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Objectives: To evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache., Intervention: Management of chronic headache following referral from Primary Care that differed in the first appointment, either a Neurology appointment or an MRI brain scan., Design and Setting: A pragmatic, non-randomised, prospective, single-centre study at a Central Hospital in London., Participants: Adult patients with chronic headache referred from primary to secondary care., Primary and Secondary Outcome Measures: Participants' use of healthcare services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months postrecruitment. Cost analyses were compared using generalised linear models. Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (Migraine Disability Assessment Scale and Headache Impact Test) and a generic questionnaire (5-level EQ-5D)., Results: Mean (SD) cost up to 6 months postrecruitment per participant was £578 (£420) for the Neurology group (n=128) and £245 (£172) for the MRI group (n=95), leading to an estimated mean cost difference of £333 (95% CI £253 to £413, p<0.001). The mean cost difference at 12 months increased to £518 (95% CI £401 to £637, p<0.001). When adjusted for baseline and follow-up imbalances between groups, this remained statistically significant. The utilisation of brain MRI improved access to care compared with the Neurology group (p<0.001). Participants in the Neurology group reported higher levels of satisfaction associated with the pathway and led to greater change in care management., Conclusion: Direct referral to brain MRI from Primary Care led to cost-savings and quicker access to care but lower satisfaction levels when compared with referral to Neurology services. Further research into the use of brain MRI for a subset of patient population more likely to be reassured by a negative brain scan should be considered., Trial Registration Number: NCT02753933., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Existing evidence identifies health benefits for children of additional daily physical activity (PA) on a range of cardiovascular and metabolic outcomes. The Daily Mile (TDM) is a popular scheme designed to increase children's PA within the school day. Emerging evidence indicates that participation in TDM can increase children's PA, reduce sedentarism and reduce skinfold measures. However, little is known about the potential effects of TDM as a public health intervention, and the benefits and disbenefits that might flow from wider implementation in 'real world' settings., Methods: We aimed to identify how TDM is being implemented in a naturalistic setting, and what implications this has for its potential impact on population health. We undertook a rapid ethnographic assessment of uptake and implementation in Lewisham, south London. Data included interviews (n = 22) and focus groups (n = 11) with stakeholders; observations of implementation in 12 classes; and analysis of routine data sources to identify school level factors associated with uptake., Results: Of the 69 primary schools in one borough, 33 (48%) had adopted TDM by September 2018. There were no significant differences between adopters and non-adopters in mean school population size (means 377 vs 397, P = 0.70), mean percentage of children eligible for free school meals (16.2 vs 14.3%, P = 0.39), or mean percentage of children from Black and Minority Ethnic populations (76.3 vs 78.2%, P = 0.41). Addressing obesity was a key incentive for adoption, although a range of health and educational benefits were also hypothesised to accrue from participation. Mapping TDM to the TIDierR-PHP checklist to describe the intervention in practice identified that considerable adaption happened at the level of borough, school, class and pupil. Population health effects are likely to be influenced by the interaction of intervention and context at each of these levels., Conclusions: Examining TDM in 'real world' settings surfaces adaptions and variations in implementation. This has implications for the likely effects of TDM, and points more broadly to an urgent need for more appropriate methods for evaluating public health impact and implementation in complex contexts.

Aims/hypothesis: Type 2 diabetes is more prevalent in black African than white European populations although, paradoxically, black African individuals present with lower levels of visceral fat, which has a known association with insulin resistance. Insulin resistance occurs at a tissue-specific level; however, no study has simultaneously compared whole body, skeletal muscle, hepatic and adipose tissue insulin sensitivity between black and white men. We hypothesised that, in those with early type 2 diabetes, black (West) African men (BAM) have greater hepatic and adipose tissue insulin sensitivity, compared with white European men (WEM), because of their reduced visceral fat., Methods: Eighteen BAM and 15 WEM with type 2 diabetes underwent a two-stage hyperinsulinaemic-euglycaemic clamp with stable glucose and glycerol isotope tracers to assess tissue-specific insulin sensitivity and a magnetic resonance imaging scan to assess body composition., Results: We found no ethnic differences in whole body, skeletal muscle, hepatic or adipose tissue insulin sensitivity between BAM and WEM. This finding occurred in the presence of lower visceral fat in BAM (3.72 vs 5.68 kg [mean difference -1.96, 95% CI -3.30, 0.62]; p = 0.01). There was an association between skeletal muscle and adipose tissue insulin sensitivity in WEM that was not present in BAM (r = 0.78, p < 0.01 vs r = 0.25 p = 0.37)., Conclusions/interpretation: Our data suggest that in type 2 diabetes there are no ethnic differences in whole body, skeletal muscle, hepatic and adipose tissue insulin sensitivity between black and white men, despite differences in visceral adipose tissue, and that impaired lipolysis may not be contributing to skeletal muscle insulin resistance in men of black African ethnicity.

Context: Intrapancreatic lipid (IPL) has been linked to β-cell dysfunction. Black populations disproportionately develop type 2 diabetes (T2D) and show distinctions in β-cell function compared with white populations., Objective: We quantified IPL in white European (WE) and black West African (BWA) men with early T2D and investigated the relationships between IPL and β-cell insulin secretory function (ISF)., Design, Setting, and Participants: We performed a cross-sectional assessment of 18 WE and 19 BWA middle-age men with early T2D as part of the South London Diabetes and Ethnicity Phenotyping study., Main Outcome Measures: The participants underwent Dixon MRI to determine IPL in the pancreatic head, body, and tail and subcutaneous and visceral adipose tissue volumes. Modeled first- and second-phase ISFs were comprehensively determined using C-peptide measurements during a 3-hour meal tolerance test and a 2-hour hyperglycemic clamp test., Results: The WE men had greater mean IPL levels compared with BWA men (P = 0.029), mainly owing to greater IPL levels in the pancreatic head (P = 0.009). The mean IPL level was inversely associated with orally stimulated first-phase ISF in WE but not BWA men (WE, r = -0.554, P = 0.026; BWA, r = -0.183, P = 0.468). No association was found with orally stimulated second-phase ISF in either WE or BWA men. No associations were found between the mean IPL level and intravenously stimulated ISF., Conclusions: The IPL levels were lower in BWA than WE men with early T2D, and the lack of inverse association with first-phase ISF in BWA men indicates that IPL might be a less important determinant of the development of T2D in BWA than in WE men., (Copyright © 2019 Endocrine Society.)