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OBJECTIVE The incidence of diabetes may be elevated following coronavirus disease 2019 (COVID-19), but it is unclear whether this is specific to severe acute respiratory syndrome coronavirus 2 infection, associated with shared risk factors for severe COVID-19 and diabetes, and/or a generic risk following illness. RESEARCH DESIGN AND METHODS People admitted to the hospital for COVID-19 and/or pneumonia between 1 April 2020 and 31 August 2020 in England were linked with the National Diabetes Audit to identify incident diabetes after discharge up to 31 March 2021. Comparator cohorts admitted with pneumonia over the same dates in 2017, 2018, and 2019 were followed until 31 March 2018, 31 March 2019, and 31 March 2020, respectively. Poisson regression models were used to calculate adjusted diabetes incidence rates. RESULTS Using the cohort of people discharged from the hospital following a diagnosis of COVID-19 without pneumonia in 2020 as the standard population (incidence rate 16.4 [95% CI 12.8–20.7] per 1,000 person-years), adjusting for age, sex, ethnicity, and deprivation, gave incidence rates of 19.0 (95% CI 13.8–25.6) and 16.6 (95% CI 13.3–20.4) per 1,000 person-years for those admitted for COVID-19 with pneumonia and pneumonia without COVID-19, respectively, in 2020. These rates are not significantly different from those found after hospital admission for pneumonia in 2019, 2018, and 2017, at 13.7 (95% CI 10.8–17.3), 13.8 (95% CI 10.9–17.4), and 14.2 (95% CI 10.9–18.3) per 1,000 person-years, respectively. CONCLUSIONS Our data do not support a clear impact of COVID-19 on the incidence of diabetes compared with risks in several comparator groups, including contemporaneously assessed risks in people hospitalized with pneumonia.

Objective Adolescence is associated with high risk hyperglycaemia. This study examines the phenomenon in a life-course context. Research design and methods 93,125 people with type 1 diabetes aged 5-30 years were identified from the National Diabetes Audit (NDA) and/or the National Paediatric Diabetes Audit (NPDA) for England and Wales for 2017/18-2019/20. For each audit year the latest HbA1c and hospital admissions for diabetic ketoacidosis (DKA) were identified. Data were analysed in sequential cohorts by year of age. Results In childhood, unreported HbA1c measurement was uncommon but by 19 years had increased to 22.3% for males and 17.3% for females, reducing to 17.9% and 13.1% respectively by 30 years. Median HbA1c at 9 years was 7.6% (60mmol/mol) (IQR 7.1%-8.4%, 54-68mmol/mol) in males and 7.7% (61mmol/mol) (8.0%-8.4%, 64-68mmol/mol) in females increasing to 8.7% (72mmol/mol) (7.5%-10.3%, 59-89mmol/mol) and 8.9% (74mmol/mol) (7.7%-10.6%, 61-92mmol/mol) respectively at 19 years before falling to 8.4% (68mmol/mol) (7.4%-9.7%, 57-83mmol/mol) and 8.2% (66mmol/mol) (7.3%-9.7%, 56-82mmol/mol) respectively at 30 years. Annual hospitalisation for DKA rose steadily from 6 years (2.0% for males, 1.4% for females) to peak at 19 years for males (7.9%) and 18 years for females (12.7%) reducing to 4.3% for males and 5.4% for females at 30 years. At all ages over 9 years the prevalence of DKA was higher in females. Conclusions HbA1c and the prevalence of DKA increase through adolescence and then decline. Measurement of HbA1c, a marker of clinical review, falls abruptly in the late teenage years. Age-appropriate services are needed to overcome these issues.

OBJECTIVE Adolescence is associated with high-risk hyperglycemia. This study examines the phenomenon in a life course context. RESEARCH DESIGN AND METHODS A total of 93,125 people with type 1 diabetes aged 5 to 30 years were identified from the National Diabetes Audit and/or the National Paediatric Diabetes Audit for England and Wales for 2017/2018–2019/2020. For each audit year, the latest HbA1c and hospital admissions for diabetic ketoacidosis (DKA) were identified. Data were analyzed in sequential cohorts by year of age. RESULTS In childhood, unreported HbA1c measurement is uncommon; however, for 19-year-olds, it increases to 22.3% for men and 17.3% for women, and then reduces to 17.9% and 13.1%, respectively, for 30-year-olds. Median HbA1c for 9-year-olds is 7.6% (60 mmol/mol) (interquartile range 7.1–8.4%, 54–68 mmol/mol) in boys and 7.7% (61 mmol/mol) (8.0–8.4%, 64–68 mmol/mol) in girls, increasing to 8.7% (72 mmol/mol) (7.5–10.3%, 59–89 mmol/mol) and 8.9% (74 mmol/mol) (7.7–10.6%, 61–92 mmol/mol), respectively, for 19-year-olds before falling to 8.4% (68 mmol/mol) (7.4–9.7%, 57–83 mmol/mol) and 8.2% (66 mmol/mol) (7.3–9.7%, 56–82 mmol/mol), respectively, for 30-year-olds. Annual hospitalization for DKA rose steadily in age from 6 years (2.0% for boys, 1.4% for girls) and peaked at 19 years for men (7.9%) and 18 years for women (12.7%), reducing to 4.3% for men and 5.4% for women at age 30 years. For all ages over 9 years, the prevalence of DKA was higher in female individuals. CONCLUSIONS HbA1c and the prevalence of DKA increase through adolescence and then decline. Measurement of HbA1c, a marker of clinical review, falls abruptly in the late teenage years. Age-appropriate services are needed to overcome these issues.

OBJECTIVE To assess the incidence of remission of type 2 diabetes in routine care settings. RESEARCH DESIGN AND METHODS People with type 2 diabetes (HbA1c ≥48 mmol/mol [6.5%] or RESULTS In 2,297,700 people with type 2 diabetes, the overall incidence of remission per 1,000 person-years was 9.7 (95% CI 9.6–9.8) and 44.9 (95% CI 44.0–45.7) in 75,610 (3.3%) people who were diagnosed CONCLUSIONS Remission of type 2 diabetes was generally infrequent in routine care settings but may be a reasonable goal for a subset of people who lose a significant amount of weight shortly after diagnosis. Policies that encourage intentional remission of type 2 diabetes should seek to reduce the ethnic and socioeconomic inequalities identified.

AIMS: People with type 2 diabetes can enter remission but may relapse or develop legacy complications. This analysis assesses whether people with remission from type 2 diabetes continue receiving annual care processes recommended in national guidelines and the potential impacts of formal recognition of remission.METHODS: People with type 2 diabetes with and without formal recognition (diagnostic code) of remission, and with and without evidence of remission (HbA 1c RESULTS: Of the 2,822,145 people with type 2 diabetes in the cohort, 16,460 (0.58%) were coded with remission in the 2018/19 NDA. After adjustment for age, sex, socioeconomic deprivation and ethnicity, people coded with remission were less likely to receive each care process than those without such coding irrespective of HbA 1c measurements (relative risk (RR) of receiving all 8 care processes 0.70 (95% CI 0.69-0.72)). For the 339,235 people with evidence of remission, irrespective of diagnostic coding compared to those without such evidence, the RR for receiving all 8 care processes was 0.94 (95% CI 0.93-0.94). CONCLUSIONS: People coded with remission of type 2 diabetes were less likely to receive diabetes care processes than those without such coding. People with evidence of remission had only a slightly reduced likelihood of receiving care processes. Formal recognition of remission may affect the provision or uptake of care processes.

To assess weight change in the Healthier You: NHS Diabetes Prevention Programme (NHS DPP) delivered via video conferencing (remote) sessions or delivered via specific digital interventions through apps or websites, during the COVID-19 pandemic compared to group-based face-to-face interventions, pre-pandemic.Prospectively collected national service-level data relating to individuals with non-diabetic hyperglycaemia (HbA1c 42-47mmol/mol (6.0-6.4%) or fasting plasma glucose 5.5-6.9mmol/l) referred to the NHS DPP from June 2016 to March 2022.Between March 2020 and March 2022, 335,961 people were referred to the programme and were offered a choice of remote or digital intervention. This was preceded by 556,793 people referred into the face-to-face programme between June 2016 and February 2022. Uptakes to intervention sessions were 47% for those offered a choice and 39% for face-to-face. Remote and digital participants were significantly younger (60 and 56 vs 65 years) and heavier (86.1kg and 91.0kg vs 84.1kg) compared to face-to-face. Weight change was assessed for 42,407 remote, 7,699 digital and 97,205 face-to-face participants with sufficient time to have finished the programme and no missing data. Mean weight losses for participants attending at least one intervention session were: 2.40(2.36-2.44)kg, 2.59(2.49-2.68)kg and 2.01 (1.98-2.04)kg for remote, digital and face-to-face participants respectively. Corresponding mean weight losses for those who completed the programme were: 3.24(3.19-3.30)kg, 4.76(4.60-4.92)kg and 3.04(3.00-3.07)kg. There were no significant differences in weight change between interventions by ethnicity and deprivation.Weight losses achieved through remote and digital interventions were greater than those previously achieved through face-to-face interventions, without evidence of exacerbation of health inequalities.

BACKGROUND: Diabetic ketoacidosis (DKA) has been reported to be increasing in frequency during the COVID-19 pandemic. We aimed to examine the rates of DKA hospital admissions and the patient demographics associated with DKA during the pandemic compared with in prepandemic years. METHODS: Using a comprehensive, multiethnic, national dataset, the Secondary Uses Service repository, we extracted all emergency hospital admissions in England coded with DKA from March 1 to June 30, 2020 (first wave of the pandemic), July 1 to Oct 31, 2020 (post-first wave), and Nov 1, 2020, to Feb 28, 2021 (second wave), and compared these with DKA admissions in the equivalent periods in 2017-20. We also examined baseline characteristics, mortality, and trends in patients who were admitted with DKA. FINDINGS: There were 8553 admissions coded with DKA during the first wave, 8729 during the post-first wave, and 10 235 during the second wave. Compared with preceding years, DKA admissions were 6% (95% CI 4-9; p

AimThis cohort study investigates the extent to which variation in ulcer healing between services can be explained by demographic and clinical characteristics.MethodsThe National Diabetes Foot Care Audit (NDFA) collated data on people with diabetic foot ulcers presenting to specialist services in England and Wales between July 2014 and March 2018. Logistic regression models were created to describe associations between risk factors and a person being alive and ulcer-free 12 weeks from presentation, and to investigate whether variation between 120 participating services persisted after risk factor adjustment. ResultsOf 27,030 people with valid outcome data, 12,925 (47.8%) were alive and ulcer-free at12 weeks, 13,745 (50.9%) had an unhealed ulcer and 360 had died (1.3%). Factors associated with worse outcome were male sex, more severe ulcers, history of cardiac or renal disease and a longer time between first presentation to a non-specialist healthcare professional and first expert assessment. After adjustment for these factors, four services (3.3%) were more than 3SD above and seven services (5.8%) were more than 3SD below the national mean for proportions that were alive and ulcer-free at follow-up.Conclusions/interpretationsVariation in the healing of diabetic foot ulcers between specialist services in England and Wales persisted after adjusting for demographic characteristics, ulcer severity, smoking, body mass index and co-morbidities. We conclude that other factors contribute to variation in healing of diabetic foot ulcers and include the time to specialist assessment.

We report contemporary age-related prevalence, characteristics and care of children and young people with type 2 diabetes in England.Individuals with a recorded diagnosis of type 2 diabetes between January 2019 and March 2020 were identified from a whole population register. Age, sex, ethnicity, deprivation quintile, weight, HbAIn total, 122,780 (4.6%) of 2,642,435 individuals in England with type 2 diabetes were aged under 40 years, comprising; 650 (0.5%) under 16 years, 910 (0.7%) aged 16-18 years, 8245 (6.7%) aged 19-25 and 112,975 (92%) aged 26-39 years. Compared to people with type 2 diabetes aged above 40 years, young people were significantly more likely to be from minority ethnic groups: 51% under 16 years, 41% 16-18 years, 38% 19-25 years, 38% 26-39 years, 27% 40-59 years and 15% 60-79 years were of Black or Asian ethnicity. In addition, those aged under 40 years were more likely to be obese, women, to live in the most-deprived socioeconomic areas and less likely to receive the NICE recommended annual care processes or achieve target HbAThe substantial number of people under 40 years of age with type 2 diabetes, are more likely to have characteristics associated with inequalities and are less likely to achieve HbA

BackgroundNeuropsychiatric symptoms in Parkinson’s disease (PD) may increase dementia (PDD) risk. The predictive value of these symptoms, however, has not been compared to clinical and demographic predictors of future PDD.Methods325 PD participants completed baseline neuropsychiatric and MDS-Task Force Level II assessments. Of these, 195 non-demented individuals were followed-up over a four-year period to detect conversion to PDD; 51 developed PDD. ROC analysis tested associations between baseline neuropsychiatric symptoms and conversion to PDD. The probability of developing PDD was also modelled as a function of neuropsychiatric inventory (NPI) total score, PD Questionnaire (PDQ) hallucinations, PDQ anxiety and contrasted to cognitive ability, age and motor function. Leave-one-out information criterion was used to evaluate which models provided useful information when predicting future PDD.ResultsThe PDD group experienced greater levels of neuropsychiatric symptoms compared to the PD-MCI and PD-N groups at baseline. Few differences were found between the PD-MCI and PD-N groups. Five neuropsychiatric measures were significantly, but weakly, associated with future PDD. The strongest was NPI total score: AUC=0.66 [0.55-0.76]. There was, however, no evidence that it contained useful out-of-sample predictive information of future PDD (delta ELPD=1.6 (SD 2.4)); Similar results held for PDQ hallucinations and PDQ anxiety. In contrast, cognitive ability (delta ELPD=35 (SD 8)) and age (delta ELPD=11 (SD 5)) provided useful predictive information of future PDD.ConclusionsCognitive ability and age strongly out-performed neuropsychiatric measures as markers of developing PDD within four years. Therefore, neuropsychiatric symptoms do not appear to be useful markers of PDD risk.

BACKGROUND: The Office for Health Improvement and Disparities, part of the UK Government Department of Health and Social Care, highlighted an emerging signal of increased non-COVID-19-related deaths in England between July and October, 2021, with a potentially disproportionate higher increase in people with diabetes. We aimed to substantiate and quantify this apparent excess mortality, and to investigate the association between diabetes routine care delivery and non-COVID-19-related-mortality in people with diabetes before and after the onset of the pandemic. METHODS: In this population-based parallel cohort study, we used the National Diabetes Audit (NDA) to identify people with diabetes in England. The primary outcome was non-COVID-19-related deaths between July 3, 2021, and Oct 15, 2021, in participants in the 2021 COVID-19 cohort (registered in the NDA in the periods Jan 1, 2019, to March 31, 2020, and Jan 1, 2020, to March 31, 2021) compared with deaths between June 29, 2019, and Oct 11, 2019 (the equivalent 15-week period in 2019) in the 2019 pre-COVID-19 comparator cohort (people registered in the NDA in the periods Jan 1, 2017, to March 31, 2018, and Jan 1, 2018 to March 31, 2019). In each cohort, multivariable logistic regression examined whether completion of eight diabetes care processes in each of the two years before the index mortality year was associated with non-COVID-19-related death, adjusting for diabetes type, age, sex, ethnicity, and socioeconomic deprivation. FINDINGS: There were 3 218 570 people in the 2021 cohort and 2 973 645 people in the 2019 comparator cohort. In the 2021 cohort, there were 30 118 non-COVID-19-related deaths in people with diabetes, compared with 27 132 in the comparator cohort, representing an 11% increase (95% CI 9-13). The unadjusted incidence rate ratio (IRR) for mortality in the 2021 cohort compared to the 2019 cohort was 1·026 (1·009-1·043; p=0·003), which was unchanged after adjustment for age, sex, ethnicity, socioeconomic deprivation, and diabetes type (IRR 1·023 (1·006-1·040); p=0·007). In the 2021 cohort, 853 660 (26·5%) people received all eight care processes in 2020-21 compared with 1 547 240 (48·1%) people in 2019-20; a 44·8% (95% CI 44·7-45·0) relative reduction. In the pre-COVID-19 comparator cohort, 1 370 315 (46·1%) people with diabetes received all eight care processes in 2018-19 compared with 1 437 740 (48·3%) in 2017-18; a 4·7% (95% CI 4·5-4·9) relative decrease. Non-COVID-19-related mortality in the 2021 cohort was highest in people who did not receive all eight care processes in either of the two previous years (OR 2·67 [95% CI 2·56-2·77]; p

Early-onset type 2 diabetes occurring in childhood or early adulthood carries a significant excess burden of microvascular diabetes complications, cardiovascular disease and premature death, compared to later onset type 2 diabetes along with adverse pregnancy outcomes in women of child-bearing age. National audit data in England reveal that 122,780 individuals under the age of 40 years are currently living with type 2 diabetes, with an over-representation of people from minority ethnicities and those in the most socioeconomically deprived quintiles. A diagnosis of type 2 diabetes earlier in life poses some unique challenges to healthcare providers that are not routinely encountered when type 2 diabetes presents later. These include; (1) the need to ensure correct diabetes classification in an age group that carries a higher probability of other types of diabetes, (2) overcoming difficulties in engaging with individuals who are of working age or in full-time education, (3) appreciating and addressing the lower attainment of diabetes treatment targets and (4) proactively supporting women of child-bearing age to optimise their future pregnancy outcomes through better preparation for pregnancy, including achieving optimum glycaemic control at the time of conception. Meanwhile, approaches to prevent type 2 diabetes in younger age groups are challenged by difficulties in identifying those at highest risk, by poorer attendance at lifestyle interventions to prevent or delay the onset of type 2 diabetes and by attenuation of associated weight loss in those that do attend. In this article, we discuss the importance of recognising and addressing the distinct challenges in delivering healthcare to those with early-onset type 2 diabetes, the greater challenges in preventing type 2 diabetes at younger ages, and key components of strategies that might address these challenges to drive improvements in pregnancy outcomes, microvascular and cardiovascular outcomes.

In product-diverse, end-of-life (EoL) production lines the relevant markets, competitors and customer bases continuously change as new products are processed. The resale market itself changes with the influx of new products, as well as hardware and software discontinuations. Competitive business decision making is often performed by a human operator and may not be timely or fully informed. These are decisions such as whether to perform a high cost repair or recycle a product or whether to use a batch of parts in repair or sell them on. These decisions can be used to optimise product life-cycle management (PLM) and profit margins. A real-time decision making capability can reduce the risk of performing non-profitable processing. The novel contribution of this work is an interoperable semantic decision support toolset that enables a capability for timely EoL decisions based on complete knowledge on profitability, predicted pricing and cost-of-production. Many decision support systems have been proposed for the EoL domain, but a lack of interoperability and use of unstructured knowledge bases has led to decisions based on knowledge that is not up to date. Using formalised, semantic technologies offers sustainable decision making in this volatile and increasingly competitive domain.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on amputation incidence in whole populations with diabetes is unknown. Previous reports are restricted to small cohorts from single specialist centers showing varying outcomes, including greater ulcer severity on presentation (1) and increased amputations (2). We aimed to carry out a population-based assessment of lower-limb major amputation, minor amputation, and revascularization procedure numbers and incidences during the first wave of the COVID-19 pandemic in England, covering the period March to June 2020, compared with equivalent time periods in 2017–2019. We also examined data 4 months following the first wave to assess if delayed presentations resulted in a rebound leading to higher than usual amputation incidence. The Secondary Uses Service data set contains data on inpatient care for all admissions to hospitals in England and was used to identify all major and minor lower-limb amputation and revascularization procedures in people with diabetes in England between 1 January 2017 and 31 October 2020, using all discharges from the hospital up to 31 December 2020. If more than one procedure was performed, all were counted for their respective analyses. For each year, the total number of people with diabetes aged 18 years and over was obtained from the National Diabetes Audit. Age, sex, ethnicity, and deprivation were identified as potential confounding factors. Due to geographical variations …

Aim: To conduct an analysis to assess whether the completion of recommended diabetes care processes (glycated haemoglobin [HbA1c], creatinine, cholesterol, blood pressure, body mass index [BMI], smoking habit, urinary albumin, retinal and foot examinations) at least annually is associated with mortality. Materials and methods: A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 people with type 2 diabetes, aged 17 to 99 years on January 1, 2009, diagnosed before January 1, 2009 and alive on April 1, 2013 was followed to December 31, 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, blood pressure, serum cholesterol, BMI, duration of diagnosis, estimated glomerular filtration rate, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, were used to investigate whether care processes recorded January 1, 2009 to March 31, 2010 were associated with subsequent mortality. Results: Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95% CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups. Conclusions: People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.

The National Diabetes Audit (NDA) collates and analyses data on the quality and variation in clinical care and outcomes for people with diabetes. It also provides opportunities to assess trends, determinants, and outcomes of diabetes to help guide clinical and public health priorities. Cohort: Between 1st January 2003 and 31st March 2020 a total of 5,280,885 people diagnosed with diabetes were included in at least one NDA data collection. To this date, median follow up was 12 and 8 years for people with type 1 diabetes and type 2 diabetes respectively. Comparisons with the 2019/20 Quality and Outcomes Framework show it included 98% of adults in England and Wales with diagnosed type 1 and type 2 diabetes. Data includes demographic characteristics (age, sex, ethnicity, age at diagnosis, deprivation), risk factors (HbA1c, blood pressure, cholesterol, body mass index, smoking status) diabetic and cardiovascular complications and deaths. Secondary analysis: Secondary analyses have included: comparisons of HbA1c and blood pressure measurements in cohorts with similar characteristics to the Epidemiology of Diabetes Interventions and Complications study and the UK Prospective Diabetes Study; COVID-19 related mortality in people with Type 1 and Type 2 diabetes and incidence of Type 2 diabetes following admission to intensive care units. Future plans: Commissioned NDA reports will continue to inform service development in England and Wales. The same data, with or without linkages to other external datasets, is also a rich resource for clinically orientated research.

BACKGROUND: In patients with type 2 diabetes, hyperglycaemia is an independent risk factor for COVID-19-related mortality. Associations between pre-infection prescription for glucose-lowering drugs and COVID-19-related mortality in people with type 2 diabetes have been postulated but only investigated in small studies and limited to a few agents. We investigated whether there are associations between prescription of different classes of glucose-lowering drugs and risk of COVID-19-related mortality in people with type 2 diabetes. METHODS: This was a nationwide observational cohort study done with data from the National Diabetes Audit for people with type 2 diabetes and registered with a general practice in England since 2003. Cox regression was used to estimate the hazard ratio (HR) of COVID-19-related mortality in people prescribed each class of glucose-lowering drug, with covariate adjustment with a propensity score to address confounding by demographic, socioeconomic, and clinical factors. FINDINGS: Among the 2 851 465 people with type 2 diabetes included in our analyses, 13 479 (0·5%) COVID-19-related deaths occurred during the study period (Feb 16 to Aug 31, 2020), corresponding to a rate of 8·9 per 1000 person-years (95% CI 8·7-9·0). The adjusted HR associated with recorded versus no recorded prescription was 0·77 (95% CI 0·73-0·81) for metformin and 1·42 (1·35-1·49) for insulin. Adjusted HRs for prescription of other individual classes of glucose-lowering treatment were as follows: 0·75 (0·48-1·17) for meglitinides, 0·82 (0·74-0·91) for SGLT2 inhibitors, 0·94 (0·82-1·07) for thiazolidinediones, 0·94 (0·89-0·99) for sulfonylureas, 0·94 (0·83-1·07) for GLP-1 receptor agonists, 1·07 (1·01-1·13) for DPP-4 inhibitors, and 1·26 (0·76-2·09) for α-glucosidase inhibitors. INTERPRETATION: Our results provide evidence of associations between prescription of some glucose-lowering drugs and COVID-19-related mortality, although the differences in risk are small and these findings are likely to be due to confounding by indication, in view of the use of different drug classes at different stages of type 2 diabetes disease progression. In the context of the COVID-19 pandemic, there is no clear indication to change prescribing of glucose-lowering drugs in people with type 2 diabetes. FUNDING: None.

IntroductionTo report the observations of point-of-care (POC) glycated hemoglobin (HbA1c) testing in people with non-diabetic hyperglycemia (NDH; HbA1c 42–47 mmol/mol (6.0%–6.4%)), applied in community settings, within the English National Health Service Diabetes Prevention Programme (NHS DPP).Research design and methodsA service evaluation assessing prospectively collected national service-level data from the NHS DPP, using data from the first referral received in June 2016–October 2018. Individuals were referred to the NHS DPP with a laboratory-measured HbA1c in the NDH range and had a repeat HbA1c measured at first attendance of the program using one of three POC devices: DCA Vantage, Afinion or A1C Now+. Differences between the referral and POC HbA1c and the SD of the POC HbA1c were calculated. The factors associated with the difference in HbA1c and the association between POC HbA1c result and subsequent attendance of the NHS DPP were also evaluated.ResultsData from 73 703 participants demonstrated a significant mean difference between the referral and POC HbA1c of −2.48 mmol/mol (−0.23%) (t=157, pConclusionPOC HbA1c testing in community settings was associated with significantly lower HbA1c values when compared with laboratory-measured referrals. Acknowledging effects of regression to the mean, we found that these differences were also associated with POC method, location, individual patient factors and time between measurements. Compared with POC HbA1c values in the NDH range, normoglycemic POC HbA1c values were associated with lower subsequent intervention attendance.

Background: \ud Diabetes has been associated with increased COVID-19-related mortality, but the association between modifiable risk factors, including hyperglycaemia and obesity, and COVID-19-related mortality among people with diabetes is unclear. We assessed associations between risk factors and COVID-19-related mortality in people with type 1 and type 2 diabetes.\ud \ud Methods: \ud We did a population-based cohort study of people with diagnosed diabetes who were registered with a general practice in England. National population data on people with type 1 and type 2 diabetes collated by the National Diabetes Audit were linked to mortality records collated by the Office for National Statistics from Jan 2, 2017, to May 11, 2020. We identified the weekly number of deaths in people with type 1 and type 2 diabetes during the first 19 weeks of 2020 and calculated the percentage change from the mean number of deaths for the corresponding weeks in 2017, 2018, and 2019. The associations between risk factors (including sex, age, ethnicity, socioeconomic deprivation, HbA1c, renal impairment [from estimated glomerular filtration rate (eGFR)], BMI, tobacco smoking status, and cardiovascular comorbidities) and COVID-19-related mortality (defined as International Classification of Diseases, version 10, code U07.1 or U07.2 as a primary or secondary cause of death) between Feb 16 and May 11, 2020, were investigated by use of Cox proportional hazards models.\ud \ud Findings: \ud Weekly death registrations in the first 19 weeks of 2020 exceeded the corresponding 3-year weekly averages for 2017–19 by 672 (50·9%) in people with type 1 diabetes and 16 071 (64·3%) in people with type 2 diabetes. Between Feb 16 and May 11, 2020, among 264 390 people with type 1 diabetes and 2 874 020 people with type 2 diabetes, 1604 people with type 1 diabetes and 36 291 people with type 2 diabetes died from all causes. Of these total deaths, 464 in people with type 1 diabetes and 10 525 in people with type 2 diabetes were defined as COVID-19 related, of which 289 (62·3%) and 5833 (55·4%), respectively, occurred in people with a history of cardiovascular disease or with renal impairment (eGFR

Aims/hypothesis: The aim of this prospective nationwide study was to examine antenatal pregnancy care and pregnancy outcomes in women with type 1 and type 2 diabetes, and to describe changes since 2002/2003. Methods: This national population-based cohort included 3036 pregnant women with diabetes from 155 maternity clinics in England and Wales who delivered during 2015. The main outcome measures were maternal glycaemic control, preterm delivery (before 37 weeks), infant large for gestational age (LGA), and rates of congenital anomaly, stillbirth and neonatal death. Results: Of 3036 women, 1563 (51%) had type 1, 1386 (46%) had type 2 and 87 (3%) had other types of diabetes. The percentage of women achieving HbA1c < 6.5% (48 mmol/mol) in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7–22.2] for type 1, 37.0% [27.3–46.2] for type 2). The number of infants born preterm (21.7% vs 39.7%) and LGA (23.9% vs 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p < 0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs 25.8/1000 births for type 1, p = 0.0012; 10.5 vs 29.2/1000 births for type 2, p = 0.0091). Conclusions/interpretation: Stillbirth rates among women with type 1 and type 2 diabetes have decreased since 2002/2003. Rates of preterm delivery and LGA infants are lower in women with type 2 compared with type 1 diabetes. In women with type 1 diabetes, suboptimal glucose control and high rates of perinatal morbidity persist with substantial variations between clinics. Data availability: Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid.

Background: Although diabetes has been associated with COVID-19 mortality, its scale and relationships with modifiable risk factors including hyperglycaemia and

OBJECTIVE To assess weight and HbA1c changes in the Healthier You: National Health Service Diabetes Prevention Programme (NHS DPP), the largest DPP globally to achieve universal population coverage. RESEARCH DESIGN AND METHODS A service evaluation assessed intervention effectiveness for adults with nondiabetic hyperglycemia (HbA1c 42–47 mmol/mol [6.0–6.4%] or fasting plasma glucose 5.5–6.9 mmol/L) between program launch in June 2016 and December 2018, using prospectively collected, national service–level data in England. RESULTS By December 2018, 324,699 people had been referred, 152,294 had attended the initial assessment, and 96,442 had attended at least 1 of 13 group-based intervention sessions. Allowing sufficient time to elapse, 53% attended an initial assessment, 36% attended at least one group-based session, and 19% completed the intervention (attended >60% of sessions). Of the 32,665 who attended at least one intervention session and had sufficient time to finish, 17,252 (53%) completed: intention-to-treat analyses demonstrated a mean weight loss of 2.3 kg (95% CI 2.2, 2.3) and an HbA1c reduction of 1.26 mmol/mol (1.20, 1.31) (0.12% [0.11, 0.12]); completer analysis demonstrated a mean weight loss of 3.3 kg (3.2, 3.4) and an HbA1c reduction of 2.04 mmol/mol (1.96, 2.12) (0.19% [0.18, 0.19]). Younger age, female sex, Asian and black ethnicity, lower socioeconomic status, and normal baseline BMI were associated with less weight loss. Older age, female sex, black ethnicity, lower socioeconomic status, and baseline overweight and obesity were associated with a smaller HbA1c reduction. CONCLUSIONS Reductions in weight and HbA1c compare favorably with those reported in recent meta-analyses of pragmatic studies and suggest likely future reductions in participant type 2 diabetes incidence.

Background: Although diabetes has been associated with COVID-19 mortality, the absolute and relative risks for Type 1 and Type 2 diabetes are unknown brbrMe

Aims To investigate the relationship between high diabetes‐related lower limb amputation incidence and foot care services in the South‐West region of England. Methods The introduction of 10 key elements of foot care service provision in one area of the South‐West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed. Results Initial reviews in 2013 showed that the 3‐year diabetes‐related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R 2 =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012–2015 and in the year 2015 only (P ≤0.0012, adjusted R 2 =0.56, and P= 0.0005, R 2=0.62, respectively). Conclusions Major diabetes‐related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence., What's new? The 10‐year incidence and prevalence of diabetic foot ulcer and amputation incidence were recorded and compared with service provision in one Clinical Commissioning Group [the National Health Service (NHS) funding body for hospital and community services in each area of the UK].Evaluation of the effective delivery of 10 key diabetes foot care service provisions was undertaken in 14 service providers in one NHS region.There was a strong negative relationship between provision of 10 key services for diabetes foot care and major diabetes‐related lower limb amputation rates.Improvement in diabetes foot care services resulted in a reduction in major amputation incidence within 2 years.The acceptability and effectiveness of peer review in evaluating diabetes foot care services were demonstrated across a whole region of England.

For the last couple of decades, information and communication technologies have been increasingly used to support the decision making in manufacturing organizations. However although these enterprise applications provide increasing amounts of information, they do not support the capture and sharing of multi-perspective knowledge across the participating domains. The aim of this paper is to investigate the capture and sharing of assembly knowledge to support collaboration across the assembly design and assembly process planning domains. In the past there have been some efforts to develop knowledge based systems however these knowledge based systems lack the ability to fully capture and share multi-perspective assembly knowledge. This is because such systems are unable to capture the full meanings and intents of the concepts used to stipulate the assembly knowledge and relationships between these concepts. This paper proposes a mechanism to support capture and sharing of assembly knowledge by using formal ontologies where the latter specify meanings of concepts in computationally interpretable form that consequently provides a base for knowledge sharing. The research concept has been experimentally demonstrated by using a selected set of assembly concepts which have been used to capture and relate assembly design and assembly process planning knowledge.

The National Diabetes Audit (NDA) is a major national clinical review that measures the effectiveness of diabetes health care against National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines and NICE Quality Standards, in England and Wales. It began in 2004, and is one of the largest clinical audits in the world. In 2014–202015 around 58% of practices in England and Wales participated, and the audit reported on 1.9 million people with diabetes [1]. Forty-two items of diabetes-specific data are collected annually from each participating practice for each individual on the practice diabetes register. Each year in Report 1, data are presented on the completion of eight diabetes care processes (BMI, microalbuminuria, smoking status, blood pressure, HbA1c, creatinine, cholesterol and foot examination), both individually and as a composite. This article is protected by copyright. All rights reserved.

The overall significance of disease of the foot in diabetes has long been neglected and few professionals involved in healthcare either consider the extent of the suffering of affected individuals or are aware that a conservative estimate of its annual cost exceeds a staggering £600 m, almost 1% of the total NHS budget [1]. Relative lack of focus on foot disease by medical professionals has also resulted in limited scientific investigation into its complex causes and this has restricted insight into its best management. Clinical guidance for foot disease in Type 2 diabetes was first outlined by the Royal College of General Practitioners in 2000 and became the basis of National Institute for Health and Care Excellence (NICE) guidance in 2004 [2]; however, it was the charity Diabetes UK that initiated real change through the National Minimum Skills and Putting Feet First reports of 2006 (updated 2011) and 2009 [3,4]. NICE guidance for the management of inpatients followed in 2010 [5], the same year in which the working group was assembled for the pilot forerunner of the National Diabetic Foot Care Audit [6]. The definitive audit was launched in the summer of 2014 [7] and it has recently published its first report [8]. This article is protected by copyright. All rights reserved.