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Background Guidelines recommend the assessment of cortisol secretion in patients with adrenal incidentalomas (AI) using the overnight dexamethasone suppression test (ONDST). This requires attendance to a health care facility and venepuncture. Alternatively, the ONDST can be done by measuring salivary cortisol and cortisone which can be collected at home. We aimed to assess the utility of these measurements in patients with AI. Materials and Methods A retrospective analysis of data from 173 patients with AI who underwent an ONDST and salivary cortisol/cortisone diurnal studies. Serum and salivary cortisol and salivary cortisone were collected at 09:00, late night and at 09:00 post dexamethasone. Dexamethasone levels were measured in the post dexamethasone samples. Serum and salivary samples were analysed with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Stata. Results We identified a strong correlation between salivary cortisone and serum cortisol post 1 mg dexamethasone (r = 0.95). Stepwise multivariate regression showed that post-dexamethasone salivary cortisone, baseline serum cortisol, salivary cortisone suppression (pre: post-dexamethasone ratio) and sex as the only significant or near significant independent variables. Performance of predictive indices using these four parameters (sensitivity = 88.5%, specificity = 91.2%; kappa 0.80) and post-dexamethasone salivary cortisone alone (sensitivity = 85.3%, specificity = 91.7%; kappa 0.77) were comparable when used to predict an ONDST serum cortisol of ≤50 nmol/L. No correlation was observed with any of the other measured parameters. Conclusion In AI patients, post dexamethasone, salivary cortisone correlates very strongly with serum cortisol in the ONDST and could therefore be used as an alternative sampling method which does not require venepuncture or attendance to hospital.

INTRODUCTION: Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. METHODS: In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. RESULTS: In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. CONCLUSION: Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.

AimsThe COVID-19 pandemic, and the focus on mitigating its effects, has disrupted diabetes healthcare services worldwide. We aimed to quantify the effect of the pandemic on diabetes diagnosis/management, using glycated haemoglobin (HbA1c) as surrogate, across six UK centres.MethodsUsing routinely collected laboratory data, we estimated the number of missed HbA1c tests for ‘diagnostic’/‘screening’/‘management’ purposes during the COVID-19 impact period (CIP; 23 March 2020 to 30 September 2020). We examined potential impact in terms of: (1) diabetes control in people with diabetes and (2) detection of new diabetes and prediabetes cases.ResultsIn April 2020, HbA1c test numbers fell by ~80%. Overall, across six centres, 369 871 tests were missed during the 6.28 months of the CIP, equivalent to >6.6 million tests nationwide. We identified 79 131 missed ‘monitoring’ tests in people with diabetes. In those 28 564 people with suboptimal control, this delayed monitoring was associated with a 2–3 mmol/mol HbA1c increase. Overall, 149 455 ‘screening’ and 141 285 ‘diagnostic’ tests were also missed. Across the UK, our findings equate to 1.41 million missed/delayed diabetes monitoring tests (including 0.51 million in people with suboptimal control), 2.67 million screening tests in high-risk groups (0.48 million within the prediabetes range) and 2.52 million tests for diagnosis (0.21 million in the pre-diabetes range; ~70 000 in the diabetes range).ConclusionsOur findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for, diabetes. For people with diabetes, missed tests will result in further deterioration in diabetes control, especially in those whose HbA1c levels are already high.

Background The short synacthen test (SST) is the most commonly performed investigation to assess adrenal function. Appropriate criteria for when an SST is performed are subject to debate. We investigated how random serum cortisol levels relate to SST response. Methods We examined random cortisol measurements taken between 04.40–23.55 p.m. results of SST baseline and 30-/60-min cortisol performed over 12 months (225 SSTs) at Salford Royal Hospital. Serum cortisol was measured on the Siemens Centaur Analyser. A 30–60-min cortisol concentration of ≥450 nmol/L defined a pass; 350–449 nmol/L defined borderline. Results Patients only proceeded to SST if random cortisol was

Objective Accurate diagnosis of polycystic ovarian syndrome (PCOS) enables clinical interventions/cardiometabolic risk factor management. Diagnosis can take over 2 years and multiple clinician contacts. We examined patterns of PCOS-associated biochemical investigations following initial consultation prior to pelvic ultrasound scan (USS). Methods We determined in 206 women (i) the range of different biochemical test panels used in the diagnosis of PCOS in primary/secondary care prior to USS relative to national guidance in the UK and (ii) the relation between testing patterns and time to USS to highlight potential delays introduced by inappropriate testing. Results In these 206 women, 47 different test combinations were requested at initial venepuncture; only 7 (3%) had the test panel suggested in UK guidance (follicle-stimulating hormone/luteinizing hormone/testosterone/sex hormone-binding globulin/prolactin). The number of tests performed prior to USS varied from one test to all seven tests. There was an inverse relation between the number of biochemistry tests requested at initial venepuncture episode and ‘time to scan’. Those who had

Background Bipolar disorder is the fourth most common mental health condition, affecting ~ 1% of UK adults. Lithium is an effective treatment for prevention of relapse and hospital admission, and is widely recommended as a first-line treatment. We previously showed in other areas that laboratory testing patterns are variable with sub-optimal conformity to guidance. We therefore examined lithium results and requesting patterns relative to monitoring recommendations. Methods Data on serum lithium levels and intervals between requests were extracted from Clinical Biochemistry laboratory information systems at the University Hospitals of North Midlands, Salford Royal Foundation Trust and Pennine Acute Hospitals from 2012 to 2018 (46,555 requests; 3371 individuals). Data were examined with respect to region/source of request, age and sex. Results Across all sites, lithium levels on many requests were outside the recommended UK therapeutic range (0.4–0.99 mmol/L); 19.2% below the range and 6.1% above the range (median [Li]: 0.60 mmol/L). A small percentage were found at the extremes (3.2% at Conclusions Our data showed: (a) lithium levels are often maintained at the lower end of the recommended therapeutic range, (b) patterns of lithium results and testing frequency were comparable across three UK sites with differing models of care and, (c) re-test intervals demonstrate a noticeable peak at the recommended 3-monthly, but not at 6-monthly intervals. Many tests were repeated outside expected frequencies, indicating the need for measures to minimise inappropriate testing.

BACKGROUND: Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin. We recently examined patient experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK.METHODS: An online self-reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1).RESULTS: Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months. For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c CONCLUSION: The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.

BackgroundLithium is viewed as the first-line long-term treatment for prevention of relapse in people with bipolar disorder.AimsThis 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.MethodWe included 46 555 lithium rest requests in 3371 individuals over 7 years from three UK centres. Using lithium results in four categories (ResultsFor 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.ConclusionWe 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.

Context Adrenal incidentalomas (AIs) are increasingly being identified during unrelated imaging. Unlike AI clinical management, data on referral patterns in routine practice are lacking. Objective This work aimed to identify factors associated with AI referral. Methods We linked data from imaging reports and outpatient bookings from a large UK teaching hospital. We examined (i) AI prevalence and (ii) pattern of referral to endocrinology, stratified by age, imaging modality, scan anatomical site, requesting clinical specialty, and temporal trends. Using key radiology phrases to identify scans reporting potential AI, we identified 4097 individuals from 479 945 scan reports (2015-2019). Main outcome measures included prevalence of AI and referral rates. Results Overall, AI lesions were identified in 1.2% of scans. They were more prevalent in abdomen computed tomography and magnetic resonance imaging scans (3.0% and 0.6%, respectively). Scans performed increased 7.7% year-on-year from 2015 to 2019, with a more pronounced increase in the number with AI lesions (14.7% per year). Only 394 of 4097 patients (9.6%) had a documented endocrinology referral code within 90 days, with medical (11.8%) more likely to refer than surgical (7.2%) specialties (P Conclusion While overall AI prevalence appeared low, scan numbers are large and rising; the number with identified AI are increasing still further. The poor AI referral rates, even in centers such as ours where dedicated AI multidisciplinary team meetings and digital management systems are used, highlights the need for new streamlined, clinically effective systems and processes to appropriately manage the AI workload.

INTRODUCTION Women with gestational diabetes (GDM) are at greatly increased risk of type 2 diabetes (T2DM). The UK guidance recommends screening for T2DM at around 6-week postpartum and annually thereafter. We evaluated conformity to this guidance in two separate time periods. METHODS The proportion of tests performed within guidance was assessed using longitudinal plasma glucose and glycated haemoglobin data in two cohorts (1999-2007, n = 251; 2015-2016, n = 260) from hospital records on women previously diagnosed with GDM. RESULTS In the 1999-2007 and 2015-2016 cohorts, 59.8% and 35.0% of women had the recommended postpartum testing, respectively (P

Aims. Polycystic ovarian syndrome (PCOS) is a common endocrine disorder characterised by ovarian morphological, systemic biochemical, and menstrual changes. Women with PCOS are at significantly increased risk of raised fasting glucose, impaired glucose tolerance, and diabetes. Recognition of these complications and early intervention are key to good health outcomes. We sought to identify DNA methylation patterns that may predict future diabetes onset in this high-risk PCOS population. Patients and Methods. Peripheral blood samples from women with PCOS and women with PCOS who later developed diabetes, were analysed by Illumina HumanMethylation450 BeadChip-arrays. Bisulphite-Pyrosequencing™ was used to validate and confirm array methylation data. Results. Array analyses identified 273 differentially methylated CpG loci (≥ 0.2 β-value change) at initial diagnosis of PCOS, between women who did or did not later develop diabetes. 19 of these sites demonstrated differential methylation in the same direction in ≥ five sample pairs. Methylation in three of the candidates (cg11897887, cg02819655, and cg25542007) showed the best concordance with corresponding array β-values, and, most clearly differentiated ‘cases’ from ‘controls’. Conclusions. We have identified novel methylation biomarkers that could predict future onset of diabetes in this high-risk population. Use of methylation analyses to identify women who are likely to develop diabetes at diagnosis of PCOS may facilitate timely lifestyle interventions to reduce future morbidity.

Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for diabetes mellitus (DM). Ironically, failure to focus of the wider implications for people with DM and other groups with long-term conditions, may place them at increased risk of poor outcomes from SARS-CoV-2 infection itself, irrespective of the implications for their longer-term health prospects.

What you need to know Immunomodulation is the cornerstone of treatment in many immune mediated inflammatory disorders, including inflammatory bowel disease, autoimmune rheumatic disease, and inflammatory skin diseases. Most require pre-treatment screening blood tests and regular blood test monitoring thereafter to detect potential toxicity. This article seeks to provide a simplified overview of blood test monitoring requirements, and is aimed at general practitioners who, increasingly, are taking responsibility for monitoring and prescribing these medications. ### What patients say Patients may have concerns about taking an immunomodulatory medication. We held a focus group with eight patients who were taking immunomodulatory therapy (three with Crohn’s disease and five with ulcerative colitis), who told us: General practitioners care for a wide range of patients who are treated with immunomodulators. Commonly prescribed immunomodulators are listed in box 1. The conditions treated include psoriasis (UK prevalence 2.2-2.8%2), rheumatoid arthritis (UK prevalence 1%3), and inflammatory bowel disease (worldwide prevalence 0.3%4). In the UK, prescribing responsibilities are transferred from specialist care to primary care using Effective Shared Care Agreements, written local agreements between specialist services and GPs. A large proportion of GPs are either directly …

Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for diabetes mellitus (DM). Ironically, failure to focus of the wider implications for people with DM and other groups with long-term conditions, may place them at increased risk of poor outcomes from SARS-CoV-2 infection itself, irrespective of the implications for their longer-term health prospects.

Recently, the UK’s national Targeted Lung Health Checks programme produced recommendations for the management of incidental findings identified during the scans performed as part of the lung cancer screening programme. We identified significant discrepancies between the recommendations for adrenal incidentaloma management and those currently implemented into UK practice (2016 European Society of Endocrinology guidelines). This may create conflict and confusion between referrers (respiratory clinicians) and receivers (endocrinologists), with potential negative impact on patients, delay and inefficient use of resources. We also address the potential cost implications of adopting a more vigilant approach as advised by the European Society of Endocrinology. Urgent multidisciplinary and unified guidelines should be established in the interest of clinical- and cost-effectiveness.

IntroductionThe 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.MethodsWe 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.ResultsWe 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.ConclusionWe 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.

ObjectivesOther than age, diabetes is the largest contributor to overall healthcare costs and reduced life expectancy in Europe. This paper aims to more exactly quantify the net impact of diabetes on different aspects of healthcare provision in hospitals in England, building on previous work that looked at the determinants of outcome in type 1 diabetes (T1DM) and type 2 diabetes (T2DM).SettingNHS Digital Hospital Episode Statistics (HES) in England was combined with the National Diabetes Audit (NDA) to provide the total number in practice of people with T1DM/T2DM.Outcome measuresWe compared differences between T1DM/T2DM and non-diabetes individuals in relation to hospital activity and associated cost.ResultsThe study captured 90% of hospital activity and £36 billion/year of hospital spend. The NDA Register showed that out of a total reported population of 58 million, 2.9 million (6.5%) had T2DM and 240 000 (0.6%) had T1DM. Bed-day analysis showed 17% of beds are occupied by T2DM and 3% by T1DM. The overall cost of hospital care for people with diabetes is £5.5 billion/year. Once the normally expected costs including the older age of T2DM hospital attenders are allowed for this fell to £3.0 billion/year or 8% of the total captured secondary care costs. This equates to £560/non-diabetes person compared with £3280/person with T1DM and £1686/person with T2DM. For people with diabetes, the net excess impact on non-elective/emergency work is £1.2 billion with additional estimated diabetes-related accident & emergency attendances at 440 000 costing the NHS £70 million/year. T1DM individuals required five times more secondary care support than non-diabetes individuals. T2DM individuals, even allowing for the age, require twice as much support as non-diabetes individuals.ConclusionsThis analysis shows that additional cost of provision of hospital services due to their diabetes comorbidities is £3 billion above that for non-diabetes, and that within this, T1DM has three times as much cost impact as T2DM. We suggest that supporting patients in diabetes management may significantly reduce hospital activity.

Whilst the estimated prevalence of adrenal incidentaloma is 0.5-2% following abdominal CT scan (1), little is known about subsequent endocrine referral patterns according to clinical specialty. We therefore examined the range of specialties that were responsible for requesting CT and MRI scans that led to reporting potential adrenal lesions. We also explored the referral pattern to endocrinology following identification. We extracted data from all radiology reports for all CT and MRI scans from Jan 2018-Oct 2019. We utilised a key phrase search strategy (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal). Where possible we excluded false hits (eg no adrenal lesion). These were lined to the referral patterns as identified by a referral logged or an attendance (new or follow-up) to endocrine clinic 3 months post index scan. These data were stratified by requesting specialty. Preliminary data showed that, out of 127878 scans, 2021 patients were identified to have a potential adrenal incidentaloma. These requests came from a total of 45 different clinical specialities (medical and surgical). The top 12 specialties accounted from 82.8% of these referrals. Medical specialties (renal, gastroenterology, respiratory, general medicine, acute medicine and geriatric medicine) accounted for 50.2%. The remaining 32.6% were via surgical specialities. The overall referral pattern in these cases was 8.5% with no difference between medical (8.6%) and surgical (8.4%) specialties. In conclusion, adrenal incidentalomas are potentially identifiable across a wide range of specialties. Currently, despite a dedicated adrenal multidisciplinary team and nationally-acknowledged quality improvement programme for the management of adrenal incidentalomas (2), the majority of cases are overlooked and not referred for endocrine review as suggested in current guidelines. We expect the findings in our centre to be reproducible elsewhere. We are considering innovative approaches to improve the process and cope with the additional workload cost-effectively. 1. Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol. 2003;149:273-285. Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Quality. 2019;In press.

Background Bipolar disorder is the fourth most common mental health condition, affecting ~1% of UK adults. Lithium is an effective treatment for prevention of relapse and hospital admission, and is widely recommended as a first-line treatment. We previously showed in other areas that laboratory testing patterns are variable with sub-optimal conformity to guidance. We therefore examined lithium results and requesting patterns relative to monitoring recommendations. Methods Data on lithium levels and intervals between requests were extracted from Clinical Biochemistry laboratory information systems at the University Hospitals of North Midlands, Salford Royal Foundation Trust and Pennine Acute Hospitals from 2012-2018 (46,555 requests; 3,371 individuals). Data were examined with respect to region/source of request, age and sex. Results Lithium levels on many requests were outside the recommended UK therapeutic range (0.4-0.99 mmol/L); 19.2% below the range and 6.1% above the range (median [Li]: 0.60 mmol/L). A small percentage were found at the extremes (3.2% at 1.4mmol/L). These findings were comparable across all sites. Most requests were from general practice (56.3%) or mental health units (34.4%), though those in the toxic range (≥1.4 mmol/L) were more likely to be from acute care or other secondary care units (63.9%). For requesting interval, there was a distinct peak at 12 weeks, consistent with guidance for those stabilised on lithium therapy. There was no peak evident at 6 months, as recommended for those aged

It is estimated that the prevalence of adrenal incidentaloma increases with age: ~3% of those aged 50 years, rising to 10% in those >70 years (1). Given the aging population together with increased utilisation of cross-sectional imaging in the UK (eg CT urogram, MR angiogram), we explored the proportion of patients with adrenal incidentaloma by age based on current imaging trends. Furthermore, there is no information currently available on the relationship between age and pattern of endocrine referrals. We extracted data for all CT and MRI scans from Jan 2018-Oct 2019 and used key phrases in radiology reports (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal) to identify potential lesions. We also extracted data on patient age and referral patterns as identified by a logged referral or an attendance (new or follow-up) to endocrine clinic 3 months post index scan, stratified by 10 year age groups. Where possible, we excluded false hits (eg no adrenal lesion). Preliminary data showed that, of the 2604 potential lesions identified by CT and MRI scans, 78.7% were on patients aged over 60 years. The numbers of identified lesions gradually increased with age to a peak in the 71-80 year age group after which these declined. Whilst patients younger that 60 years had fewer potential lesions identified, they were more likely to be referred to endocrine services (73 out of 55 patients; 13.2%) than those in the older age group (168 out of 2049; 8.2%; p

The estimated prevalence of adrenal incidentaloma at abdominal CT scan is 0.5-2% (1). However, from clinical practice, we noticed that incidentalomas are referred from other imaging modalities (eg MRI) and of other sites (eg thorax, spine). We therefore explored the relationship between prevalence rates and (i) imaging modality and (ii) its change over time, in a real world clinical setting from a large UK teaching hospital/trauma centre. We also examined the referral pattern of potential lesions to endocrinology. We extracted data from all radiology reports for all CT and MRI scans from Jan 2018-Oct 2019. We utilised a key phrase search strategy (eg adrenal adenoma/lesion/mass/nodule/incidentaloma, incidental adrenal, indeterminate adrenal). Where possible we excluded false hits (eg no adrenal lesion). These were linked to the referral patterns as identified by a referral logged or an attendance (new or follow-up) to endocrine clinic 3 months post index scan. Preliminary data showed that, from a total of 127878 scans performed, 2604 potential lesions were reported (prevalence 2.0%), comprising 2496/88838 (2.8%) CT scans and 108/39040 (0.3%) MRI scans. The number of scans/month increased in 2019 vs 2018 (6.9% for CT and 12.6% for MRI). Only 9.0% and 15.7% of reported potential lesions detected by CT and MRI, respectively, were referred for endocrine review. Hence, MRI patients were more likely to be referred than those with CT scans (p=0.018). Referral rates were lower in 2019 than 2018 (8.6% vs 14.4%; p less than 0.001). This approach has its limitations but allows efficiently review of large cohorts. Adrenal incidentalomas pose a rising challenge in view of increasing reliance on scanning. Despite a dedicated adrenal multidisciplinary team with a national track record in improving management of incidentalomas (2), the referral rate of potential lesions is worryingly low and not improving, with >90% of cases overlooked. This work is part of on-going innovation to enhance the pick-up rate for these cases whilst addressing the increased endocrine workload in a cost-effective manner. 1. Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol. 2003;149:273-285. 2. Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Quality. 2019;In press.

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 (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.

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.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-value0.05 were retained.59% of respondents were50 years old and 66% had diabetes for20 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.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.

Background United Kingdom national guidelines do not recommend routine testing for thyroid disease in people with type 2 diabetes mellitus (T2DM). However, some studies suggest an increased risk of thyroid dysfunction in T2DM. The aim of this study was to evaluate the current practice of screening for thyroid disease in patients with T2DM. Methods Patients with pre-existing T2DM ( n = 339) were selected from records for routine glycated haemoglobin testing performed in December 2008. Using routinely collected primary/secondary care data from 2009 to 2017, we examined longitudinal thyroid-stimulating hormone and free thyroxine requests to determine the overall proportion of patients screened for thyroid dysfunction and the time interval between thyroid tests requested. Results Thirty-three patients (9.7%) had pre-existing thyroid disease. Of the remaining 306 patients, 96.4% had at least one thyroid test during the follow-up period. When the time interval between tests was evaluated in these patients, there was a discrete peak in thyroid function test requests at 12 months, consistent with routine annual testing. Most requests (77%) originated from a general practice setting. Conclusions Contrary to current guidelines, we have provided evidence suggestive of regular screening for thyroid dysfunction in patients with T2DM, particularly in general practice. The appropriateness of this practice remains unclear, but may warrant further examination to assess the clinical benefits of screening, balanced against cost.

IntroductionAdrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients.MethodsWe developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability.ResultsImplementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs.ConclusionsThe system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.

A monomeric form of C-reactive protein (CRP) which precipitates with cell wall pneumococcal C polysaccharide (CWPS) and retains the ability to reversibly bind to its ligand phosphocholine has been produced through urea-induced dissociation at an optimized concentration of 3 M urea over a 10 weeks period. Dissociated samples were purified via size exclusion chromatography and characterized by western blot, phosphocholine affinity chromatography and CWPS precipitation. Human serum samples from patients with raised CRP levels (>100 mg/L as determined by the clinical laboratory assay) were purified by affinity and size exclusion chromatography and analyzed (n = 40) to determine whether circulating monomeric CRP could be detected ex vivo. All 40 samples tested positive for pentameric CRP via western blot and enzyme linked immunosorbent assay (ELISA) analysis. Monomeric C-reactive protein was also identified in all 40 patient samples tested, with an average level recorded of 1.03 mg/L (SE = ±0.11). Both the in vitro monomeric C-reactive protein and the human serum monomeric protein displayed a molecular weight of approximately 23 kDa, both were recognized by the same anti-CRP monoclonal antibody and both reversibly bound to phosphocholine in a calcium-dependent manner. In common with native pentameric CRP, the in vitro mCRP precipitated with CWPS. These overlapping characteristics suggest that a physiologically relevant, near-native monomeric CRP, which retains the structure and binding properties of native CRP subunits, has been produced through in vitro dissociation of pentameric CRP and also isolated from serum with markedly elevated CRP levels. This provides a clear route toward the in-depth study of the structure and function of physiological monomeric CRP.

BACKGROUND:\ud Serum sex hormone-binding globulin levels have been associated with mortality in adult men with type 2 diabetes (T2DM).\ud \ud OBJECTIVES:\ud To confirm the association of serum sex hormone-binding globulin with mortality and then determine whether this association is mediated by age and total testosterone concentration.\ud \ud MATERIALS AND METHODS:\ud We studied 364 men (median age: 66 years) with T2DM over a median follow-up of 4.3 years using the Cox regression to study associations between sex hormone-binding globulin, age, total testosterone, and mortality.\ud \ud RESULTS:\ud Mortality was significantly and independently associated with sex hormone-binding globulin, age, and total testosterone. In pairwise combinations of age and sex hormone-binding globulin dichotomized by median values, the association of sex hormone-binding globulin with mortality was age-dependent. Relative to the combination of age >66 years/SHBG >35 nmol/L (mortality 22.5%), the other combinations were associated with significantly less mortality (mortality in men ≤66 years/SHBG ≤ 35 nmol/L was 3.23%). In men >66 years, SHBG ≤ 35 nmol/L was associated with decreased mortality (HR: 0.41, p = 0.037) compared with SHBG > 35 nmol/L. In men ≤66 years, there was no significant difference between those with sex hormone-binding globulin above or below the median (HR: 1.73, p = 0.56, reference: SHBG ≤ 35 nmol/L). TT < 12 nmol/L was associated with increased mortality in both age categories. Men >66 years with the reference combination of SHBG > 35 nmol/L and TT < 12 nmol/L (36.84%) nmol/L had significantly higher mortality than those with SHBG > 35 nmol/L and TT ≥ 12 (18.06%) and those with SHBG ≤ 35 nmol/L and TT < 12 nmol/L (13.79%).\ud \ud DISCUSSION:\ud Our data suggest sex hormone-binding globulin and total testosterone have particular impact on mortality in men aged over 66 years. Further, in older men, the combination of high sex hormone-binding globulin levels and low total testosterone is associated with greater risk than either high sex hormone-binding globulin or low total testosterone individually.\ud \ud CONCLUSIONS:\ud Our findings are compatible with data suggesting the importance of sex hormone-binding globulin lies in mediating free testosterone levels.

Several recent reports have described associations between gestational diabetes (GDM) and changes to the epigenomic landscape where the DNA samples were derived from either cord or placental sources. We employed genome-wide 450Karray analysis to determine changes to the epigenome in a unique cohort of maternal blood DNA from 11 pregnant women prior to GDM development relative to matched controls. Hierarchical clustering segregated the samples into two distinct clusters comprising GDM and healthy pregnancies. Screening identified 100 CpGs with a mean β-value difference of ≥0.2 between cases and controls. Using stringent criteria, 5 CpGs (within COPS8, PIK3R5, HAAO, CCDC124, and C5orf34 genes) demonstrated potentials to be clinical biomarkers as revealed by differential methylation in 8 of 11 women who developed GDM relative to matched controls. We identified, for the first time, maternal methylation changes prior to the onset of GDM that may prove useful as biomarkers for early therapeutic intervention.

AimsLithium was first found to have an acute antimanic effect in 1948 with further corroboration in the early 1950s. It took some time for lithium to become the standard treatment for relapse prevention in bipolar affective disorder. In this study, our aims were to examine the factors associated wtih the likelihood of maintaining lithium levels within the recommended therapeutic range and to look at the stability of lithium levels between blood tests. We examined this relation using clinical laboratory serum lithium test requesting data collected from three large UK centres, where the approach to managing patients with bipolar disorder and ordering lithium testing varied.Method46,555 lithium rest requests in 3,371 individuals over 7 years were included from three UK centres. Using lithium results in four categories (ResultFor 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. At all test intervals, lithium test result history in the previous 12-months was associated with the proportion of next test results on target (BNF/NICE criteria), with 90% remaining within range target after 6-months if all tests in the previous 12-months were on target. Age/duration of lithium therapy had no 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%) than those in the 0.40–0.79 mmolL group (2%), irrespective of testing frequency. Thus prior history in relation to stability of lithium level in the previous 12 months is a predictor of future stability of lithium level.ConclusionWe propose that, for those who achieve 12-months of lithium tests within the 0.40–0.79mmol/L range, it would be reasonable to increase the interval between tests to 6 months, irrespective of age, freeing up resource to focus on those less concordant with their lithium monitoring. Where lithium level is 0.80–0.99mmol/L test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.

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.

Gestational diabetes mellitus (GDM; approximately 5% of pregnancies) represents the most important risk factor for development of later-onset diabetes mellitus. We examined concordance between GDM diagnosis defined using the original 1999 World Health Organization (WHO) criteria and the more recent 2013 WHO criteria and 2015 National Institute for Health and Care Excellence (NICE) criteria. We studied two groups: a case-control group of 257 GDM positive and 266 GDM negative cases, and an incident cohort 699 GDM positive and 6,231 GDM negative cases. In the incident cohort, GDM prevalence was 3.7% (WHO 1999 criteria), 11.4% (NICE 2015 criteria) and 13.7% (WHO 2013 criteria). Our results showed that a significant number of additional cases are detected using the more recent NICE and WHO criteria than the original 1999 WHO criteria, but these additional cases represent an intermediate group with 'moderate' dysglycaemia (abnormal blood glucose levels). Our results also show that use of these newer criteria misses a similar group of intermediate cases that were defined as GDM by the 1999 WHO criteria and that glycated haemoglobin in isolation is unlikely to replace the oral glucose tolerance test in GDM diagnosis.

What you need to know A 67 year old woman with no significant medical history required urgent orthopaedic surgery after a fall. In preparation, her bloods were collected and a random cortisol was requested, which came back at 763 nmol/L. She did not have diabetes or hypertension. The anaesthetist reviewed and commented: “High cortisol, not safe for surgery until further evaluation.” A 24 year old man with previously well controlled type 1 diabetes presented with repeated hypoglycaemic episodes. Serum cortisol in clinic at 9 am came back as 143 nmol/L. Cortisol, secreted by the adrenal cortex, regulates blood pressure, glucose metabolism, and physiological responses to stress. Both cortisol over-secretion (hypercortisolism, Cushing’s syndrome) and under-secretion (hypocortisolism such as in Addison’s disease) are uncommon: the prevalence of Addison’s disease is 6-9 per 100 000,1 while that of Cushing’s syndrome is 4/100 000.2 However, given the potential for life threatening consequences (such as in acute adrenal crisis) and the range of associated non-specific symptoms, it is critical for clinicians to understand how to interpret and manage cortisol status. Cortisol excess could be due to an adrenal cortisol-secreting tumour or to a functional pituitary tumour (Cushing’s disease), or, less commonly, malignant tumours can …

ObjectiveEvaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement.MethodFrom the National Diabetes Audit in 2015–2016 and 2016–2017, GPP target glycaemic control (TGC—%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR —%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers.ResultsValues from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo –;–), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS–;0.07/Lo 0.09;0.07), dapagliflozin (XS –;0.04/Lo –;0.4), sulphonylurea (XS −0.18;−0.12/Lo–;–) and insulin (XS−0.14;0.02/ Lo−0.09;–). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000.ConclusionsGPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.

Correlation between midnight and post dexamethasone salivary cortisone and cortisol and post dexamethasone serum cortisol concentrations in patients with unilateral and bilateral adrenal incidentalomas Background: The commonest functional abnormality in adrenal incidentalomas (AI) is autonomous cortisol secretion. Most guidelines recommend a 1 mg overnight dexamethasone suppression test (ONDST) as a screening test for this abnormality. This requires either a short stay or attendance to hospital as well as the inconvenience of venepuncture. Aim: To investigate the utility of using salivary samples in an ONDST by correlating post dexamethasone salivary cortisol (SaC) and cortisone (SaCn) and midnight salivary cortisol (MSaC) and cortisone (MSaCn) concentrations with post dexamethasone cortisol (SC). Methods: Using linear regression analysis we correlated post SC with SaC and SaCn and with MSaC and MSaCn. Results: We examined the results of 57 patients with unilateral or bilateral adrenal incidentalomas who underwent a 1 mg dexamethasone suppression test on our unit. The SC range

Background: Adrenal incidentalomas (AI) are incidentally identified lesions whilst scanning for other purposes. They are mostly benign and hormonally inactive but about 20% are hormonally-active or malignant, requiring prompt intervention. The overall reported AI prevalence is 3-5% but increases with age (up to 7% of those above 70 years). Guidelines stipulate that patients with AI should be investigated, but only a small proportion of patients are referred for an endocrine work up.. We are not aware of any work that systematically looked at the proportion of missed cases of AI. Aim: To identify the proportion of missed cases with AI.Methods: Data on adrenal lesions reported on CT scans were collected, utilising pre-agreed key phrases to identify AI. These included the terms: Adrenal adenoma, Adrenal incidentaloma, Adrenal lesion, Adrenal mass, Adrenal nodule, Incidental adrenal, Indeterminate adrenal. These data were collected from 2014-2016, focusing on the referral for the month of November each year as a representative sample. Patients with known cancer were excluded and those with genuine AIs were then checked (based on MDT note entry and/or review of endocrinology letters) to confirm whether they were appropriately identified and then referred to endocrinology for further assessment or not.Results: November 2014: Out of a total 57 cases, identified using the key phrases, 30 had previously known malignancies and hence were excluded. This left a net of 27 genuine AI cases. Out of those, only 8 (29.6%) were referred for further assessment. November 2015: Out of a total 76 cases, 35 had genuine AIs (with 41 cases of known malignancy). Only 10 AIs were referred on (28.6%) November 2016: Out of a total 77 cases, 62 had genuine AIs (with 15 cases of known malignancy). Only 20 AIs were referred on (32.3%) The missed cases are equivalent to approximately one third of the endocrinology workload for our unit. Conclusion: Despite an established and dedicated MDT, only a third of cases are referred for further evaluation, with 70% are being overlooked. The potential for missing functional or malignant cases is a serious patient safety risk. Paradoxically, the financial implication for managing this work load is - to our knowledge - significant and has never been considered in a systematic way.

Background: Adrenal incidentalomas (AI) are incidentally identified lesions whilst scanning for other purposes. They are mostly benign and hormonally inactive but about 20% are hormonally-active or malignant, requiring prompt intervention. The overall reported AI prevalence is 3-5% but increases with age (up to 7% of those above 70 years). The arranged investigations (hormonal work-up and further scanning) pose significant financial pressure on providers. Methods: We developed a cost-effectiveness tool “the Adrenal Incidentaloma Intervention Cost Assessment Tool (AI2CAT)”.We developed a novel web-based, electronic Adrenal Incidentaloma Management System (eAIMS).We conducted time & motion study utilising the estimated time managing an individual AI case. This was undertaken for different phases of our work: (i) pre-intervention, (ii) The implementation of case prioritisation strategy + utilisation of eAIMS and (iii) future proactive case identification and streamlining into low- and high-risk groups. Results: Projecting our unit’s case load to a UK-wide context, there could be 50,000 new cases PA/year.Utilising the AI2CAT tool and the time and motion analysis data, demonstrated that introducing the eAIMS system in combination with the MDT prioritisation process (Phase 2) reduced the number of tasks required in the AI management pathway. This resulted in a reduction in the hands-on total time taken (from AI identification to MDT decision) by 48.6%.Utilising standardised staff costs, hands-on time was reduced by 28.2% of total costs/patient. Conclusion: We have developed an electronic management system for AI, together with a cost-effectiveness tool to measure the potential cost implications. The combined approach of using the eAIMS system together with a prioritisation strategy resulted in reduced staff hands-on time and cost per case.

Background: The most common functional abnormality in adrenal incidentalomas (AI) is autonomous cortisol secretion. Most guidelines recommend a 1 mg overnight dexamethasone suppression test (ONDST) as a screening test for this abnormality. There is some evidence that simultaneous measurement of post dexamethasone serum dexamethasone (SD) with serum cortisol (SC) improves the accuracy of the ONDST. We have therefore been routinely measuring SD in our unit to ensure adequate concentrations when interpreting the results of this test. Aim: To measure the correlation between SD and SC concentrations and SD with the decrement in serum cortisol levels from baseline (9 am the day before the test) to the post dexamethasone level (DSC) in the ONDST. Method: We examined the results of 57 patients with unilateral or bilateral adrenal incidentalomas who underwent a 1 mg ONDST on our unit. Using linear regression analysis, we correlated SC and SD concentrations and serum SD concentration with the DSC. We also examined whether lower levels of SD were associated with adequate suppression of SC following ONDST. Results: SD levels range 16, median 7.656 nmol/L. SC range