Sodium-glucose co-transporter-2 inhibitor cardiovascular outcome trials and generalizability to English primary care

AIM

To identify people in English primary care with equivalent cardiovascular risk to participants in the sodium-glucose co-transporter-2 inhibitor (SGLT-2i) cardiovascular outcome trials (CVOTs). A secondary objective was to report the usage of SGLT-2is.

METHODS

Cross-sectional analysis of people registered with participating practices in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network on the 31 December 2016. We derived: (1) proportions of the primary care population eligible for inclusion in each SGLT-2i CVOT (CANVAS, DECLARE, EMPA-REG and VERTIS); (2) characteristics of the eligible population compared with trial participants (demographics, disease duration and vascular risk); and (3) differences within the eligible population prescribed SGLT-2is.

RESULTS

The proportions of people with type 2 diabetes (N = 84 394) meeting the inclusion criteria for each CVOT were: DECLARE 27% [95% confidence interval (CI) 26.5-27.1]; CANVAS 17% (16.6-17.1); VERTIS 7% (7.1-7.4); and EMPA-REG 7% (6.5-6.8). Primary care populations fulfilling inclusion criteria were 5-8 years older than trial cohorts, and <10% with inclusion criteria of each trial were prescribed an SGLT-2i; a greater proportion were men, and of white ethnicity.

CONCLUSIONS

There was variation in proportions of the primary care type 2 diabetes population fulfilling inclusion criteria of SGLT-2i CVOTs. The more stringent the inclusion criteria, the lower the proportion identified in a primary care setting. Prescription rates for SGLT-2is were low in this national database, and there were demographic disparities in prescribing.

Obstructive sleep apnoea in Type 2 diabetes mellitus: increased risk for overweight as well as obese people included in a national primary care database analysis

AIMS

To determine obstructive sleep apnoea prevalence in people with Type 2 or Type 1 diabetes in a national primary care setting, stratified by BMI category, and to explore the relationship between patient characteristics and obstructive sleep apnoea.

METHODS

Using the Royal College of General Practitioners Research and Surveillance Centre database, a cross-sectional analysis was conducted. Diabetes type was identified using a seven-step algorithm and was grouped by Type 2 diabetes, Type 1 diabetes and no diabetes. The clinical characteristics of these groups were analysed, BMI-stratified obstructive sleep apnoea prevalence rates were calculated, and a multilevel logistic regression analysis was completed on the Type 2 diabetes group.

RESULTS

Analysis of 1 275 461 adult records in the Royal College of General Practitioners Research and Surveillance Centre network showed that obstructive sleep apnoea was prevalent in 0.7%. In people with Type 2 diabetes, obstructive sleep apnoea prevalence increased with each increasing BMI category, from 0.5% in those of normal weight to 9.6% in those in the highest obesity class. By comparison, obstructive sleep apnoea prevalence rates for these BMI categories in Type 1 diabetes were 0.3% and 4.3%, and in those without diabetes 1.2% and 3.9%, respectively. Obstructive sleep apnoea was more prevalent in men than women in both diabetes types. When known risk factors were adjusted for, there were increased odds ratios for obstructive sleep apnoea in people with Type 2 diabetes in the overweight and higher BMI categories.

CONCLUSIONS

Obstructive sleep apnoea was reported in people with both types of diabetes across the range of overweight categories and not simply in the highest obesity class.

Measuring Quality of Healthcare Outcomes in Type 2 Diabetes from Routine Data: a Seven-nation Survey Conducted by the IMIA Primary Health Care Working Group

Background: The Institute of Medicine framework defines six dimensions of quality for healthcare systems: (1) safety, (2) effectiveness, (3) patient centeredness, (4) timeliness of care, (5) efficiency, and (6) equity. Large health datasets provide an opportunity to assess quality in these areas. Objective: To perform an international comparison of the measurability of the delivery of these aims, in people with type 2 diabetes mellitus (T2DM) from large datasets. Method: We conducted a survey to assess healthcare outcomes data quality of existing databases and disseminated this through professional networks. We examined the data sources used to collect the data, frequency of data uploads, and data types used for identifying people with T2DM. We compared data completeness across the six areas of healthcare quality, using selected measures pertinent to T2DM management. Results: We received 14 responses from seven countries (Australia, Canada, Italy, the Netherlands, Norway, Portugal, Turkey and the UK). Most databases reported frequent data uploads and would be capable of near real time analysis of healthcare quality.The majority of recorded data related to safety (particularly medication adverse events) and treatment efficacy (glycaemic control and microvascular disease). Data potentially measuring equity was less well recorded. Recording levels were lowest for patient-centred care, timeliness of care, and system efficiency, with the majority of databases containing no data in these areas. Databases using primary care sources had higher data quality across all areas measured. Conclusion: Data quality could be improved particularly in the areas of patient-centred care, timeliness, and efficiency. Primary care derived datasets may be most suited to healthcare quality assessment.

Association between glycaemic control and common infections in people with Type 2 diabetes: a cohort study

AIM

To investigate the impact of glycaemic control on infection incidence in people with Type 2 diabetes.

METHODS

We compared infection rates during 2014 in people with Type 2 diabetes and people without diabetes in a large primary care cohort in the UK (the Royal College of General Practitioners Research and Surveillance Centre database). We performed multilevel logistic regression to investigate the impact of Type 2 diabetes on presentation with infection, and the effect of glycaemic control on presentation with upper respiratory tract infections, bronchitis, influenza-like illness, pneumonia, intestinal infectious diseases, herpes simplex, skin and soft tissue infections, urinary tract infections, and genital and perineal infections. People with Type 2 diabetes were stratified by good [HbA_1c < 53 mmol/mol (< 7%)], moderate [HbA_1c 53-69 mmol/mol (7-8.5%)] and poor [HbA_1c > 69 mmol/mol (> 8.5%)] glycaemic control using their most recent HbA_1c concentration. Infection incidence was adjusted for important sociodemographic factors and patient comorbidities.

RESULTS

We identified 34 278 people with Type 2 diabetes and 613 052 people without diabetes for comparison. The incidence of infections was higher in people with Type 2 diabetes for all infections except herpes simplex. Worsening glycaemic control was associated with increased incidence of bronchitis, pneumonia, skin and soft tissue infections, urinary tract infections, and genital and perineal infections, but not with upper respiratory tract infections, influenza-like illness, intestinal infectious diseases or herpes simplex.

CONCLUSIONS

Almost all infections analysed were more common in people with Type 2 diabetes. Infections that are most commonly of bacterial, fungal or yeast origin were more frequent in people with worse glycaemic control.

Glucose test provenance recording in UK primary care: was that fasted or random?

AIMS

To describe the proportion of glucose tests with unrecorded provenance in routine primary care data and identify the impact on clinical practice.

METHODS

A cross-sectional analysis was conducted of blood glucose measurements from the Royal College of General Practitioner Research and Surveillance Centre database, which includes primary care records from >100 practices across England and Wales. All blood glucose results recorded during 2013 were identified. Tests were grouped by provenance (fasting, oral glucose tolerance test, random, none specified and other). A clinical audit in a single primary care practice was also performed to identify the impact of failing to record glucose provenance on diabetes diagnosis.

RESULTS

A total of 2 137 098 people were included in the cross-sectional analysis. Of 203 350 recorded glucose measurements the majority (117 893; 58%) did not have any provenance information. The most commonly reported provenance was fasting glucose (75 044; 37%). The distribution of glucose values where provenance was not recorded was most similar to that of fasting samples. The glucose measurements of 256 people with diabetes in the audit practice (size 11 514 people) were analysed. The initial glucose measurement had no provenance information in 164 cases (64.1%). A clinician questioned the provenance of a result in 41 cases (16.0%); of these, 14 (34.1%) required repeating. Lack of provenance led to delays in the diagnosis of diabetes [median (range) 30 (3-614) days].

CONCLUSIONS

The recording of glucose provenance in UK primary care could be improved. Failure to record provenance causes unnecessary repeated testing, delayed diagnosis and wasted clinician time.

Correlates of psychological care strategies for people with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study

AIMS

To assess the ways in which healthcare professionals address psychological problems of adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study.

METHODS

Approximately 120 primary care physicians, 80 diabetes specialists and 80 nurses and dietitians providing diabetes care participated in each of 17 countries (N=4785). Multiple regression analyses were used to evaluate independent statistically significant associations of respondent attributes concerning psychological care strategies, including assessment of diabetes impact on the patient's life, assessment of depression, provision of psychological assessment and support, and coordination with mental health professionals.

RESULTS

Psychological care strategies were positively associated with each other but differed by healthcare practice site and discipline; nurses and dietitians were less likely to assess depression than other healthcare professionals, while primary care physicians were less likely to coordinate with mental health specialists or ask patients how diabetes affects their lives. Psychological care was positively associated with healthcare professionals' beliefs that patients need help dealing with emotional issues and that clinical success depends on doing so, and also with level of psychological care training, multidisciplinary team membership and availability of resources for psychological care. There were significant between-country variations in psychological care strategies, before and after adjustment for individual-level factors, and significant country-by-covariate interactions for almost all individual-level factors investigated.

CONCLUSIONS

Improvements in training and resources, recognition and assessment of psychological problems, and increased belief in the efficacy of psychological support may enhance healthcare professionals' efforts to address psychological problems in adults with diabetes.

Incidence, worry and discussion about dosing irregularities and self-treated hypoglycaemia amongst HCPs and patients with type 2 diabetes: results from the UK cohort of the Global Attitudes of Patient and Physicians (GAPP2) survey

AIMS

The Global Attitude of Patients and Physicians 2 (GAPP2) survey sought to address gaps in understanding about real-world basal insulin-taking behaviour and self-treated hypoglycaemia in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

The Global Attitude of Patients and Physicians 2 was an international, online, cross-sectional study of patients aged at least 40 years with type 2 diabetes taking analogue insulins, and healthcare professionals (HCPs). Patients were recruited from general consumer online research panels, comprising a representative sample of the population to minimise bias. HCPs were recruited from online specialist research panels. The results of the UK cohort are presented here.

RESULTS

The UK cohort constituted 12% of the total GAPP2 population. In this cohort, 15-25% of patients reported that they had reduced, missed or mistimed at least one dose of insulin in the previous month. On the last occasion that patients had reduced a dose, 82% had done so intentionally - most frequently because of concerns about hypoglycaemia. HCP estimates of the numbers of patients with dosing irregularities were nearly fourfold higher than patient reports. More than one-third of HCPs believe their patients under-report the frequency of self-treated hypoglycaemia. Nevertheless, a proportion did not regularly discuss these concerns with their patients.

CONCLUSIONS

Healthcare professionals are in the best position to support patients in making appropriate insulin dose adjustments to help regularise blood glucose levels and reduce treatment-induced hypoglycaemic events. This can be achieved by initiating frequent discussions with all patients and providing education and training when appropriate.

The trajectory of dispersal research in conservation biology. Systematic review

Dispersal knowledge is essential for conservation management, and demand is growing. But are we accumulating dispersal knowledge at a pace that can meet the demand? To answer this question we tested for changes in dispersal data collection and use over time. Our systematic review of 655 conservation-related publications compared five topics: climate change, habitat restoration, population viability analysis, land planning (systematic conservation planning) and invasive species. We analysed temporal changes in the: (i) questions asked by dispersal-related research; (ii) methods used to study dispersal; (iii) the quality of dispersal data; (iv) extent that dispersal knowledge is lacking, and; (v) likely consequences of limited dispersal knowledge. Research questions have changed little over time; the same problems examined in the 1990s are still being addressed. The most common methods used to study dispersal were occupancy data, expert opinion and modelling, which often provided indirect, low quality information about dispersal. Although use of genetics for estimating dispersal has increased, new ecological and genetic methods for measuring dispersal are not yet widely adopted. Almost half of the papers identified knowledge gaps related to dispersal. Limited dispersal knowledge often made it impossible to discover ecological processes or compromised conservation outcomes. The quality of dispersal data used in climate change research has increased since the 1990s. In comparison, restoration ecology inadequately addresses large-scale process, whilst the gap between knowledge accumulation and growth in applications may be increasing in land planning. To overcome apparent stagnation in collection and use of dispersal knowledge, researchers need to: (i) improve the quality of available data using new approaches; (ii) understand the complementarities of different methods and; (iii) define the value of different kinds of dispersal information for supporting management decisions. Ambitious, multi-disciplinary research programs studying many species are critical for advancing dispersal research.

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national comparisons on barriers and resources for optimal care--healthcare professional perspective

AIMS

The second Diabetes Attitudes, Wishes and Needs (DAWN2) study sought cross-national comparisons of perceptions on healthcare provision for benchmarking and sharing of clinical practices to improve diabetes care.

METHODS

In total, 4785 healthcare professionals caring for people with diabetes across 17 countries participated in an online survey designed to assess diabetes healthcare provision, self-management and training.

RESULTS

Between 61.4 and 92.9% of healthcare professionals felt that people with diabetes needed to improve various self-management activities; glucose monitoring (range, 29.3-92.1%) had the biggest country difference, with a between-country variance of 20%. The need for a major improvement in diabetes self-management education was reported by 60% (26.4-81.4%) of healthcare professionals, with a 12% between-country variance. Provision of diabetes services differed among countries, with many healthcare professionals indicating that major improvements were needed across a range of areas, including healthcare organization [30.6% (7.4-67.1%)], resources for diabetes prevention [78.8% (60.4-90.5%)], earlier diagnosis and treatment [67.9% (45.0-85.5%)], communication between team members and people with diabetes [56.1% (22.3-85.4%)], specialist nurse availability [63.8% (27.9-90.7%)] and psychological support [62.7% (40.6-79.6%)]. In some countries, up to one third of healthcare professionals reported not having received any formal diabetes training. Societal discrimination against people with diabetes was reported by 32.8% (11.4-79.6%) of participants.

CONCLUSIONS

This survey has highlighted concerns of healthcare professionals relating to diabetes healthcare provision, self-management and training. Identifying between-country differences in several areas will allow benchmarking and sharing of clinical practices.

Scalp EEG-based discrimination of cognitive deficits after traumatic brain injury using event-related Tsallis entropy analysis

Traumatic brain injury (TBI) is the leading cause of death and disability in children and adolescents in the U.S. This is a pilot study, which explores the discrimination of chronic TBI from normal controls using scalp EEG during a memory task. Tsallis entropies are computed for responses during an old-new memory recognition task. A support vector machine model is constructed to discriminate between normal and moderate/severe TBI individuals using Tsallis entropies as features. Numerical analyses of 30 records (15 normal and 15 TBI) show a maximum discrimination accuracy of 93% (p-value = 7.8557E-5) using four features. These results suggest the potential of scalp EEG as an efficacious method for noninvasive diagnosis of TBI.

RECURRENT OSTEOID OSTEOMA OF THE LUNATE: A CASE REPORT AND REVIEW OF THE LITERATURE

Osteoid osteoma is a benign tumour of bone that rarely localises in the carpal bones. Its treatment by curettage and bone grafting is considered to be curative and its recurrence is thought to be rare.

We report a case of an osteoid osteoma of the lunate, which recurred seven years after the initial operation. Recurrent osteoid osteoma of the lunate bone has not been reported in the literature. We present this case report for its atypical presentation and diagnostic difficulty and also to alert the readers of the possibility of an osteoid osteoma as a cause of the chronic unexplained wrist pain in young adults.

Accelerated MVAC as neoadjuvant chemotherapy for patients with muscle-invasive transitional cell carcinoma of the bladder

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Background: Meta-analysis data demonstrate a 5% absolute survival benefit for the use of neoadjuvant chemotherapy (NAC) using cisplatin-based combination regimens in the radical treatment of muscle-invasive bladder cancer (MIBC). However, there is currently no randomized controlled trial data on the optimum regimen for this setting. Accelerated MVAC (AMVAC) is effective in advanced disease, and has the potential advantage over other NAC regimens of minimising delays to definitive, potentially curative therapy. We present data regarding its use as NAC in MIBC patients.

Methods: Retrospective analysis was performed on all 80 consecutive patients with muscle-invasive transitional cell carcinoma of the bladder, treated during a 50-month period at 2 U.K. centers. Patients received either 3 or 4 cycles of methotrexate 30mg/m2, vinblastine 3mg/m2, doxorubicin 30mg/m2 and 4-hour infusion of cisplatin 70mg/m2 at 2-week intervals, with G-CSF support, prior to definitive therapy with either radical surgery (RS) or radical radiotherapy (RT).

Results: All planned cycles of chemotherapy were completed in 84% of patients. All 80 patients received their planned definitive therapy. Pathological complete response (pCR) was seen in 43% of 60 patients treated with surgery following chemotherapy. There were no chemotherapy-related deaths and grade 3 or 4 toxicities were seen in 11% of patients. Median duration of chemotherapy was 34 days. Dose reduction or delay was required in 7% and 9% of patients, respectively. Objective radiological local response was seen in 75% of patients. At a median follow-up of 27.5 months, 25 (32%) patients have relapsed and 11 (14%) died. Two-year disease-free survival was 65% overall, and was statistically significantly superior in patients who were radiologically node-negative prior to chemotherapy.

Conclusions: AMVAC is a safe, well-tolerated, and easily deliverable regimen with excellent treatment outcomes and minimizes delays to definitive treatment. It is an appropriate comparator for future randomized trials.

No significant financial relationships to disclose.

The use of poison baits to control feral cats and red foxes in arid South Australia II. Bait type, placement, lures and non-target uptake

Context Poison baits are often used to control both foxes and feral cats but success varies considerably. Aims This study investigated the influence of bait type, placement and lures on bait uptake by the feral cat, red fox and non-target species to improve baiting success and reduce non-target uptake. Methods Six short field trials were implemented during autumn and winter over a five-year period in northern South Australia. Key results Results suggest that poison baiting with Eradicat or dried kangaroo meat baits was inefficient for feral cats due to both low rates of bait detection and poor ingestion rates for baits that were encountered. Cats consumed more baits on dunes than swales and uptake was higher under bushes than in open areas. The use of auditory or olfactory lures adjacent to baits did not increase ingestion rates. Foxes consumed more baits encountered than cats and exhibited no preference between Eradicat and kangaroo meat baits. Bait uptake by native non-target species averaged between 14 and 57% of baits during the six trials, accounting for up to 90% of total bait uptake. Corvid species were primarily responsible for non-target uptake. Threatened mammal species investigated and nibbled baits but rarely consumed them; however, corvids and some common rodent species ingested enough poison to potentially receive a lethal dose. Conclusions It is likely that several factors contributed to poor bait uptake by cats including the presence of alternative prey, a preference for live prey, an aversion to scavenging or eating unfamiliar foods and a stronger reliance on visual rather than olfactory cues for locating food. Implications Further trials for control of feral cats should concentrate on increasing ingestion rates without the requirement for hunger through either involuntary ingestion via grooming or development of a highly palatable bait.

Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

Insulin for type 2 diabetes: choosing a second-line insulin regimen

Guidance has been published on the choice of initial insulin regimen for patients with type 2 diabetes [NPH (isophane) insulin or a long-acting insulin analogue] but not on how to choose a second regimen when glycaemic control becomes unsatisfactory.

AIMS

To develop pragmatic clinical guidance for choosing a second-line insulin regimen tailored to the individual needs of patients with type 2 diabetes after failure of first-line insulin therapy.

METHODS

Formulation of a consensus by expert panel based on published evidence and best clinical practice, taking into account patient preferences, lifestyle and functional capacity.

RESULTS

Six patient-dependent factors relevant to the choice of second-line insulin regimen and three alternative insulin regimens (twice-daily premixed, basal-plus and basal-bolus) were identified. The panel recommended one or more insulin regimens compatible with each factor, emphasising the fundamental importance of a healthy lifestyle that includes exercise and weight reduction. These recommendations were incorporated into an algorithm to provide pragmatic guidance for clinicians.

CONCLUSION

The three alternative insulin regimens offer different benefits and drawbacks and it is important to make the right choice to optimise outcomes for patients.

A systematic review of the clinical effectiveness and cost-effectiveness and economic modelling of minimal incision total hip replacement approaches in the management of arthritic disease of the hip

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of minimal incision approaches to total hip replacement (THR) for arthritis of the hip.

DATA SOURCES

Major electronic databases were searched from 1966 to 2007. Relevant websites were also examined and experts in the field were consulted.

REVIEW METHODS

Studies of minimal (one or two) incision THR compared with standard THR were assessed for inclusion in the review of clinical effectiveness. A systematic review of economic evaluations comparing a minimal incision approach to standard THR was also performed and the estimates from the systematic review of clinical effectiveness were incorporated into an economic model. Utilities data were sourced to estimate quality-adjusted life-years (QALYs). Due to lack of data, no economic analysis was conducted for the two mini-incision surgical method.

RESULTS

Nine randomised controlled trials (RCTs), 17 non-randomised comparative studies, six case series and one registry were found to be useful for the comparison of single mini-incision THR with standard THR. One RCT compared two mini-incision THR with standard THR, and two RCTs, five non-randomised comparative studies and two case series compared two mini-incision with single mini-incision THR. The RCTs were of moderate quality. Most had fewer than 200 patients and had a follow-up period of less than 1 year. The single mini-incision THR may have some perioperative advantages, e.g. blood loss [weighted mean difference (WMD) -57.71 ml, p<0.01] and shorter operative time, of uncertain practical significance. It may also offer a shorter recovery period and greater patient satisfaction. Evidence on long-term outcomes (especially revision) is too limited to be useful. Lack of data prevented subgroup analysis. With respect to the two-incision approach, data were suggestive of shorter recovery compared with single-incision THR, but conclusions must be treated with caution. The costs to the health service, per patient, of single mini-incision THR depend upon assumptions made, but are similar at one year (7060 pounds sterling vs 7350 pounds sterling for standard THR). For a 40-year time horizon the costs were 11,618 pounds sterling for mini-incision and 11,899 pounds sterling for standard THR. Two existing economic evaluations were identified, but they added little, if any, value to the current evidence base owing to their limited quality. In the economic model, mini-incision THR was less costly and provided slightly more QALYs in both the 1- and 40-year analyses. The mean QALYs at 1 year were 0.677 for standard THR and 0.695 for mini-incision THR. At 40 years, the mean QALYs were 8.463 for standard THR and 8.480 for mini-incision. At 1 year the probabilistic sensitivity analyses indicate that mini-incision THR has a 95% probability of being cost-effective if society's willingness to pay for a QALY were up to 50,000 pounds sterling. This is reduced to approximately 55% for the 40-year analysis. The results were driven by the assumption of a 1-month earlier return to usual activities and a decreased hospital length of stay and operation duration following mini-incision THR. If mini-incision THR actually required more intensive use of resources it would become approximately 200 pounds sterling more expensive and would only be cost-effective (cost per QALY>30,000 pounds sterling) if recovery was 1.5 weeks faster. A threshold analysis around risk of revision showed, using the same cost per QALY threshold, mini-incision THR would have to have no more than a 7.5% increase in revisions compared with standard THR for it to be no longer considered cost-effective (one more revision for every 200 procedures performed). Further sensitivity analysis involved relaxing assumptions of equal long-term outcomes where possible. and broadly similar results to the base-case analysis were found in this and further sensitivity analyses.

CONCLUSIONS

Compared with standard THR, minimal incision THR has small perioperative advantages in terms of blood loss and operation time. It may offer a shorter hospital stay and quicker recovery. It appears to have a similar procedure cost to standard THR, but evidence on its longer term performance is very limited. Further long-term follow-up data on costs and outcomes including analysis of subgroups of interest to the NHS would strengthen the current economic evaluation.

Raising diabetes awareness in the public domain

Type 2 diabetes mellitus (T2DM) is a chronic, debilitating and costly disease associated with severe complications, and has been recognised as such by the United Nations (UN). But despite being a leading cause of death and serious disability worldwide, the public often perceive T2DM as a relatively mild condition. Furthermore, many people do not know that T2DM is preventable and that steps can be taken to minimise the risk of developing the disease. Improved public awareness of T2DM and its link with obesity and physical inactivity is critical, not only to prevention but also management of diabetes. Recognising this need, the UN has issued a resolution calling on member states to observe World Diabetes Day and implement education and mass media initiatives to raise public awareness of diabetes and its complications. This article reviews selected local, national and international public awareness campaigns to illustrate the range of initiatives that together can work towards the goals of the UN Resolution. By building understanding of diabetes, changing beliefs and attitudes and promoting positive behaviours, such initiatives can help combat the global diabetes epidemic and improve the health and wellbeing of people.

Improving glucose management: ten steps to get more patients with type 2 diabetes to glycaemic goal. Recommendations from the Global Partnership for Effective Diabetes Management

Despite increasingly stringent clinical practice guidelines for glycaemic control, the implementation of recommendations has been disappointing, with over 60% of patients not reaching recommended glycaemic goals. As a result, current management of glycaemia falls significantly short of accepted treatment goals. The Global Partnership for Effective Diabetes Management has identified a number of major barriers that can prevent individuals from achieving their glycaemic targets. This article proposes 10 key practical recommendations to aid healthcare providers in overcoming these barriers and to enable a greater proportion of patients to achieve glycaemic goals. These include advice on targeting the underlying pathophysiology of type 2 diabetes, treating early and effectively with combination therapies, adopting a holistic, multidisciplinary approach and improving patient understanding of type 2 diabetes. Implementation of these recommendations should reduce the risk of diabetes-related complications, improve patient quality of life and impact more effectively on the increasing healthcare cost related to diabetes.

Improving glucose management: ten steps to get more patients with type 2 diabetes to glycaemic goal

Despite increasingly stringent clinical practice guidelines for glycaemic control, the implementation of recommendations has been disappointing, with over 60% of patients not reaching recommended glycaemic goals. As a result, current management of glycaemia falls significantly short of accepted treatment goals. The Global Partnership for Effective Diabetes Management has identified a number of major barriers that can prevent individuals from achieving their glycaemic targets. This article proposes 10 key practical recommendations to aid healthcare providers in overcoming these barriers and to enable a greater proportion of patients to achieve glycaemic goals. These include advice on targeting the underlying pathophysiology of type 2 diabetes, treating early and effectively with combination therapies, adopting a holistic, multidisciplinary approach and improving patient understanding of type 2 diabetes. Implementation of these recommendations should reduce the risk of diabetes-related complications, improve patient quality of life and impact more effectively on the increasing healthcare cost related to diabetes.

Home range, activity and habitat use of European rabbits (Oryctolagus cuniculus) in arid Australia: implications for control

The home range, activity and habitat use of wild European rabbits in northern South Australia were compared during winter and summer, and results used to suggest improvements to control techniques. Average home range was significantly smaller in summer (2.1 ha) than winter (4.2 ha) and there was no significant difference between the sexes. Rabbits used both dune and swale habitat but most warrens and more surface fixes were recorded in dune habitat in both seasons. Proportionally more surface fixes were found in swale habitat at night than during the day. The proportion of diurnal fixes on the surface was not significantly influenced by season, averaging 47% in winter and 62% in summer. Only 30% of radio-collared rabbits flushed by humans retreated to warrens. Comparable levels of diurnal surface activity in both winter and summer suggest that the death rate from fumigation or warren destruction may be similar in both seasons. High levels of diurnal surface activity suggest that warren fumigation may be ineffective unless rabbits can first be flushed to their warrens. The use of dogs to flush rabbits before fumigation or ripping should increase the efficacy of control. Activity data suggest that fumigation or ripping should be conducted between 0900 and 1600 hours in winter and 1100 and 1800 hours in summer when radio-collared rabbits were most likely to be down their warrens. Home-range data suggest that the effectiveness of poison baiting may be increased by placing bait lines closer together in summer and, although bait lines should be concentrated in dune habitat, some poison should also be placed in swale feeding areas remote from warrens. The most successful control method for radio-collared rabbits was fumigation with phosphine gas tablets, with 10 of 11 rabbits successfully killed. Pressure fumigation with chloropicrin was also successful but 1080 poisoning and warren destruction using shovels were all relatively unsuccessful.

Is multidisciplinary learning effective among those caring for people with diabetes?

The role of multi-professional learning for those providing clinical services to people with diabetes has yet to be defined. Several assumptions are generally made about education in the context of multi-professional settings. It is argued that different professions learning together could potentially improve professional relationships, collaborative working practices and ultimately standards of care. Greater respect and honesty may emerge from a team approach to learning with a commensurate reduction in professional antagonism. Personal and professional confidence is reportedly enhanced through close contact with other professionals during team-based learning exercises. We have examined current evidence to support multidisciplinary learning in the context of medical education generally as well as in diabetes education. Previous investigation of available literature by Cochrane reviewers, aimed at identifying studies of interprofessional education interventions, yielded a total of 1042 articles, none of which met the stated inclusion criteria. Searches involving more recent publications failed to reveal more robust evidence. Despite a large body of literature on the evaluation of interprofessional education, studies generally lacked the methodological rigour needed to understand the impact of interprofessional education on professional practice and/or health care outcomes. Nevertheless, planners continue to advocate, and endorse, joint training between different groups of workers (including nurses, doctors and those in professions allied to medicine) with the objective of producing an integrated workforce of multidisciplinary teams. Whilst the concept of multi-professional learning has strong appeal, it is necessary for those responsible for educating health care professionals to demonstrate its superiority over separate learning experiences.

Pulmonary challenges in neurotrauma

Traumatic injury to the central nervous system presents a formidable clinical challenge to any practitioner. Part of that challenge is to anticipate the pulmonary sequelae that may occur in this patient population. Direct pulmonary trauma commonly occurs with CNS injury and requires immediate treatment to prevent further compromise of the patient's condition. Neurologic deficits can then be compounded by complications such as ARDS and aspiration pneumonia that can be minimized if not prevented. The nurse is a key health care professional who can implement these interventions and effect better patient outcomes.

Assessing validity in written tests of general practice - exploration by factor analysis of candidate response patterns to paper 1 of the MRCGP examination

OBJECTIVE

To investigate the content validity of Paper 1 of the MRCGP examination.

METHOD

Exploratory factor analysis was carried out on candidate responses to Paper 1 of the May and October MRCGP examination in 1998. Contribution of each test question across factors was assessed using a pattern matrix of the oblique rotation. Common dimensions and variations between factor sets were identified. Key testing areas were then matched against the 'domains of competence' intended to be assessed by Paper 1 (as defined within the examination blueprint matrix).

RESULTS

Whilst critical appraisal, disease prevention/evidence-based medicine and clinical management emerged as areas tested consistently, content variation was observed between factor sets extracted from both sittings. In addition, some overlap, in terms of domains tested, was seen among other assessment instruments used within the examination.

CONCLUSION

Paper 1 conforms to the majority of its stated intentions. However, further development of techniques for investigating validity will be required in order to minimize content variation between both sittings of the examination as well as to help more closely define areas of competence to be tested by Paper 1 of the MRCGP examination.

Single-strand conformation polymorphism analysis by capillary and microchip electrophoresis: a fast, simple method for detection of common mutations in BRCA1 and BRCA2

As a result of intensive studies on hereditary breast and ovarian cancers, two breast cancer susceptibility genes, BRCA1 and BRCA2, have been identified. In each gene, a small number of specific mutations have been found at relatively high frequency in certain ethnic populations. The mutations, 185delAG and 5382insC in BRCA1 and 6174delT in BRCA2, have been identified as common mutations in the Ashkenazi Jewish population, with a combined frequency of 2.0 to 2.5%. Women who have one of the above three common mutations are at a high risk of developing breast or ovarian cancer. Consequently, accurate and cost-effective detection of these three mutations may have important implications for risk assessment in susceptible women and men. In this report, we describe a fast and simple capillary electrophoresis (CE)-based method using a polymer network for screening the three common mutations in BRCA1 and BRCA2. Fluorescent dye-labeled primers (6-FAM-tagged) were used to amplify three DNA fragments of 258, 296, and 201 bp for detection of the 185delAG, 5382insC, and 6174delT mutations, respectively. After the PCR products were denatured, a single-strand conformation polymorphism (SSCP) profile could be obtained for each mutation in less than 10 min by CE in a polymer network. We demonstrate the potential provided by translating this assay to the microchip format where the SSCP analysis is complete in 120 s, representing only a fraction of the reduction in analysis time that can be achieved with microchip technology. The speed and simplicity of the SSCP methodology for detection of these mutations make it attractive for use in the clinical diagnostic laboratory.

Acousto-optical deflection-based laser beam scanning for fluorescence detection on multichannel electrophoretic microchips

Laser beam scanning driven by an acousto-optical deflector (AOD) is presented for multimicrochannel laser-induced fluorescence (LIF) detection during microchip-based electrophoresis. While fast laser beam scanning for LIF detection on capillary or microchannel arrays can been achieved with galvanometric scanning or a translating stage, it can also be accomplished by using acoustic waves to deflect the laser beam in a manner that is dependent on the acoustic frequency. AOD scanning differs from other approaches in that no moving parts are required, and the scan frequency is faster than conventional approaches. Using a digital/analog (D/A) converter to provide addressing voltages to a voltage/frequency converter, rapidly changing the frequency input to the AOD allows the laser beam to be addressed accurately on a microchip. With the ability to change the frequency on the nanosecond time scale, scanning rates as high as 30 Hz for Windows-based LabView programming are possible, with much faster scan rates achievable if a microprocessor-embedded system is utilized. In addition to spatial control, temporal control is easily attainable via raster scanning or random addressing, allowing for the scanning process to be self-aligning. Since the D/A output voltages drive the scanning of the laser beam over all channels, the software can define addressing voltages corresponding to the microchannel centers and, subsequently, fluorescence data can be collected from only those locations. This method allows for flexible, high-speed, self-align scanning for fluorescence detection in capillary or microchip electrophoresis and has the potential to be applied to a number of applications.

Creating a general practice national minimum data set: present possibility or future plan?

AIM

To assess the feasibility of implementing the recommendations of the New Zealand National Minimum Data Set working party in computerised general practices.

METHOD

Doctors from 12 computerised general practices belonging to the Royal New Zealand College of General Practitioners' Dunedin Research Unit Computer Network participated in the study (five Dunedin practices, four in rural Otago and Southland, and three in Christchurch). A three-month sample of data was extracted from practice computers and evaluated for completeness and compliance to the national minimum data set structure. Rates of recording practice identifier, provider, patient identifiers, sex, ethnicity, government subsidy eligibility, consultation identifier and date, prescriptions and Read codes were calculated for each practice.

RESULTS

Apart from data recorded automatically by computers, there was a wide range in the extent of missing data. Of the data requiring manual computer entry, patient demography and subsidy eligibility were most comprehensively recorded (date of birth 99.9%, sex 99.6%, eligibility to subsidies 98.5%). Data with little immediate clinical or management relevance were poorly recorded (Read codes 32.4% and ethnicity 5.0%).

CONCLUSIONS

It is possible to derive a common minimum data set from different computerised general practices. However some data elements will be missing unless suitable education and support are provided for the doctors and other staff members who record patient information.

Neuroendocrine responses to d-fenfluramine and insulin-induced hypoglycemia in chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a disorder characterized by severe physical and mental fatigue and fatiguability of central rather than peripheral origin. We hypothesized that CFS is mediated by changes in hypothalamopituitary function and so measured the adrenocorticotrophic hormone (ACTH), cortisol, growth hormone, and prolactin responses to insulin-induced hypoglycemia, and the ACTH, cortisol, and prolactin responses to serotoninergic stimulation with dexfenfluramine in nondepressed CFS patients and normal controls. We have shown attenuated prolactin responses to hypoglycemia in CFS. There was also a greater ACTH response and higher peak ACTH concentrations (36.44 +/- 4.45 versus 25.60 +/- 2.78 pg ml), whereas cortisol responses did not differ, findings that are compatible with impaired adrenal cortical function. This study provided evidence for both pituitary and adrenal cortical impairment in CFS and further studies are merited to both confirm and determine more precisely their neurobiological basis so that rational treatments can be evolved.

Toxicity of the organophosphate chemical warfare agents GA, GB, and VX: implications for public protection

The nerve agents, GA, GB, and VX are organophosphorus esters that form a major portion of the total agent volume contained in the U.S. stockpile of unitary chemical munitions. Congress has mandated the destruction of these agents, which is currently slated for completion in 2004. The acute, chronic, and delayed toxicity of these agents is reviewed in this analysis. The largely negative results from studies of genotoxicity, carcinogenicity, developmental, and reproductive toxicity are also presented. Nerve agents show few or delayed effects. At supralethal doses, GB can cause delayed neuropathy in antidote-protected chickens, but there is no evidence that it causes this syndrome in humans at any dose. Agent VX shows no potential for inducing delayed neuropathy in any species. In view of their lack of genotoxicity, the nerve agents are not likely to be carcinogens. The overreaching concern with regard to nerve agent exposure is the extraordinarily high acute toxicity of these substances. Furthermore, acute effects of moderate exposure such as nausea, diarrhea, inability to perform simple mental tasks, and respiratory effects may render the public unable to respond adequately to emergency instructions in the unlikely event of agent release, making early warning and exposure avoidance important. Likewise, exposure or self-contamination of first responders and medical personnel must be avoided. Control limits for exposure via surface contact of drinking water are needed, as are detection methods for low levels in water or foodstuffs.

The stability of binocular fixation during reading in adults and children

The authors recorded the binocular eye-movements of children and adults while they read single words appropriate for their reading ability. Normal data were obtained from nine- to 11-year-old primary-school children and adults, because very little is known about changes in binocular vergence during reading. These normal data were compared with those from poor readers of the same age who had passed or failed the Dunlop Test. On average, normal children made larger vergence errors while they fixated words than did adults. There were no differences between the groups of children, therefore the authors conclude that poor vergence control during reading fixations is not the immediate cause of the non-word error effect found among children who fail the Dunlop Test.