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Abstract Background Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used in first-world countries and are generally well tolerated. Specifically, less cardiovascular toxicity has been reported in comparison with tricyclic antidepressants. Here we report QT interval prolongation after an overdose of the SSRI sertraline. Case presentation A previously healthy female patient presented with an attempted suicide with overdoses sertraline (2250 mg), diazepam (200 mg), and temazepam (400 mg). Routine laboratory studies were normal and her ECG upon admission showed a normal QT interval. The next day, her ECG showed prolongation of the QTc interval up to 525 ms. After discontinuation of sertraline the QT interval normalized. Echocardiography and exercise electrocardiography were normal. After hospitalization, the patient resumed sertraline in the normally recommended dose and QT interval remained within normal ranges. Conclusion It seems that the SSRI sertraline in overdose may cause QT interval prolongation.

Several transitions, or new patterns and dynamics in the contributors and health outcomes, have altered the character and burden of the multi-decade, worldwide growth in prevalence of type 2 diabetes (T2DM). These changes have led to different needs for prevention and care. These dynamics have been driven by diverse demographic, socio-economic, behavioural, and health system response factors. In this Perspective, we describe these transitions and how their attributes have set the stage for multimorbidity, or multiple long-term conditions (MLTCs), to be the next major challenge in the diabetes epidemic. We also describe how the timing and character of these stages differ in high-, middle-, and low-income countries. These challenges call for innovation and a stronger focus on MLTCs across the spectrum of cause, effectiveness, and implementation studies to guide prevention and treatment priorities., Competing Interests: Competing interests: S.M. has received speaker Honoraria from Lilly and Sanofi, UK. K.K. has acted as a consultant, speaker or received grants for investigator-initiated studies for Astra Zeneca, Bayer, Novo Nordisk, Sanofi-Aventis, Servier, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Oramed Pharmaceuticals, Pfizer, Roche, Daiichi-Sankyo, Applied Therapeutics, Embecta and Nestle Health Science. J.P.S. is a Partner at Lane Clark & Peacock LLP and Chair of the Royal Society for Public Health and reports consultancy fees from Novo Nordisk outside of this work. J.V. was the National Clinical Director for Diabetes and Obesity at NHS England from April 2013 to September 2023 and currently is the National Clinical Lead for Multiple Long Term Conditions at NHS England., (© 2025. The Author(s).)

Aims: The aim was to determine the effect of the COVID-19 pandemic on diabetic retinopathy and referral rates in the English National Health Service (NHS) Diabetic Eye Screening Programme (DESP)., Methods: Non-patient identifiable data are submitted centrally from the 57 regional centres in the NHS DESP on a quarterly basis and analysed using STATA, comparing 01/04/2019-31/03/2020 and 01/04/2021-31/03/2022. Patient characteristics were analysed from National Diabetes Audit (NDA) data., Results: There were 2,274,635 grades from the 57 centres in 2019-2020 and 2,199,623 grades in 2021-2022. The proportion of eyes with referable DR increased from 3.1% in 2019-2020 to 3.2% in the 2021-2022 NHS year (p < 0.01) with a small increase in the level of non-referable DR from 24.6% to 24.8% (p < 0.01). The median proportion of ungradable eyes in 2019-2020 was 2.6% (IQR: 2.3% to 3.3%) increasing to 3.1% (IQR: 2.5% to 3.7%) in 2021-2022. NDA data demonstrated that the proportions with type 1 diabetes receiving eye screening were higher in the latter year (8.3% vs. 7.3%)., Conclusion: The COVID-19 pandemic was associated with small increases in referable retinopathy rates from 3.1% to 3.2%, non-referable DR from 24·6% to 24.8% and an increase in the ungradable image rate from 2.6% to 3.1%, the latter increase possibly being caused by untreated cataract during the pandemic. Risk stratification of invitations in the recovery period was believed to have contributed to keeping the referable rates low and supports a similar approach in extension of the screening interval for low-risk groups., (© 2025 The Author(s). Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims/hypothesis: People with diabetes-related foot ulcers (DFUs) have high mortality rates. This analysis assesses the impact of selected risk factors on short-term mortality using a population registered in the National Diabetes Foot Care Audit (NDFA)., Methods: Mortality rates at 12, 26 and 52 weeks was assessed in people with a new DFU registered by a specialist diabetes footcare service in the NDFA in England and Wales between April 2017 and March 2022. Poisson regression models were created to explore risk factors for mortality., Results: In 71,000 people registered with a new DFU, mortality rates at 12, 26 and 52 weeks was 4.2%, 8.2% and 14.4%, respectively. At 26 weeks, higher mortality rates was associated with older age (rate ratio 2.15; 95% CI 2.03, 2.28, for age ≥80 years vs age 65-79 years), certain ulcer characteristics (area ≥1 cm 2 [1.50; 95% CI 1.42, 1.59], deep ulcers [1.26; 95% CI 1.18, 1.35] or hindfoot location [1.53; 95% CI 1.44, 1.62]) and recorded evidence of ischaemia in the lower limb (1.78; 95% CI 1.69, 1.88) and various comorbidities (heart failure [2.13; 95% CI 2.00, 2.26], myocardial infarction [1.45; 95% CI 1.29, 1.63], stroke [1.37; 95% CI 1.22, 1.53], renal replacement therapy [2.34; 95% CI 2.09, 2.61] and chronic kidney disease stage 3 or greater [1.20; 95% CI 1.12, 1.29]). The 26-week mortality rate exceeded 25% for 7.3% of all individuals, rising to 11.5% of those aged 65 years and older, and 22.1% of those aged 80 years and over., Conclusions/interpretation: Short-term mortality rates in people with a DFU is high. Teams managing people with DFUs should consider modifying the burdensome interventions and care required to heal such ulcers so maximising the quality of residual life, rather than focusing exclusively on healing., Competing Interests: Data availability: Data from the National Diabetes Audit and the National Diabetes Foot Care Audit may be obtained via the Data Request Service at NHS England (see https://digital.nhs.uk/services/data-access-request-service-dars ). Funding: NH received funding from NHS England to undertake this analysis. Authors’ relationships and activities: JV is grateful for support from the North West London National Institute for Health Research (NIHR) Applied Research Collaboration, the Imperial NIHR Biomedical Research Centre, and CW+, the official charity of Chelsea and Westminster Hospital NHS Foundation Trust. JV was National Clinical Director for Diabetes and Obesity at NHS England from April 2013 to September 2023, is currently the National Clinical Lead for Multiple Long-Term Conditions (MLTC) at NHS England, and is North West London NIHR Applied Research Collaboration Theme Lead for MLTC. FG is the current Clinical Lead for the NDFA, and WJ is a former Clinical Lead for the NDFA. BY is the Clinical Lead for the NDA. NH, BY and JV are members of the NDA Research Advisory Group. The other author declares that there are no relationships or activities that might bias, or be perceived to bias, their work. Contribution statement: NH, BY, WJ, JV and FG made substantial contributions to the conception and design of the study. ACY compiled the data and NH undertook the data analysis. All authors interpreted the data, drafted the paper, revised it for intellectual content and approved the final version. NH is the guarantor of this work., (© 2024. The Author(s).)

Aim: To assess mortality and complication trends in people with type 1 diabetes during the 11 years before the SARS-CoV2 pandemic (2009-2019)., Materials and Methods: Sequential cohorts of people in England with type 1 diabetes aged ≥20 years from the National Diabetes Audit (2006/2007 to 2016/2017) were analysed. Discretized Poisson regression models, adjusted for age, sex, ethnicity, socioeconomic deprivation and duration of diabetes, were used to calculate mortality and hospitalization rates., Results: Demographic characteristics changed little; average diabetes duration increased. All-cause mortality was unchanged. Cardiovascular and kidney disease mortality declined. Mortality from respiratory disease, diabetes and dementia increased in younger people (aged 20-74 years) as did mortality from liver disease and dementia in the elderly (aged ≥75 years). Younger Asian and Black people had lower all-cause mortality than those of White ethnicity; elderly Mixed, Asian and Black people had lower all-cause mortality. People from more deprived areas had higher all-cause mortality. The deprivation gradient for mortality was steeper at younger ages. In younger people, rates of hospitalization increased for myocardial infarction, stroke, heart failure and kidney disease but only for kidney disease in the elderly. Rates of a composite measure of cardiovascular hospitalizations increased in younger people (rate ratio [RR] 1.07, 95% confidence interval [CI] 1.03-1.11) but declined in the elderly (RR 0.91, 95% CI 0.86-0.95)., Conclusion: Between 2009 and 2019, hospitalizations for cardiovascular disease increased at younger ages (20-74 years) and hospitalizations for kidney disease increased at all ages, but mortality from cardiovascular and kidney disease declined. All-cause mortality rates were unchanged., (© 2024 The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Background: In the UK, obesity rates are rising concurrently with declining mortality rates. Yet, there is limited research on the shifts of mortality trends and the impact of obesity-related mortality. In this study, we examine mortality trends and the cause-specific proportional composition of deaths by body mass index., Methods: We used primary healthcare records from the Clinical Practice Research Datalink between 2004 and 2019, linked to national death registration data. There were 880,683 individuals with at least one BMI measurement and a 5-year survival period. We used discrete Poisson regression and joinpoint analysis to estimate the all-cause and cause-specific mortality rate and significance of the trends., Findings: Between January 1, 2004, and December 31, 2019, all-cause mortality rates declined in the obese category by 3% on average per year (from 23.3 to 14.6 deaths per 1000 person years) in males and 2% on average per year (from 12.5 to 9.4 deaths per 1000 person years) in females. Cardiovascular disease mortality declined 7% on average per year (from 12.4 to 4.4 deaths per 1000 person years) in males and 4% on average per year (from 5.5 to 3.0 deaths per 1000 person years) in females in the obese category. Increases in mortality rates from neurological conditions occurred in all BMI categories in males and females. By the end of the study, cancers became the primary contributor of death in males in all BMI categories and females in the overweight category., Interpretation: There have been significant declines in all-cause and cardiovascular disease mortality in males and females, leading to a diversification of mortality, with cancers contributing to the highest proportion of deaths and increases in causes such as neurological and respiratory conditions. Further screening, prevention, and treatment implementation for a broader set of diseases is necessary for continued mortality improvements., Funding: Imperial College London, Science Foundation Ireland., Competing Interests: FZ reports a consultancy fee from Daiichi Sankyo; NH is funded by NHS England., (© 2024 The Authors.)

Aims/hypothesis: The risk of dying within 2 years of presentation with diabetic foot ulceration is over six times the risk of amputation, with CVD the major contributor. Using an observational evaluation of a real-world implementation pilot, we aimed to assess whether for those presenting with diabetic foot ulceration in England, introducing a 12-lead ECG into routine care followed by appropriate clinical action was associated with reduced mortality., Methods: Between July 2014 and December 2017, ten multidisciplinary diabetic foot services in England participated in a pilot project introducing 12-lead ECGs for new attendees with foot ulceration. Inception coincided with launch of the National Diabetes Footcare Audit (NDFA), whereby all diabetic footcare services in England were invited to enter data on new attendees with foot ulceration. Poisson regression models assessed the mortality RR at 2 and 5 years following first assessment of those receiving care in a participating pilot unit vs those receiving care in any other unit in England, adjusting for age, sex, ethnicity, deprivation, type and duration of diabetes, ulcer severity, and morbidity in the year prior to first assessment., Results: Of the 3110 people recorded in the NDFA at a participating unit during the pilot, 33% (1015) were recorded as having received an ECG. A further 25,195 people recorded in the NDFA had attended another English footcare service. Unadjusted mortality in the pilot units was 16.3% (165) at 2 years and 37.4% (380) at 5 years for those who received an ECG, and 20.5% (430) and 45.2% (950), respectively, for those who did not receive an ECG. For people included in the NDFA at other units, unadjusted mortality was 20.1% (5075) and 42.6% (10,745), respectively. In the fully adjusted model, mortality was not significantly lower for those attending participating units at 2 (RR 0.93 [95% CI 0.85, 1.01]) or 5 years (RR 0.95 [95% CI 0.90, 1.01]). At participating units, mortality in those who received an ECG vs those who did not was lower at 5 years (RR 0.86 [95% CI 0.76, 0.97]), but not at 2 years (RR 0.87 [95% CI 0.72, 1.04]). Comparing just those that received an ECG with attendees at all other centres in England, mortality was lower at 5 years (RR 0.87 [95% CI 0.78, 0.96]), but not at 2 years (RR 0.86 [95% CI 0.74, 1.01])., Conclusions/interpretation: The evaluation confirms the high mortality seen in those presenting with diabetic foot ulceration. Overall mortality at the participating units was not significantly reduced at 2 or 5 years, with confidence intervals just crossing parity. Implementation of the 12-lead ECG into the routine care pathway proved challenging for clinical teams-overall a third of attendees had one, although some units delivered the intervention to over 60% of attendees-and the evaluation was therefore underpowered. Nonetheless, the signals of potential mortality benefit among those who had an ECG suggest that units in a position to operationalise implementation may wish to consider this., Data Availability: Data from the National Diabetes Audit can be requested through the National Health Service Digital Data Access Request Service process at: https://digital.nhs.uk/services/data-access-request-service-dars/dars-products-and-services/data-set-catalogue/national-diabetes-audit-nda., (© 2024. The Author(s).)

Background: People with type 1 diabetes and raised glucose levels are at greater risk of retinopathy, nephropathy, neuropathy, cardiovascular disease, sexual health problems and foot disease. The UK National Institute for Health and Care Excellence (NICE) recommends continuous subcutaneous 'insulin pump' therapy for people with type 1 diabetes whose HbA1c is above 69 mmol/mol. Insulin pump use can improve quality of life, cut cardiovascular risk and increase treatment satisfaction. About 90,000 people in England and Wales meet NICE criteria for insulin pumps but do not use one. Insulin pump use also varies markedly by deprivation, ethnicity, sex and location. Increasing insulin pump use is a key improvement priority. Audit and feedback is a common but variably effective intervention. Limited capabilities of healthcare providers to mount effective responses to feedback from national audits, such as the National Diabetes Audit (NDA), undermines efforts to improve care. We have co-developed a theoretically and empirically informed quality improvement collaborative (QIC) to strengthen local responses to feedback with patients and carers, national audits and healthcare providers. We will evaluate whether the QIC improves the uptake of insulin pumps following NDA feedback., Methods: We will undertake an efficient cluster randomised trial using routine data. The QIC will be delivered alongside the NDA to specialist diabetes teams in England and Wales. Our primary outcome will be the proportion of people with type 1 diabetes and an HbA1c above 69 mmol/mol who start and continue insulin pump use during the 18-month intervention period. Secondary outcomes will assess change in glucose control and duration of pump use. Subgroup analyses will explore impacts upon inequalities by ethnicity, sex, age and deprivation. A theory-informed process evaluation will explore diabetes specialist teams' engagement, implementation, fidelity and tailoring through observations, interviews, surveys and documentary analysis. An economic evaluation will micro-cost the QIC, estimate cost-effectiveness of NDA feedback with QIC and estimate the budget impact of NHS-wide QIC roll out., Discussion: Our study responds to a need for more head-to-head trials of different ways of reinforcing feedback delivery. Our findings will have implications for other large-scale audit and feedback programmes., Trial Registration: ISRCTN82176651 Registered 18 October 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

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., (© 2023 by the American Diabetes Association.)

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., (© 2023 by the American Diabetes Association.)

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  < 48 mmol/mol without prescription for glucose-lowering drugs in preceding 26 weeks), included in the 2018/19 National Diabetes Audit (NDA) for England and Wales were followed up to identify care processes received between 1 January 2019 and 31 March 2020., 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., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aim: This cohort study investigates the extent to which variation in ulcer healing between services can be explained by demographic and clinical characteristics., Methods: The National Diabetes Foot Care Audit 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., Results: Of 27,030 people with valid outcome data, 12,925 (47.8%) were alive and ulcer-free at 12 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/interpretations: Variation 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., (© 2022 Diabetes UK.)

Introduction: We report contemporary age-related prevalence, characteristics and care of children and young people with type 2 diabetes in England., Methods: 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, HbA 1c and receipt of the nine National Institute for Health & Care Excellence (NICE) recommended annual care processes were extracted from electronic clinical records and analysed by pre-specified age bands., Results: In 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 HbA 1c ., Interpretation: The 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 1c targets and receive recommended care processes. These findings highlight the need to consider novel approaches to service provision for this high-risk group., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)