cobas 8000 analyser) were extracted from the laboratory information system for the period 1 January 2012 to 1 April 2021, along with relevant patient demographic/test data. Samples with a macroprolactin screening test performed (on samples with prolactin > 700 miu/L) were included in the main analysis.

RESULTS

During the study period, 2782 macroprolactin checks were performed (12.5% of all prolactin tests) in 1810 individuals (599 males/2183 females, median-age: 35, interquartile range: 25-47, range: 16-93 years). Multiple macroprolactin checks were carried out on 465 patients (1437 measurements) with 94 patients (141 measurements) screening positive (<60% recovery). Only 19 patients (18 female) had at least one result above and one below the 60% screening cut-off, with 10 of these patients having results close to the 60% cut-off; in 9 patients, results were clearly different between repeat samples. In seven cases, the adjusted monomeric prolactin showed a potentially clinically significant difference.

CONCLUSIONS

In this study, only 19/465 patients appeared to change macroprolactin status based on a 60% PEG recovery cut-off. The majority of these 19 patients were on antipsychotic/antidepressant medication(s) or had a prolactinoma; in only 7 did monomeric prolactin change significantly. This suggests that once macroprolactin status has been determined, clinical decision making is rarely affected by repeating it.

Effect of the COVID-19 pandemic on mental health visits in primary care: an interrupted time series analysis from nine INTRePID countries

Background

The COVID-19 pandemic impacted mental health disorders, affecting both individuals with pre-existing conditions and those with no prior history. However, there is limited evidence regarding the pandemic's impact on mental health visits to primary care physicians. The International Consortium of Primary Care Big Data Researchers (INTRePID) explored primary care visit trends related to mental health conditions in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden, and the USA.

Methods

We conducted an interrupted time series analysis in nine countries to examine changes in rates of monthly mental health visits to primary care settings from January 1st, 2018, to December 31st, 2021. Sub-group analysis considered service type (in-person/virtual) and six categories of mental health conditions (anxiety/depression, bipolar/schizophrenia/other psychotic disorders, sleep disorders, dementia, ADHD/eating disorders, and substance use disorder).

Findings

Mental health visit rates increased after the onset of the pandemic in most countries. In Argentina, Canada, China, Norway, Peru, and Singapore, this increase was immediate ranged from an incidence rate ratio of 1·118 [95% CI 1.053-1.187] to 2.240 [95% CI 2.057-2.439] when comparing the first month of pandemic with the pre-pandemic trend. Increases in the following months varied across countries. Anxiety/depression was the leading reason for mental health visits in most countries. Virtual visits were reported in Australia, Canada, Norway, Peru, Sweden, and the USA, accounting for up to 40% of the total mental health visits.

Interpretation

Findings suggest an overall increase in mental health visits, driven largely by anxiety/depression. During the COVID-19 pandemic, many of the studied countries adopted virtual care in particular for mental health visits. Primary care plays a crucial role in addressing mental ill-health in times of crisis.

Funding

Canadian Institutes of Health Research grant #173094 and the Rathlyn Foundation Primary Care EMR Research and Discovery Fund.

Counting the lifetime cost of obesity: Analysis based on national England data

AIM

Obesity has a significant impact on all-cause mortality rate and overall health care resource use (HCRU). These outcomes are also strongly linked to age, sex and local deprivation of the population. We aimed to establish the lifetime costs of obesity by demographic group/geographic area using published mortality rates and HCRU use for integrated care boards (ICB) in England in the context of costs of therapeutic intervention.

METHODS

Population and expected mortality rates by age, sex and deprivation were obtained from national data. Obesity class prevalence was taken from the health of the nation study. The published impact of obesity by age, group, sex and deprivation on mortality and HCRU were applied to estimate life years lost and lifetime HCRU [by sex, age band and body mass index (BMI) class for each ICB]. The year 2019 was chosen as the study basis data to avoid influences of COVID-19 pandemic on obesity rates with application of 2022/23 HCRU values. Outcomes including prevalence, deaths, life years lost, HCRU and lifetime HCRU were compared by age and sex groups across four BMI classes normal/underweight (BMI <25 kg/m2 ), overweight (25-29.9 kg/m2 ), obese class I and II (30-39.9 kg/m2 ), and obese class III (≥40), with benchmarking being set against all population being BMI <25 kg/m2 overall and by each of the 42 ICBs. We also associated future life with deaths to provide an estimate of 'future life years lost' occurring each year.

RESULTS

Total population aged >16 years was 45.4 million (51% female).

PREVALENCE

13.7 million (28% of the total adult population) had a BMI ≥30 mg/m2 and BMI ≥40 kg/m2 were 1.50 million (12%) of these 1.0 million (68%) were female and of these 0.6 million 40% were women aged 16-49 years. In addition, 35% of those with a BMI ≥40 kg/m2 were in the top deprivation quintile (i.e. overall 20%). Mortality was based on expected deaths of 518K/year, and modelling suggested that if a BMI <25 kg/m2 was achieved in all individuals, the death rate would fall by 63K to 455K/year for the English population (12% reduction). For those with a BMI ≥40 kg/m2 the predicted reduction was 12K deaths (54% lower); while in those aged 16-49 years with a BMI ≥40 kg/m2 72% of deaths were linked to obesity. For future life years lost, we estimated 2.5 years were lost in people with BMI 30-39.9 kg/m2 6.7 years when BMI ≥40 kg/m2 . However, for those aged 16-49 years with a BMI ≥40 kg/m2 , 8.3 years were lost. HCRU, for weight reduction, the annual HCRU decrease from BMI ≥40 kg/m2 to BMI 30-39.9 kg/m2 was £342 per person and from BMI 30-39.9 to 25-29.9 kg/m2 the reduction was £316/person. However, lifetime costs were similar because of reduced life expectancy for obese individuals. In quality adjusted life years (QALY), overall, 791 689 future life years were lost (13.1% of all) in people with BMI ≥25 kg/m2 and were related to excess weight. When the NICE £30 000 per QALY value was applied to the estimated total 791 689 future life years lost then the potential QALY value reduction lost was equivalent to £24 billion/year or £522/person in the obese population. For morbidly obese men and women the potential QALY value lost was £2864/person/year. Regarding geography, across the 42 ICBs, we observed significant variation in the prevalence of BMI ≥40 (1.8%-4.3%), excess mortality (11.6%-15.4%) and HCRU linked to higher BMI (7.2%-8.8%). The areas with the greatest impact on HCRU were in the north-west, north-east and Midlands of England, while the south shows less impact.

CONCLUSION

The expected increases in annual HCRU because of obesity, when considered over a lifetime, are being mitigated by the increased mortality of obese individuals. Our data suggest that simple short-term HCRU reduction brought about through BMI reduction will be insufficient to fund additional specialist weight reduction interventions. The HRCUs associated with BMI are not in most cases related to short-term health conditions. They are a cumulative result over a number of years, so for age 16-49 years reducing BMI from ≥40 to 30-39.9 kg/m2 might show an annual decrease in HCRU/person by £325/year for women and £80/year for men but this might not have immediately occurred within that year. For those aged >70 years reducing BMI from ≥40 to 30-39.9 kg/m2 might show an annual decrease in HCRU/person by £777/year for women and £796/year for men but also may not be manifest within that year. However, for the morbidly obese men and women, the potential QALY value lost was £2864 per person per year with the potential for these funds to be applied to intensive weight management programmes, including pharmacotherapy.

Weight change following diagnosis with psychosis: a retrospective cohort study in Greater Manchester, UK

INTRODUCTION

Weight gain in the months/years after diagnosis/treatment of severe enduring mental illness (SMI) is a major predictor of future diabetes, dysmetabolic profile and increased risk of cardiometabolic diseases. There is limited data on the longer-term profile of weight change in people with a history of SMI and how this may differ between individuals. We here report a retrospective study on weight change over the 5 years following an SMI diagnosis in Greater Manchester UK, an ethnically and culturally diverse community, with particular focus on comparing non-affective psychosis (NAP) vs affective psychosis (AP) diagnoses.

METHODS

We undertook an anonymised search in the Greater Manchester Care Record (GMCR). We reviewed the health records of anyone who had been diagnosed for the first time with first episode psychosis, schizophrenia, schizoaffective disorder, delusional disorder (non-affective psychosis = NAP) or affective psychosis (AP). We analysed body mass index (BMI) change in the 5-year period following the first prescription of antipsychotic medication. All individuals had taken an antipsychotic agent for at least 3 months. The 5-year follow-up point was anywhere between 2003 and 2023.

RESULTS

We identified 9125 people with the diagnoses above. NAP (n = 5618; 37.3% female) mean age 49.9 years; AP (n = 4131; 60.5% female) mean age 48.7 years. 27.0% of NAP were of non-White ethnicity vs 17.8% of AP individuals. A higher proportion of people diagnosed with NAP were in the highest quintile of social disadvantage 52.4% vs 39.5% for AP. There were no significant differences in baseline BMI profile. In a subsample with HbA1c data (n = 2103), mean HbA1c was higher in NAP at baseline (40.4 mmol/mol in NAP vs 36.7 mmol/mol for AP). At 5-year follow-up, there was similarity in both the overall % of individuals in the obese ≥ 30 kg/m2 category (39.8% NAP vs 39.7% AP), and % progressing from a normal healthy BMI transitioned to obese/overweight BMI (53.6% of NAP vs 55.6% with AP). 43.7% of those NAP with normal BMI remained at a healthy BMI vs 42.7% with AP. At 5-year follow-up for NAP, 83.1% of those with BMI ≥ 30 kg/m2 stayed in this category vs 81.5% of AP.

CONCLUSION

The results of this real-world longitudinal cohort study suggest that the changes in BMI with treatment of non-affective psychosis vs bipolar disorder are not significantly different, while 43% maintain a healthy weight in the first 5 years following antipsychotic prescription.

Changes in prescribing of psychotropic vs some physical health medication in primary care through the COVID-19 pandemic in England: a national-level survey

INTRODUCTION

The COVID-19 pandemic globally impacted healthcare provision. Prescribing changes in common medications can be used as a marker for new diagnoses. We describe how the prescribing of specific psychotropics was impacted by the pandemic.

METHODS

Primary Care Prescribing data for different classes of drugs from March 2017 to February 2022 were considered. To capture the impact during periods of restricted access to health services for new diagnoses/existing conditions, repeat prescriptions/episodic prescribing were included with account taken of historical trends. The pre-pandemic prescriptions issued each month from March 2018 to February 2020 were linearly extrapolated forward to give an expected annual growth (EAG). The monthly average expected prescriptions for the pandemic period (March 2020-February 2022) were compared.

RESULTS

Physical health medications had lower monthly prescriptions during the pandemic, most markedly for antibiotics - 12.5% (EAG - 1.3%). Bronchodilator prescribing showed a marked increase in the early pandemic months from March 2020 of 5% (EAG 0.1%). Mental health medication prescribing increased above trend for hypnotics/anxiolytics by 0.2% (EAG - 2.3%), while antidepressants fell by - 0.2% (EAG 5.0%), with no net change for antipsychotics (EAG 2.8%), but a temporary increase in antipsychotic prescribing in the early pandemic period. For all the main antidepressants prescribed in England (Sertraline, Mirtazapine, Venlafaxine, Fluoxetine and Citalopram), prescribing actually decreased in the main pandemic period vs historical trend.

CONCLUSIONS

The increase in anxiolytic/hypnotic prescribing above trend links to pandemic effects on anxiety/worry. If anything, there was a slight fall in prescribing of the main antidepressants prescribed, which given prevailing circumstances at the time, suggests that access to services may have restricted access to timely assessment.

Number of CAG repeats and mortality in middle aged and older men

DESIGN

The androgen receptor (AR) mediates peripheral effects of testosterone. Previous data suggests an association between the number of CAG repeats in exon-1 of the AR gene and AR transcriptional activity. The aim of this analysis was to determine the association between the number of AR CAG repeats and all-cause mortality in men and the influence of testosterone level on the association.

PATIENTS AND MEASUREMENTS

Follow-up data to 27 January 2018 were available for men aged 40-79 years recruited across six countries of the European Male Aging Study between 2003 and 2005. Cox proportional hazards modelling was used to determine the association between CAG repeat number/mortality. Results were expressed as hazard ratios (HR)/95% confidence intervals (CI).

RESULTS

One thousand nine hundred and seventy-seven men were followed up. Mean baseline age was 60 ± 11.1 years. Mean duration of follow-up was 12.2 years. At follow up 25.1% of men had died. CAG repeat length ranged from 6 to 39, with the highest proportion of CAG repeat number at 21 repeats (16.4%). In a multivariable model, compared to men with 22-23 AR CAG repeats: for men with <22 and >23 AR CAG HR, 95% CI for mortality were, <22 CAG repeats 1.17 (0.93-1.49) and >23 CAG repeats 1.14 (0.88-1.47). In a post-hoc analysis, the association was significant for men in the lowest tertile of baseline testosterone (<14.2 nmol/L) with >23 CAG repeats: in the adjusted model for <22 and >23 CAG repeats, respectively, 1.49 (0.97-2.27) and 1.68 (1.06-2.67) versus 22-23 repeats.

CONCLUSIONS

Our European-wide cohort data overall found no association of androgen receptor CAG repeat number and mortality in men. However, post hoc analysis suggested that an association might be present in men with lower baseline testosterone concentrations, which merits further investigation.

A study to investigate genetic factors associated with weight gain in people with diabetes: analysis of polymorphisms in four relevant genes

BACKGROUND

Weight change is often seen in people with diabetes. We investigated the effects of genes associated with weight change/glucose handling/insulin-signalling.

MATERIALS/METHODS

DNA from diabetes individuals and non-diabetes individuals, plus clinical data, were available from the DARE study (n = 379 individuals: T1D n = 111; T2D n = 222; controls n = 46). Weight gain was assessed by temporal change of Body Mass Index (BMI). Genotyping was performed for CAV1rs926198, LEPRrs1137101, BDNFrs6265 and FTOrs9939609.

RESULTS

No differences in genotype distributions were observed for the four SNPs in all groups un-stratified by weight gain. Following stratification differences in genotype distribution were observed. For those BMI relatively stable; controls showed a difference in genotype distributions versus T1D (CAV1rs926198, LEPRrs1137101). In T2D vs controls, significant differences were observed in genotype distribution for all four genes. For BMI increase, the only difference by category was LEPRrs1137101 (bothT1D/T2D vs controls). In BMI-stable groups, CAV1rs926198, T1D individuals showed lower T allele frequency (p=0.004) vs non-diabetes and for LEPRrs1137101 a higher G allele frequency versus controls (p=0.002). For T2D, CAV1rs926198, T allele frequency was lower in T2D than controls (p=0.005). For LEPR rs1137101, the G allele frequency was higher than in controls (p=0.004). In those with BMI increase, LEPRrs1137101 T1D individuals had higher G allele frequency versus controls (p=0.002) as did T2D vs controls (p=0.03).

CONCLUSION

Differences in allele frequency were seen between diabetes individuals and non-diabetes diagnosed at baseline in relation to the likelihood of BMI increase of >10%. It is established that the G allele of LEPRrs1137101 is associated with weight gain/obesity. However, this is the first report of CAV1rs926198 polymorphism being associated with weight stability/gain in diabetes.

A Longitudinal Clinical Trajectory Analysis Examining the Accumulation of Co-morbidity in People with Type 2 Diabetes (T2D) Compared with Non-T2D Individuals

BACKGROUND

Type 2 diabetes mellitus (T2D) is commonly associated with an increasing complexity of multimorbidity. While some progress has been made in identifying genetic and non-genetic risk factors for T2D, understanding the longitudinal clinical history of individuals before/after T2D diagnosis may provide additional insights.

METHODS

In this study, we utilised longitudinal data from the DARE (Diabetes Alliance for Research in England) study to examine the trajectory of clinical conditions in individuals with and without T2D. Data from 1932 individuals (T2D n = 1196 vs. matched non-T2D controls n = 736) were extracted and subjected to trajectory analysis over a period of up to 50 years (25 years pre-diagnosis/25 years post-diagnosis). We also analysed the cumulative proportion of people with diagnosed coronary artery disease (CAD) in their general practice (GP) record with an analysis of lower respiratory tract infection (RTI) as a comparator group.

RESULTS

The mean age of diagnosis of T2D was 52.6 (95% confidence interval 52.0-53.4) years. In the years leading up to T2D diagnosis, individuals who eventually received a T2D diagnosis consistently exhibited a considerable increase in several clinical phenotypes. Additionally, immediately prior to T2D diagnosis, a significantly greater prevalence of hypertension (35%)/RTI (34%)/heart conditions (17%)/eye, nose, throat infection (19%) and asthma (12%) were observed. The corresponding trajectory of each of these conditions was much less dramatic in the matched controls. Post-T2D diagnosis, proportions of T2D individuals exhibiting hypertension/chronic kidney disease/retinopathy/infections climbed rapidly before plateauing. At the last follow-up by quintile of disadvantage, the proportion (%) of people with diagnosed CAD was 6.4% for quintile 1 (least disadvantaged) and 11% for quintile 5 (F = 3.4, p = 0.01 for the difference between quintiles).

CONCLUSION

These findings provide novel insights into the onset/natural progression of T2D, suggesting an early phase of inflammation-related disease activity before any clinical diagnosis of T2D is made. Measures that reduce social inequality have the potential in the longer term to reduce the social gradient in health outcomes reported here.

Diabetes detection in women with gestational diabetes and polycystic ovarian syndrome

Gestational diabetes mellitus (GDM) and polycystic ovarian syndrome (PCOS) represent two of the highest risk factors for development of type 2 diabetes mellitus in young women. As these increasingly common conditions generally affect younger women, early detection of dysglycemia is key if preventative measures are to be effective. While international guidance recommends screening for type 2 diabetes, current screening strategies suffer from significant challenges.First, guidance lacks consensus in defining which tests to use and frequency of monitoring, thereby sending mixed messages to healthcare professionals.Second, conformity to guidance is poor, with only a minority of women having tests at the recommended frequency (where specified). Approaches to improve conformity have focused on healthcare related factors (largely technology driven reminder systems), but patient factors such as convenience and clear messaging around risk have been neglected.Third, and most critically, current screening strategies are too generic and rely on tests that become abnormal far too late in the trajectory towards dysglycemia to offer opportunities for effective preventative measures. Risk factors show wide interindividual variation, and insulin sensitivity and β cell function are often abnormal during pre-diabetes stage, well before frank diabetes.New, consistent, targeted screening strategies are required that incorporate early, prevention focused testing and personalised risk stratification.

Evaluation of a male-specific psychotherapeutic program for major depressive disorder compared to cognitive behavioral therapy and waitlist: study protocol for a six-arm randomized clinical superiority trial examining depressed eugonadal and hypogonadal men receiving testosterone

Background

Treatment of major depressive disorder (MDD) in men is complicated by the endorsement of traditional masculinity ideologies (TMI) often leading to reluctance toward psychotherapy, therapy interfering processes, or premature termination. In addition, it has been shown that men with MDD have a significantly increased risk of being hypogonadal (e.g., total testosterone levels <12.1 nmoL/L). Therefore, it is recommended to examine depressed men with regard to their testosterone status and if hypogonadism is present to combine psychotherapy with testosterone treatment (TT).

Aim

This project aims to evaluate a male-specific psychotherapeutic program (MSPP) for MDD in depressed eugonadal and hypogonadal men receiving testosterone in comparison to a standard cognitive behavioral therapy (CBT) for MDD and a Waitlist.

Methods

The study presents a 2×3 factorial study design. In total, 144 men aged between 25 and 50 will be stratified by testosterone status (eugonadal/hypogonadal) and then randomized into one of the three conditions (MSPP, CBT, or Waitlist). Additionally, a healthy control group of 100 men will be recruited, which will undergo only baseline assessments. Both standardized psychotherapy programs will encompass 18 sessions delivered in a weekly manner. Aligned with the TT-related medical visits of the 72 hypogonadal men, all participants will be followed up with clinical assessments and bio sampling at weeks 0, 6, 15, 24, and 36.

Expected results

Compared to Waitlist control groups, treatment groups are expected to be more effective and efficacious (depression score reduction of ≥50%) at week 24 and at the follow-up at week 36. The MSPP is expected to show higher effectiveness and efficacy for depressive symptoms and higher acceptability (lower dropout rate) as compared to CBT.

Discussion

This study represents the first attempt to test a male-specific psychotherapy for MDD in a single-setting compared to standard CBT and a Waitlist control condition using randomized clinical trial methodology. In addition, the potential positive adjunct effect of psychotherapy to TT in reducing depressive burden and improving quality of life in hypogonadal depressed men represents a neglected research area and might introduce new hypogonadism screening procedures in depressed men and combined treatment approaches for depressed men suffering from hypogonadism. Limitations are the rigorous inclusion and exclusion criteria, which limit the generalizability of the study results to first episode treatment naïve depressed men.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT05435222.

Associations and mitigations: an analysis of the changing risk factor landscape for chronic kidney disease in primary care using national general practice level data

OBJECTIVES

Early recognition of chronic kidney disease (CKD) should be achieved by every modern healthcare system. The objective of this study was to investigate CKD risk factor trends in England using general practice level data.

DESIGN

Observational analysis of data at practice level for all general practices in England. Practice characteristics identified as potential CKD risk factors included comorbidities and local demography. Data were analysed using both univariate and multivariate analysis to identify significant factors that were associated with CKD diagnosis for the period 1 April 2019 to 31 March 2020.

SETTING

Publicly available data from UK primary care sources including Primary Care Quality and Outcomes Framework database, practice-level prescribing data from the British National Formulary and Public Health England health outcome data.

PARTICIPANTS

All data submitted from 6471 medium to large practices in England were included (over 46 million patients).

RISK FACTOR ANALYSIS

Potential risk factors were grouped into four classes based on existing literature: demographic factors, comorbidities, service and practice outcome factors, and prescribing data effects.

RESULTS

The original model's prediction of CKD improved from r² 0.38 to an r² of 0.66 when updated factors were included. Positive associations included known risk factors with higher relative risk such as hypertension and diabetes, along with less recognised factors such as depression and use of opiates. Negative associations included NSAIDs which are traditionally associated with increased CKD risk, and prescribing of antibiotics, along with more northerly locations.

CONCLUSIONS

CKD is a preventable disease with high costs and consequences. These data and novel analysis give clearer relative risk values for different patient characteristics with some unexpected findings such as potential harmful association between CKD and opiates, and a more benign association with NSAIDs. A deeper understanding of CKD risk factors is important to update and implement local and national management strategies. Further research is required to establish the causal nature of these associations and to refine location appropriate actions to minimise harm from CKD on regional and local levels.

The number of androgen receptor CAG repeats and mortality in men

INTRODUCTION

The androgen receptor (AR) mediates peripheral effects of testosterone. Evidence suggests that the number of CAG repeats in exon-1 of the AR gene negatively correlates with AR transcriptional activity. The aim of this analysis was to determine the association between CAG repeat number and mortality in men.

METHODS

Men aged 40-79 years were recruited from primary care for participation in the UK arm of the European Male Aging Study between 2003 and 2005. Cox proportional hazards modelling was used to determine the association between CAG repeat number/mortality. Results were expressed as hazard ratios(HR)/95% confidence intervals (CI).

RESULTS

312 men were followed up. The mean baseline age was 59.5 years. At follow up, 85/312(27%) men had died. CAG repeat length ranged from 14 to 39, with the highest proportion of CAG repeat number at 21 repeats(16.4%). In a multivariable model, using men with CAG repeat numbers of 22-23 as the reference, men with a lower number of CAG repeats(<22) showed a trend for a higher mortality in the follow-up period (HR 1.46 (0.75, 2.81)) as did men with higher number of repeats (>23) (1.37 (0.65, 2.91)).

CONCLUSION

Our data suggest that CAG repeat number may partially influence the risk of mortality in men. Further larger studies are required to quantify the effect.

Mortality Rate Associated with Diabetes: Outcomes From a General Practice Level Analysis in England Using the Royal College of General Practitioners (RCGP) Database Indicate Stability Over a 15 Year Period

INTRODUCTION

Total population mortality rates have been falling and life expectancy increasing for more than 30 years. Diabetes remains a significant risk factor for premature death. Here we used the Oxford Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) practices to determine diabetes-related vs non-diabetes-related mortality rates.

METHODS

RCGP RSC data were provided on annual patient numbers and deaths, at practice level, for those with and without diabetes across four age groups (< 50, 50-64, 65-79, ≥ 80 years) over 15 years. Investment in diabetes control, as measured by the cost of primary care medication, was also taken from GP prescribing data.

RESULTS

We included 527 general practices. Over the period 2004-2019, there was no significant change in life years lost, which varied between 4.6 and 5.1 years over this period. The proportion of all diabetes deaths by age band was significantly higher in the 65-79 years age group for men and women with diabetes than for their non-diabetic counterparts. For the year 2019, 26.6% of deaths were of people with diabetes. Of this 26.6%, 18.5% would be expected from age group and non-diabetes status, while the other 8.1% would not have been expected-pro rata to nation, this approximates to approximately 40,000 excess deaths in people with diabetes vs the general population.

CONCLUSION

There remains a wide variation in mortality rate of people with diabetes between general practices in UK. The mortality rate and life years lost for people with diabetes vs non-diabetes individuals have remained stable in recent years, while mortality rates for the general population have fallen. Investment in diabetes management at a local and national level is enabling us to hold the ground regarding the life-shortening consequences of having diabetes as increasing numbers of people develop T2DM at a younger age.

Liothyronine for hypothyroidism: a candidate for disinvestment or in need of further research? A value of information analysis

OBJECTIVE

Medicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to deimplementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost-effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research.

DESIGN

Cost utility and value of information analyses.

SETTING

Primary care within the National Health Service in the UK.

PARTICIPANTS

Fifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism.

INTERVENTIONS

Liothyronine plus levothyroxine versus levothyroxine alone.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information.

RESULTS

20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12 053 and 1.014, respectively. The incremental cost-effectiveness ratio of £11 881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20 000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64 m per year in the UK.

CONCLUSIONS

A definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost.

Comparing cost of intravenous infusion and subcutaneous biologics in COVID-19 pandemic care pathways for rheumatoid arthritis and inflammatory bowel disease: A brief UK stakeholder survey

OBJECTIVES

One important group of people at higher risk from the SARS-CoV-2(COVID-19) pandemic are those with autoimmune conditions including rheumatoid arthritis/inflammatory bowel disease. To minimise infection risk, many people have been switched from intravenous to subcutaneous biologics including biosimilars.

DESIGN

The survey was designed to understand comparative economic issues related to the intravenous infusion vs subcutaneous biologic administration routes for infliximab. The survey focused on direct cost drivers/indirect cost drivers. Acquisition costs of medicines were not included due to data not being available publicly. Wider policy implications linked to the pandemic were also explored.

SETTING/PARTICIPANTS

Semistructured single telephone interviews were carried out with twenty key stakeholders across the National Health Service(NHS) from 35 clinical/42 pharmacy/28 commissioning roles. The interviews were undertaken virtually during April 2020. From interview (n = 20) results, a simple cost analysis was developed plus a qualitative analysis of reports on wider policy/patient impacts.

RESULTS

Key findings included evidence of significant variation in local infusion tariffs UK wide, with interviewees reporting that not all actual costs incurred are captured in published tariff costs. A cost analysis showed administration costs 50% lower in the subcutaneous compared to infusion routes, with most patients administering subcutaneous medicines themselves. Other indirect benefits to this route included less pressure on infusion unit waiting times/reduced risk of COVID-19 infection plus reduced patient 'out of pocket' costs. However, this was to some extent offset by increased pressure on home-care and community/primary care services.

CONCLUSIONS

Switching from infusion to subcutaneous routes is currently driven by the COVID-19 pandemic in many services. A case for biologics (infusion vs subcutaneous) must be made on accurate real-world economic analysis. In an analysis of direct/indirect costs, excluding medicine acquisition costs, subcutaneous administration appears to be the more cost saving option for many patients even without the benefit of industry funded home-care. What's known One important group of people at high risk in COVID-19 pandemic are those with autoimmune conditions, including those with rheumatoid arthritis and inflammatory bowel disease. Depending on the complexity of their condition, some of the patients in this group may be receiving intravenous biologic infusion therapy which under normal circumstances is administered within a hospital or day hospital setting. The National Institute for Health and Care Excellence has published new guidance to ensure that patients having intravenous treatment are assessed for possible switching to the same treatment in subcutaneous form. What's new A cost analysis showed that administration costs for subcutananous routes are 50% lower than for infusion routes, with most patients administering subcutaneous medicines themselves. Other indirect benefits to this route included less pressure on infusion unit waiting times and reduced risk of COVID-19 infection, along with reduced patient costs. Cost savings were partly offset by increased pressure on home-care and community/primary care services.

Is a fasting testosterone level really necessary for the determination of androgen status in men?

BACKGROUND

As circulating testosterone may be suppressed in the post-prandial state, it has been recommended that measurements are carried out with the patient fasted.

OBJECTIVES

In this regard, we assessed the effect of fasting/non-fasting status on total testosterone (T) levels in men.

MATERIALS AND METHODS

Data was collected in a single UK Hospital in men with two serum T requests taken within a 6-month period of each other and sampled at a time of day ≤ 2 h apart. Three groups were established, with T levels compared via signed-rank test in men with both a fasting and non-fasting sample (Group 1; n = 69), and in men with paired non-fasting (Group 2; n = 126) and paired fasting (Group 3; n = 18) samples. The differences in T levels between the paired samples was compared between the three groups using the rank-sum test and also via multiple regression analysis with the groups factorised.

RESULTS

Median (Interquartile Range, IQR) age did not vary significantly between Groups 1, 2 and 3 at 49 (38-56), 51.5 (42-60) and 51.5 (40-59) years, respectively. No significant difference (p = 0.89) was found between the T levels in Group 1 with non-fasting (median (IQR) T = 11.1 (9.3-13.6) nmol/L) versus fasting samples T = 10.8 (8.9-14.1) nmol/L). Paired T levels did not significantly differ in each of the other two groups (2 and 3). There was no significant association between the differences in paired T levels between the three groups, even when the model was adjusted for age and time, with Group 1 (as reference) versus Group 2 (p = 0.79) and versus Group 3 (p = 0.63).

DISCUSSION

We found no significant differences between fasting and non-fasting T levels. A definitive confirmatory study is required to determine whether fasting status is necessary to diagnose hypogonadism.

CONCLUSION

Non-requirement of fasting status when checking testosterone levels would remove a major hurdle in the diagnosis of hypogonadism.

Differential diagnoses of pseudolymphomatous folliculitis: considerations as regards one case

Pseudolymphomatous folliculitis (PLF) is a rare disease of cutaneous lymphoid hyperplasia, with a low index of clinical suspicion. We present the clinical case of a 19-year-old male patient, with a solitary violet erythematous nodule of 6 months of evolution, located in the right infraorbital region, without presenting another symptomatology. Histopathological examination showed a lymphocytic infiltrate that surrounds the hair follicles, sebaceous and sweat glands that focally destroy their basement membrane. PLF was diagnosed based on histological and immunohistochemical studies. In the multiple studies and case reports, the variability of the initial clinical diagnosis never corresponds to PLF, becoming a pathology with a low suspect index.

Seasonal Variation in Antidepressant Prescribing: Year on Year Analysis for England

OBJECTIVE

The number of prescriptions for antidepressants in England has almost doubled in the past decade. The objective of this study was to examine if this growth and seasonal variation in prescribing rates of different antidepressants by general practice are linked.

METHOD

The number of prescriptions and quantity of antidepressants prescribed each month between January 1, 2014, and December 31, 2019 from the general practice prescribing data reports for each British National Formulary code and practice were analyzed. The data were aggregated to obtain the monthly total and analyzed to identify patterns by medication.

RESULTS

: We included all oral antidepressant medications prescribed in England in 2019 for a total of 74 million prescriptions, which was equivalent to 2.36 billion defined daily doses. Monthly variation in daily prescribing percentage of the annual average over the year in total and antidepressant medications showed small but generally consistent seasonal variation, an average of up to 1.61% in total items and 1.47% in defined daily dose (highest prescribing in November/December). The seasonality varied by agents, with agents having highest seasonality also showing the most growth (r² = 0.5, P = .002). This relation was strongest for mirtazapine and sertraline. There was a clear relation between average seasonality and year on year growth in antidepressant medication prescribing for 2016-2019 (r² = .536, P = .002).

CONCLUSIONS

The study confirmed seasonal variation in antidepressant prescribing with a peak in November/December. Growth in the antidepressant prescribing year on year was related to seasonality and requires further scrutiny in terms of understanding the factors that underlie the seasonal variation seen.