The reduced cost of providing a nationally recognised service for familial hypercholesterolaemia

OBJECTIVE: Familial hypercholesterolaemia (FH) affects 1 in 500 people in the UK population and is associated with premature morbidity and mortality from coronary heart disease. In 2008, National Institute for Health and Care Excellence (NICE) recommended genetic testing of potential FH index cases and cascade testing of their relatives. Commissioners have been slow to respond although there is strong evidence of cost and clinical effectiveness. Our study quantifies the recent reduced cost of providing a FH service using generic atorvastatin and compares NICE costing estimates with three suggested alternative models of care (a specialist-led service, a dual model service where general practitioners (GPs) can access specialist advice, and a GP-led service).METHODS: Revision of existing 3?year costing template provided by NICE for FH services, and prediction of costs for running a programme over 10?years. Costs were modelled for the first population-based FH service in England which covers Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP). Population 1.95 million.RESULTS: With expiry of the Lipitor (Pfizer atorvastatin) patent the cost of providing a 10-year FH service in SHIP reduces by 42.5% (£4.88 million on patent vs £2.80 million off patent). Further cost reductions are possible as a result of the reduced cost of DNA testing, more management in general practice, and lower referral rates to specialists. For instance a dual-care model with GP management of patients supported by specialist advice when required, costs £1.89 million.CONCLUSIONS: The three alternative models of care are now <50% of the cost of the original estimates undertaken by NICE

Liver fibrosis markers and all cause mortality in people with type 2 diabetes:a population based study (The Ayrshire Diabetes Outcomes Cohort (ADOC) Study)

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Nonalcoholic Fatty Liver Disease without overlapping Metabolic Associated Fatty Liver Disease and the risk of incident type 2 diabetes

Background and aims: re-classifying NAFLD as metabolic-associated fatty liver (MAFLD) has been proposed. While some people fulfil criteria for NAFLD, they do not have MAFLD; and whether NAFLD-only subjects have increased the risk of type 2 diabetes remains unknown. We compared risk of incident T2D in individuals with: (a) NAFLD-only; and (b) MAFLD, to individuals without fatty liver, considering effect modification by sex.Methods: 246 424 Koreans without diabetes or a secondary cause of ultrasound-diagnosed hepatic steatosis were studied. Subjects were stratified into: (a) NAFLD-only status and (b) NAFLD that overlapped with MAFLD (MAFLD). Cox proportional hazards models with incident T2D as the outcome were used to estimate hazard ratios (HRs) for: (a) and (b). Models were adjusted for time-dependent covariates, and effect modification by sex was analysed in subgroups.Results: a total of 5439 participants had NAFLD-only status and 56 839 met MAFLD criteria. During a median follow-up of 5.5 years, 8402 incident cases of T2D occurred. Multivariable-adjusted HRs (95% CI) for incident T2D comparing NAFLD-only and MAFLD to the reference (neither condition) were 2.39 (1.63–3.51) and 5.75 (5.17–6.36) (women), and 1.53 (1.25–1.88) and 2.60 (2.44–2.76) (men), respectively. The increased risk of T2D in the NAFLD-only group was higher in women than in men (p for interaction by sex &lt;0.001) and consistently observed across all subgroups. Risk of T2D was increased in lean participants regardless of metabolic dysregulation (including prediabetes).Conclusions: NAFLD-only participants without metabolic dysregulation and the criteria for MAFLD are at increased risk of developing T2D. This association was consistently stronger in women than in men.<br/

Baseline and change in serum uric acid level over time and resolution of nonalcoholic fatty liver disease in young adults:The Kangbuk Samsung Health Study

Aims: Whether changes in serum uric acid (SUA) are associated with resolution of nonalcoholic fatty liver disease (NAFLD) is uncertain. We aimed to determine the association between (i) baseline SUA and (ii) SUA changes over time, and NAFLD resolution. Materials and Methods: A retrospective cohort study, comprising 38,483 subjects aged &lt;40 years with pre-existing NAFLD, were undertaken. The effects of SUA changes over time were studied in 25,266 subjects. Participants underwent a health examination between 2011 and 2019, and had at least one follow-up liver ultrasound until December 2020. Exposures included baseline SUA levels, and SUA changes between baseline and subsequent visits, categorized into quintiles. The reference group was the third quintile (Q3) containing zero change. The primary endpoint was resolution of NAFLD. Results: During a median follow-up of 4 years, low baseline SUA and decreases in SUA over time, were independently associated with NAFLD resolution (p for trend &lt;0.001). Using SUA as a continuous variable, the likelihood of NAFLD resolution was increased by 10% and 13% in men and women, respectively, per 1 mg/dL decrease in SUA. In a time-dependent model with changes in SUA treated as a time-varying covariate, the aHRs (95%CIs) for NAFLD resolution comparing Q1 (highest decrease) and Q2 (slight decrease) to Q3 (reference) were 1.63 (1.49-1.78) and 1.23 (1.11-1.35) in men and 1.78 (1.49-2.12) and 1.18 (0.95-1.46) in women, respectively. Conclusions: Low baseline SUA levels and a decrease in SUA levels over time were both associated with NAFLD resolution in young adults.<br/

Determining fluid migration and isolation times in multiphase crustal domains using noble gases

Geochemical characteristics in subsurface fluid systems provide a wealth of information about fluid sources, migration, and storage conditions. Determining the extent of fluid interaction (aquifer-hydrocarbon connectivity) is important for oil and gas production and waste storage applications, but is not tractable using traditional seismic methods. Furthermore, the residence time of fluids is critical in such systems and can vary from tens of thousands to billions of years. Our understanding of the transport length scales in multiphase systems, while equally important, is more limited. Noble gas data from the Rotliegend natural gas field, northern Germany, are used here to determine the length scale and isolation age of the combined water-gas system. We show that geologically bound volume estimates (i.e., gas to water volume ratios) match closed-system noble gas model predictions, suggesting that the Rotliegend system has remained isolated as a closed system since hydrocarbon formation. Radiogenic helium data show that fluid isolation occurred 63–129 m.y. after rock and/or groundwater deposition (ca. 300 Ma), which is consistent with known hydrocarbon generation from 250 to 140 Ma, thus corroborating long-term geologic isolation. It is critical that we have the ability to distinguish between fluid systems that, despite phase separation, have remained closed to fluid loss from those that have lost oil or gas phases. These findings are the first to demonstrate that such systems remain isolated and fully gas retentive on time scales >100 m.y. over >10 km length scales, and have broad implications for saline aquifer CO2 disposal site viability and hydrocarbon resource prediction, which both require an understanding of the length and time scales of crustal fluid transport pathways

Human Performance Models of Pilot Behavior

Five modeling teams from industry and academia were chosen by the NASA Aviation Safety and Security Program to develop human performance models (HPM) of pilots performing taxi operations and runway instrument approaches with and without advanced displays. One representative from each team will serve as a panelist to discuss their team s model architecture, augmentations and advancements to HPMs, and aviation-safety related lessons learned. Panelists will discuss how modeling results are influenced by a model s architecture and structure, the role of the external environment, specific modeling advances and future directions and challenges for human performance modeling in aviation

Tests for diagnosing and monitoring non-alcoholic fatty liver disease in adults

Non-alcoholic fatty liver disease (NAFLD) is a metabolic liver disease that encompasses a spectrum of progressive pathological conditions, ranging from non-alcoholic fatty liver (NAFL) to steatohepatitis (NASH), fibrosis, and cirrhosis. When hepatic steatosis occurs in the absence of excessive alcohol consumption and other recognised causes of liver fat, and with cardiometabolic risk factors, it is likely that the diagnosis is NAFLD as NAFLD is principally a diagnosis of exclusion. NAFLD is the commonest liver disease in high income countries, and is estimated to affect at least 25%-30% of adults in the general population and up to 70%-90% of persons with obesity or type 2 diabetes.1NAFLD is associated not only with liver related morbidity and mortality, but also with an increased risk of developing cardiovascular disease and type 2 diabetes.2 3 Liver biopsy remains the reference method for diagnosing NAFLD, as it provides the most accurate assessment of disease grade and stage.4 5 However, undertaking a liver biopsy is costly, risky, and potentially painful. Moreover, interpretation of NAFLD severity can be compromised by sampling errors in what can be a patchy disease.6 7 In this article, we discuss the diagnosis of NAFLD, testing for liver fibrosis in those with NAFLD, and monitoring of those most likely to develop advanced liver disease. We examine the evidence and guidelines from Europe, the United States, and the UK\u2019s National Institute for Health and Care Excellence (NICE)8-10 for and against the use of specific diagnostic tests. Our approach to the use of liver ultrasound in establishing a diagnosis of hepatic steatosis differs from the recent NICE guidelines,10 but complements British Society of Gastroenterology guidelines.11 Treatment options are beyond the scope of this article

Serum 25-hydroxy vitamin D and the risk of low muscle mass in young and middle-aged Korean adults

Objective: Despite the known benefit of vitamin D in reducing sarcopenia risk in older adults, its effect against muscle loss in the young population is unknown. We aimed to examine the association of serum 25-hydroxy vitamin D [25(OH)D] level and its changes over time with the risk of incident low muscle mass (LMM) in young and middle-aged adults.Design: This study is a cohort study.Methods: The study included Korean adults (median age: 36.9 years) without LMM at baseline followed up for a median of 3.9 years (maximum: 7.3 years). LMM was defined as the appendicular skeletal muscle (ASM) mass by body weight (ASM/weight) of 1 s.d. below the sex-specific mean for the young reference group. Cox proportional hazard models were used to estimate hazard ratios (HRs) with 95% CIs.Results: Of the 192,908 individuals without LMM at baseline, 19,526 developed LMM. After adjusting for potential confounders, the multivariable-adjusted HRs (95% CIs) for incident LMM comparing 25(OH)D levels of 25-&lt;50, 50-&lt;75, and ≥75 nmol/L to 25(OH)D &lt;25 nmol/L were 0.93 (0.90-0.97), 0.85 (0.81-0.89), and 0.77 (0.71-0.83), respectively. The inverse association of 25(OH)D with incident LMM was consistently observed in young (aged &lt;40 years) and older individuals (aged ≥40 years). Individuals with increased 25(OH)D levels (&lt;50-≥50 nmol/L) or persistently adequate 25(OH)D levels (≥50 nmol/L) between baseline and follow-up visit had a lower risk of incident LMM than those with persistently low 25(OH)D levels.Conclusions: Maintaining sufficient serum 25(OH)D could prevent unfavourable changes in muscle mass in both young and middle-aged Korean adults.</p