SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review

A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.

Risk of Stroke in Real-World US Individuals with Type 2 Diabetes Receiving Semaglutide or a Dipeptidyl Peptidase 4 Inhibitor

INTRODUCTION

People with type 2 diabetes (T2D) have a higher risk of stroke and worse outcomes than those without T2D. Pooled data from randomized controlled trials indicate that the glucagon-like peptide 1 receptor agonist semaglutide is associated with stroke risk reduction in people with T2D at high cardiovascular risk. We compared real-world stroke risk in people with T2D or T2D plus atherosclerotic cardiovascular disease (ASCVD) initiating either semaglutide or a dipeptidyl peptidase 4 inhibitor (DPP4i).

METHODS

Adults (≥ 18 years old) in a US claims database with a claim indicating initiation of either semaglutide or a DPP4i (index date) during the index period (1 January 2018-30 September 2020), a diagnosis code for T2D on or before the index date and at least 12 months' continuous enrolment in the database pre-index were included and propensity score matched 1:1 on baseline demographic and clinical characteristics. The primary outcome was time to first stroke event during follow-up. Healthcare resource utilization was also compared between groups.

RESULTS

The analysis included 17,920 matched pairs with T2D and 4234 matched pairs with T2D and ASCVD. The groups were well matched on baseline characteristics. People initiating semaglutide had a lower risk of stroke over short-term follow-up than those initiating a DPP4i (T2D: hazard ratio 0.63 [95% confidence interval 0.41-0.95], p = 0.029; T2D plus ASCVD: 0.45 [0.24-0.86], p = 0.015). Semaglutide was also associated with a lower rate of inpatient, outpatient and emergency room visits compared with a DPP4i.

CONCLUSION

This proof-of-concept analysis indicates that semaglutide has the potential to reduce the risk of stroke in people with T2D when prescribed in clinical practice.

Real-world costs of obesity-related complications over eight years: a US retrospective cohort study in 28,500 individuals

BACKGROUND

Obesity-related complications (ORCs) are associated with high costs for healthcare systems. We assessed the relationship between comorbidity burden, represented by both number and type of 14 specific ORCs, and total healthcare costs over time in people with obesity in the USA.

METHODS

Adults (≥ 18 years old) identified from linked electronic medical records and administrative claims databases, with a body mass index measurement of 30-< 70 kg/m2 between 1 January 2007 and 31 March 2012 (earliest measurement: index date), and with continuous enrolment for ≥ 1 year pre index (baseline year) and ≥ 8 years post index, were included. Individuals were grouped by type and number of ORCs during the pre-index baseline year. The primary outcome was annual total adjusted direct per-person healthcare costs.

RESULTS

Of 28,583 included individuals, 12,686 had no ORCs, 7242 had one ORC, 4180 had two ORCs and 4475 had three or more ORCs in the baseline year. Annual adjusted direct healthcare costs increased with the number of ORCs and over the 8-year follow-up. Outpatient costs were the greatest contributor to baseline annual direct costs, irrespective of the number of ORCs. For specific ORCs, costs generally increased gradually over the follow-up; the largest percentage increases from year 1 to year 8 were observed for chronic kidney disease (+ 78.8%) and type 2 diabetes (+ 47.8%).

CONCLUSIONS

In a US real-world setting, the number of ORCs appears to be a cost driver in people with obesity, from the time of initial obesity classification and for at least the following 8 years.

Cardiovascular and renal outcomes of GLP-1 receptor agonists vs. DPP-4 inhibitors and basal insulin in type 2 diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

To compare the cardiovascular and renal outcomes of GLP-1 RA versus DPP4i and basal insulin in the management of T2DM.

METHODS

Data from 22 studies involving over 200,000 participants were pooled using the inverse variance method and random-effects meta-analysis. The review was reported in accordance with PRISMA.

RESULTS

Compared with DPP4i, treatment with GLP-1 RA was associated with a greater benefit on composite cardiovascular outcomes (HR:0.77, 95% CI:0.69-0.87), myocardial infarction (HR:0.82, 95% CI:0.69-0.97), stroke (HR:0.83, 95% CI: 0.74-0.93), cardiovascular mortality (HR:0.76, 95% CI:0.68-0.85) and all-cause mortality (HR:0.65, 95% CI:0.48-0.90). There was no difference in effect on heart failure (HR:0.97, 95% CI:0.82-1.15). Compared with basal insulin, GLP-1 RA was associated with better effects on composite cardiovascular outcomes (HR:0.62, 95% CI:0.48-0.79), heart failure (HR:0.57, 95% CI:0.35-0.92), myocardial infarction (HR:0.70, 95% CI:0.58-0.85), stroke (HR:0.50, 95% CI:0.40-0.63) and all-cause mortality (HR:0.31, 95% CI:0.20-0.48). Evidence from a small number of studies suggests that GLP-1 RA had better effects on composite and individual renal outcomes, such as eGFR, compared with either DPP4i and basal insulin.

CONCLUSION

Available evidence suggests that treating T2DM with GLP-1 RA can yield better benefits on composite and specific cardiorenal outcomes than with DPP4i and basal insulin.

PROSPERO REGISTRATION NUMBER

CRD42022335504.

Dosimetry Reconstruction in Radiopharmaceutical Therapy Using a Sparse Network of External γ-Sensors

PURPOSE/OBJECTIVE(S)

Radiopharmaceutical therapy (RPT) has demonstrated promise in the treatment of neuroendocrine and prostate cancer. Due to the highly varied biodistribution and non-homogeneity of total integrated dose across cancer patients, a system for real-time dosimetry based on continuous measurement is desirable to deliver sufficient dose for tumor ablation while preventing toxicity from off-target uptake by organs at risk (OAR). Single time point imaging (mostly SPECT)-based dosimetry offers a snapshot of the body-wide dose distribution at a given time point, but even single SPECT imaging is generally limited in availability, often leading to significant inaccuracies in estimating total integrated dose. Therefore, accurate personalized dosimetry in RPT is an unmet need and requires continuous dosimetry measurements of tumors and OARs across multiple half-lives of the therapeutic radiopharmaceutical. Using a priori knowledge of tumor and OAR locations from pretherapy imaging, we have developed a novel algorithm that utilizes a network of custom uncollimated, optical fiber-based γ-counting probes to isolate the real-time in vivo tumor and OAR uptake in 177Lu-PSMA-617 and 225Ac-MACROPA-YS5 therapy.

MATERIALS/METHODS

The proposed system was successfully validated in athymic mice models bearing varying numbers of tumors from two human prostate cancer cell lines (PC3-pip, PC3-flu). Uncollimated γ counts using the developed probes were acquired outside of the mice for 10 minutes, starting at 0 hr, 6 hrs, 12 hrs, 24 hrs, and 48 hrs after the injection of 177Lu-PSMA-617. The percent injected activity per mL of tissue (%IA/mL) of each tumor and OAR was reconstructed at every time point and compared to the %IA/mL extracted from SPECT/CT immediately after the recording.

RESULTS

The developed system's %IA/mL reconstruction in PC3-pip tumors, PC3-flu tumors, kidneys, and bladders is highly correlative with the %IA/mL extracted from state-of-art in vivo dosimetry techniques, with %IA/mL ranging from 0.1% to 160% assuming a 29.6 MBq 177Lu-PSMA-617 administration. The least squares linear regression fit between the reconstructed activity and the activity measured from SPECT/CT is given by Estimated %IA/mL = 0.91 x SPECT %IA/mL, with an R2 of 0.991, and Pearson's r of 0.9975. There is a nearly 1:1 mapping between the proposed model and SPECT/CT.

CONCLUSION

A novel dose reconstruction algorithm for personalized dosimetry in RPT that utilizes a sparse set of external γ-counters and a priori knowledge of tumor and OAR locations was developed and validated in in vivo human prostate cancer murine models. The proposed system enables continuous dosimetry measurements of multiple tumors and OAR noninvasively, with high accessibility, high temporal resolution, and across multiple classes of ɑ and β-based RPT. Similar experiments using 225Ac-MACROPA-YS5 are ongoing and additional results will be reported.

Medicolegal claims in general surgery: a 10-year retrospective review of claims against the NHS in England

INTRODUCTION

Every year 12,000 medicolegal claims are brought against the NHS in England at a cost of £8 billion-6.7% of the NHS England budget. In 1,000 of these claims the primary speciality is General Surgery. The aims of this paper were to examine 10 years of claims against General Surgery Departments in NHS England, identify the common causes and injuries, review the associated cost and suggest strategies for improvement.

METHODS

Data regarding medicolegal claims made against NHS General Surgical Departments in England from 2010 to 2020 were obtained from the Clinical Negligence Scheme for Trusts. A retrospective review was undertaken to examine the number of claims, cost of claims closed with and without damages, primary causes and primary injuries.

RESULTS

A total of 10,027 claims were made between 2010 and 2020. Of these, 9,377 were closed in that time, with cost totalling £851,558,930. Of claims closed, an average of 608 per year were closed with damages and 329 without damages. Claims with damages resulted in more than forty-five times greater cost per claim compared with those closed without damages. Overall, cost increased by over 50% between 2010 and 2020. Common causes included 'failure/delay in treatment', 'intraoperative problems' and 'failure/delay in diagnosis'. Common injuries included 'additional/unnecessary operation(s)', 'unnecessary pain', 'fatality' and 'bowel damage/dysfunction'.

CONCLUSION

Medicolegal expenditure represents a serious concern for the NHS, worsening each year. This retrospective review highlights the rising cost along with the most common causes and primary injuries. Action is required at every level of the NHS to improve surgical care, consent and communication with our patients, and by doing so minimise poor outcomes and their resultant medicolegal consequences.

A critical evaluation of physical and manufacturing properties of genuine and counterfeit rotary nickel-titanium endodontic instruments

BACKGROUND

Rotary nickel-titanium (NiTi) instruments are made to exacting standards and are costly to manufacture, and quality control is paramount. Consequently, unauthorized factories make counterfeit instruments that are less expensive and may therefore be attractive to dentists. Little information exists about the metallurgy and manufacturing quality of such instruments. There is the potential for counterfeit instruments to be at higher risk of fracture during treatment, thereby compromising clinical outcomes. The aim of this study was to evaluate physical and manufacturing properties of genuine and counterfeit ProTaper Next™ and Mtwo® rotary NiTi instruments.

METHODS

This study investigated the metallurgical properties, manufacturing quality, microhardness and number of cycles to failure of two commonly used rotary NiTi systems and compared them with counterfeit products purporting to be genuine articles.

RESULTS

Counterfeit instruments were found to be inferior in manufacturing standards and were less resistant to cyclic fatigue when compared to genuine instruments.

CONCLUSIONS

Counterfeit rotary NiTi instruments may be less efficient at preparing root canals and may be at higher risk of fracture during endodontic treatment. Dentists must be aware that, although less expensive, counterfeit instruments may be of dubious manufacturing quality and at higher risk of fracture if used in patients. © 2023 Australian Dental Association.

Obesity-related complications, healthcare resource use and weight loss strategies in six European countries: the RESOURCE survey

BACKGROUND

Obesity-related complications (ORCs), such as type 2 diabetes (T2D) and cardiovascular disease, contribute considerably to the clinical and economic impacts of obesity. To obtain a holistic overview of health and weight management attempts for people with obesity in Europe, we designed the cross-sectional RESOURCE survey to collect data on comorbidities, healthcare resource use (HCRU) and weight loss strategies from people with obesity in France, Germany, Italy, Spain, Sweden and the UK.

METHODS

Adults (≥18 years old) with self-reported body mass index (BMI) ≥30 kg/m2 who reported interacting with primary or secondary healthcare services in the past 12 months, but had not been pregnant during this time, were recruited from an existing consumer research panel. All data were self-reported via an online survey (May-June 2021). Weight changes over the past year were calculated from participants' estimated weights.

RESULTS

Of the 1850 participants in the survey, 26.3% reported that they had ≥3 ORCs from a set of 15 conditions of interest. The most frequently reported ORCs were hypertension (39.3% of participants), dyslipidaemia (22.8%) and T2D (17.5%). Participants in obesity class III (BMI 40 to <70 kg/m2) were more likely to report multiple ORCs than those in lower obesity classes. The presence of multiple ORCs was linked to various types of HCRU, including a significantly increased chance of reporting hospitalization in the past year. Most participants (78.6%) had attempted to lose weight in the past year, but of those who also reported estimated weight changes, 73.4% had not experienced clinically meaningful weight loss of ≥5%.

CONCLUSIONS

ORCs are common in people with obesity, and are linked to increased HCRU. Together with the low reported success rate of weight loss attempts, this highlights an unmet need in Europe for enhanced weight management support for people with obesity.

Evaluating the Long-Term Cost-Effectiveness of Once-Weekly Semaglutide 1 mg Versus Liraglutide 1.8 mg: A Health Economic Analysis in the UK

INTRODUCTION

Glucagon-like peptide-1 (GLP-1) receptor agonists represent highly efficacious treatment options for type 2 diabetes. Liraglutide was amongst the first authorised for use in 2010, but once-weekly semaglutide represents the most efficacious GLP-1 analogue currently available for type 2 diabetes. The aim of the present analysis was therefore to evaluate the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus liraglutide 1.8 mg with a lowered acquisition cost in the UK, as potentially lower cost liraglutide formulations may soon be developed.

METHODS

Outcomes were projected over patients' lifetimes using the IQVIA Core Diabetes Model (v9.0). Baseline cohort characteristics were sourced from SUSTAIN 2, with changes in HbA1c, blood pressure and body mass index applied from a network meta-analysis, in which SUSTAIN 2 was used to inform the semaglutide arm. Modelled patients received semaglutide or liraglutide for 3 years, after which treatment was intensified to basal insulin. Costs were accounted from a healthcare payer perspective and expressed in 2021 pounds sterling (GBP). The acquisition cost of liraglutide was reduced by 33% compared with the currently marketed formulation.

RESULTS

Life expectancy and quality-adjusted life expectancy were projected to improve with once-weekly semaglutide 1 mg, by 0.05 years and 0.06 quality-adjusted life years, respectively, versus liraglutide 1.8 mg. Clinical benefits were due to a reduced incidence of diabetes-related complications with semaglutide. Direct costs were estimated to be GBP 280 lower with semaglutide, entirely because of avoidance of diabetes-related complications versus liraglutide. Semaglutide 1 mg was therefore considered dominant versus liraglutide 1.8 mg, even with the liraglutide price reduced by 33%.

CONCLUSION

Once-weekly semaglutide 1 mg is likely to represent a dominant treatment option versus liraglutide 1.8 mg for the treatment of type 2 diabetes in the UK, even with the liraglutide price reduced by 33%.

Clinical and medico-legal considerations in endodontics

Endodontic treatment can be challenging for a number of reasons, including the microscopic nature of the clinical environment, reliance on tactile sensation and lack of direct visualization of the work being performed. Commonly, endodontic patients present with pain and distress, which can exacerbate an already difficult clinical situation. Complications may might arise prior to, or during treatment, despite practising with the utmost care and skill. Preventing and managing these complications can take considerable time and energy, and oftentimes assistance from or referral to more experienced colleagues is required. The aim of this review is to discuss medico-legal considerations in endodontics, with clinical correlations and a focus on the Australian legal landscape. [Correction added on 18 October 2023, after first online publication: The abstract was amended from a structured to an unstructured abstract.].

The endodontic-periodontal juncture: Where two worlds meet. An overview of endo-perio lesions

Endodontic and periodontal infections can be difficult to differentiate from one another and often share common clinical features making diagnosis challenging. The aim of this review is to discuss endodontic and periodontal infections in situations where they occur concurrently, or where one influences the other. The available literature investigating endodontic and periodontal infections was examined for contemporary knowledge regarding endodontic-periodontal interactions. Strategies to facilitate diagnosis and treatment planning are discussed. When endodontic and periodontal infections occur together, or signs and symptoms are similar, diagnosis can be challenging. Determining the primary source of infection is imperative to ensure appropriate treatment planning. The pulp and periodontal tissues are intimately related, with many possible pathways for infection from one to the other. Diagnosis of the primary source of the infection can be difficult and sometimes an inter-disciplinary approach to treatment is required. © 2023 Australian Dental Association.

Stroke Prevention and Treatment in People With Type 2 Diabetes: Is There a Role for GLP-1 (Glucagon-Like Peptide-1) Analogues?

Stroke is a leading cause of disability and death, and people with type 2 diabetes (T2D) have a greater risk of stroke and death or disability from stroke. The underlying pathophysiology associating stroke and T2D is complicated by the association of risk factors for stroke frequently seen in people with T2D. Treatments to reduce the excess risk of new-onset stroke or to improve outcomes in people with T2D following stroke would be of major clinical interest. In practice, the focus of care in people with T2D remains treating risk factors for stroke, such as lifestyle and pharmacological interventions for hypertension, dyslipidemia, obesity, and glycemic control. More recently, cardiovascular outcome trials primarily designed to assess the cardiovascular safety of GLP-1RAs (glucagon-like peptide-1 receptor analogues) have consistently observed a reduced stroke risk in people with T2D. This is supported by several meta-analyses of cardiovascular outcome trials observing clinically important risk reductions in stroke. Moreover, phase II trials have described reductions in poststroke hyperglycemia in people with acute ischemic stroke suggestive of improved outcomes following admission to hospital with acute stroke. In this review, we discuss the increased risk of stroke in people with T2D and outline the key associated mechanisms responsible. We discuss the evidence from cardiovascular outcome trials exploring GLP-1RA use and highlight areas of potential interest for future work in this rapidly developing area of clinical research.

Estimating the value of sodium-glucose cotransporter-2 inhibitors within the context of contemporary guidelines and the totality of evidence

AIMS

To comprehensively estimate the cost-effectiveness of sodium glucose cotransporter-2 (SGLT2) inhibitor usage in the management of type 2 diabetes mellitus (T2DM) at established clinical review points, incorporating the totality of proven health benefits.

MATERIALS AND METHODS

This study considered the cardio- and reno-protective effects of SGLT2 inhibitors using the Cardiff type 2 diabetes model. Conventional cost-effectiveness evaluations were undertaken for eligible populations at relevant intensification points reflecting the 2022 guidelines versus the 2015 National Institute of Health and Care Excellence (NICE) guidelines; incremental cost-effectiveness ratio lifetime trajectories and timepoints for complete cost-offset were estimated for each pathway. Treatment effects, utility decrements and costs (applied additively and discounted at 3.5%) were sourced from the published literature.

RESULTS

For all subpopulations on treatment pathways reflecting the NG28-2022 guidelines, SGLT2 inhibitor introduction was cost-effective, becoming cost-saving between 2 and 16 years post-initiation. Despite increases in pharmacy costs, predicted lifetime costs were lower than for pathways reflecting the NG28-2015 guidelines, driven by a reduction in heart failure hospitalization and chronic kidney disease costs. Incremental gains in quality-adjusted life years (ranging from 0.58-1.12) resulted in dominance for the updated NG28-2022 guidance in all scenarios.

CONCLUSIONS

Our results show that SGLT2 inhibitors have the potential to lower healthcare costs while improving health outcomes in eligible patient subpopulations.

The challenges and pitfalls of incorporating evidence from cardiovascular outcomes trials in health economic modelling of type 2 diabetes

The clinical evidence base for evaluating modern type 2 diabetes interventions has expanded greatly in recent years, with numerous efficacious treatment options available (including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors). The cardiovascular safety of these interventions has been assessed individually versus placebo in numerous cardiovascular outcomes trials (CVOTs), statistically powered to detect differences in a composite endpoint of major adverse cardiovascular events. There have been growing calls to incorporate these data in the long-term modelling of type 2 diabetes interventions because current diabetes models were developed prior to the conduct of the CVOTs and therefore rely on risk equations developed in the absence of these data. However, there are numerous challenges and pitfalls to avoid when using data from CVOTs. The primary concerns are around the heterogeneity of the trials, which have different study durations, inclusion criteria, rescue medication protocols and endpoint definitions; this results in significant uncertainty when comparing two or more interventions evaluated in separate CVOTs, as robust adjustment for these differences is difficult. Analyses using CVOT data inappropriately can dilute clear evidence from head-to-head clinical trials, and blur healthcare decision making. Calibration of existing models may represent an approach to incorporating CVOT data into diabetes modelling, but this can only offer a valid comparison of one intervention versus placebo based on a single CVOT. Ideally, model development should utilize patient-level data from CVOTs to prepare novel risk equations that can better model modern therapies for type 2 diabetes.

Eight-year trends in obesity-related complications and health care cost progression in a US population with obesity: A retrospective cohort study

AIMS

Obesity-related complications (ORCs) impose a substantial health burden on affected individuals, and economic costs to health care systems. We examined ORCs and the progression of direct health care costs over 8 years, stratified by obesity class.

MATERIALS AND METHODS

Adults with obesity were identified in linked US medical records and administrative claims databases. The index date was the first body mass index measurement of 30 to <70 kg/m² between 1 January 2007 and 31 March 2012; a ≥8-year continuous enrolment post-index was required for inclusion. Diagnosis codes for five specific ORCs and total health care costs were recorded in each year of follow-up. Costs adjusted for clinical and demographic factors were also estimated.

RESULTS

Of 28 583 eligible individuals, 17 892 had class I obesity, 6550 had class II obesity and 4141 had class III obesity. From baseline to year 8, the presence of type 2 diabetes and knee osteoarthritis doubled in all obesity classes, with even larger increases for chronic kidney disease and heart failure. Observed and adjusted total health care costs generally increased from the baseline year to year 8. The difference in costs between obesity classes increased over time: at year 1, individuals with class III obesity had 26.8% higher costs than those in class I, but at year 8, this difference was 40.7%. Outpatient costs constituted half of the total observed costs across obesity classes.

CONCLUSIONS

ORC rates and health care costs increase over time, and are greater in higher obesity classes. This could be mitigated by approaches that limit obesity progression.

Once-weekly semaglutide versus insulin aspart for the treatment of type 2 diabetes in the UK: A long-term cost-effectiveness analysis based on SUSTAIN 11

AIM

To evaluate the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus insulin aspart in the UK.

MATERIALS AND METHODS

Long-term outcomes were projected over patients' lifetimes using the IQVIA CORE Diabetes Model (vers 9.0). SUSTAIN 11 was used to inform baseline cohort characteristics and treatment effects. Patients were modelled to receive once-weekly semaglutide plus basal insulin for 3 years before intensifying to basal-bolus insulin, compared with basal-bolus insulin for lifetimes in the aspart arm. Costs were accounted from a healthcare payer perspective in the UK, expressed in 2021 pounds sterling (GBP).

RESULTS

Once-weekly semaglutide 1 mg was associated with improvements in quality-adjusted life expectancy of 0.18 quality-adjusted life years (QALYs) versus insulin aspart, due to a reduced incidence and delayed time to onset of diabetes-related complications. Direct costs were estimated to be GBP 800 higher with semaglutide, with higher treatment costs partially offset by cost savings from avoidance of diabetes-related complications. Once-weekly semaglutide 1 mg was therefore associated with an incremental cost-effectiveness ratio of GBP 4457 per QALY gained versus insulin aspart.

CONCLUSIONS

Based on a willingness-to-pay threshold of GBP 20 000 per QALY gained, once-weekly semaglutide 1 mg was projected to be highly cost-effective versus insulin aspart for the treatment of type 2 diabetes in the UK.

Four cases of acute comitant esotropia associated with diffuse intrinsic pontine glioma in children

BACKGROUND

Acute acquired concomitant esotropia (AACE) is usually a benign form of strabismus that infrequently is associated with intracranial pathology. Clinicians have noted an increase in its incidence and theorize that it may be related to public health "lockdown" measures taken in response to the COVID-19 pandemic. With an increased incidence of AACE clinicians must firstly differentiate AACE from common accommodative esotropia and secondly recognize AACE as a possible sign of serious neuropathology.Diffuse Intrinsic Pontine Glioma (DIPG) is a devastating diagnosis for affected families. Children typically present at age 6-7 years with cranial nerve palsies, long tract signs, and/or cerebellar signs. Diagnosis is made from characteristic findings on magnetic resonance brain imaging (MRI brain) and treatment includes radiotherapy and palliative care. Two years from diagnosis, 90% of affected children will have died from their disease.

CASE SERIES

We present four cases that attended our pediatric ophthalmology clinic with AACE either as a presenting sign of DIPG or as a clinical finding following a DIPG diagnosis. Patient A (age 5 years) presented to the emergency eye clinic with sudden onset diplopia and intermittent esotropia. Suppression later developed, they had 0.00 logMAR visual acuity either eye, and bilateral physiological hypermetropia. MRI brain imaging requested as a result of the unusual presentation led to the DIPG diagnosis. The other 3 cases (ages 11, 5 & 5 years) were assessed post DIPG diagnosis and found to have an esotropia measuring bigger on 1/3-meter fixation than 6-meter fixation, full ocular motility, physiological hypermetropia or emmetropia, and visual acuity normal for age. Other than patient B (age 11 years), who had papilledema and gaze evoked nystagmus when they were assessed 2 weeks prior to death, no patient had any other clinical eye findings.

CONCLUSIONS

This small series of 4 patients attending our clinic within a 12-month period supports the notion that children presenting with AACE should routinely be offered brain MRI. Not all children with DIPG-associated AACE have significant ophthalmic findings indicative of intracranial pathology. With the potential for increased incidence of AACE related to lockdowns, clinicians should be reminded of the infrequent possibility their patient has a more serious condition.

The role of sodium-glucose co-transporter-2 inhibitors in frail older adults with or without type 2 diabetes mellitus

Sodium-glucose co-transporter-2 (SGLT2) inhibitors offer significant outcome benefits beyond glucose lowering, including reduced risk of cardiovascular death, all-cause mortality, major adverse cardiovascular events, hospitalisations for heart failure and progression of renal disease. Considering these therapeutic effects, minimal incremental risk for hypoglycaemia and simplicity of administration, this drug class appears to be an attractive therapeutic option for older adults, and post hoc analysis of trial data provides support for the use of SGLT2 inhibitors in this population. Nevertheless, despite favourable clinical trial data, there has been some hesitance in clinical practice prescribing these drugs to older frail adults due to the limited therapeutic experience in this population and insufficient long-term safety data. In this review article, we evaluate the risk-benefit profile for the use of SGLT2 inhibitors in this population and suggest that rather than being a treatment to avoid, SGLT2 inhibitors should be considered a valid therapeutic option for older frail adults with or without diabetes.

Risk of stroke in patients with type 2 diabetes receiving semaglutide or a dipeptidyl peptidase-4 inhibitor: a real-world US claims database analysis

Introduction

People with type 2 diabetes (T2D) have a higher risk of stroke than those without, are likely to experience stroke at a younger age, and have worse outcomes. The cardiovascular benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in T2D have been demonstrated in randomized controlled trials. A meta-analysis of these data has shown that GLP-1 RAs are associated with a significant reduction in the risk of stroke; however, there remains an evidence gap for the real-world effect of semaglutide specifically on stroke risk.

Purpose

To compare real-world risk of stroke in patients with T2D or T2D + atherosclerotic cardiovascular disease (ASCVD) initiating either semaglutide or a dipeptidyl peptidase-4 inhibitor (DPP-4i).

Methods

For inclusion, adults (≥18 years) in a US claims database required a claim indicating initiation of either semaglutide or a DPP-4i (index date) during the index period (1/1/18–30/9/20), a diagnosis code for T2D on or before the index date, and 12 months' continuous enrolment pre-index. Exclusion criteria were a claim for semaglutide, DPP-4i or injectable glucose-lowering medication, or diagnosis code for type 1 or secondary diabetes in the 12 months pre-index; or a claim associated with pregnancy or gestational diabetes any time during the study period. Patients were propensity score matched 1:1 on 27 baseline demographic and clinical characteristics. Patients who also had a diagnosis code for ASCVD pre-index were matched separately on 26 variables. Primary outcome was time to first stroke event during follow-up, defined as a medical claim with stroke as primary diagnosis during inpatient or emergency room visit. Patients with no event were censored at end of enrolment or end of study period (30/9/20), whichever was earliest.

Results

Post-matching, there were 17,920 pairs with T2D and 4234 pairs with T2D+ASCVD. The groups were well matched on baseline characteristics (Table). For T2D, patients initiating semaglutide had a lower risk of stroke than those initiating a DPP-4i (hazard ratio [HR], 0.63; 95% confidence interval [CI]: 0.41–0.95; p=0.029). This trend was more pronounced for T2D+ASCVD (HR, 0.45 [0.24–0.86]; p=0.015). Overall, 34 patients with T2D receiving semaglutide (0.2%) experienced a stroke event (incidence rate [IR] per 100 person-years, 0.25), compared with 60 patients receiving a DPP-4i (0.3%; IR, 0.40; IR ratio [IRR], 0.62; 95% CI: 0.40–0.95). For the groups with T2D+ASCVD, 13 patients receiving semaglutide (0.3%; IR, 0.40) and 32 receiving a DPP-4i (0.8%; IR, 0.90) experienced a stroke event (IRR, 0.44 [0.23–0.85]). The Figure shows cumulative incidence of stroke over follow-up (median 237–258 days).

Conclusion

This analysis provides initial insights into the potential of semaglutide to reduce real-world stroke risk in patients with T2D. Analyses with additional comparison groups and longer follow-up are needed to determine the broader clinical and economic implications.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was funded by Novo Nordisk A/S. Medical writing support was provided by Oxford PharmaGenesis, Oxford, UK with funding from Novo Nordisk A/S.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Healthcare costs and hospitalizations in US patients with type 2 diabetes and cardiovascular disease: A retrospective database study (OFFSET)

AIM

To investigate the budget implications of treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) versus other glucose-lowering treatment (here termed 'standard of care' [SoC]) during 2012-2019.

MATERIALS AND METHODS

GLP-1 RA-naïve adults with type 2 diabetes (T2D) in the IBM MarketScan database with at least one glucose-lowering medication claim within 6 months after their first cardiovascular disease (CVD) hospitalization were included (index date was the date of first claim for a GLP-1 RA for the GLP-1 RA group, and the date of the first claim, independent of medication type, for the SoC group). Monthly healthcare costs and hospitalization risk over 12 months postindex date were compared for those who initiated a GLP-1 RA posthospitalization versus those with a claim for any other glucose-lowering medication.

RESULTS

Postindex date, mean observed total costs were lower for patients receiving a GLP-1 RA compared with SoC ($3853 vs. $4288). In adjusted analysis, both groups had similar total healthcare costs (P = .56). This was driven by significantly lower inpatient and outpatient costs and higher drug costs in the GLP-1 RA group compared with SoC (P < .001). Risks of all-cause (adjusted hazard ratio: 0.85) and CVD-related hospitalization (0.76) were significantly lower in the GLP-1 RA group compared with SoC (P < .001). Similar results were observed in a subgroup with atherosclerotic CVD.

CONCLUSIONS

These findings suggest that, in US patients with T2D and a CVD-related hospitalization, the added medical cost of treatment with GLP-1 RAs is offset by lower inpatient and outpatient care costs, resulting in budget neutrality against SoC.

Oncology clinical trial disruption during the COVID-19 pandemic: a COVID-19 and cancer outcomes study

Background

COVID-19 disproportionately impacted patients with cancer as a result of direct infection, and delays in diagnosis and therapy. Oncological clinical trials are resource-intensive endeavors that could be particularly susceptible to disruption by the pandemic, but few studies have evaluated the impact of the pandemic on clinical trial conduct.

Patients and methods

This prospective, multicenter study assesses the impact of the pandemic on therapeutic clinical trials at two large academic centers in the Northeastern United States between December 2019 and June 2021. The primary objective was to assess the enrollment on, accrual to, and activation of oncology therapeutic clinical trials during the pandemic using an institution-wide cohort of (i) new patient accruals to oncological trials, (ii) a manually curated cohort of patients with cancer, and (ii) a dataset of new trial activations.

Results

The institution-wide cohort included 4756 new patients enrolled to clinical trials from December 2019 to June 2021. A major decrease in the numbers of new patient accruals (−46%) was seen early in the pandemic, followed by a progressive recovery and return to higher-than-normal levels (+2.6%). A similar pattern (from −23.6% to +30.4%) was observed among 467 newly activated trials from June 2019 to June 2021. A more pronounced decline in new accruals was seen among academically sponsored trials (versus industry sponsored trials) (P < 0.05). In the manually curated cohort, which included 2361 patients with cancer, non-white patients tended to be more likely taken off trial in the early pandemic period (adjusted odds ratio: 2.60; 95% confidence interval 1.00-6.63), and substantial pandemic-related deviations were recorded.

Conclusions

Substantial disruptions in clinical trial activities were observed early during the pandemic, with a gradual recovery during ensuing time periods, both from an enrollment and an activation standpoint. The observed decline was more prominent among academically sponsored trials, and racial disparities were seen among people taken off trial.

AB1384 CLINICAL SIGNIFICANCE OF DENSE FINE SPECKLED PATTERN ANA

Background

The clinical significance of Dense Fine Speckled (DFS) pattern Anti-nuclear antibodies (ANA) by indirect immunofluorescence method (IIF) is unclear and has been inversely associated with rheumatic disease 12.

Objectives

Our purpose was to determine associations between DFS pattern ANA and the disease categories of inflammatory arthritis, ANA associated rheumatic diseases (AARD), fibromyalgia/chronic pain syndrome/chronic fatigue syndrome and atopic disorder.

Methods

This retrospective study used data from patients tested for ANA by IIF between August 2017 to August 2019 at the University of Minnesota Medical Center. Comparisons between the diagnostic categories listed in objectives were made for patients with negative ANA, positive ANA (any pattern) and DFS pattern. Individual disease diagnoses belonging to the above categories were also analyzed. The inflammatory arthritis category included seropositive rheumatoid arthritis (RA), seronegative RA, RA with unknown serology, ankylosing spondylitis, and psoriatic arthritis. The disease category of AARD included systemic lupus erythematosus (SLE), systemic sclerosis, mixed connective tissue disease, idiopathic inflammatory myopathies, Sjogren’s syndrome (SS), and undifferentiated connective tissue disorder (UCTD). Atopic disorders included atopic dermatitis, allergic rhinitis, urticaria, and asthma. Frequency of Raynaud’s phenomenon (RP) was also calculated.

Results

13,845 patients with an ANA during the study period were identified. 9106 (65.8%) had negative ANA and 4739 (34.2%) had positive ANA by IIF (including all patterns). 640 (4.6%) had ANA positive DFS patterns. Relative risk (RR) was calculated for diagnostic categories and individual diseases. For patients with positive ANA and DFS pattern, the RR for diagnostic codes of inflammatory arthritis categories [1.35 (1.07- 1.71), p=0.02] was higher when compared to the frequency of codes in ANA negative. RR for AARD among patients with DFS pattern was also higher [1.78 (1.44- 2.2), p <0.001]. There was no significant difference in the frequency of diagnostic codes of chronic pain/fibromyalgia/chronic fatigue syndrome [1.02 (0.9- 1.2), p=0.84] atopic disorder [0.68 (0.4- 1.15), p=0.16] for DFS+ compared to the ANA group. The frequency of AARD diagnostic codes was lower for patients with DFS pattern [0.64 (0.52- 0.79), p<0.001] compared to ANA positive patients with all other patterns, consistent with published data. There was no significant difference of frequency of diagnostic codes for the rest of the disease categories when comparison was made between ANA positive DFS pattern and ANA positive with other patterns.

Individual disease diagnostic codes of RA were higher among DFS+ patients when compared to ANA- patients. The frequency of diagnostic codes of SLE, SS, UCTD, fibromyalgia, Raynaud’s phenomenon, and autoimmune thyroid disease was also higher among patients with DFS pattern compared to ANA- patients. The frequency of diagnostic codes of seropositive RA was lower among patients with DFS pattern compared to ANA+ with all other patterns. The frequency of diagnostic codes of SLE, SSc, UCTD, and chronic pain was also lower among DFS+ patients, compared to those with ANA of all other patterns, consistent with prior reports.

Conclusion

The frequency of diagnostic codes of RA, SS and Raynaud’s was higher among DFS pattern ANA compared to ANA negative group but was not significantly different from ANA positive with other patterns. This suggests that the presence of a DFS pattern should not be used to indiscriminately exclude the presence of a rheumatic disease.

References

[1]Mariz HA, Sato EI, Barbosa SH, Rodrigues SH, Dellavance A, Andrade LEC. Pattern on the antinuclear antibody-HEp-2 test is a critical parameter for discriminating antinuclear antibody-positive healthy individuals and patients with autoimmune rheumatic diseases. Arthritis Rheum. 2011;63(1):191-200. doi:10.1002/art.30084

[2]Watanabe A, Kodera M, Sugiura K, et al. Anti-DFS70 Antibodies in 597 Healthy Hospital Workers. ARTHRITIS Rheum. 2004;50(3):892-900. doi:10.1002/art.20096

Disclosure of Interests

None declared

Defining the Role of SGLT2 Inhibitors in Primary Care: Time to Think Differently

Disease burden in people with diabetes is mainly driven by long-term complications such as cardiovascular disease, heart failure and chronic kidney disease. This is a consequence of the interconnection between the cardiovascular, renal and metabolic systems, through a continuous chain of events referred to as 'the cardiorenal metabolic continuum'. Increasing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial effects across all stages of the cardiorenal metabolic continuum, reducing morbidity and mortality in a wide range of individuals, from those with diabetes and multiple risk factors to those with established heart failure and chronic kidney disease, regardless of the presence of diabetes. Despite this robust evidence base, the complexity of label indications and misconceptions concerning potential side effects have resulted in a lack of clear understanding in primary care regarding the implementation of SGLT2is in clinical practice. With this in mind, we provide an overview of the clinical and economic benefits of SGLT2is across the cardiorenal metabolic continuum together with practical considerations in order to help address some of these concerns and clearly define the role of SGLT2is in primary care as a holistic outcomes-driven treatment with the potential to reduce disease burden across the cardiorenal metabolic spectrum.

The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review

Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.

Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review

We designed a systematic literature review to identify available evidence on adherence to and persistence with antidiabetic medication in people with type 2 diabetes (T2D). Electronic screening and congress searches identified real-world noninterventional studies (published between 2010 and October 2020) reporting estimates of adherence to and persistence with antidiabetic medication in adults with T2D, and associations with glycaemic control, microvascular and/or macrovascular complications, hospitalizations and healthcare costs. Ninety-two relevant studies were identified, the majority of which were retrospective and reported US data. The proportions of patients considered adherent (median [range] 51.2% [9.4%-84.3%]) or persistent (median [range] 47.7% [16.9%-94.0%]) varied widely across studies. Multiple studies reported an association between greater adherence/persistence and greater reductions in glycated haemoglobin levels. Better adherence/persistence was associated with fewer microvascular and/or macrovascular outcomes, although there was little consistency across studies in terms of which outcomes were improved. More adherent and more persistent patients were typically less likely to be hospitalized or to have emergency department visits/admissions and spent fewer days in hospital annually than less adherent/persistent patients. Greater adherence and persistence were generally associated with lower hospitalization costs, higher pharmacy costs and lower or budget-neutral total healthcare costs compared with lower adherence/persistence. In conclusion, better adherence and persistence in people with T2D is associated with lower rates of microvascular and/or macrovascular outcomes and inpatient hospitalization, and lower or budget-neutral total healthcare expenditure. Education and treatment strategies to address suboptimal adherence and persistence are needed to improve clinical and economic outcomes.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Meeting the Challenge of Virtual Diabetes Care: A Consensus Viewpoint on the Positioning and Value of Oral Semaglutide in Routine Clinical Practice

While glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as semaglutide, are among the most effective drugs for treating people with type 2 diabetes (T2D), they are clinically under-utilised. Until recently, the only route for semaglutide administration was via subcutaneous injection. However, an oral formulation of semaglutide was recently licensed, with the potential to address therapy inertia and increase patient adherence to treatment, which is essential in controlling blood glucose and reducing complications. The availability of oral semaglutide provides a new option for both clinicians and patients who are reluctant to use an injectable agent. This has been of particular importance in addressing the challenge of virtual diabetes care during the COVID-19 pandemic, circumventing the logistical problems that are often associated with subcutaneous medication administration. However, there remains limited awareness of the clinical and economic value of oral semaglutide in routine clinical practice. In this article, we present our consensus opinion on the role of oral semaglutide in routine clinical practice and discuss its value in reducing the burden of delivering diabetes care in the post-COVID-19 pandemic period of chronic disease management.

Emerging Horizons in Heart Failure with Preserved Ejection Fraction: The Role of SGLT2 Inhibitors

Heart failure with preserved ejection fraction (HFpEF) is a condition with increasing disease burden. Prevalence of HFpEF is increasing, reflecting an increasingly elderly and comorbid population, as well as reinforcing the need for more treatments for this disease. The pathophysiology of HFpEF is complex. Some inflammatory processes seen in HFpEF are shared with diabetes mellitus (DM) and there is an association seen between the two conditions. It is therefore no wonder that treatments for diabetes may have some effect on heart failure outcomes. Current treatment strategies in HFpEF are limited, with treatments focusing on symptom control rather than morbidity or mortality benefit. However, there are now promising results from the EMPEROR-Preserved study that show significantly reduced cardiovascular death or hospitalisation for heart failure (HHF) in patients taking empagliflozin, compared to those taking placebo. These results indicate a promising future for sodium-glucose co-transporter 2 (SGLT2) inhibitors in HFpEF. The ongoing DELIVER trial (investigating the use of dapagliflozin in HFpEF) is awaited but could provide further evidence of support for SGLT2 inhibitors in HFpEF. With hospital admissions for HFpEF increasing in the UK, the economic impact of treatments that reduce HHF is vast. The European Society of Cardiology (ESC) recently added SGLT2 inhibitors to their guidelines for treatment of heart failure with reduced ejection fraction (HFrEF) following DAPA-HF and EMPEROR-Reduced trials and we suggest that similar changes be made to guidelines to support the use of SGLT2 inhibitors in the management of HFpEF in upcoming months.

A Narrative Review of Chronic Kidney Disease in Clinical Practice: Current Challenges and Future Perspectives

Chronic kidney disease (CKD) is a complex disease which affects approximately 13% of the world's population. Over time, CKD can cause renal dysfunction and progression to end-stage kidney disease and cardiovascular disease. Complications associated with CKD may contribute to the acceleration of disease progression and the risk of cardiovascular-related morbidities. Early CKD is asymptomatic, and symptoms only present at later stages when complications of the disease arise, such as a decline in kidney function and the presence of other comorbidities associated with the disease. In advanced stages of the disease, when kidney function is significantly impaired, patients can only be treated with dialysis or a transplant. With limited treatment options available, an increasing prevalence of both the elderly population and comorbidities associated with the disease, the prevalence of CKD is set to rise. This review discusses the current challenges and the unmet patient need in CKD.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Mapping the movement for climate change and health in England: a descriptive review and theory of change analysis

Aims:

There are a growing number of organisations working to address the connections between climate change and health. This article introduces the concept of ‘theories of change’ – the methodology by which organisations or movements hope to bring about social change – and applies it to the current climate change and health movement in England. Through movement mapping, the article describes and offers reflections on the climate change and health ecosystems in England.

Methods:

Organisations working on climate change and health in England were identified and publicly available information was collated to map movement characteristics, target stakeholders and methodologies deployed, using an inductive, iterative approach.

Results:

A total of 98 organisations working on health and climate change (and/or sustainability) were initially identified, of which 70 met the inclusion criteria. Most organisations target two or more stakeholders, with healthcare workers, management structures, and government being most commonly cited. Methodological approaches identified include Formal education programmes; Awareness-raising; Purchasing-procurement power; Advocacy; Financial; Media-messaging; Networking; Knowledge generation; and Policy making, of which education, awareness-raising, and advocacy are most commonly used.

Conclusion:

There is a tendency for climate change and health organisations in England to focus on individual level and sectoral change over system change. More could be made of the potential for the healthcare professions’ voice and messaging for the wider climate movement. Given the rapid boom of climate change and health organisations in recent years, a mind-set shift that recognises different players as part of a cohesive ecosystem with better coordination and collaboration may reduce unnecessary work, and facilitate more cohesive outcomes.

Serum potassium variability as a predictor of clinical outcomes in patients with cardiorenal disease or diabetes: a retrospective UK database study

Background

Hyperkalaemia is an electrolyte abnormality associated with adverse clinical outcomes; however, few studies have investigated the relationship with patterns of hyperkalaemia over time. This study explored the impact of time spent in a hyperkalaemic state and variability of serum potassium (sK⁺) on major adverse cardiovascular events (MACE) and all-cause mortality in patients with chronic kidney disease (CKD), resistant hypertension, heart failure and diabetes.

Methods

Cohorts comprised adult patients diagnosed with CKD stage 3+, resistant hypertension, heart failure or diabetes, and/or renin–angiotensin–aldosterone system inhibitor prescription, between 1 January 2003 and 30 June 2018, from the UK Clinical Practice Research Datalink. Associations between percentage of follow-up spent in a hyperkalaemic state (sK⁺ ≥5.0 mmol/L, ≥5.5 mmol/L, ≥6.0 mmol/L) or sK⁺ variability (standard deviation above or below median standard deviation) and all-cause mortality or MACE were investigated.

Results

For sK⁺ ≥5.0 mmol/L, time spent in a hyperkalaemic state was associated with reduced risk of all-cause mortality across all cohorts. For higher sK⁺ thresholds, this trend was attenuated or reversed; for time spent in a hyperkalaemic state at sK⁺ ≥6.0 mmol/L, an increased risk of mortality was seen in the overall cohort and for patients with diabetes, resistant hypertension or prescribed renin–angiotensin–aldosterone system inhibitors, with no consistent association seen for patients with CKD or heart failure. Risk of MACE in the overall cohort and in patients with CKD, diabetes or resistant hypertension increased with time spent in a hyperkalaemic state at all sK⁺ thresholds; however, no correlation was seen in patients with heart failure or those receiving dialysis. High sK⁺ variability was associated with a higher risk of MACE compared with low sK⁺ variability across most sK⁺ categories in the overall population and in all disease cohorts, except patients on dialysis; however, no association between sK⁺ variability and all-cause mortality was observed.

Conclusions

Patterns of hyperkalaemia, including time spent in hyperkalaemia and sK⁺ variability, are associated with adverse clinical outcomes. Regular monitoring of sK⁺ in high-risk populations in broader community, primary care and outpatient settings may enable guideline-recommended management of hyperkalaemia and help avoid adverse events.

The Value of Insulin Degludec in Frail Older Adults with Type 2 Diabetes

Insulin represents a mainstay of glucose-lowering therapy for many adults with type 2 diabetes mellitus (T2DM). Insulin treatments prescribed as standard care for the majority of people with T2DM, such as basal human insulin, may not be optimal in the treatment of frail older adults because of the increased demand on health care staff to administer multiple daily injections and monitor the patient. When choosing an insulin regimen for a frail older person with T2DM, predictability of glucose lowering effect, risk of hypoglycaemia, ease of administration, and simplicity and flexibility of dosing are major determining factors. Multiple daily injections may be too complex for older frail adults, whilst providing an unnecessary degree of tight glycaemic control and low doses of once-daily basal insulin analogues such as insulin degludec may be a reasonable option as cognitive decline or functional disability increases. Although insulin degludec has a substantially higher acquisition cost than routinely used basal human insulin, it has a longer, more predictable pharmacological profile and is more amenable to once-daily administration, translating into a reduced burden of care and potential cost savings for insulin-treated frail older adults. Insulin acquisition cost represents only a small proportion of the total cost of treatment, and it is important to consider the value perspective of insulin therapy in frail older adults from all stakeholders in the health care system.

Rewilding European urban spaces

Background

In the context of global climate change, deforestation, biodiversity loss, and the impact of urban living on public health, the rewilding of urban areas and surrounding spaces may offer a host of benefits for physical and mental health as well as improvements to environmental and planetary health. This review offers a contemporary appraisal of the role and impact of rewilding urban areas within Europe, considering the success of existing policies and offering suggestions for future projects.

Findings

Rewilding projects across Europe vary in scale and intensity. Given ongoing urbanisation across much of Europe, there is increasing need for green and natural spaces. Protection and enhancement of natural spaces, development of newly rewilded areas, and increased connectedness of natural spaces represent ways to increase prevalence and access to such spaces. Rewilding offers a number of potential benefits to human health, including restoration of biodiversity which may support food security, and sequestration of carbon dioxide which plays an important role in reducing climate change. Green spaces in cities counteract heat island effects and help to maintain temperatures. There are also documented benefits to mental health and faster recovery times from illness.

Lessons

There is scope to improve rewilding projects to enhance their success across Europe. Current limitations to rewilding projects include:

The lack of a clear definition of rewilding and the broad scope of projects that fall under this concept. Challenges in monitoring and evaluation, and the need for a clear framework for effective evaluation of such projects. Increased and improved communication and advocacy.

Key messages

Rewilding offers a range of potential benefits to human and planetary health, and there is increasing interest in such projects. There are limitations to rewilding projects that must be overcome in order to improve policy and practice in this area.

Vaccinating Adolescents and Children Significantly Reduces COVID-19 Morbidity and Mortality across All Ages: A Population-Based Modeling Study Using the UK as an Example

Debate persists around the risk-benefit balance of vaccinating adolescents and children against COVID-19. Central to this debate is quantifying the contribution of adolescents and children to the transmission of SARS-CoV-2, and the potential impact of vaccinating these age groups. In this study, we present a novel SEIR mathematical disease transmission model that quantifies the impact of different vaccination strategies on population-level SARS-CoV-2 infections and clinical outcomes. The model employs both age- and time-dependent social mixing patterns to capture the impact of changes in restrictions. The model was used to assess the impact of vaccinating adolescents and children on the natural history of the COVID-19 pandemic across all age groups, using the UK as an example. The base case model demonstrates significant increases in COVID-19 disease burden in the UK following a relaxation of restrictions, if vaccines are limited to those ≥18 years and vulnerable adolescents (≥12 years). Including adolescents and children in the vaccination program could reduce overall COVID-related mortality by 57%, and reduce cases of long COVID by 75%. This study demonstrates that vaccinating adolescents and children has the potential to play a vital role in reducing SARS-CoV-2 infections, and subsequent COVID-19 morbidity and mortality, across all ages. Our results have major global public health implications and provide valuable information to inform a potential pandemic exit strategy.

Optimising the Heart Failure Treatment Pathway: The Role of SGLT2 Inhibitors

Sodium-glucose cotransporter 2 (SGLT2) inhibitors were first developed as glucose-lowering therapies for the treatment of diabetes. However, these drugs have now been recognised to prevent worsening heart-failure events, improve health-related quality of life, and reduce mortality in people with heart failure with reduced ejection fraction (HFrEF), including those both with and without diabetes. Despite robust clinical trial data demonstrating favourable outcomes with SGLT2 inhibitors for patients with HFrEF, there is a lack of familiarity with the HF indication for these drugs, which have been the remit of diabetologists to date. In this article we use consensus expert opinion alongside the available evidence and label indication to provide support for the healthcare community treating people with HF regarding positioning of SGLT2 inhibitors within the treatment pathway. By highlighting appropriate prescribing and practical considerations, we hope to encourage greater, and safe, use of SGLT2 inhibitors in this population.

Approaching the motional ground state of a 10-kg object

The motion of a mechanical object, even a human-sized object, should be governed by the rules of quantum mechanics. Coaxing them into a quantum state is, however, difficult because the thermal environment masks any quantum signature of the object's motion. The thermal environment also masks the effects of proposed modifications of quantum mechanics at large mass scales. We prepared the center-of-mass motion of a 10-kilogram mechanical oscillator in a state with an average phonon occupation of 10.8. The reduction in temperature, from room temperature to 77 nanokelvin, is commensurate with an 11 orders-of-magnitude suppression of quantum back-action by feedback and a 13 orders-of-magnitude increase in the mass of an object prepared close to its motional ground state. Our approach will enable the possibility of probing gravity on massive quantum systems.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.