Ability of verbal autopsy data to detect deaths due to uncontrolled hyperglycaemia: testing existing methods and development and validation of a novel weighted score

OBJECTIVES

Verbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4).

SETTING

This study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi.

PARTICIPANTS

All deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga.

RESULTS

Of the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen's kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%.

CONCLUSION

Our results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist.

Retrospective observational study of the impact on emergency admission of telehealth at scale delivered in community care in Liverpool, UK

OBJECTIVE

To assess the effect of a real world, ongoing telehealth service on the use of secondary healthcare.

DESIGN

A retrospective observational study with anonymous matched controls.

SETTING

Primary and community healthcare. Patients were recruited over 4 years in 89 general practices in Liverpool, UK and remotely managed by a dedicated clinical team in Liverpool Community Health.

PARTICIPANTS

5154 patients with chronic obstructive pulmonary disease, heart failure or diabetes were enrolled in the programme, of whom 3562 satisfied the inclusion criteria of this study.

INTERVENTION

At least 9 weeks of telehealth including vital sign collection, questionnaires, education, support and informal coaching by clinical staff.

PRIMARY OUTCOME

Reduction in the number of emergency admissions in the 12 months after start, compared with the year before start. Secondary subgroup analysis to improve future targeting and personalisation of the service.

RESULT

The average number of emergency admissions for the intervention group at baseline is 0.35, 95% CI 0.32 to 0.38. The differential decrease in emergency admissions in the intervention group in comparison with the control group, the average treatment effect, is 0.08, 95 CI 0.05 to 0.11, corresponding to an average percentage decrease of 22.7%. In subgroup analysis, a score is calculated that can be used prospectively to predict individual benefit from the intervention. Patients with an above median score (37%) are predicted average reduction in emergency admissions of 0.15, 95% CI 0.09 to 0.2, corresponding to a percentage decrease in admissions of 25.3%.

CONCLUSION

The telehealth intervention has a positive impact across a wide cohort of patients with different diseases. Prospective scoring of patients and allocation to targeted telehealth interventions is likely to improve the effectiveness and efficiency of the service.

Impact of drugs on hypoglycaemia in hospitalised patients

Objectives

Hospital admission rates for hypoglycaemia now exceed those for hyperglycaemias among older adults. A growing number of reports associating hypoglycaemia with non-antidiabetic drugs have been published. Clinical pharmacists are often faced with hypoglycaemia in patients taking multiple medications. This study assessed the potential relationship between prescribed drugs and episodes of hypoglycaemia during hospitalisation.

Methods

Point-of-care blood glucose values and prescribed drugs were analysed in patients admitted to a regional hospital. Hypoglycaemia cases were defined as patients with at least one hypoglycaemic event (random glucose value ≤3.9 mmol/L), and normoglycaemic cases as those with random glucose concentrations within the range of 4.5-5.8 mmol/L. Analyses were carried out using multivariate logistic regressions and Cox proportional hazard models.

Results

373 patients (53% males; median age=74 years) were included in the analysis and of these, 64 (17%) had at least one hypoglycaemic event. Patients who experienced a hypoglycaemic event had a longer length of stay (median=10 vs 7 days, p<0.01) and a higher rate of antidiabetic drugs prescription (83% vs 37%, p<0.01). The number of non-antidiabetic drugs was associated with an increased risk of hypoglycaemia during hospitalisation (HR 2.3, 95% CI 1.4 to 4, p<0.01). After adjusting by confounders, heparin and pantoprazole were found to be associated with hypoglycaemia.

Conclusions

The relationship between hypoglycaemia and polypharmacy reinforces the advice to limit polymedication as much as possible, especially in elderly patients. This result underlines the potential involvement of clinical pharmacists with the aim to reduce the risk of hypoglycaemia during hospitalisation.

Effects of retinopathy and chronic kidney disease on long-term mortality in type 2 diabetic inpatients with normal urinary albumin or protein: a retrospective cohort study

OBJECTIVE

Normoalbuminuric chronic kidney disease (NA-CKD) is recognised as a distinct phenotype of diabetic kidney disease, but the role of diabetic retinopathy (DR) in predicting long-term mortality among these patients remains unclear. Here, we aimed to investigate the effects of DR and CKD on mortality in type 2 diabetic patients with normoalbuminuria.

DESIGN

We conducted this study as a retrospective cohort study.

SETTING

We collected clinical information from the medical records of a public medical centre in central Taiwan.

PARTICIPANTS

Patients with type 2 diabetes (n=665) who were hospitalised due to poor glucose control were consecutively enrolled and followed for a median of 6.7 years (IQR 4.1‒9.6 years). Patients with either urinary protein excretion >150 mg/day or urine albumin excretion >30 mg/day were excluded.

PRIMARY OUTCOME MEASURE

All-cause mortality served as the primary follow-up outcome, and the mortality data were obtained from the national registry in Taiwan.

RESULTS

The patients with CKD and DR showed the highest mortality rate (log-rank p<0.001). The risks of all-cause mortality (HR 2.263; 95% CI 1.551 to 3.302) and cardiovascular mortality (HR 2.471; 95% CI 1.421 to 4.297) were significantly greater in patients with CKD and DR than in those without CKD or DR, after adjusting for the associated risk factors.

CONCLUSIONS

DR is an independent predictor for all-cause and cardiovascular mortality in type 2 diabetic inpatients with normoalbuminuria. Moreover, DR with CKD shows the highest risks of all-cause and cardiovascular mortality among these patients. Funduscopy screening can provide additive information on mortality in patients with type 2 diabetes, even among those with NA-CKD.

Projecting diabetes prevalence among Mexicans aged 50 years and older: the Future Elderly Model-Mexico (FEM-Mexico)

OBJECTIVE

Diabetes has been growing as a major health problem and a significant burden on the population and on health systems of developing countries like Mexico that are also ageing fast. The goal of the study was to estimate the future prevalence of diabetes among Mexico's older adults to assess the current and future health and economic burden of diabetes.

DESIGN

A simulation study using longitudinal data from three waves (2001, 2003 and 2012) of the Mexican Health and Aging Study and adapting the Future Elderly Model to simulate four scenarios of hypothetical interventions that would reduce diabetes incidence and to project the future diabetes prevalence rates among populations 50 years and older.

PARTICIPANTS

Data from 14 662 participants with information on self-reported diabetes, demographic characteristics, health and mortality.

OUTCOME MEASURES

We obtained, for each scenario of diabetes incidence reduction, the following summary measures for the population aged 50 and older from 2012 to 2050: prevalence of diabetes, total population with diabetes, number of medical visits.

RESULTS

In 2012, there were approximately 20.7 million persons aged 50 and older in Mexico; 19.3% had been diagnosed with diabetes and the 2001-2003 diabetes incidence was 4.3%. The no-intervention scenario shows that the prevalence of diabetes is projected to increase from 19.3% in 2012 to 34.0% in 2050. Under the 30% incidence reduction scenario, the prevalence of diabetes will be 28.6% in 2050. Comparing the no-intervention scenario with the 30% and 60% diabetes incidence reduction scenarios, we estimate a total of 816 320 and 1.6 million annual averted cases of diabetes, respectively, for the year 2020.

DISCUSSION

Our study underscores the importance of diabetes as a disease by itself and also the potential healthcare demands and social burden of this disease and the need for policy interventions to reduce diabetes prevalence.

Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings

OBJECTIVES

Poorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings.

DESIGN

Systematic review.

SETTING

Primary care and community settings.

INCLUDED STUDIES

Randomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%).

INTERVENTIONS

Interventions were classified as organisational, patient-oriented, professional, financial or regulatory.

OUTCOMES

Primary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity.

RESULTS

Forty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by -0.34% (95% CI -0.46% to -0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good.

CONCLUSIONS

This review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective.

Self-rated health and type 2 diabetes risk in the European Prospective Investigation into Cancer and Nutrition-InterAct study: a case-cohort study

OBJECTIVES

To investigate the association between self-rated health and risk of type 2 diabetes and whether the strength of this association is consistent across five European centres.

DESIGN

Population-based prospective case-cohort study.

SETTING

Enrolment took place between 1992 and 2000 in five European centres (Bilthoven, Cambridge, Heidelberg, Potsdam and Umeå).

PARTICIPANTS

Self-rated health was assessed by a baseline questionnaire in 3399 incident type 2 diabetic case participants and a centre-stratified subcohort of 4619 individuals from the European Prospective Investigation into Cancer and Nutrition (EPIC)-InterAct study which was drawn from a total cohort of 340 234 participants in the EPIC.

PRIMARY OUTCOME MEASURE

Prentice-weighted Cox regression was used to estimate centre-specific HRs and 95% CIs for incident type 2 diabetes controlling for age, sex, centre, education, body mass index (BMI), smoking, alcohol consumption, energy intake, physical activity and hypertension. The centre-specific HRs were pooled across centres by random effects meta-analysis.

RESULTS

Low self-rated health was associated with a higher hazard of type 2 diabetes after adjusting for age and sex (pooled HR 1.67, 95% CI 1.48 to 1.88). After additional adjustment for health-related variables including BMI, the association was attenuated but remained statistically significant (pooled HR 1.29, 95% CI 1.09 to 1.53). I(2) index for heterogeneity across centres was 13.3% (p=0.33).

CONCLUSIONS

Low self-rated health was associated with a higher risk of type 2 diabetes. The association could be only partly explained by other health-related variables, of which obesity was the strongest. We found no indication of heterogeneity in the association between self-rated health and type 2 diabetes mellitus across the European centres.

Does an intensive self-management structured education course improve outcomes for children and young people with type 1 diabetes? The Kids In Control OF Food (KICk-OFF) cluster-randomised controlled trial protocol

INTRODUCTION

The Kids In Control OF Food (KICk-OFF) is a cluster-randomised controlled trial, which aims to determine the efficacy of a 5 day structured education course for 11-year-olds to 16-year-olds with type 1 diabetes (T1DM) when compared with standard care, and its cost effectiveness. Less than 15% of children and young people with T1DM in the UK meet the recommended glycaemic target. Self-management education programmes for adults with T1DM improve clinical and psychological outcomes, but none have been evaluated in the paediatric population. KICk-OFF is a 5-day structured education course for 11-year-olds to 16- year-olds with T1DM. It was developed with input from young people, parents, teachers and educationalists.

METHODS AND ANALYSIS

36 paediatric diabetes centres across the UK randomised into intervention and control arms. Up to 560 participants were recruited prior to centre randomisation. KICk-OFF courses are delivered in the intervention centres, with standard care continued in the control arm. Primary outcomes are change in glycaemic control (HbA1c) and quality of life between baseline and 6 months postintervention, and the incidence of severe hypoglycaemia. Sustained change in self-management behaviour is assessed by follow-up at 12 and 24 months. Health economic analysis will be undertaken. Data will be reported according to the CONSORT statement for cluster-randomised clinical trials. All analyses will be by intention-to-treat with a two-sided p value of <0.05 being regarded as statistically significant. The study commenced in 2008. Data collection from participants is ongoing and the study will be completed in 2013.

ETHICS

The study has been approved by the Sheffield Research Ethics Committee.

DISSEMINATION

Results will be reported in peer reviewed journals and conferences.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37042683.

An exploratory qualitative interview study about collaboration between medicine and dentistry in relation to diabetes management

OBJECTIVE

To explore knowledge and attitudes regarding the links between diabetes and periodontitis of medical and dental healthcare professionals as well as those of people with diabetes.

DESIGN

Qualitative interview study.

PARTICIPANTS

4 people with diabetes, four dental professionals, three general practitioners (GPs) with a specialist interest in diabetes, one GP without a specialist interest in diabetes, three diabetic nurse specialists and two consultant diabetologists.

SETTING

Primary and secondary care in Newcastle upon Tyne.

METHODS

Interviews were audio recorded and transcribed verbatim. Framework analysis was used iteratively to achieve progressive focusing and to develop conceptual ideas.

RESULTS

3 inter-related themes emerged: (1) uncertain knowledge-a lack of familiarity about the links between periodontitis and diabetes; (2) unworkable knowledge-that even if the links between periodontitis and diabetes were known, it is impossible for anything to be done for patient benefit given the differing systems that medical and dental health professionals work in and (3) isolated knowledge-the perceived division that exists between the medical and dental professions has the potential to negatively impact on advances in diabetes patient care. The patients simply wanted all the healthcare professionals to be giving the same messages consistently and to help them access the (dental) care they need.

CONCLUSIONS

The research on the links between periodontal disease and diabetes appears to have limited impact on the organisation of diabetes care, and the divisions that exist between the medical and dental professions have the potential to negatively impact on patient care.

Aspirin treatment and risk of first incident cardiovascular diseases in patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register

OBJECTIVES

To investigate the benefits and risks associated with aspirin treatment in patients with type 2 diabetes and no previous cardiovascular disease (CVD) in clinical practice.

DESIGN

Population-based cohort study between 2005 and 2009, mean follow-up 3.9 years.

SETTING

Hospital outpatient clinics and primary care in Sweden.

PARTICIPANTS

Men and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14 038).

MAIN OUTCOME MEASURES

Risks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis.

RESULTS

There was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99).

CONCLUSIONS

The results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.

Quality improvement needed in quality improvement randomised trials: systematic review of interventions to improve care in diabetes

OBJECTIVE

Despite the increasing numbers of published trials of quality improvement (QI) interventions in diabetes, little is known about the risk of bias in this literature.

DESIGN

Secondary analysis of a systematic review.

DATA SOURCES

Medline, the Cochrane Effective Practice and Organisation of Care (EPOC) database (from inception to July 2010) and references of included studies.

ELIGIBILITY CRITERIA

Randomised trials assessing 11 predefined QI strategies or financial incentives targeting health systems, healthcare professionals or patients to improve the management of adult outpatients with diabetes.

ANALYSIS

Risk of bias (low, unclear or high) was assessed for the 142 trials in the review across nine domains using the EPOC version of the Cochrane Risk of Bias Tool. We used Cochran-Armitage tests for trends to evaluate the improvement over time.

RESULTS

There was no significant improvement over time in any of the risk of bias domains. Attrition bias (loss to follow-up) was the most common source of bias, with 24 trials (17%) having high risk of bias due to incomplete outcome data. Overall, 69 trials (49%) had at least one domain with high risk of bias. Inadequate reporting frequently hampered the risk of bias assessment: allocation sequence was unclear in 82 trials (58%) and allocation concealment was unclear in 78 trials (55%). There were significant reductions neither in the proportions of studies at high risk of bias over time nor in the adequacy of reporting of risk of bias domains.

CONCLUSIONS

Nearly half of the included QI trials in this review were judged to have high risk of bias. Such trials have serious limitations that put the findings in question and therefore inhibit evidence-based QI. There is a need to limit the potential for bias when conducting QI trials and improve the quality of reporting of QI trials so that stakeholders have adequate evidence for implementation.

Impact of universal health insurance coverage in Thailand on sales and market share of medicines for non-communicable diseases: an interrupted time series study

OBJECTIVE

In 2001, Thailand implemented the Universal Coverage Scheme (UCS), a public insurance system that aimed to achieve universal access to healthcare, including essential medicines, and to influence primary care centres and hospitals to use resources efficiently, via capitated payment for outpatient services and other payment policies for inpatient care. Our objective was to evaluate the impact of the UCS on utilisation of medicines in Thailand for three non-communicable diseases: cancer, cardiovascular disease and diabetes.

DESIGN

Interrupted time-series design, with a non-equivalent comparison group.

SETTING

Thailand, 1998-2006.

DATA

Quarterly purchases of medicines from hospital and retail pharmacies collected by IMS Health between 1998 and 2006.

INTERVENTION

UCS implementation, April-October 2001.

OUTCOME MEASURES

Total pharmaceutical sales volume and percent market share by licensing status and National Essential Medicine List status.

RESULTS

The UCS was associated with long-term increases in sales of medicines for conditions that are typically treated in outpatient primary care settings, such as diabetes, high cholesterol and high blood pressure, but not for medicines for diseases that are typically treated in secondary or tertiary care settings, such as heart failure, arrhythmias and cancer. Although the majority of increases in sales were for essential medicines, there were also postpolicy increases in sales of non-essential medicines. Immediately following the reform, there was a significant shift in hospital sector market share by licensing status for most classes of medicines. Government-produced products often replaced branded generic or generic competitors.

CONCLUSIONS

Our results suggest that expanding health insurance coverage with a medicine benefit to the entire Thai population increased access to medicines in primary care. However, our study also suggests that the UCS may have had potentially undesirable effects. Evaluations of the long-term impacts of universal health coverage on medicine utilisation are urgently needed.

Is thiazolidinediones use a factor in delaying the need for insulin therapy in type 2 patients with diabetes? A population-based cohort study

OBJECTIVE

To understand the independent role of thiazolidinediones (TZDs) in delaying progression to parenteral insulin therapy.

DESIGN

Population-based retrospective cohort study.

SETTING

British Columbia, Canada.

PARTICIPANTS

A total of 18 867 type 2 diabetes patients (mean age 58.9) treated with metformin as first-line therapy who then switched or added a TZD or sulphonylurea as a second-line treatment between 1 January 1998 and 31 March 2008.

OUTCOME MEASURES

Multivariable Poisson regression models were used to estimate the effect of using TZD compared to sulphonylureas on time to the initiation of insulin treatment (third-line).

RESULTS

The adjusted rate difference in women aged <60 showed 2.22 fewer insulin initiation events per 100 person-years (PYs) in the TZD group versus the sulphonylurea group (95% CI -3.46 to -0.99). Men in the same age group had 1.50 fewer insulin initiation events per 100 PYs in the TZD group versus the sulphonylurea group (95% CI -2.44 to -0.56). The average time in days to initiation on insulin in the sulphonylurea, rosiglitazone and pioglitazone group was 343, 252 and 339, respectively. The cumulative hazard for starting insulin for sulphonylurea patients at 12, 24, 36 and 48 months was approximately three times higher compared to TZD patients.

CONCLUSIONS

Second-line TZD therapy compared to second-line sulphonylurea therapy was associated with a lower incidence of insulin initiation as third-line treatment in patients with type 2 diabetes, with a mean delay of 90 days. This duration of delay must be weighed against the absence of a proven reduction in morbidity or mortality with TZDs and their known serious cardiovascular harm.

Systematic review of SGLT2 receptor inhibitors in dual or triple therapy in type 2 diabetes

BACKGROUND

Despite the number of medications for type 2 diabetes, many people with the condition do not achieve good glycaemic control. Some existing glucose-lowering agents have adverse effects such as weight gain or hypoglycaemia. Type 2 diabetes tends to be a progressive disease, and most patients require treatment with combinations of glucose-lowering agents. The sodium glucose co-transporter 2 (SGLT2) receptor inhibitors are a new class of glucose-lowering agents.

OBJECTIVE

To assess the clinical effectiveness and safety of the SGLT2 receptor inhibitors in dual or triple therapy in type 2 diabetes.

DATA SOURCES

MEDLINE, Embase, Cochrane Library (all sections); Science Citation Index; trial registries; conference abstracts; drug regulatory authorities; bibliographies of retrieved papers.

INCLUSION CRITERIA

Randomised controlled trials of SGLT2 receptor inhibitors compared with placebo or active comparator in type 2 diabetes in dual or combination therapy.

METHODS

Systematic review. Quality assessment used the Cochrane risk of bias score.

RESULTS

Seven trials, published in full, assessed dapagliflozin and one assessed canagliflozin. Trial quality appeared good. Dapagliflozin 10 mg reduced HbA1c by -0.54% (weighted mean differences (WMD), 95% CI -0.67 to -0.40) compared to placebo, but there was no difference compared to glipizide. Canagliflozin reduced HbA1c slightly more than sitagliptin (up to -0.21% vs sitagliptin). Both dapagliflozin and canagliflozin led to weight loss (dapagliflozin WMD -1.81 kg (95% CI -2.04 to -1.57), canagliflozin up to -2.3 kg compared to placebo).

LIMITATIONS

Long-term trial extensions suggested that effects were maintained over time. Data on canagliflozin are currently available from only one paper. Costs of the drugs are not known so cost-effectiveness cannot be assessed. More data on safety are needed, with the Food and Drug Administration having concerns about breast and bladder cancers.

CONCLUSIONS

Dapagliflozin appears effective in reducing HbA1c and weight in type 2 diabetes, although more safety data are needed.

Promoting physical activity in sedentary elderly Malays with type 2 diabetes: a protocol for randomised controlled trial

INTRODUCTION

Like many countries Malaysia is facing an increase in the number of people with type 2 diabetes mellitus diabetes (T2DM) and modifiable lifestyle factors such as sedentary behaviour are important drivers of this increase. The level of physical activity is low among elderly Malay people. In Malaysia, strategies to promote physical activity in elderly Malay people with T2DM are not well documented in the research literature. This paper discusses an intervention to increase physical activity in elderly Malay people with T2DM. The aim of our study was to evaluate the effectiveness of personalised feedback alone and in combination with peer support in promoting and maintaining physical activity in comparison with usual care.

METHODS AND ANALYSIS

A three-arm randomised controlled trial will be conducted among sedentary Malay adults aged 60 years and above with T2DM attending an urban primary healthcare clinic in Malaysia. The participants will be randomised into three groups for a 12-week intervention with a follow-up at 24 and 36 weeks to assess adherence. The primary outcome of this study is pedometer-determined physical activity. Glycaemic and blood pressure control, body composition, cardiorespiratory fitness, balance, lipid profile, health-related quality of life, psychological well-being, social support and self-efficacy for exercise are the secondary measures. Linear mixed models will be used to determine the effect of the intervention over time and between groups. ETHICAL AND DISSEMINATION: The Monash University Human Research Ethics Committee and the Malaysian Ministry of Health's Medical Research Ethics Committee approved this protocol. The findings of this study will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION

This study protocol has been registered with the Malaysian National Medical Research Registry and with the Current Controlled Trial Ltd (http://www.controlled-trials.com/ISRCTN71447000/).

Dyslipidaemia in HIV-1-infected patients receiving protease inhibitors after initial treatment with first-line-based non-nucleoside reverse transcriptase inhibitors: a cross-sectional study

OBJECTIVES

Lipid abnormalities associated with antiretroviral therapy in people with HIV infection are more frequent with protease inhibitors (PI)-based regimens. Whether effects extend to patients receiving a PI subsequent to failure on non-nucleoside reverse-transcriptase inhibitors (NNRTI)-based regimen is still unknown. We investigated the effects of secondary treatment with a PI on the lipid profile in a group of patients with HIV infection in Cameroon.

DESIGN

This was a cross-sectional study.

SETTING

This study was carried out at the registered centre for HIV treatment of the Yaounde Jamot Hospital in Cameroon.

PARTICIPANTS

Participants were consecutively recruited between November 2009 and January 2010. There were 138 HIV-1 patients on initial treatment with an NNRTI regimen and 66 HIV patients on secondary treatment with a PI for at least 12 months. Lipid abnormalities were based on the National Cholesterol Education Program, Adult Treatment Panel III criteria.

OUTCOME MEASURES

Levels of lipid parameters among patients on PI and NNRTI.

RESULTS

Median (IQR) levels (mg/dl), NNRTI-treated versus PI-treated patients were 185 (149-225) and 189 (147-244) for total cholesterol, 46 (27-66) and 42 (28-82) for high-density lipoprotein (HDL)-cholesterol, 121 (90-169) and 126.9 (71-176) for low-density lipoprotein (LDL)-cholesterol, 134 (98-174) and 138 (111-167) for triglycerides, and 4.3 (2.9-6.2) and 5.1 (2.6-7.9) for total/HDL-cholesterol ratio (all p>0.32). The most frequent lipid abnormality in the two groups was high LDL-cholesterol (46.4% (NNRTI) vs 54.5% (PI)). The occurrence of lipid abnormalities was similar in the two groups (all p>0.29).

CONCLUSIONS

The use of PI does not appear to deteriorate the lipid profile of HIV patients above and beyond abnormalities induced by an unsuccessful initial treatment with NNRTI. Monitoring of lipid profile during HIV treatment regardless of the regimens would improve timely detection and management of abnormalities, to mitigate related risks.

ICAM-1 K469E polymorphism is a genetic determinant for the clinical risk factors of T2D subjects with retinopathy in Indians: a population-based case-control study

OBJECTIVE

Elevated levels of intercellular adhesion molecule-1 (ICAM-1) are demonstrated in diabetes complications. The current study aims to understand association of K469E (rs5498) in ICAM-1 gene, in type 2 diabetic (T2D) subjects with retinopathy.

DESIGN

Case-control study.

SETTING

Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Study, an epidemiology study (on prevalence of diabetic retinopathy in T2D subjects (T2DR) from south India) and outpatient department of Sankara Nethralaya, a tertiary care hospital, in Chennai, India.

PARTICIPANTS

A total of 356 T2D subjects of >15 years of diabetes duration, with (n=199) and without (n=157) retinopathy.

METHODS

The rs5498 polymorphism was genotyped by direct sequencing. Multivariate analysis for various clinical covariates was done using SPSS V.14. Comparative assessment of structure stability, folding rate of the variants were assessed using bioinformatics tools like STRIDE, MuPro, ModellerV97, fold rate server, etc.

RESULTS

The AA genotype of rs5498 was seen at a higher frequency in the retinopathy group (p=0.012). The risk for diabetic retinopathy (DR) increased in the presence of AA genotype (OR=1.89-4.82) after the sequential addition of various clinical covariates. Multivariate logistic regression analysis showed 8.26 times high risk for developing DR in the AG genotype (p=0.003). Structural superimposition of ICAM-1 wild type (K469) and variant (E469) showed 0.943 Å of backbone root mean square deviation as calculated by PYMOL software. A difference in the fold rate time was also observed between the wild type (5.4/s) and variant (3.3/s).

CONCLUSIONS

This study shows that allele A of rs5498 in ICAM-1 is a putative risk predisposing allele for T2D retinopathy and its clinical covariates in Indian population. The folding rate of the protein decreases for the A allele implicating a potential effect on the structure and function of ICAM-1.

Type 2 diabetes: a cohort study of treatment, ethnic and social group influences on glycated haemoglobin

OBJECTIVES

To assess whether in people with poorly controlled type 2 diabetes (HbA1c>7.5%) improvement in HbA1c varies by ethnic and social group.

DESIGN

Prospective 2-year cohort of type 2 diabetes treated in general practice.

SETTING AND PARTICIPANTS

All patients with type 2 diabetes in 100 of the 101 general practices in two London boroughs. The sample consisted of an ethnically diverse group with uncontrolled type 2 diabetes aged 37-71 years in 2007 and with HbA1c recording in 2008-2009.

OUTCOME MEASURE

Change from baseline HbA1c in 2007 and achievement of HbA1c control in 2008 and 2009 were estimated for each ethnic, social and treatment group using multilevel modelling.

RESULTS

The sample consisted of 6104 people; 18% were white, 63% south Asian, 16% black African/Caribbean and 3% other ethnic groups. HbA1c was lower after 1 and 2 years in all ethnic groups but south Asian people received significantly less benefit from each diabetes treatment. After adjustment, south Asian people were found to have 0.14% less reduction in HbA1c compared to white people (95% CI 0.04% to 0.24%) and white people were 1.6 (95% CI 1.2 to 2.0) times more likely to achieve HbA1c controlled to 7.5% or less relative to south Asian people. HbA1c reduction and control in black African/Caribbean and white people did not differ significantly. There was no evidence that social deprivation influenced HbA1c reduction or control in this cohort.

CONCLUSIONS

In all treatment groups, south Asian people with poorly controlled diabetes are less likely to achieve controlled HbA1c, with less reduction in mean HbA1c than white or black African/Caribbean people.

Impact of one or two visits strategy on hypertension burden estimation in HYDY, a population-based cross-sectional study: implications for healthcare resource allocation decision making

CONTEXT

The prevalence of hypertension in developing countries is coming closer to values found in developed countries. However, surveys usually rely on readings taken at a single visit, the option to implement the diagnosis on readings taken at multiple visits, being limited by costs.

OBJECTIVE

To estimate more accurately the magnitude and extent of the resource that should be allocated to the prevention of hypertension.

DESIGN

Population-based cross-sectional survey with triplicate blood pressure (BP) readings taken on two separate home-visits.

SETTING

Rural and urban locations in three areas of Yemen (capital, inland and coast).

PARTICIPANTS

A nationally representative sample of the Yemen population aged 15-69 years (5063 men and 5179 women), with an overall response rate of 92% in urban and 94% in rural locations.

MAIN OUTCOME MEASURE

Hypertension diagnosed as systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg and/or self-reported use of antihypertensive drugs.

RESULTS

Hypertension prevalence (age-standardised to the WHO world population 2001) based on fulfilling the same criteria on both visits (11.3%; 95% Cl 10.7% to 11.9%), was 35% lower than estimation based on the first visit (17.3%; 16.5% to 18.0%). Advanced age, blood glucose ≥7 mmol/l or proteinuria ≥1+ at dipstick test at visit one were significant predictors of confirmation at visit 2. The 959 participants found to be hypertensive at visit 1 or at visit 2 only and thus excluded from the final diagnosis had a rate of proteinuria (5.0%; 3.8% to 6.5%) comparable to rates of the general population (6.1%; 5.6% to 6.6%), and of subjects normotensive at both visits (5.6%; 5.1% to 6.2%). Only 1.9% of Yemen population classified at high or very high cardiovascular (CV) risk at visit 1 moved to average, low or moderate CV risk categories after two visits.

CONCLUSIONS

Hypertension prevalence based on readings obtained after two visits is 35% lower than estimation based on the first visit, subjects were excluded from final diagnosis belonging to low CV risk classes.

Medication intensification in diabetes in rural primary care: a cluster-randomised effectiveness trial

OBJECTIVE

To determine the effectiveness of a provider-based intervention to improve medication intensification among patients with diabetes.

DESIGN

Effectiveness cluster-randomised trial. Baseline and follow-up cross-sections of diabetes physicians' patients.

SETTING

Eleven U.S. Southeastern states, 2006-2008.

PARTICIPANTS

205 Rural primary care physicians, 95 completed the study.

INTERVENTION

Multicomponent interactive intervention including web-based continuing medical education (CME), performance feedback and quality improvement tools.

PRIMARY OUTCOME MEASURES

Medication intensification, a dose increase of an existing medication or the addition of a new class of medication for glucose, blood pressure and lipids control on any of the three most recent office visits.

RESULTS

Of 364 physicians attempting to register, 102 were randomised to the intervention and 103 to the control arms; 95 physicians (intervention, n=48; control, n=47) provided data on their 1182 of their patients at baseline (intervention, n=715; control, n=467) and 945 patients at follow-up (intervention, n=479; control, n=466). For A1c control, medication intensification increased in both groups (intervention, pre 26.4% vs post 32.6%, p=0.022; control, pre 24.8% vs post 31.1%, p=0.033) (intervention, adjusted OR (AOR) 1.37; 95% CI 1.06 to 1.76; control, AOR 1.41 (95% CI 1.06 to 1.89)); however, we observed no incremental benefit solely due to the intervention (group-by-time interaction, p=0.948). Among patients with the worst glucose control (A1c >9%), intensification increased in both groups (intervention, pre 34.8% vs post 62.5%, p=0.002; control, pre 35.7% vs post 61.4%, p=0.008).

CONCLUSIONS

A wide-reach, low-intensity, web-based interactive multicomponent intervention had no significant incremental effect on medication intensification for control of glucose, blood pressure or lipids for patients with diabetes of physicians practising in the rural Southeastern USA.

TRIAL REGISTRATION

NCT00403091.

Relationships between black tea consumption and key health indicators in the world: an ecological study

OBJECTIVES

The aim of this study was to investigate potential statistical relationships between black tea consumption and key health indicators in the world. The research question is: Does tea consumption is correlated with one or more epidemiological indicators?

DESIGN

Ecological study using a systematic data-mining approach in which the unit of the analysis is a population of one country.

SETTING

Six variables, black tea consumption data and prevalence data of respiratory diseases, infectious diseases, cancer, cardiovascular diseases and diabetes, have been studied at a global level.

PARTICIPANTS

Data from 50 participating countries in the World Health Survey were investigated. PRIMARY AND SECONDARY OUTCOMES MEASURES: Level of statistical relationships between variables.

RESULTS

Principal component analysis established a very high contribution of the black tea consumption parameter on the third axis (81%). The correlation circle confirmed that the 'black tea' vector was negatively correlated with the diabetes vector and was not correlated with any of the other four health indicators. A linear correlation model then confirmed a significant statistical correlation between high black tea consumption and low diabetes prevalence.

CONCLUSIONS

This innovative study establishes a linear statistical correlation between high black tea consumption and low diabetes prevalence in the world. These results are consistent with biological and physiological studies conducted on the effect of black tea on diabetes and confirm the results of a previous ecological study in Europe. Further epidemiological research and randomised studies are necessary to investigate the causality.