Point-of-care testing as a tool for screening for diabetes and pre-diabetes

AIM

To determine the utility of finger-prick point-of-care testing (POCT) of blood glucose for the detection of dysglycaemia.

METHODS

A fasting POCT and an oral glucose tolerance test (OGTT) with laboratory assays were performed as part of the baseline screening for 5309 participants enrolled in the Te Wai o Rona Diabetes Prevention Strategy. Participants were aged 46 +/- 19 years with no self-reported diabetes. Dysglycaemia, including diabetes, was defined using World Health Organization criteria. Agreement between the two fasting plasma glucose measurements and their screening properties (with sensitivity and specificity for cut points) were compared using receiver operator characteristic analysis.

RESULTS

A total of 3225 participants had both capillary and venous fasting blood sampled within 30 min and then underwent OGTT. New diabetes was found in 161 participants (5.0%) and pre-diabetes in 414 [impaired glucose tolerance 299 (9.3%), impaired fasting glucose 115 (3.6%)]. The mean difference in capillary and venous measures was 0.02 mmol/l (95% confidence interval -0.04 to +0.01; limits of agreement -1.37 to 1.33 mmol/l). Capillary POCT was a poorer predictor of dysglycaemia and impaired glucose tolerance and new diabetes (area under curve 0.76 and 0.71) than venous laboratory analysis (area under curve 0.87 and 0.81 respectively). Optimal screening criteria were best at a venous glucose of 5.4 mmol/l; 77% sensitivity/specificity.

CONCLUSIONS

POCT significantly underestimated the true blood glucose at diagnostic levels for diabetes. POCT cannot be recommended as a means of screening for or diagnosing diabetes or pre-diabetes.

Enteral feeding misconnections: a consortium position statement

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.

Should liver function tests be included in definitions of metabolic syndrome? Evidence from the association between liver function tests, components of metabolic syndrome and prevalent cardiovascular disease

AIMS

The definition of metabolic syndrome (MS) continues to be debated and does not include abnormal liver function tests (LFTs). This study aims to determine: (1) the association between the five ATP3 MS diagnostic components and different LFTs, and (2) the association between raised LFTs and prevalent cardiovascular disease (CVD).

METHODS

A total of 1357 patients, without alcoholism or known liver disease, from randomly selected households from rural Victoria, Australia, attended for biomedical assessment. Receiver operating characteristic (ROC) areas under the curve (AUC) were determined for associations between the ATP3 diagnostic components, and between LFTs and ATP3 diagnostic components.

RESULTS

The range of ROC AUC for ATP3 diagnostic components was 0.60-0.77. Waist had the strongest association and blood pressure the weakest. The strength of association between ATP3 diagnostic components and gamma GT (GGT) was similar (0.63-0.72), but was less for alanine transaminase and aspartate transaminase. Using the ROC-derived GGT cut-off (men 27 IU, women 20 IU), those with MS and a high GGT had more CVD than those with MS and a low GGT, and those without MS (18% vs. 10% vs. 7%, respectively; P < 0.001). Among those with MS, after adjusting for covariates, the odds ratio of CVD was 2.66 (1.18-5.96) for a high GGT compared to a low GGT. CVD was not significantly more prevalent in MS patients with a low GGT compared to non-MS patients.

CONCLUSIONS

We suggest that including a raised GGT in the criteria for MS could increase its predictive nature for CVD. Prospective studies are needed to confirm this finding.

Ethnic differences in diabetic retinopathy

AIMS/HYPOTHESIS

To compare the prevalence of diabetic retinopathy in European, Maori and Pacific peoples with diabetes.

METHODS

Biomedical assessment and retinal examination, using photography where possible, was undertaken in 458 (67.5% of eligible) randomly selected household survey participants with known diabetes (168 Europeans, 144 Maori, 149 Pacific people). Glycaemia was measured by glycated haemoglobin, fructosamine and random glucose.

RESULTS

In those with Type 2 diabetes, the prevalence of moderate or more severe retinopathy was 4.0% in Europeans, 12.9% in Maori and 15.8% in Pacific people (P = 0.003). There was no significant ethnic difference in the prevalence of retinopathy overall or in that of macular disease. Cataracts were more common in Pacific people (19.3%, 16.4%, 36.6%, respectively, P < 0.001). After adjusting for diabetes duration and ethnicity, Type 1 diabetes was associated with 5.3(1.7-16.4)-fold increase in moderate or more severe retinopathy. Although Maori and Pacific people with Type 2 diabetes were more hyperglycaemic, with higher systolic and lower diastolic blood pressure, in the logistic regression analysis, moderate or more severe retinopathy was associated with diabetes duration, insulin therapy, ethnicity and the extent of renal disease, but not glycaemia.

CONCLUSIONS

These data demonstrate that moderate or more severe retinopathy is more common in Polynesians than Europeans. The reasons for this are unclear, but may be related to long-standing hyperglycaemia.

Early results of the Acclaim elbow replacement

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function.

No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).

A case control study of diabetic patients who default from primary care in urban New Zealand

AIM

Diabetic patients defaulting from specialist care have worse metabolic control and complications than those attending regularly. We have compared the clinical characteristics of defaulters and more regular health care attenders on a population basis in a multi-ethnic community.

METHODS

We performed a 2:1 case control study of those defaulting from care for at least 10 months identified from a cross-sectional household survey of known diabetes in inner urban South Auckland, New Zealand. Thirty-seven cases and 52 controls with type 2 diabetes were examined (28 and 36 having retinal photography).

RESULTS

Defaulters were less likely to have been damaged by their diabetes (including less severe/proliferative retinopathy 16.7% vs. 0%, respectively, P<0.05), more likely to have worse foot care (95% vs. 79% poor nail or skin care, P<0.05) but had similar metabolic control as regular attenders. Most patients could either give no reason for default (40%) or claimed that their diabetes had gone (14%). Twenty-four (65%) reported that nothing could lead them to start attending for diabetes care.

CONCLUSION

We conclude that unlike those defaulting from specialist care, many, but not all, of those with diabetes defaulting from all care generally have comparable metabolic control and less complication than regular attenders. The patients had a range of attitudes to their diabetes suggesting that attracting such patients back into care, prior to a major clinical event or the development of symptoms, is unlikely without major effort.

Relationship between maternal glycaemia and birth weight in glucose-tolerant women from different ethnic groups in New Zealand

AIM

The aim of this study was to compare the population attributable fraction(PAF) for a large baby (> or =4 kg) due to glycaemia, weight and smoking in glucose-tolerant women from different ethnic groups.

METHODS

A retrospective review of screening for gestational diabetes (GDM)and associated birth weight was undertaken in New Zealand European (n= 529), Maori (n= 540) and Pacific (n= 916) women. The proportion with a large baby was compared by 1-h post 50-g glucose challenge test tertile and maternal weight tertile.

RESULTS

Large babies were more common from Pacific and European than Maori women (24.3%, 18.8%, 8.9%, respectively; P<0.001). Birth weight increased significantly with increasing glucose among Pacific women (P<0.001) even after adjusting for maternal weight and other confounders. The risk of having a large baby was 2.56 (1.82-3.60)-fold greater in women in the highest maternal weight tertile (> or =84 kg), with a significantly greater PAF in Pacific women(27.2%, 12.9%, 16.4%, respectively; P<0.001). The odds ratio (OR) of having a large baby increased with even mildly elevated maternal 1-h glucose concentrations [OR for 5.6-6.2 mmol/l: 1.54 (1.11-2.14); for > or =6.3 mmol/l: 2.06 (1.50-2.82)], with no ethnic differences in PAF (11.1-11.8%, 16.7-18.7%, respectively). Smoking and being Maori were associated with smaller babies.

CONCLUSIONS

Increased maternal weight and glycaemia are associated with a greater proportion of large babies among glucose-tolerant women. Growth of Pacific babies may be more sensitive to a higher maternal glucose when the mother is obese.

Mortality in individuals with Type 2 diabetes and heart disease in a unique New Zealand population

AIMS

To determine rate and predictors of mortality in patients with Type 2 diabetes living in a population with a large proportion of Maori and Pacific peoples who were admitted to hospital with myocardial infarction (MI) or congestive cardiac failure (CCF).

METHODS

The study population included 4193 individuals with Type 2 diabetes who lived in South Auckland and who participated in a primary care audit between 1994 and 1999. We studied a subgroup of 319 patients who subsequently had a hospital admission for MI or CCF between 1999 and 2001. We examined their demographics, drug treatment, vascular risk factors and mortality up to 2003.

RESULTS

Following discharge, the prescription of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, aspirin and statins had all increased significantly. Vascular risk factors including total cholesterol, high-density lipoprotein (HDL) cholesterol, systolic blood pressure and glycated haemoglobin (HbA(1c)) improved significantly. Nevertheless, mortality remained high with individuals admitted because of an MI 7.2-fold more likely to die early and those with a CCF admission 5.9-fold more likely to die early than other individuals with Type 2 diabetes. Maori patients have an 80% excess mortality.

CONCLUSIONS

Patients with past admission for MI and/or CCF remain at exceptionally high risk of death for at least 4 years after hospital admission, even with improvements in management of cardiovascular risk factors. Maori individuals are at particular risk.

Is grand multiparity associated with an increased risk of dysglycaemia?

AIMS/HYPOTHESIS

We sought to determine the risk of diabetes and IGT/IFG with grand multiparity.

SUBJECTS, MATERIALS AND METHODS

Women, aged > or =25 years, from the Australian Diabetes, Obesity and Lifestyle Study and the Crossroads Undiagnosed Disease Study (a rural study in Victoria, Australia), participated in a household census (response 67 and 70%, respectively), subsequently attending a biomedical examination that included an oral glucose tolerance test (58% [6198] and 69% [819]).

RESULTS

After adjusting for age, obesity and socio-economic status, diabetes, but not IGT/IFG, was less common among women with a parity of 1 to 2 (odds ratio [OR]=0.64 [0.48-0.84]) and 3 to 4 (OR=0.72 [0.53-0.96]) than in grand multiparous women. This relationship was unrelated to past hysterectomy, use of the oral contraceptive pill or menopausal status.

CONCLUSIONS/INTERPRETATION

Grand multiparity is associated with an increased risk of diabetes but not of IGT/IFG. We postulate that parity accelerates transition from IGT/IFG to diabetes, more than it does transition from normal glucose tolerance to IGT/IFG.

Dental health in rural Victoria: the Crossroads Household Survey

BACKGROUND

The aims of this study were to describe dental health and perceived barriers to dental care in a regional centre and surrounding smaller towns in rural Victoria.

METHODS

A stratified, randomized, face-to-face household survey was undertaken to assess levels of edentulism and access to oral health services. A study response rate of 70.3 per cent (6316/9260) was achieved.

RESULTS

When compared with those in the regional centre, people living in the shire capitals were more likely to travel greater distances to see a dentist and were less likely to have seen a dentist within the past 12 months. While there was little difference in the edentulous proportion living in shire capitals compared with the regional centre, the level of edentulousness over the entire region was greater than overall Australian estimates. Differences in perceived barriers to care within the region were less than expected. Existing perceived barriers were lack of need, time until available appointments, attitudes of dentists and lack of public dental facilities. Differences in these barriers existed between socio-economic groups.

CONCLUSIONS

This study shows that the prevalence of edentulism was higher in the areas studied relative to the Australian population. Significant patient perceived barriers to care exist which may contribute to the problem.

Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes

OBJECTIVE

To compare international guidelines for the care of women with diabetes and pregnancy with reported current practice among New Zealand tertiary centres.

RESEARCH DESIGN AND METHODS

A literature review of national and international guidelines for the care of women with diabetes in pregnancy was undertaken. Guideline activities were placed within nine facets of care, from preconception advice, through pregnancy from screening to follow-up. New Zealand tertiary centres guidelines were obtained and placed in the same framework.

RESULTS

International guideline consensus was inconsistent across most facets of care. Those for the detection and diagnosis of gestational diabetes mellitus (GDM) were particularly discordant internationally, although intranational agreement has occurred.

CONCLUSIONS

International guidelines for the care of women with diabetes in pregnancy remain fragmented. The development of one set of guidelines based on the consensus of international best practice could overcome many of the misconceptions associated with diabetes in pregnancy.

Sedation and Patient Safety

The safety of patients receiving sedation and sedating analgesia therapies is a system property. There are multiple team members and processes needed to ensure safety that reside outside the purview of nursing. This article outlines safety considerations in sedation using the Eindhoven classification system as framework for aggregating contributing factors in error events into a useful format. Using this approach offers consistency in investigation and a framework for making sense of data. For this article, sedatives and analgesic medication related events are considered.

Choice and availability of takeaway and restaurant food is not related to the prevalence of adult obesity in rural communities in Australia

OBJECTIVES

To establish whether choice and availability of takeaway and restaurant food consumption are associated with increased obesity.

DESIGN

Crossroads Undiagnosed Disease Study: a cross-sectional study undertaken between June 2001 and March 2003.

SETTING

A regional centre and six shire capitals of variables size in rural Victoria, Australia.

PARTICIPANTS

In total, 1454 residents of randomly selected households.

MEASUREMENTS

Obesity (by body mass index (BMI) or waist circumference), weekly recreational activity, self-reported frequency of takeaway consumption, number of local takeaway and restaurant food outlets in the area.

RESULTS

The prevalence of obesity ranged from 25.5-30.8% and was higher than the general Australian population among both men and women. Those in the regional centre were less likely than those in large and small shire capitals to participate in recreational activity of 150 min or more (39.7 vs 48.4%, 46.0% respectively, P=0.023) and yet reported better access to facilities and amenities for physical activity. Recreational activity of > or =150 min/week was associated with 0.75 (0.58-0.97) fold less risk of obesity. BMI was unrelated to takeaway consumption. Waist circumference was significantly lower among those eating no takeaways, but similar whether takeaways were consumed <1/month or > or =1/week. Increased takeaway consumption was associated with increased consumption of higher fat preparations of dairy and meat products. Availability of takeaway outlets and restaurants was unrelated to obesity.

CONCLUSION

The obesity epidemic exists among those without significant consumption of or availability to takeaway foods. In a setting of easy availability of food, the obesity epidemic relates strongly to reduced physical activity, but not to consumption of takeaway food.

In-hospital breast feeding rates among women with gestational diabetes and pregestational Type 2 diabetes in South Auckland

AIM

To describe the uptake of breast feeding in mothers with either Type 2 diabetes or gestational diabetes (GDM) in a hospital serving a multiethnic community in South Auckland, New Zealand.

RESEARCH DESIGN AND METHODS

A retrospective study of all women attending the Diabetes in Pregnancy clinic over a 4-year period was undertaken: 30 women had Type 2 diabetes and 373 GDM.

RESULTS

Compared with mothers with GDM, mothers with Type 2 diabetes were less likely to breast feed in any way as the first feed (41.4% vs. 68.0%, P = 0.011) or at discharge (69.0% vs. 84.0%, P = 0.039). In the combined group, there were no differences in uptake of breast feeding by ethnicity, age, parity, body mass index, smoking or antenatal glycaemia, use of insulin or presence of hypertension. Breast feeding on discharge was associated with a higher APGAR score, breast feeding as the first feed (78.2% vs. 19.4%, P < 0.001) and lower rates of delivery by Caesarean section (17.0% vs. 31.8%, P = 0.006). Logistic regression showed breast feeding as the first feed, the major determinant for breast feeding on discharge.

CONCLUSIONS

Factors delaying breast feeding as the first feed are the major determinant of breast feeding on discharge. Strategies to increase breast feeding as the first feed among women with Type 2 diabetes, and those having a Caesarean section, may be useful in increasing the uptake of breast feeding in the longer term.

Controlling the diabetes epidemic: how should we screen for undiagnosed diabetes and dysglycaemia?

AIMS

To compare the detection of undiagnosed diabetes and dysglycaemia (impaired glucose tolerance, impaired fasting glucose, diabetes) using risk factors and laboratory measures of glycaemia.

METHODS

Casual blood glucose samples were taken from 1899 (69.4% of 2737 invited) European, Maori and Pacific Islands subjects aged 40-79 years from randomly selected households in South Auckland, New Zealand. Of these, 534 attended for a 75-g oral glucose tolerance test (OGTT) if an elevated result was identified [327/478 (68.4%)] or if randomly selected with a 'normal' screening result [207/308 (67.2%)].

RESULTS

Several Europeans with undiagnosed diabetes (25.0%) and dysglycaemia (31.4%) had no diabetes risk factors. Most Maori and Pacific Islanders had at least one risk factor. The area under the receiver operating curve (ROC) for the detection of undiagnosed diabetes was 0.92 (0.89-0.95) using fasting glucose, 0.86 (0.82-0.90) using HbA1c, 0.75 (0.69-0.80) using random glucose, but 0.60 (0.55-0.66) using risk factor screening. The ROC for detecting any dysglycaemia was 0.88 (0.85-0.90), 0.68 (0.64-0.71), 0.72 (0.69-0.75), 0.61 (0.58-0.65), respectively. Screening using fasting glucose (the best test) detected 90.4% of new diabetes and 78.4% of dysglycaemia; risk factor screening followed by fasting glucose detected significantly less cases [88 (82-93)% and 86 (82-89)%, respectively] with 9.2% less OGTTs.

CONCLUSIONS

Using risk factors for the identification of who should receive a blood test for dysglycaemia adds little to direct screening with the risk of missing some with significant hyperglycaemia. Screening for dysglycaemia may best be undertaken using blood tests without initial risk factor symptom screening.

Impact of an integrated approach to diabetes care at the Rumbalara Aboriginal Health Service

AIMS

To describe the effectiveness of an integrated primary-secondary care diabetes clinic on metabolic control among indigenous patients in a rural community.

METHODS

A retrospective audit of attendance to the clinic over 2 years (2 August 1999 to 31 August 2001). The service included a weekly specialist diabetes clinic integrated with the primary care team at the Rumbalara Aboriginal Health Service, Mooroopna, Victoria, Australia. Between clinics, follow up was provided by the Aboriginal health worker and other members of the integrated care team. Of the 47 patients seen, 20 had an HbA1c persistently > or =9.0% (of 21 patients identified in the community) and seven had gestational diabetes.

RESULTS

Among 40 patients without gestational diabetes, microalbuminuria or proteinuria were present in 62%, retinopathy was present in 50%, neuropathy was present in 50% and at least one past cardiac or vascular event/surgical procedure had occurred in 25%. Of these, the 30 patients seen more than once increased their self glucose monitoring (baseline (53.3%) vs. last visit (90%); P = 0.003) and reduced their HbA1c (10.4 +/- 2.2%vs. 7.9 +/- 1.9%; P < 0.001), systolic blood pressure (138 +/- 20 vs. 127 +/- 18 mmHg; P = 0.003) and diastolic blood pressure (78 +/- 11 vs. 73 +/- 12 mmHg; P = 0.037) and total cholesterol (6.1 +/- 1.7 vs. 5.1 +/- 1.6 mmol/L; P = 0.002), but not their weight, smoking or triglycerides.

CONCLUSION

The introduction of an integrated diabetes care service in an Aboriginal health service can overcome many of the pre-existing barriers to achieving metabolic targets. Poor metabolic control in Aboriginal patients is often due to lack of resources and inappropriateness of approach, rather than "compliance".

The New Zealand Diabetes Passport Study: a randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications

AIMS

To assess the efficacy (change in HbA1c) of a patient-held communication, self-empowerment and educational device for people with diabetes (the New Zealand Diabetes Passport) in patients with poor glycaemic control.

RESEARCH DESIGN AND METHODS

A 12-month, multicentre, general practice-based randomized controlled trial in urban, provincial and rural New Zealand involving 398 people with poorly controlled Type 1 or Type 2 diabetes. The intervention included a specifically designed and piloted New Zealand Diabetes Passport including information relating to diabetes knowledge, self-assessments, and guidance concerning how to engage with diabetes health professionals. The primary end point was change in HbA1c. Assessments were made at 0, 6 and 12 months.

RESULTS

Two hundred and twenty-two patients received the Passport, 176 the control booklet, coming from 69 and 66 general practitioners, respectively. Use of the Passport was associated with a relative reduction in HbA1c of 0.4% (P = 0.017) and a relative increase in weight of 1.0 kg/m2 (P = 0.028), but no changes in diabetes knowledge, attitudes to diabetes or risk factors for diabetic tissue damage.

CONCLUSIONS

The dissemination of the New Zealand Diabetes Passport, in isolation, was not associated with improvements in either diabetes knowledge or self-empowerment. While a small improvement in glycaemic control occurred, this was probably due to changes in insulin therapy in the intervention group. It is possible that linking the use of the Passport with other behavioural and educational interventions may make the Passport more useful. Further study is required to confirm the effect of such multifaceted interventions.

Tale of two churches: differential impact of a church-based diabetes control programme among Pacific Islands people in New Zealand

AIMS

To compare the impact on weight and exercise of a 2-year church-based diabetes risk reduction programme in four churches in South Auckland, New Zealand.

METHODS

A prospective non-randomized controlled study of a modular lifestyle and diabetes awareness intervention programme applying community development principles. The study involved four complete church congregations, two Samoan and two Tongan, with 516 participants at commencement. Risk of Type 2 diabetes is high among both ethnic groups.

RESULTS

Overall, 285 subjects were available for their second assessment. In one intervention church, weight gain was controlled (vs. control 0 +/- 4.8 vs. +3.1 +/- 9.8 kg, respectively; P=0.05), diabetes knowledge (+46 +/- 26% vs. +4 +/- 17%; P<0.001) and regular exercise (at least 3 days per week: +22% vs. -8%; P=0.032) increased and readiness to change weight (P=0.007) shifted towards maintenance (e.g. maintenance +41% vs. +8%, respectively). The other intervention church increased diabetes knowledge (+19 +/- 24 vs. +8 +/- 25; P<0.024), but no other significant personal changes occurred. Attendance and perceived utility of the programme were greater in the first intervention church.

CONCLUSIONS

A moderate intensity, community-based, structured diabetes awareness and lifestyle programme can reduce diabetes risk, but increasing diabetes knowledge alone is not necessarily associated with healthier lifestyle choices. Continuous and detailed monitoring of penetration of interventions may be essential to help guide the timing of interventions and identify the need for additional strategies to increase participation and motivation.

Genomic organization and localization of mouse Nma/BAMBI: possible implications related to ameloblastoma formation

Our laboratory has determined the DNA sequence and transcriptional expression pattern of a mouse cDNA clone termed Nma/BAMBI. This clone encodes a highly conserved protein with 89% identity to the human homologue (termed Nma) and 78% similarity to the Xenopus homologue (termed BAMBI) at the predicted amino acid level. Nma/BAMBI encodes a 260-amino-acid transmembrane protein that has homology to the transforming growth factor (TGF) beta type I receptor family. This protein contains an extracellular ligand binding domain, a 24-amino-acid transmembrane domain, and a short intracellular domain that lacks a functional serine/threonine kinase domain. It is believed that Nma/BAMBI is important in the negative regulation of TGF beta signal transduction pathways during development and has implications in tumor progression. We have determined the genomic organization of the mouse Nma/BAMBI gene and confirmed the chromosomal mapping to human chromosome 10 and mouse chromosome 2. Furthermore, we report the production and utilization of an anti-peptide antibody in preliminary immunohistochemical analysis of an ameloblastoma.