Effectiveness of changes in the delivery of diabetes care in a rural community

Diabetes has a significant impact upon health in rural Maori communities. A diabetes club was established to support self-care and improve diabetes management in a rural community in Northland, New Zealand. A structured approach to care and an associated audit were also introduced. Patient involvement and ownership of the condition were considered important issues. Monitoring of care processes increased by 79%. The first year of audit was associated with a reduction in mean fructosamine from 369 +/- 85 micromol L-1 to 321 +/- 65 micromol L-1 and this was sustained for a further 3 years. The number of people using insulin increased from 15 to 22%. The audit process facilitated the implementation of changes in the delivery of care. We conclude that the data indicate that the enthusiastic delivery of care in general practice, with a devolution of power to the patient, linked to an audit service can result in improved management among patients with Type 2 diabetes.

Diabetes in general practice: Tongans in Tonga and South Auckland

The aim of this study was to compare the management and treatment outcomes of Tongan diabetic patients in Tonga and South Auckland, New Zealand. This was achieved by comparison of Tongan diabetic patients within clinical audits from a general practice in Tonga (n = 124) with those from participating general practices in South Auckland (n = 168). Our results indicate that some measures of diabetes care and outcomes were similar or even better in Tonga, while some interventions were not available in Tonga. Control of weight, glucose, blood pressure and cholesterol remained difficult in both areas. Severe diabetic foot damage was more common among Tongan patients in Tonga (6.5% vs 1.8%, P < 0.05). This international comparison shows that Tongans in both Tonga and New Zealand remain at high-risk of complications independent of the health system under which care is being delivered. While barriers to implementation may differ in the two settings, improvements in the co-ordination of care are likely to be of benefit in both settings.

Polynesians: prone to obesity and Type 2 diabetes mellitus but not hyperinsulinaemia

AIMS

To compare the extent of hyperinsulinaemia among New Zealand Europeans and Polynesians (an ethnic group at high risk of Type 2 diabetes mellitus).

METHODS

A cross-sectional survey from randomly selected households was conducted in inner urban South Auckland. Subjects were either European, Maori or Pacific Islands Polynesians aged 40-79 years and were screened for diabetes using a random blood glucose. Those with an elevated result, and 20% randomly selected from those with a normal screening result, were invited to a 75-g glucose tolerance test. WHO criteria (1998) for diabetes were used.

RESULTS

In those aged 40-59 years, total prevalence of diabetes was 7.5 (6.2-9.0)% in Europeans but 21.1 (16.6-25.6)% among Maori and 25.0 (19.8-30.1)% among Pacific peoples; obesity (body mass index >or= 31.0 kg/m2) was present in 26% Europeans, 63% Maori and 69% Pacific peoples. Non-diabetic Polynesians were relatively hyperglycaemic and hyperinsulinaemic. After adjusting for the degree of obesity, Polynesians had similar insulin levels to Europeans.

CONCLUSIONS

These findings indicate that Polynesians are not intrinsically insulin resistant as a group, a prerequisite found in most other ethnic groups at high risk of Type 2 diabetes mellitus. The high prevalence of Type 2 diabetes in Polynesians could be the result of their high prevalence of obesity.

Developmental regulation of dentin sialophosphoprotein during ameloblast differentiation: a potential enamel matrix nucleator

The two major dentin matrix proteins, dentin sialoprotein and dentin phosphoprotein have been shown to be expressed as a single large transcript termed dentin sialophosphoprotein (DSPP). These non-collagenous matrix proteins, identified biochemically by their unique physical-chemical properties, are specific cleavage products of a large parent acidic phosphorylated protein (pI 4.0). Previous studies have shown expression of dentin sialoprotein at the protein level by ameloblasts. The purpose of this study was to determine the temporal-spatial pattern of DSPP expression during amelogenesis. In situ hybridization and immunohistochemistry were performed on sections of developing mouse molars. These data were correlated with RT-PCR analysis of in vitro enamel organ epithelium monolayer cell cultures enriched for ameloblasts. Our data indicates initial expression of the DSPP transcripts and protein during early ameloblast differentiation prior to the secretory phase when the majority of the enamel matrix is formed. Ameloblasts appear to tightly down-regulate DSPP transcription as enamel matrix formation is up-regulated. These data demonstrate DSPP expression during amelogenesis is under highly controlled developmental regulation. Therefore, DSPP may have a primary role in the initial mineralization events of both enamel and dentin, acting as a potential nucleator of hydroxyapatite crystal formation.

Identification and characterization of a cDNA for mouse ameloblastin

Ameloblastin was first identified as one of the most abundant novel transcripts from a random screening of a rat incisor cDNA library. In situ hybridization experiments have shown ameloblastin expression to be specific to ameloblasts, with highest levels in secretory and maturation stage ameloblasts and cells of the epithelial root sheath. Ameloblastin has been identified as a candidate gene for the local hypoplastic form of autosomal dominant amelogenesis imperfecta, by virtue of it's location within the critical disease locus. The purpose of this study was to isolate a full length mouse ameloblastin cDNA and determine its temporal expression pattern during odontogenesis. A newborn mouse molar cDNA library was screened using a rat ameloblastin cDNA probe. Positive clones were confirmed by PCR analysis with ameloblastin-specific primers, and their size determined with vector-specific primers. Phage clones were rescued to phagemid using Exassist helper phage and the nucleotide sequence determined. We report here the identification of two clones, exhibiting alternative splicing of the putative open reading frame, and use of multiple polyadenylation signals. Nucleotide sequence analysis indicated a high degree of similarity to rat ameloblastin, rat amelin 1 and 2 and porcine sheathlin. Reverse transcriptase-PCR analysis using mouse first and second mandibular molar mRNA indicated initial expression at E-14. This is one day after the initial expression of tuftelin (E-13) and one day prior to that of amelogenin (E-15).

Human ameloblastin gene: genomic organization and mutation analysis in amelogenesis imperfecta patients

A gene encoding the enamel protein ameloblastin (AMBN) was recently localized to a region on chromosome 4q21 containing a gene for the inherited enamel defect local hypoplastic amelogenesis imperfecta (AIH2). Ameloblastin protein is located at the Tomes processes of secretory ameloblasts and in the sheath space between rod-interrod enamel, and the AMBN gene therefore represents a viable candidate gene for local hypoplastic amelogenesis imperfecta (AI). In this study, the genomic organization of human AMBN was characterized. The gene was shown to consist of 13 exons and 12 introns. An alternatively spliced 45 bp sequence was shown not to represent a separate exon and is most likely spliced by the use of a cryptic splice site. The finding that there were no recombinations between an intragenic microsatellite and AIH2 encouraged us to evaluate this gene's potential role as a candidate gene for local hypoplastic AI. Mutation screening was performed on all 13 exons in 20 families and 8 sporadic cases with 6 different forms of AI. DNA variants were found but none that was associated exclusively with local hypoplastic AI or any of the other variants of AI in the identified Swedish families. This study excludes the coding regions and the splice sites of AMBN from a causative role in the pathogenesis of AIH2.

A community diabetes educator course for the unemployed in South Auckland, New Zealand

PURPOSE

This paper describes an education program that targeted long-term unemployed people from the community and trained them to work as diabetes educators in their own communities in an attempt to address issues of cultural appropriateness.

METHODS

Government funding was obtained to conduct two 22-week training courses for people who had been selected by their communities. These courses built on participants' existing cultural skills and provided appropriate diabetes training.

RESULTS

The results indicate that the courses were successful both in creating a cadre of culturally acceptable diabetes educators and providing employment for course participants.

CONCLUSIONS

Previously unemployed lay people are able to provide diabetes education in the primary prevention and group settings. Such individuals are able to incorporate extensive cultural skills in their work.

Predisposition to nephropathy in Polynesians is associated with family history of renal disease, not diabetes mellitus

AIMS

Familial clustering of diabetes and nephropathy suggests that either common environmental or inherited mechanisms are important in developing diabetic nephropathy. If an inherited mechanism is important, the albumin excretion rate might be increased in those at future risk. This study aimed to determine whether people with a family history of diabetes or people with a family history of renal disease were most at risk.

METHODS

In a two-by-two factorial study of urinary albumin in non-diabetic Polynesians, 90 people with a first degree relative (FDR) with end-stage renal failure (ESRF) and diabetes (group 1) were compared with 90 people with a FDR with non-diabetic ESRF (group 2), with 90 people with a FDR with diabetes but no known nephropathy (group 3) and 90 people with no known relatives with either diabetes or nephropathy (group 4). Groups were matched for ethnicity and age.

RESULTS

Subjects with a family history of ESRF (groups 1 and 2) had an increased mean albumin-creatinine ratio (1.25 vs. 1.00 mg/mmol, P = 0.01), but in subjects with a family history of diabetes (groups 1 and 3), the mean ratios were not significantly different from those without a family history of diabetes (1.06 vs. 1.17 mg/mmol; P = 0.2). In those with a family history of nephropathy, fasting blood glucose and systolic blood pressure were increased, while fasting insulin and 2 h insulin concentrations were lower. A family history of diabetes was associated with an increased fasting blood glucose and 2-h blood glucose. By multiple linear regression, the mean systolic blood pressure (P = 0.02), the 2-h glucose concentration (P = 0.05), a family history of renal failure (P = 0.04), female sex (P = 0.0001) and the total cholesterol (P = 0.01) were each independently associated with microalbuminuria, while a family history of diabetes was not (P = 0.09).

CONCLUSIONS

These data suggest that among Polynesians there is no specific inherited tendency to diabetic nephropathy per se. The risk of nephropathy does not appear to be associated with the degree of familial risk of diabetes itself. Rather, the risk of diabetic nephropathy may be the result of a familial risk of nephropathy from any cause and is associated with diabetes through relative hypoinsulinaemia and hyperglycaemia.

Prevalence and characteristics of diabetic patients with no ongoing care in South Auckland

OBJECTIVE

To describe the prevalence of default from diabetes care and to reveal associated characteristics among patients with known diabetes in urban South Auckland, New Zealand.

RESEARCH DESIGN AND METHODS

We developed a cross-sectional household study of patients with known diabetes and compared those patients with and without ongoing care. Ongoing care was defined as having been clinically reviewed at least once in the previous 10 months.

RESULTS

Of the 1,488 European, Maori, and Pacific Islander subjects with known diabetes, 107 (6.3%) had not seen a general practitioner or a diabetes service in the previous 10 months. Subjects not attending a diabetes service were more likely than subjects attending a diabetes service to have been diagnosed when screened asymptomatically (11.7 vs. 5.2%, P = 0.008) and after gestational diabetes (39.7 vs. 11.7%, P < 0.001). Maori were most likely to have no ongoing care (10.8 vs. 5.8% European and 6.6% of Pacific Islander subjects, P = 0.01). Nonattenders were younger, were diagnosed at a younger age, knew less about diabetes, were less satisfied with past care, and were less likely to require medication.

CONCLUSIONS

The elevated number of diabetic individuals not attending ongoing care is a significant problem in this population, and it may reflect a decisional balance as seen in problem behaviors. Diagnosis when asymptomatic may contribute to default from ongoing care; in this case, caution is required if population-based screening programs are being considered.

Capture-recapture, epidemiology, and list mismatches: two lists

In recent years, capture-recapture methods for closed populations have been extensively applied to epidemiology. For example, suppose we have several incomplete lists of diabetics and we wish to estimate the total number of diabetics by estimating the number missing from all the lists. A major problem is that the information about individuals on the lists may have been given incorrectly or the information may have been typed incorrectly so that some list matches are missed. Using the concept of tag loss borrowed from animal population studies, we consider methods for estimating both the probabilities of making list errors and the population size for just two independent lists. The effect of heterogeneity on the errors is examined. The methods are applied to a large data set of diabetic persons consisting of a list obtained from a survey and a list obtained from doctors' records. It was found that the error rates were high and that ignoring the errors led to a gross overestimate of the total number of diabetic persons.

Incidence and risk factors for neonatal hypoglycaemia among women with gestational diabetes mellitus in South Auckland

AIMS

To describe the incidence and risk factors for neonatal hypoglycaemia among the offspring of women with gestational diabetes mellitus (GDM) in South Auckland, New Zealand

METHODS

A retrospective audit was undertaken of singleton pregnancies delivered between 1991 and 1994. Data were obtained for 373 women and their deliveries (57 European, 76 Maori, 198 Pacific Islands, 42 other).

RESULTS

Pacific Islands women were most likely to have large babies with neonatal hypoglycaemia in spite of a high use of insulin. Postnatally Maori and Pacific Islands women had a high incidence of Type 2 diabetes mellitus (21.4, 21.7 vs. 4.3% Europeans, 12.0% others, P =0.035). Babies experiencing hypoglycaemia were more likely to have a mother with past GDM (51.2 vs. 27.2%, P = 0.01) and greater hyperglycaemia (at diagnosis fasting 6.8 +/- 1.7 vs. 5.7 +/- 1.1 mmol/l, P < 0.001; finger-prick glucose 5.7 +/- 1.0 vs. 5.2 +/- 0.8 mmol/l, P < 0.001). Macrosomia, Caesarian section and special care baby unit admission were more common in pregnancies complicated by neonatal hypoglycaemia.

CONCLUSIONS

Maternal hyperglycaemia was a major contributing factor to neonatal hypoglycaemia in this population. Undiagnosed Type 2 diabetes was common among Maori and Pacific Islands women, confirming the need for earlier detection and treatment.

Enamelin maps to human chromosome 4q21 within the autosomal dominant amelogenesis imperfecta locus

Amelogenesis imperfecta is a group of hereditary enamel defects. Of the autosomal dominant forms, only the local hypoplastic type has been mapped to human chromosome 4q 13-4q21. Enamelin is a large enamel matrix protein secreted by ameloblasts. The purpose of this study was to determine the human chromosomal localization of enamelin to establish an association with various forms of amelogenesis imperfecta. Chromosomal mapping was performed by polymerase chain reaction (PCR) amplification using somatic hybrid and deletion/derivation cell line panels with an enamelin primer set based on 100% conserved regions between pig and mouse cDNAs. Sequence-tagged site content mapping using eight markers within the critical local hypoplastic amelogenesis imperfecta region was then performed using an isolated human enamelin genomic BAC clone. The human enamelin amplicon was confirmed by DNA sequence analysis, revealing 81% and 73% identity to pig and mouse cDNAs, respectively. PCR amplification using a somatic cell hybrid panel placed enamelin on chromosome 4 with analysis of a regional chromosome 4 mapping panel refining the localization to 4q 13.1-q21.23. An identified human enamelin BAC genomic clone was shown to contain markers D4S2604 and D4S2670, as well as the first exon of the human ameloblastin gene, placing enamelin in the critical amelogenesis imperfecta locus between markers HIS1 and D4S2604 at 4q21. Our results suggest that enamelin is a strong candidate gene for this disease. Furthermore, human 4q21 may contain a second cluster of enamel matrix genes located proximally to the identified cluster of dentin and bone genes.

Managers' tactics of influence: perceptions of regular and temporary employees

The paper concerns managers' perceived influence tactics with regular and temporary employees. 156 subordinates completed the Behavioral Alteration Techniques Scale. Mean ratings of managers' use of tactics of influence with regular employees were significantly higher than those with temporary employees on 9 of the 22 measured techniques.

Perceptions of leader-member exchange: comparison of permanent and temporary employees

This study was done to explore how perceived scores for leader-member exchange varies among temporary employees and permanent employees. Study of 158 subordinates indicated no significant difference between the two member groups.

Cloning, characterization and immunolocalization of human ameloblastin

Amelogenesis imperfecta is a broad classification of hereditary enamel defects, exhibiting both genetic and clinical diversity. Most amelogenesis imperfecta cases are autosomal dominant disorders, yet only the local hypoplastic form has been mapped to human chromosome 4q between D4S242 1 and the albumin gene. An enamel protein cDNA, termed ameloblastin (also known as amelin and sheathlin), has been isolated from rat, mouse and pig. Its human homolog has been mapped to chromosome 4q21 between markers D4S409 and D4S400, flanking the local hypoplastic amelogenesis imperfecta critical region. Therefore, ameloblastin is a strong candidate gene for this form of amelogenesis imperfecta. To facilitate genetic studies related to this dental disease, we isolated and characterized a human ameloblastin cDNA. A human third molar cDNA library was screened and two ameloblastin clones identified. Nucleotide sequencing of these cDNAs indicated alternative splicing of the putative open reading frame, use of different polyadenylation signals, and a high degree of similarity to reported rat, mouse and porcine cDNAs. Immunohistochemistry studies on embryonic human teeth using an antibody to recombinant ameloblastin indicated ameloblastin expression by ameloblasts with localization in the enamel matrix associated with the sheath structures.

Screening for gestational diabetes mellitus in a multiethnic population in New Zealand

We have compared the characteristics of those screened and unscreened for gestational diabetes mellitus (GDM) in a multiethnic population in New Zealand. All obstetric records for a 12-month period were reviewed manually and electronically. Pre-gestational diabetes status, screening for GDM and obstetric history were recorded. Data for 4885 singleton pregnancies, uncomplicated by known pre-existing diabetes were available. Overall 50.6% of women were screened for GDM using a glucose challenge test, ranging between 36.8% among Europeans to 68.5% among Pacific Islanders (P<0. 001). Attendance at a follow up oral glucose tolerance test among those with a positive screen was 77.4%, with no ethnic difference. Rates of GDM were 3.3, 7.9 and 8.1% for Europeans, Maori and Pacific Islanders. An estimated 45-72% of women with GDM went undetected. Although increasing weight was associated with an increased likelihood of screening, 44.9, 34.8 and 21.1% of obese (weight 85+kg) Europeans, Maori and Pacific Islanders, respectively, were not screened. Increasing age was not associated with increased screening. Screening for GDM is not occurring even in those with clear and agreed indications for selective screening. We hypothesise that the current debate over criteria for selective screening may be undermining screening for those most at risk.

Frequency-dependent effect of nitric oxide donor nitroglycerin on bone

Recently, we showed that supplementation with nitric oxide (NO) via donor nitroglycerin (NG) alleviated the ovariectomy and corticosteroid-induced bone loss in rats. In humans, high doses or frequent applications of NG (i.e., for angina) lead to rapid loss of its efficacy in relieving angina. To examine whether there is a similar effect on the loss of efficacy of NG on bone, we examined the frequency-dependent effects of NG on bone mineral density (BMD), bone mass, trabecular bone volumes (BV/TV), and blood pressure in rats. Thirty 7-month-old female Brown Norway rats underwent ovariectomy, and an additional six rats were sham-operated. The ovariectomized rats were treated either with vehicle (ovariectomized control), 17beta-estradiol (E2; positive control), or 0.2 mg NG (via dermal application) once, twice, or three times a day. Before and at the end of the 10-week treatment period, BMD of the lumbar spine was measured by dual-energy X-ray absorptiometric (DXA) scanning and expressed as a percentage change. BMD in ovariectomized rats was significantly lower (-2.5 +/- 2.0%) compared with the sham-operated rats (+6.3 +/- 5.3%; p < 0.01). Estrogen therapy completely abolished the ovariectomy-induced potential bone loss (+5.9 +/- 3.4%). Application of NG once daily also completely prevented (+6.2 +/- 2.8%; p < 0.01) the ovariectomy-induced bone loss (i.e., it was as effective as estrogen). However, the beneficial effects of NG on BMD were significantly reduced with increased frequency of application of NG (+1.9 +/- 2.1%, twice a day and -0.2 +/- 3.3% three times a day). Estrogen or once daily administration of NG preserved femur weights, BV/TV, and decreased urinary deoxypyridinoline levels as expected. However, a higher level of serum osteocalcin and bone-specific alkaline phosphatase levels were maintained only with once daily administration of NG. There were no adverse effects of these doses of NG on blood pressure, but a tendency to lower blood pressure was noticed with increased frequency of NG. These results confirmed our previous findings that NO donors counteract the bone loss associated with estrogen deficiency. However, these beneficial effects of maintaining BMD are lost with increased frequency of NG application.

Roles and activities of the Commonwealth Government University Departments of Rural Health

Since 1996, University Departments of Rural Health (UDRH) have been established at Broken Hill, Mount Isa, Shepparton, Launceston, Whyalla, Alice Springs and Geraldton. Each UDRH is underpinned by Commonwealth funding for an initial period of 5 years. The role of the UDRHs is to contribute to an increase in the rural and remote health workforce through education and training programs, as well as a reduction in the health differentials between rural and urban people and between indigenous and non-indigenous peoples. A strong population health focus involving partnerships between existing health providers in a targeted region and the university sector underpins their operation. While UDRHs have been established as a means of addressing a national workforce problem, their organisational arrangements with universities and local service providers vary widely, as does the program mix of activities in education, research service development, facilitation and advocacy. This article outlines some of the activities and progress of the UDRHs to date.

The development of a national agreed minimum diabetes dataset for New Zealand

The development of a minimum diabetes dataset (MDD) for monitoring diabetes in New Zealand was intended to facilitate diabetes quality initiatives. Existing published datasets were reviewed and a draft MDD for New Zealand was distributed to all 147 specialist, general practice and relevant community groups. Data definitions were either identical or compatible with other datasets and dataset items included if there were at least six supportive replies. All groups were followed up by letter and telephone. A total of 26 (18%) replies were received. Comments were reviewed and the recommended MDD finalised. There was agreement that this dataset would be embedded into the software of at least three commercially available patient management systems. In conclusion, developling an agreed national MDD was difficult, in spite of its potential utility for local, regional and national collation of diabetes data allowing those involved to generate a picture of diabetes and its outcomes.