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Heald A, Lu W, Robinson A, Schofield H, Rashid H, Dunn G, Whyte MB, Jude E, Gibson JM, Stedman M, Edmonds M. Mortality in people with a diabetes foot ulcer: An update from the Salford podiatry clinic follow-up study. Diabet Med 2024:e15328. [PMID: 38594820 DOI: 10.1111/dme.15328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Wenqi Lu
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Adam Robinson
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Hamid Rashid
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - George Dunn
- Department of Podiatry, East Cheshire Trust, Macclesfield, UK
| | - Martin B Whyte
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Edward Jude
- Department of Diabetes, Tameside General Hospital and Glossop Integrated Care NHS Foundation Trust, Ashton under Lyne, UK
| | - J Martin Gibson
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Heald A, Stedman M, Fryer AA, Davies MB, Rutter MK, Gibson JM, Whyte M. Counting the lifetime cost of obesity: Analysis based on national England data. Diabetes Obes Metab 2024; 26:1464-1478. [PMID: 38312024 DOI: 10.1111/dom.15447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/13/2023] [Accepted: 12/23/2023] [Indexed: 02/06/2024]
Abstract
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.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | | | | | | | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - J Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Martin Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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Stedman M, Whyte MB, Laing I, Fryer AA, Torres BM, Robinson A, Mannan F, Gibson JM, Rayman G, Heald AH. Failure to control conventional cardiovascular risk factors in women with type 2 diabetes might explain worse mortality. Diabetes Metab Res Rev 2023; 39:e3695. [PMID: 37592876 DOI: 10.1002/dmrr.3695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/10/2023] [Accepted: 07/03/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION The standardised mortality rate (SMR) for people with diabetes in England is 1.5-1.7, with differences in outcomes between sexes. There has been little work examining the factors that could have an impact on this or on what may determine sex differences in outcome. METHODS Data were extracted for patients with type 2 diabetes (T2D) in Salford (England) in 2010 for the years up to 2020, including any deaths recorded. Expected deaths were calculated from annual Office of National Statistics mortality rate and life expectancy by age and gender, adjusted for the local Index of Multiple Deprivation (IMD). This provided the SMR deprivation (SMRd), and life expectancy years lost per death (LEYLD). The effects of treatment type, and clinical features on SMRd relative to sex were examined by univariable and multivariable analysis. RESULTS Data from n = 11,806 (F = 5184; M = 6622) patients were included. Of these, n = 5540 were newly diagnosed and n = 3921 died (F = 1841; M = 2080). In total, n = 78,930 patient years. The expected deaths numbered n = 2596 (adjusted for age, sex, and IMD). Excess deaths were n = 1325 (F = 689; M = 636). Life expectancy years lost (LEYL) 18,989 (F = 9714; M = 9275). SMRd 1.51 (F = 1.60; M = 1.44) and LEYLD 4.84 years (F = 5.28; M = 4.46). The impact of risk factors was not different by sex. However, women had higher prevalence of % diagnosed >65 years of age; % last eGFR <60 mLs/min/1.73 m2 , and lower prevalence of % prescribed ACE-inhibitor/ARB, DPP4-inhibitor and SGLT2-inhibitor. Applying the male prevalence rate to the female population and expected mortality suggested n = 437 (55%) of excess T2D female deaths were attributed to sex difference in the prevalence of these risk and protective factors. CONCLUSIONS Outcomes in women with T2DM are worse than in men, contributed to by greater prevalence of adverse factors and less prescribing of cardioprotective medication.
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Affiliation(s)
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Ian Laing
- Department of Clinical Biochemistry, Royal Preston Hospital, Preston, UK
| | | | - Bernardo Meza Torres
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Adam Robinson
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
| | - Fahmida Mannan
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
| | - J Martin Gibson
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Adrian H Heald
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
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Heald AH, Stedman M, Horne L, Rea R, Whyte MB, Syed AA, Paisley A, Gibson JM, Anderson SG, Ollier W. The change in glycaemic control immediately after the 3rd COVID-19 vaccination in people with type 1 diabetes. Diabet Med 2023; 40:e15119. [PMID: 37083020 DOI: 10.1111/dme.15119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023]
Affiliation(s)
- A H Heald
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - M Stedman
- Res Consortium, Andover, Hampshire, UK
| | - L Horne
- Vernova Healthcare, Watersgreen Medical Centre, Macclesfield, UK
| | - R Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS FT, Oxford, UK
| | - M B Whyte
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
| | - A A Syed
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - A Paisley
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - J M Gibson
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - S G Anderson
- Glasgow-Caribbean Centre for Development Research and The George Alleyne Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - W Ollier
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Heald AH, Stedman M, Horne L, Rea R, Whyte M, Gibson JM, Anderson SG, Ollier W. The change in glycaemic control immediately after COVID-19 vaccination in people with type 1 diabetes. Diabet Med 2022; 39:e14774. [PMID: 34936128 DOI: 10.1111/dme.14774] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/20/2021] [Indexed: 01/17/2023]
Abstract
AIMS Evidence suggests that some people with type 1 diabetes mellitus (T1DM) experience temporary instability of blood glucose (BG) levels after COVID-19 vaccination. We aimed to assess this objectively. METHODS We examined the interstitial glucose profile of 97 consecutive adults (age ≥ 18 years) with T1DM using the FreeStyle Libre® flash glucose monitor in the periods immediately before and after their first COVID-19 vaccination. The primary outcome measure was percentage (%) interstitial glucose readings within the target range 3.9-10 mmol/L for 7 days prior to the vaccination and the 7 days after the vaccination. Data are mean ± standard error. RESULTS There was a significant decrease in the % interstitial glucose on target (3.9-10.0) for the 7 days following vaccination (mean 52.2% ± 2.0%) versus pre-COVID-19 vaccination (mean 55.0% ± 2.0%) (p = 0.030). 58% of individuals with T1DM showed a reduction in the 'time in target range' in the week after vaccination. 30% showed a decrease of time within the target range of over 10%, and 10% showed a decrease in time within target range of over 20%. The change in interstitial glucose proportion on target in the week following vaccination was most pronounced for people taking metformin/dapagliflozin + basal bolus insulin (change -7.6%) and for people with HbA1c below the median (change -5.7%). CONCLUSION In T1DM, we have shown that initial COVID-19 vaccination can cause temporary perturbation of interstitial glucose, with this effect more pronounced in people talking oral hypoglycaemic medication plus insulin, and when HbA1c is lower.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Linda Horne
- Vernova Healthcare, Watersgreen Medical Centre, Macclesfield, UK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS FT, Oxford, UK
| | - Martin Whyte
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
| | - J Martin Gibson
- The School of Medicine, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - Simon G Anderson
- University of the West Indies, Cavehill Campus, Bridgetown, Barbados
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Willam Ollier
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Fryer AA, Holland D, Stedman M, Duff CJ, Green L, Scargill J, Hanna FWF, Wu P, Pemberton RJ, Bloor C, Heald AH. Variability in Test Interval Is Linked to Glycated Haemoglobin (HbA1c) Trajectory over Time. J Diabetes Res 2022; 2022:7093707. [PMID: 35615258 PMCID: PMC9126657 DOI: 10.1155/2022/7093707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/20/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS We previously showed that the glycated haemoglobin (HbA1c) testing frequency links to diabetes control. Here, we examine the effect of variability in test interval, adjusted for the frequency, on change in HbA1c (ΔHbA1c). Materials & Methods. HbA1c results were collected on 83,872 people with HbA1c results at baseline and 5 years (±3 months) later and ≥6 tests during this period. We calculated the standard deviation (SD) of test interval for each individual and examined the link between deciles of SD of the test interval and ΔHbA1c level, stratified by baseline HbA1c. RESULTS In general, less variability in testing frequency (more consistent monitoring) was associated with better diabetes control. This was most evident with moderately raised baseline HbA1c levels (7.0-9.0% (54-75 mmol/mol)). For example, in those with a starting HbA1c of 7.0-7.5% (54-58 mmol/mol), the lowest SD decile was associated with little change in HbA1c over 5 years, while for those with the highest decile, HbA1c rose by 0.4-0.6% (4-6 mmol/mol; p < 0.0001). Multivariate analysis showed that the association was independent of the age/sex/hospital site. Subanalysis suggested that the effect was most pronounced in those aged <65 years with baseline HbA1c of 7.0-7.5% (54-58 mmol/mol). We observed a 6.7-fold variation in the proportion of people in the top-three SD deciles across general practices. CONCLUSIONS These findings indicate that the consistency of testing interval, not the just number of tests/year, is important in maintaining diabetes control, especially in those with moderately raised HbA1c levels. Systems to improve regularity of HbA1c testing are therefore needed, especially given the impact of COVID-19 on diabetes monitoring.
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Affiliation(s)
- Anthony A. Fryer
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | | | | | - Christopher J. Duff
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance NHS Group, Oldham, UK
| | - Fahmy W. F. Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- Centre for Health & Development, Staffordshire University, Staffordshire, UK
| | - Pensée Wu
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - R. John Pemberton
- Diabetes UK (North Staffordshire Branch), Porthill, Stoke-on-Trent, Staffordshire, UK
| | - Christine Bloor
- Diabetes UK (North Staffordshire Branch), Porthill, Stoke-on-Trent, Staffordshire, UK
| | - Adrian H. Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
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Heald AH, Holland D, Stedman M, Davies M, Duff CJ, Parfitt C, Green L, Scargill J, Taylor D, Fryer AA. Can we check serum lithium levels less often without compromising patient safety? BJPsych Open 2021; 8:e18. [PMID: 34915951 PMCID: PMC8715256 DOI: 10.1192/bjo.2021.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Lithium is viewed as the first-line long-term treatment for prevention of relapse in people with bipolar disorder. AIMS This study examined factors associated with the likelihood of maintaining serum lithium levels within the recommended range and explored whether the monitoring interval could be extended in some cases. METHOD We included 46 555 lithium rest requests in 3371 individuals over 7 years from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40-0.79 mmol/L; 0.80-0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where lithium results remained stable or switched category on subsequent testing, considering the effects of age, duration of lithium therapy and testing history. RESULTS For tests within the recommended range (0.40-0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall, 3 monthly testing was associated with 90% of lithium results remaining within range, compared with 85% at 6 monthly intervals. In cases where the lithium level in the previous 12 months was on target (0.40-0.79 mmol/L; British National Formulary/National Institute for Health and Care Excellence criteria), 90% remained within the target range at 6 months. Neither age nor duration of lithium therapy had any significant effect on lithium level stability. Levels within the 0.80-0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) compared with those in the 0.4-0.79 mmol/L group (2%), irrespective of testing frequency. CONCLUSION We propose that for those who achieve 12 months of lithium tests within the 0.40-0.79 mmol/L range, the interval between tests could increase to 6 months, irrespective of age. Where lithium levels are 0.80-0.99 mmol/L, the test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.
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Affiliation(s)
- Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK, and The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | | | | | - Chris J Duff
- School of Medicine, Keele University, Keele, Staffordshire, UK, and Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Ceri Parfitt
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Lewis Green
- St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance, Manchester, UK
| | | | - Anthony A Fryer
- School of Medicine, Keele University, Keele, Staffordshire, UK, and Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
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Miles DK, Heald AH, Stedman M. How fast should social restrictions be eased in England as COVID-19 vaccinations are rolled out? Int J Clin Pract 2021; 75:e14191. [PMID: 33788370 PMCID: PMC8250364 DOI: 10.1111/ijcp.14191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/27/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Vaccination against the COVID-19 virus began in December 2020 in the UK and into Spring 2021 has been running at 5% population/week. High levels of social restrictions were implemented for the third time in January 2021 to control the second wave and resulting increases in hospitalisations and deaths. Easing those restrictions must balance multiple challenging priorities, weighing the risk of more deaths and hospitalisations against damage done to mental health, incomes and standards of living, education and provision of non-Covid-19 healthcare. METHODS Weekly and monthly officially published data for 2020/21 were used to estimate the influence of seasonality and social restrictions on the spread of COVID-19 by age group, on the economy and on healthcare services. These factors were combined with the estimated impact of vaccinations and immunity from past infections into a model that retrospectively reflected the actual numbers of reported deaths closely both in 2020 and early 2021. The model was applied prospectively to the next 6 months to evaluate the impact of different speeds of easing social restrictions. RESULTS The results show vaccinations as significantly reducing the number of hospitalisations and deaths. The central estimate is that relative to rapid easing, the avoided loss of 57 000 life-years from a strategy of relatively slow easing over the next several months comes at a cost in terms of GDP reduction of around £0.4 million/life-year loss avoided. This is over 10 times higher than the usual limit the NHS uses for spending against Quality Adjusted Life Years (QALYs) saved. Alternative assumptions for key factors affecting the spread of the virus give significantly different trade-offs between costs and benefits of different speeds of easing. Disruption of non-Covid-19 Healthcare provision also increases in times of higher levels of social restrictions. CONCLUSION In most cases, the results favour a somewhat faster easing of restrictions in England than current policy implies.
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Affiliation(s)
- David K. Miles
- Imperial College Business School, Imperial CollegeLondonUK
| | - Adrian H. Heald
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalfordUK
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Stedman M, Taylor P, Premawardhana L, Okosieme O, Dayan C, Heald AH. Trends in costs and prescribing for liothyronine and levothyroxine in England and wales 2011-2020. Clin Endocrinol (Oxf) 2021; 94:980-989. [PMID: 33411974 DOI: 10.1111/cen.14414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Recent prescribing policies in England and Wales have imposed significant restrictions on liothyronine prescribing in general practice driven by the prohibitive costs and uncertain benefits of liothyronine in the management of hypothyroidism. However, the impact of these policies on liothyronine usage and costs is still unclear. METHODS Data were downloaded from the NHS monthly General Practice Prescribing Data in England and from the Comparative Analysis System for Prescribing Audit (CASPA) in Wales for 2011-2020. Trends over the period in amount and costs of levothyroxine and liothyronine prescribing were analysed. RESULTS The total medication costs per year for England Wales for hypothyroidism rose from £60.8 million to £129.8 million in 2015-16 and have since reduced to £88.4 million. Levothyroxine prescriptions have been growing above the population growth rate at 0.7%/annum in England and 1.1% in Wales. The costs/patient/year for liothyronine rose from £550 to £3000 in 2015-16 and has since fallen to £2500. Use of liothyronine as a percentage of levothyroxine started to fall in 2015-16 at 7%/annum in England and 3% in Wales. Nevertheless, 0.5% of levothyroxine-treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-20. CONCLUSION In spite of strenuous attempts to limit prescribing of liothyronine in general practice, a significant number of patients continue to receive this therapy. The price differential of liothyronine vs levothyroxine should be examined again in light of the continuing use of liothyronine.
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Affiliation(s)
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Lakdasa Premawardhana
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
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Heald AH, Stedman M, Whyte M, Livingston M, Albanese M, Ramachandran S, Hackett G. Lessons learnt from the variation across 6741 family/general practices in England in the use of treatments for hypogonadism. Clin Endocrinol (Oxf) 2021; 94:827-836. [PMID: 33420743 DOI: 10.1111/cen.14412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We have previously reported rates of diagnosis of male hypogonadism in United Kingdom (UK) general practices. We aimed to identify factors associated with testosterone prescribing in UK general practice. METHODS We determined for 6741 general practices in England, the level of testosterone prescribing in men and the relation between volume of testosterone prescribing and (1) demographic characteristics of the practice, (2) % patients with specific comorbidities and (3) national GP patient survey results. RESULTS The largest volume (by prescribing volume) agents were injectable preparations at a total cost in the 12-month period 2018/19 of £8,172,519 with gel preparations in second place: total cost £4,795,057. Transdermal patches, once the only alternative to testosterone injections or implants, were little prescribed: total cost £222,022. The analysis accounted for 0.27 of the variance in testosterone prescribing between general practices. Thus, most of this variance was not accounted for by the analysis. There was a strong univariant relation (r = .95, P < .001) between PDE5-I prescribing and testosterone prescribing. Other multivariant factors independently linked with more testosterone prescribing were as follows: HIGHER proportion of men with type 2 diabetes(T2DM) on target control (HbA1c ≤ 58 mmol/mol) and HIGHER overall practice rating on the National Patient Survey for good experience, while non-white ethnicity and socio-economic deprivation were associated with less testosterone prescribing. There were a number of comorbidity factors associated with less prescribing of testosterone (such as T2DM, hypertension and stroke/TIA). CONCLUSION Our analysis has indicated that variation between general practices in testosterone prescribing in a well developed health economy is only related to small degree (r2 = 0.27) to factors that we can define. This suggests that variation in amount of testosterone prescribed is largely related to general practitioner choice/other factors not studied and may be amenable to measures to increase knowledge/awareness of male hypogonadism, with implications for men's health.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Martin Whyte
- Clinical and Experimental Medicine, University of Surrey, Surrey, UK
| | - Mark Livingston
- Department of Clinical Biochemistry, Black Country Pathology Services, Walsall, UK
- School of Medicine and Clinical Practice & Department of Biomedical Science and Physiology, Faculty of Science & Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Marco Albanese
- Herzzentrum Hirslanden Zentralschweiz, Luzern, Switzerland
| | - Sud Ramachandran
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands/Institute for Science and Technology in Medicine, Keele University, Staffordshire, UK
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Miles DK, Stedman M, Heald AH. "Stay at Home, Protect the National Health Service, Save Lives": A cost benefit analysis of the lockdown in the United Kingdom. Int J Clin Pract 2021; 75:e13674. [PMID: 32790942 PMCID: PMC7435525 DOI: 10.1111/ijcp.13674] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has transformed lives across the world. In the UK, a public health driven policy of population "lockdown" has had enormous personal and economic impact. METHODS We compare UK response and outcomes with European countries of similar income and healthcare resources. We calibrate estimates of the economic costs as different % loss in Gross Domestic Product (GDP) against possible benefits of avoiding life years lost, for different scenarios where current COVID-19 mortality and comorbidity rates were used to calculate the loss in life expectancy and adjusted for their levels of poor health and quality of life. We then apply a quality-adjusted life years (QALY) value of £30,000 (maximum under national guidelines). RESULTS There was a rapid spread of cases and significant variation both in severity and timing of both implementation and subsequent reductions in social restrictions. There was less variation in the trajectory of mortality rates and excess deaths, which have fallen across all countries during May/June 2020. The average age at death and life expectancy loss for non-COVID-19 was 79.1 and 11.4 years, respectively, while COVID-19 were 80.4 and 10.1 years; including adjustments for life-shortening comorbidities and quality of life plausibly reduces this to around 5 QALY lost for each COVID-19 death. The lowest estimate for lockdown costs incurred was 40% higher than highest benefits from avoiding the worst mortality case scenario at full life expectancy tariff and in more realistic estimations they were over 5 times higher. Future scenarios showed in the best case a QALY value of £220k (7xNICE guideline) and in the worst-case £3.7m (125xNICE guideline) was needed to justify the continuation of lockdown. CONCLUSION This suggests that the costs of continuing severe restrictions are so great relative to likely benefits in lives saved that a rapid easing in restrictions is now warranted.
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Affiliation(s)
| | | | - Adrian H. Heald
- Department of Diabetes and EndocrinologySalford Royal Hospitals NHS TrustSalfordUnited Kingdom
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUnited Kingdom
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Heald AH, Stedman M, Tian Z, Wu P, Fryer AA. Modelling the impact of the mandatory use of face coverings on public transport and in retail outlets in the UK on COVID-19-related infections, hospital admissions and mortality. Int J Clin Pract 2021; 75:e13768. [PMID: 33070412 PMCID: PMC7645947 DOI: 10.1111/ijcp.13768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/13/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The rapid spread of the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/)(COVID-19) virus resulted in governments around the world instigating a range of measures, including mandating the wearing of face coverings on public transport/in retail outlets. METHODS We developed a sequential assessment of the risk reduction provided by face coverings using a step-by-step approach. The UK Office of National Statistics (ONS) Population Survey data were utilised to determine the baseline total number of community-derived infections. These were linked to reported hospital admissions/hospital deaths to create case admission risk ratio and admission-related fatality rate. We evaluated published evidence to establish an infection risk reduction for face coverings. We calculated an Infection Risk Score (IRS) for a number of common activities and related it to the effectiveness of reducing infection and its consequences, with a face covering, and evaluated their effect when applied to different infection rates over 3 months from July 24, 2020, when face coverings were made compulsory in England on public transport/retail outlets. RESULTS We show that only 7.3% of all community-based infection risk is associated with public transport/retail outlets. In the week of July 24, The reported weekly community infection rate was 29 400 new cases at the start (July 24). The rate of growth in hospital admissions and deaths for England was around -15%/week, suggesting the infection rate, R, in the most vulnerable populations was just above 0.8. In this situation, average infections over the evaluated 13 week follow-up period, would be 9517/week with face covering of 40% effectiveness, thus, reducing average infections by 844/week, hospital admissions by 8/week and deaths by 0.6/week; a fall of 9% over the period total. If, however, the R-value rises to 1.0, then, average community infections would stay at 29 400/week and mandatory face coverings could reduce average weekly infections by 3930, hospital admissions by 36 and deaths by 2.9/week; a 13% reduction. If the R-value rose and stayed at 1.2, then, expected average community-derived hospital admissions would be 975/week and 40% effective face coverings would reduce this by 167/week and reduce possible expected hospital deaths from 80/week to 66/week. These reductions should be seen in the context that there was an average of 102 000/week all-cause hospital emergency admissions in England in June and 8900 total reported deaths in the week ending August 7, 2020. CONCLUSION We have illustrated that the policy on mandatory use of face coverings in retail outlets/on public transport may have been very well followed, but may be of limited value in reducing hospital admissions and deaths, at least at the time that it was introduced, unless infections begin to rise faster than currently seen. The impact appears small compared with all other sources of risk, thereby raising questions regarding the effectiveness of the policy.
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Affiliation(s)
- Adrian H. Heald
- Department of Diabetes and EndocrinologySalford Royal NHS Foundation TrustSalfordUK
- The School of MedicineManchester Academic Health Sciences CentreThe University of ManchesterManchesterUK
| | | | - Zixing Tian
- The School of MedicineManchester Academic Health Sciences CentreThe University of ManchesterManchesterUK
| | - Pensee Wu
- School of MedicineKeele UniversityKeeleUK
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Stedman M, Rea R, Duff CJ, Livingston M, Moreno G, Gadsby R, Lunt H, Fryer AA, Heald AH. Applying Parkes Grid Method to Evaluate Impact of Variation in Blood Glucose Monitoring (BGM) Strip Accuracy Performance in Type 1 Diabetes Highlights the Potential for Amplification of Imprecision With Less Accurate BGM Strips. J Diabetes Sci Technol 2021; 15:76-81. [PMID: 32172590 PMCID: PMC7783004 DOI: 10.1177/1932296820905880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The National Health Service spends £170 million on blood glucose monitoring (BGM) strips each year and there are pressures to use cheaper less accurate strips. Technology is also being used to increase test frequency with less focus on accuracy.Previous modeling/real-world data analysis highlighted that actual blood glucose variability can be more than twice blood glucose meter reported variability (BGMV). We applied those results to the Parkes error grid to highlight potential clinical impact. METHOD BGMV is defined as the percent of deviation from reference that contains 95% of results. Four categories were modeled: laboratory (<5%), high accuracy strips (<10%), ISO 2013 (<15%), and ISO 2003 (<20%) (includes some strips still used).The Parkes error grid model with its associated category of risk including "alter clinical decision" and "affect clinical outcomes" was used, with the profile of frequency of expected results fitted into each BGM accuracy category. RESULTS Applying to single readings, almost all strip accuracy ranges derived in a controlled setting fell within the category: clinically accurate/no effect on outcomes areas.However modeling the possible blood glucose distribution in more detail, 30.6% of longer term results of the strips with current ISO accuracy would fall into the "alter clinical action" category. For previous ISO strips, this rose to 44.1%, and for the latest higher accuracy strips, this fell to 12.8%. CONCLUSION There is a minimum standard of accuracy needed to ensure that clinical outcomes are not put at risk. This study highlights the potential for amplification of imprecision with less accurate BGM strips.
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Affiliation(s)
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
| | - Christopher J. Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- School of Primary, Community and Social Care, Keele University, Stoke-on-Trent, UK
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, UK
| | | | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Lunt
- University of Otago, Christchurch, New Zealand
| | - Anthony A. Fryer
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- School of Primary, Community and Social Care, Keele University, Stoke-on-Trent, UK
| | - Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, UK
- Adrian H. Heald, DM, Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford M6 8HD, UK.
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Stedman M, Rea R, Duff CJ, Livingston M, McLoughlin K, Wong L, Brown S, Grady K, Gadsby R, Paisley A, Fryer AA, Heald AH. People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement. Diabetes Res Clin Pract 2020; 170:108479. [PMID: 33002551 DOI: 10.1016/j.diabres.2020.108479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing. METHODS An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained. RESULTS 59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c. CONCLUSION Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.
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Affiliation(s)
- M Stedman
- Res Consortium, Andover, Hampshire, United Kingdom
| | - R Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
| | - C J Duff
- Department of Clinical Biochemistry, Royal Stoke Hospital, Stoke on Trent, United Kingdom; Institute for Science and Technology in Medicine, Keele University, United Kingdom
| | - M Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, United Kingdom
| | | | - L Wong
- Salford Royal Hospital, Salford, United Kingdom
| | - S Brown
- Salford Royal Hospital, Salford, United Kingdom
| | - K Grady
- Salford Royal Hospital, Salford, United Kingdom
| | - R Gadsby
- Warwick Medical School, University of Warwick, United Kingdom
| | - A Paisley
- Salford Royal Hospital, Salford, United Kingdom
| | - A A Fryer
- Department of Clinical Biochemistry, Royal Stoke Hospital, Stoke on Trent, United Kingdom; Institute for Science and Technology in Medicine, Keele University, United Kingdom
| | - A H Heald
- Salford Royal Hospital, Salford, United Kingdom; The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, United Kingdom.
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Heald AH, Stedman M, Farman S, Khine C, Davies M, De Hert M, Taylor D. Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection. BMC Psychiatry 2020; 20:528. [PMID: 33160310 PMCID: PMC7648310 DOI: 10.1186/s12888-020-02915-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing. METHODS The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. RESULTS We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic. CONCLUSIONS The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.
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Affiliation(s)
- A. H. Heald
- grid.5379.80000000121662407Manchester University, The School of Medicine and Manchester Academic Health Sciences Centre, Manchester, UK ,Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK ,University Psychiatric Center, Leuven, KU Belgium
| | | | - S. Farman
- grid.466705.60000 0004 0633 4554Mersey Deanery Psychiatry Rotation, Manchester, UK
| | - C. Khine
- grid.415352.40000 0004 1756 4726Department of Medicine, Kings Mill Hospital, Mansfield, UK
| | - M. Davies
- Res Consortium, Research, Andover, USA
| | - M. De Hert
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Pharmacy, London, UK
| | - D. Taylor
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Pharmacy, London, UK
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Tian Z, Stedman M, Whyte M, Anderson SG, Thomson G, Heald A. Personal protective equipment (PPE) and infection among healthcare workers - What is the evidence? Int J Clin Pract 2020; 74:e13617. [PMID: 32734641 DOI: 10.1111/ijcp.13617] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The worldwide outbreak of coronavirus disease-19 (COVID-19) has already put healthcare workers (HCWs) at a high risk of infection. The question of how to give HCWs the best protection against infection is a priority. METHODS We searched systematic reviews and original studies in Medline (via Ovid) and Chinese Wan Fang digital database from inception to May, 2020, using terms 'coronavirus', 'health personnel', and 'personal protective equipment' to find evidence about the use of full-body PPEs and other PPEs by HCW exposed highly infectious diseases. RESULTS Covering more of the body could provide better protection for HCWs. Of importance, it is not just the provision of PPE but the skills in donning and doffing of PPE that are important, this being a key time for potential transmission of pathogen to the HCW and in due time from them to others. In relation to face masks, the evidence indicates that a higher-level specification of face masks and respirators (such as N95) seems to be essential to protect HCWs from coronavirus infection. In community setting, the use of masks in the case of well individuals could be beneficial. Evidence specifically around PPE and protection from the COVID-19 virus is limited. CONCLUSION Covering more of the body, and a higher-level specification of masks and respirators could provide better protection for HCWs. Community mask usecould be beneficial. High quality studies still need to examine the protection of PPE against COVID-19.
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Affiliation(s)
- Zixing Tian
- Faculty of Biology, Medicine and Health, Medicine and Health, Manchester Academic Health Science Centre, the University of Manchester, Manchester, UK
| | | | - Martin Whyte
- Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Simon G Anderson
- University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
- Division of Cardiovascular, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - George Thomson
- Acute Medical Unit, The Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Adrian Heald
- Faculty of Biology, Medicine and Health, Medicine and Health, Manchester Academic Health Science Centre, the University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hosptial, Salford, UK
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Stedman M, Lunt M, Davies M, Fulton-McAlister E, Hussain A, van Staa T, Anderson SG, Heald AH. Controlling antibiotic usage-A national analysis of General Practitioner/Family Doctor practices links overall antibiotic levels to demography, geography, comorbidity factors with local discretionary prescribing choices. Int J Clin Pract 2020; 74:e13515. [PMID: 32306458 DOI: 10.1111/ijcp.13515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Ecological studies show association between antimicrobial resistance (AMR), and inappropriate oral antibiotics use. Moderating antibiotic prescribing requires an understanding of all drivers of local prescribing. The aim was to quantify how much is determined by external factors compared with discretionary clinical choices. METHODS Oral antibiotic usage taken from England General Practitioner/Family Doctor practice prescribing data was aggregated using WHO/ATC defined daily doses (DDDs). The average annual antibiotic daily prescribing rate (AAADPR) in each practice was the total DDD of oral antibiotics divided by registered population and 365. The AAADPR of English practices in 2017_18 was linked by regression to factors including demographics, geography, medical comorbidities, clinical performance, patient satisfaction, medical workforce characteristics and prescribing selection. The regression coefficients for modifiable prescribing selection factors were applied to the difference between the median and top decile practice values to establish overall reduction opportunities through changing prescribing behaviour. RESULTS Twenty five factors accounted for 58% of the AAADPR variation in 5889 practices supporting 49.8 million patients. Non-modifiable factors linked increased AAADPR to more northerly location, higher prevalence of diabetes, COPD, CHD, and asthma; higher white ethnicity; higher patient satisfaction and lower population density. Modifiable behaviour accounted for 11% of the variation in AAADPR, with increases associated with a wider range of antibiotics, higher proportion taken as liquids, higher doses in each prescription, lower guideline compliance, lower targeted antibiotics, lower spend/dose, and less seasonal variation. If all practices achieved the level of modifiable factors of the top decile, this model suggests that overall AAADPR could reduce by 31%. CONCLUSION Such analysis is associative and does not infer causation. However, demographics, location, medical condition of the population, and prescribing selection are drivers of overall antibiotic prescribing. This analysis provides benchmarks for both non-modifiable and modifiable factors against which practices could evaluate their opportunities to reduce antibiotic prescribing.
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Affiliation(s)
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Erin Fulton-McAlister
- Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | | | - Tjeerd van Staa
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Simon G Anderson
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- The George Alleyne Chronic Disease Research Centre, University of the West Indies, Cavehill, Barbados
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
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Heald A, Livingstone M, Albanese M, Stedman M. P-02-83 Strong Link Identified in Family Doctors / General Practitioners Between Prescription of Treatments for Erectile Dysfunction and Hypogonadism. J Sex Med 2020. [DOI: 10.1016/j.jsxm.2020.04.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Heald A, Livingstone M, Albanese M, Stedman M. P-02-56 Can Any Lessons Be Seen From the Variation Across Family/General Practices in Application of Treatments for Hypogonadism? J Sex Med 2020. [DOI: 10.1016/j.jsxm.2020.04.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Heald A, Davies M, Lunt M, Fulton-McAlister E, Abid H, Van Staa T, Anderson S, Stedman M. Controlling antibiotic usage - analysis of nationally published data from GP practices including demography, geography, comorbidity and prescribing factors highlights opportunities to reduce overall prescribing through changes in discretionary prescribing choices. Future Healthc J 2020; 7:s9-s10. [PMID: 32455258 DOI: 10.7861/fhj.7.1.s9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Adrian Heald
- University of Manchester School of Medicine and Manchester Academic Health Sciences Centre, Manchester, UK
| | | | - Mark Lunt
- University of Manchester School of Medicine and Manchester Academic Health Sciences Centre, Manchester, UK
| | | | | | - Tjeerd Van Staa
- School of Health Sciences University of Manchester, Manchester, UK
| | - Simon Anderson
- The George Alleyne Chronic Disease Research Centre, Bridgetown, Barbados
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Heald AH, Livingston M, Fryer A, Moreno GYC, Malipatil N, Gadsby R, Ollier W, Lunt M, Stedman M, Young RJ. Route to improving Type 1 diabetes mellitus glycaemic outcomes: real-world evidence taken from the National Diabetes Audit. Diabet Med 2018; 35:63-71. [PMID: 29120503 DOI: 10.1111/dme.13541] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 02/01/2023]
Abstract
AIM To use general practice-level data for England, available through the National Diabetes Audit, and primary care prescribing data to identify prescription treatment factors associated with variations in achieved glucose control (HbA1c ). METHODS General practice-level National Diabetes Audit data on Type 1 diabetes, including details of population characteristics, services, proportion of people achieving target glycaemic control [HbA1c ≤58 mmol/mol (7.5%)] and proportion of people at high glycaemic risk [HbA1c >86 mmol/ml (10%)], were linked to 2013-2016 primary care diabetes prescribing data on insulin types and blood glucose monitoring for all people with diabetes. RESULTS A wide variation was found between the 10th percentile and the 90th percentile of general practices in both target glycaemic control (15.6% to 44.8%, respectively) and high glycaemic risk (4.8% to 28.6%, respectively). Our analysis suggests that, given the extrapolated total of 280 000 people with Type 1 diabetes in the UK, there may be the potential to increase the number of those within target glycaemic control from 80 000 to 101 000; 53% of this increase (11 000 people) would result from service improvements and 47% (10 000 people) from medication and technology changes. The same improvements would also provide the opportunity to reduce the number of people at high glycaemic risk from 42 000 to 26 500. A key factor associated with practice-level target HbA1c achievement would be greater use of insulin pumps for up to an additional 56 000 people. CONCLUSION If the HbA1c achievement rates in service provision, medication and use of technology currently seen in practices in the 90th percentile were to be matched with regard to HbA1c achievement rates in all general practices, glycaemic control might be improved for 36 500 people, with all the attendant health benefits.
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Affiliation(s)
- A H Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - M Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - A Fryer
- Institute for Applied Clinical Sciences, Keele University, Keele, UK
| | - G Y C Moreno
- Co-ordinator of the Obesity Clinic in the Medicine School of Instituto Politécnico Nacional, Mexico City, Mexico
| | - N Malipatil
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - R Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | - W Ollier
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - M Lunt
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - M Stedman
- RES Consortium, Andover, Wiltshire, UK
| | - R J Young
- National Diabetes Audit, Central Office Diabetes UK, London, UK
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Heald AH, Livingston M, Stedman M, Wyrko Z. Higher levels of apomorphine and rotigotine prescribing reduce overall secondary healthcare costs in Parkinson's disease. Int J Clin Pract 2016; 70:907-915. [PMID: 27870257 DOI: 10.1111/ijcp.12844] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/27/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) affects around 100,000 people in England. A number of non-oral therapies can improve both the quality of life and reduce patient needs for health and social care. However, these can be relatively expensive at £2000-£10,000 per year per patient. Our aim was to examine how prescribing of these agents relates to secondary care costs. METHODS Using practice level primary care prescribing data and hospital episode statistical data in England, we investigated the relation between general practitioner prescriptions of apomorphine injections/rotigotine patches and the secondary care costs accrued for their diagnosed PD patients for 2011-2014. The median age of the PD patients was 78 years. RESULTS In the period 2011-2014, 58% of the average annual £437 million secondary care costs for PD patients came from non-elective admissions. 80% of this came from seven Healthcare Resource Group Chapters linked to PD comorbidities. Compared with practices not using non-oral therapies, practices prescribing Apomorphine saved £897 per year per patient of secondary care costs to offset the average additional prescribing cost of £475 per overall patient per year. For Rotigotine, saving was £718 per year per patient of secondary care costs offsetting £137 prescribing cost. Practices in the highest quartile of non-oral prescribing were using non-oral agents in up to 28% of their PD patients. CONCLUSIONS Those practices which used more non-oral therapies appear to incur less secondary care costs. A total of 70% of the advanced PD patients are not being given access to non-oral treatment. This is a challenge for all physicians looking after the older patient.
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Affiliation(s)
- A H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - M Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Z Wyrko
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Basile G, Becker P, Bergamin A, Cavagnero G, Franks A, Jackson K, Kuetgens U, Mana G, Palmer EW, Robbie CJ, Stedman M, Stümpel J, Yacoot A, Zosi G. Combined optical and X–ray interferometry for high–precision dimensional metrology. Proc Math Phys Eng Sci 2000. [DOI: 10.1098/rspa.2000.0536] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- G. Basile
- Istituto di Metrologia ‘G. Colonetti’, Strada delle Cacce 73, 10135 Torino, Italy
| | - P. Becker
- Physikalisch–Technische Bundesanstalt, D–38023 Braunschweig, Germany
| | - A. Bergamin
- Istituto di Metrologia ‘G. Colonetti’, Strada delle Cacce 73, 10135 Torino, Italy
| | - G. Cavagnero
- Istituto di Metrologia ‘G. Colonetti’, Strada delle Cacce 73, 10135 Torino, Italy
| | - A. Franks
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - K. Jackson
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - U. Kuetgens
- Physikalisch–Technische Bundesanstalt, D–38023 Braunschweig, Germany
| | - G. Mana
- Istituto di Metrologia ‘G. Colonetti’, Strada delle Cacce 73, 10135 Torino, Italy
| | - E. W. Palmer
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - C. J. Robbie
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - M. Stedman
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - J. Stümpel
- Physikalisch–Technische Bundesanstalt, D–38023 Braunschweig, Germany
| | - A. Yacoot
- National Physical Laboratory, Teddington, Middlesex TW11 0LW, UK
| | - G. Zosi
- Istituto di Fisica Generale ‘A. Avogadro’, University of Turin, 10125 Torino, Italy
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Yew NS, Wang KX, Przybylska M, Bagley RG, Stedman M, Marshall J, Scheule RK, Cheng SH. Contribution of plasmid DNA to inflammation in the lung after administration of cationic lipid:pDNA complexes. Hum Gene Ther 1999; 10:223-34. [PMID: 10022547 DOI: 10.1089/10430349950019011] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cationic lipid-mediated gene transfer to the mouse lung induces a dose-dependent inflammatory response that is characterized by an influx of leukocytes and elevated levels of the cytokines interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and interferon gamma (IFN-gamma). We have examined the contribution of plasmid DNA (pDNA) to this observed toxicity, specifically the role of unmethylated CpG dinucleotides, which have been previously shown to be immunostimulatory. We report here that complexes of cationic lipid GL-67 and unmethylated pDNA (pCF1-CAT) instilled into the lungs of BALB/c mice induced highly elevated levels of the cytokines TNF-alpha, IFN-gamma, IL-6, and IL-12 in the bronchoalveolar lavage fluids (BALF). In contrast, BALF of animals administered either GL-67 alone or GL-67 complexed with SssI-methylated pDNA contained low levels of these cytokines. Similar results were observed using a plasmid (pCF1-null) that does not express a transgene, demonstrating that expression of chloramphenicol acetyltransferase (CAT) was not responsible for the observed inflammation. The response observed was dose dependent, with animals receiving increasingly higher amounts of unmethylated pDNA exhibiting progressively higher levels of the cytokines. Concomitant with this increase in cytokine levels were also elevated numbers of neutrophils in the BALF, suggesting a possible cause- and-effect relationship between neutrophil influx and generation of cytokines. Consistent with this proposal is the observation that reduction of neutrophils in the lung by administration of antibodies against Mac-1alpha and LFA-1 also diminished cytokine levels. This reduction in cytokine levels in the BALF was accompanied by an increase in transgene expression. In an attempt to abate the inflammatory response, sequences in the pDNA encoding the motif RRCGYY, shown to be most immunostimulatory, were selectively mutagenized. However, instillation of a plasmid in which 14 of the 17 CpG sites were altered into BALF/c mice did not reduce the levels of cytokines in the BALF compared with the unmodified vector. This suggests that other unmethylated motifs, in addition to RRCGYY, may also contribute to the inflammatory response. Together, these findings indicate that unmethylated CpG residues in pDNA are a major contributor to the induction of specific proinflammatory cytokines associated with instillation of cationic lipid:pDNA complexes into the lung. Strategies to abate this response are warranted to improve the efficacy of this nonviral gene delivery vector system for the treatment of chronic diseases.
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Affiliation(s)
- N S Yew
- Genzyme Corporation, Framingham, MA 01701-9322, USA
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Adam R, Stedman M, Winn J, Howard M, Williams JI, Ali J. Improving trauma care in Trinidad and Tobago. W INDIAN MED J 1994; 43:36-8. [PMID: 7941493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Identification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post-ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.
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Affiliation(s)
- R Adam
- Department of Surgery, U.W.I., Trinidad
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Ali J, Adam R, Stedman M, Howard M, Williams J. Cognitive and attitudinal impact of the Advanced Trauma Life Support program in a developing country. J Trauma 1994; 36:695-702. [PMID: 8189473 DOI: 10.1097/00005373-199405000-00017] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Improvement in trauma patient outcome has been reported after Advanced Training Life Support training (ATLS) in the developing country of Trinidad and Tobago (T & T). The cognitive impact of ATLS training was assessed from pre-ATLS and post-ATLS performance of T & T physicians in multiple choice question tests and comparison with post-ATLS test performance among Nebraska physicians. Overall, improvement between the pre-test and post-test among the T & T physicians was 22.0% +/- 2.0%. All physicians including failures (199 out of 212 passed) improved in their post-test scores. Individual item analysis of the post-test, including the KR-20 determination, varied but the overall performance was similar for both physician groups with the T & T physicians performing slightly better in test 2 (6 of 16 vs. 25 of 100 failures, p < 0.05). Attitudinal impact was assessed through 87 questionnaires from 50 physicians (92% response) and 37 nurses (89% response). Physicians (97.8% compared with 69.7%) were more aware of the ATLS training, and both groups (physicians, 77.3%; nurses, 69.6%) differentiated ATLS-trained physicians based on better resuscitation, more timely and appropriate consultation, greater confidence in trauma management, and improvement in trauma mortality and morbidity; all respondents recommended ATLS training for all emergency room physicians. The demonstrated positive cognitive and attitudinal effects very likely contributed to the improved post-ATLS trauma patient outcome.
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Affiliation(s)
- J Ali
- Department of Surgery, University of Toronto, Canada
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Ali J, Adam R, Stedman M, Howard M, Williams JI. Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma 1994; 36:391-4. [PMID: 8145322 DOI: 10.1097/00005373-199403000-00020] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Ali
- Department of Surgery, University of Toronto, Ontario, Canada
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Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, Pitt-Miller P, Stedman M, Winn J, Williams JI. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma 1993; 34:890-8; discussion 898-9. [PMID: 8315686 DOI: 10.1097/00005373-199306000-00022] [Citation(s) in RCA: 199] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 1990. Outcome data were analyzed for all dead or severely injured patients (ISS > or = 16; n = 413 pre-ATLS and n = 400 post-ATLS). Trauma mortality decreased post-ATLS (134 of 400 vs. 279 of 413) throughout the hospital, including the ICU (13.6% post-ATLS ICU mortality vs. 55.2% pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs. 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0%) versus post-ATLS (68.3%), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7% pre-ATLS vs. 6.3% post-ATLS for penetrating and 76.6% pre-ATLS versus 46.2% post-ATLS for blunt). For each ISS category, mortality was greater in the pre-ATLS group (ISS > or = 24 pre-ATLS mortality 47.9% vs. 16.7% post-ATLS; ISS 25-40 pre-ATLS mortality 91.0% vs. 71.0% post-ATLS). The overall ratio of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Ali
- Department of Surgery, University of Toronto, Ontario, Canada
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Abstract
Scanning tunnelling microscopy has been used to examine the structure of proteins deposited on a graphite surface. Three molecules have been studied; immunoglobulin G (IgG), Complement component 1q (C1q) and ATP-citrate lyase (ACL). The images show IgG as a tri-lobed molecule, consistent with the known 3D structure as determined by X-ray crystallography. The C1q images differ from the well known "tulip bunch" model derived by electron microscopy, but are consistent with the model if it is assumed that the six globular heads have aggregated. Molecules of ACL are visible as discrete units, with some hints of substructure. These results highlight the potential of STM in studying protein structures, but also illustrate the difficulties of interpreting micrographs of proteins whose structure is currently unknown.
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Affiliation(s)
- T N Wells
- Glaxo Institute for Molecular Biology, S.A., Geneva, Switzerland
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Abstract
Scanning tunnelling microscopy (STM) has been used to examine the shape of individual immunoglobulin G (IgG) molecules deposited onto a graphite surface. IgG was chosen for this study as it has a well-characterized and distinctive three-dimensional structure. The micrographs clearly reveal the IgG molecule as trilobed, corresponding with the known structural organization of IgG. Comparison of these images with the structure of IgG determined by X-ray crystallography shows that the STM images are consistent with the crystal structure. This illustrates that STM is a valuable technique for examining protein structure, allowing rapid determination of the overall molecular shape that is consistent with more established techniques.
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Affiliation(s)
- R J Leatherbarrow
- Department of Chemistry, Imperial College of Science, Technology and Medicine South Kensington, London, U.K
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Franks A, Gale B, Stedman M. Grazing incidence optics:amplitude-wavelength mapping as a unified approach to specification, theory, and metrology. Appl Opt 1988; 27:1508-1517. [PMID: 20531606 DOI: 10.1364/ao.27.001508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The concept of amplitude-wavelength space applied to the development of an x-ray optic provides a means of summarizing and unifying the complex data associated with each stage of its development: the specification; manufacturing tolerances; and etrology. The determination of manufacturing tolerances requires calculation of the image aberrations of perturbed optical systems and is most usefully carried out using a modified asymptotic Debye theory. Its range of applicability and that of other theories is illustrated in amplitude-wavelength space. Subnanometer perturbations are measured by mechanical or optical techniques, and the measuring instruments are calibrated by means of x-ray interferometry in terms of the primary standards of length.
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