Bariatric Surgery and Psychological Health: A Randomised Clinical Trial in Patients with Obesity and Type 2 Diabetes.

PURPOSE: This study investigated the impact of either Roux-en-Y gastric bypass with silastic ring (SR-RYGB) or sleeve gastrectomy (SG) types of bariatric surgery on psychological health and explored the role of pre-existing depressive symptoms on weight loss. MATERIALS AND METHODS: A total of 114 participants with obesity and type 2 diabetes were randomized to receive SR-RYGB or SG at a single centre. Data from the Hospital Anxiety and Depression Scale (HADS), RAND 36-item Health Survey and body weight were collected before surgery and annually for 5 years. RESULTS: Sixteen patients were lost to follow-up at 5 years. Of the 98 patients who completed 5-year psychological follow-up assessments, 13 had mild to severe depressive symptoms (SR-RYGB n = 6, SG n = 7). SR-RYGB and SG resulted in similar psychological health improvement but percent weight loss at 5 years was greater for SR-RYGB by 10.6% (95% CI: 7.2 to 14.0, P < 0.0001). Scores for depressive symptoms and most RAND-36 domains improved significantly from baseline to 5 years in both groups. Patients with pre-existing depressive symptoms had similar percent weight loss at 5 years compared to patients without depressive symptoms, irrespective of procedural type. CONCLUSION: Patients receiving either SR-RYGB or SG had comparable psychosocial functioning, which was maintained to 5 years post-surgery. Pre-existing depressive symptoms did not affect weight loss achieved at 5 years. These findings confirm previous longitudinal studies demonstrating that bariatric surgery is generally associated with improved psychosocial functioning.

Expansion and consolidation of fracture liaison service in New Zealand public healthcare setting - Waitemata District Health Board Experience.

AIM: To describe the service delivery of the Fracture Liaison Service (FLS) at Waitemata District Health Board (WDHB) for the year 2020, and to outline how the service evolved in recent years. METHOD: We reviewed and analysed the WDHB FLS database as well as 4-month and 12-month patient follow-up records from the calendar year 2020. RESULTS: In 2020, we identified and assessed 1,225 patients. We either directly initiated anti-osteoporosis medication (AOM) (256), recommended to start AOM with patient's GP (477), or recommended to continue or switch to a different AOM (441) in the vast majority (1174 = 95.8%). In remaining 51 patients, AOM was either deemed unnecessary (owing to relatively young age and good DEXA indices) or patient refused it. Three hundred and thirty dual energy X-ray absorptiometry (DEXA) scans were arranged by FLS, and 79.5% were found to be either osteoporotic (32.9%) or osteopenic (46.6%). At 4-month and 12-month follow-up, 85.1% and 74.4%, respectively, of those expected to be on treatment were on treatment. CONCLUSION: The WDHB FLS has expanded and consolidated considerably in recent years. Nationwide implementation of effective FLSs should significantly reduce the burden of fragility fractures.

A retrospective audit of the characteristics and treatment outcomes in patients with diabetes-related charcot neuropathic osteoarthropathy.

AIMS: To review the characteristics, management and outcomes one year after diagnosis in patients with diabetes related charcot neuropathic osteoarthropathy (CN) treated at the Diabetes Podiatry service, Waitemata District Health Board (WDHB) between 2000-2014. METHODS: Patients with diabetes and recorded diagnosis of CN were identified from the podiatry service records. Clinical details were retrospectively obtained from WDHB databases and patient medical records. RESULTS: Forty-one patients were included, 31 had type 2 diabetes, 10 had type 1 diabetes. At presentation, the median duration of all-type diabetes was 15 years. The median time from symptom onset to diagnosis was 17 weeks. Symptoms at presentation were: oedema (49%), warmth (73%), erythema (17%), swelling (90%) and pain (60%). Concomitant ulcers were present in 32%, deformities 83%, osteomyelitis 2% and septic arthritis 2%. Mean time to ambulation in modified shoes was 21.3 weeks (±11.5). Complication rates one year from diagnosis for ulcers, osteomyelitis, amputations and all-cause mortality were 34%, 2%, 2% and 5% respectively. CONCLUSION: Time to diagnosis of CN was shorter than previously reported, though the high rate of deformities still suggests a significant delay in diagnosis. Increased education of healthcare professionals and people with diabetes-related neuropathy is important to ensure early diagnosis and appropriate management to reduce deformities and complications.

Implementation of fracture liaison service in a New Zealand public hospital: Waitemata district health board experience.

AIM: To analyse the performance of a Fracture Liaison Service (FLS) at Waitemata District Health Board (WDHB), and to detail how systematic secondary fracture prevention can be delivered in a secondary healthcare setting in New Zealand. METHOD: Clinical details of patients supervised by the WDHB FLS during the calendar year 2014 were reviewed and analysed. Additional information including treatment compliance and re-fracture rates were sought a year after initial intervention. RESULTS: During the 12-month period, 301 patients with fragility fracture were seen by the WDHB FLS. All patients had clinical and laboratory assessment, one-to-one education by the FLS co-ordinator. One hundred and twenty-one patients had dual energy x-ray absorptiometry (DEXA) performed. One hundred and thirty-four of 226 treatment naive patients were started or recommended to be started on a bone protection therapy, bisphosphonate in almost all cases, and another 25 of 75 patients had adjustment made to their current therapy. Of those who were started or continued on treatment, adherence rate was 70% at a mean follow-up of 12 months. CONCLUSION: An effective secondary fracture prevention programme, such as a FLS, can be successfully implemented in a New Zealand district hospital setting.

Diabetic Dead-in-Bed Syndrome: A Possible Link to a Cardiac Ion Channelopathy.

Sudden unexpected nocturnal death among patients with diabetes occurs approximately ten times more commonly than in the general population. Malignant ventricular arrhythmia due to Brugada syndrome has been postulated as a cause, since a glucose-insulin bolus can unmask the Brugada electrocardiographic signature in genetically predisposed individuals. In this report we present a 16-year-old male with insulin-dependent diabetes who died suddenly at night. His diabetes had been well controlled, without significant hypoglycaemia. At autopsy, he had a full stomach and a glucose level of 7 mmol/L in vitreous humor, excluding hypoglycaemia. Genetic analysis of autopsy DNA revealed a missense mutation, c.370A>G (p.Ile124Val), in the GPD1L gene. A parent carried the same mutation and has QT prolongation. Mutations in this gene have been linked to Brugada syndrome and sudden infant death. The patient may have died from a ventricular arrhythmia, secondary to occult Brugada syndrome, triggered by a full stomach and insulin. The data suggest that molecular autopsies are warranted to investigate other cases of the diabetic dead-in-bed syndrome.

Long-term outcomes in gastric bypass patients with and without type 2 diabetes--Waitemata District Health Board experience.

BACKGROUND/OBJECTIVES: Dramatic early postoperative improvement or resolution of type 2 diabetes mellitus (T2DM) has been widely reported after bariatric surgery but there is limited long-term data on T2DM outcome. Moreover, data on long-term weight outcomes of government funded bariatric surgery in New Zealand is lacking. We report weight and glycaemic outcomes in subjects with and without T2DM who underwent gastric bypass surgery (GBP) at Waitemata District Health Board (WDHB). METHODS: Clinical records of those who underwent a GBP (Roux-en-Y gastric bypass or loop gastric bypass) at WDHB between 2001 and 2007 were reviewed. Relevant pre- and postoperative data, including weight and diabetes related parameters, were collected from hospital records and analysed. Missing clinical data was attained by contacting patients, their primary practitioners and local laboratories, and also by performing HbA1c in T2DM subjects in whom latest diabetes status was unclear. RESULTS: Data of 126 subjects was analysed. Their mean age was 43.7 years, 73% were female and 83% were Pakeha/European. Mean preoperative weight was 136.2 kg (SD plus or minus 29.1, range 81.3-241) with a mean BMI of 48.3 kg/m². Postoperative nadir weight was 80.6 kg (SD plus or minus 18.1, range 48.0-132.8) at 20.8 months (SD plus or minus 14.6, range 4-98) (BMI 28.6) with percentage of excess body weight loss (%EBWL) of 84.7%. Latest mean weight was 90.5 kg (SD plus or minus 18.8, range 57-140) (BMI 32.2, %EBWL 70.7%) at a mean of 63.4 months (SD plus or minus 19.7, range 12-109) post-op. Thirty four subjects (27.0%) had preoperative diagnosis of T2DM, of whom 29 (85.3%) had complete remission at some stage postoperatively. At the latest follow-up, 19 of 33 (57.6%) remained in complete remission, and the rest had either never remitted or had evidence of T2DM relapse after an initial remission. Weight loss outcomes were comparable between T2DM and non-T2DM subjects, and also between European and Maori and Pacific Islanders. CONCLUSION: GBP resulted in substantial weight loss in essentially all subjects, and weight loss was well maintained over time. GBP also had dramatic and favourable effect on T2DM but did not uniformly result in prolonged diabetes remission. Long-term glycaemic surveillance is desirable.

A survey of thyroid function test abnormalities in patients presenting with atrial fibrillation and flutter to a New Zealand district hospital.

AIM: Subclinical and overt hyperthyroidism is a known trigger of atrial fibrillation and flutter (AF). We wanted to see if thyroid function tests (TFT) were being requested appropriately in patients with atrial fibrillation or flutter at North Shore Hospital, and how common subclinical or overt hyperthyroidism was in our local inpatient population presenting with AF. METHOD: Clinical data on 250 patients admitted to North Shore Hospital with a history of AF was retrospectively analysed, including prior history of thyroid dysfunction, measurement of TFT and their results at the time of admission, subsequent management of subjects with abnormal TFT, and the association of amiodarone treatment or use of radiocontrast with TFT derangements. RESULTS: Of the 250 patients analysed, only a small (7.2%) proportion had known thyroid dysfunction prior to admission, most of whom had hypothyroidism on thyroxine replacement. Although the majority (77%) of AF patients had had TFT checked either at the time of admission or in the prior 6 months, a significant proportion (23%) had not. Of the patients in whom TFT were performed, 82% were normal. Abnormalities included subclinical hyperthyroidism (2.1%), overt hyperthyroidism (3.1%), subclinical hypothyroidism (11%), and overt hypothyroidism (1.6%). CONCLUSION: Despite a relatively low frequency, hyperthyroid conditions in patients presenting to North Shore Hospital with AF were sufficiently prevalent to continue recommending TFT assessment in these patients. Although the majority of AF patients were being adequately screened with TFT, a significant proportion was not, and those with abnormalities were not well followed up.

Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand.

INTRODUCTION: In New Zealand, Maori and Pacific (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) people with Type 2 diabetes are more likely to suffer poor outcomes than other New Zealanders. Responsibility for addressing this outcome differential is falling on primary care and general practice in particular. This paper compares the general practice care provided to people with Type 2 diabetes in South and West Auckland, according to ethnicity. METHOD: An external audit of general practice diabetes care is carried out in South and West Auckland by the Diabetes Care Support Service. The results of 5917 routine patient audits carried out in 2003 are included in this study. Number of visits, recording of important information, risk factors, and treatments are compared between different ethnic groups. RESULTS: Maori and Pacific people with diabetes who attend a regular GP had a higher average number of consultations than Europeans (5.7, 5.4, and 4.8 visits per year respectively). They were as likely as Europeans to have undergone important regular examinations and investigations. Maori were more likely than Europeans to be on some treatments. However, Maori and Pacific people were more likely to have a range of adverse risk factors for diabetes complications than Europeans. These include being a smoker (35, 18, and 13% respectively), having an HbA1c greater than 8% (50, 56, 23%), and having microalbuminuria (55, 50, 27%). DISCUSSION: Although there were no large differences in the process measures of general practice diabetes care provided to different ethnic groups in South and West Auckland, Maori and Pacific people were not achieving the same outcomes of care in terms of risk factors for diabetes complications. Many of these risk factors are influenced by other factors in the wider community; however the New Zealand health system needs to consider how it can better address these differences.

First national audit of the outcomes of care in young people with diabetes in New Zealand: high prevalence of nephropathy in Maori and Pacific Islanders.

BACKGROUND: Diabetes is an important cause of morbidity and mortality amongst young people. Despite improvements in technology, maintenance of good glycaemic control is hard to achieve. METHODS: In July 2003, 12 paediatric and adult hospital-based diabetes services across New Zealand were invited to take part in an audit of the process and outcomes of care. By March 2004, 9 centres had submitted data on 1282 (1117 with Type 1 diabetes, 105 with Type 2) children and young people born after 1 January 1978. RESULTS: There were significant centre differences in terms of glycaemic control, rates of microvascular complications and complication screening. The group mean HbA1c was 9.1 plus and minus 0.3%. Amongst 789 people aged 16-25 years, the prevalence of retinopathy was 12.8% (range 0-26%); nephropathy was 17.1% (range 7-28 %). Of those with a duration of diabetes <10 years, 25% had retinopathy and 27% nephropathy. Over the age of 12, microalbuminuria was more common amongst Maori and Pacific Islanders (43.8%) compared to Europeans (17%) or Others (17.8%). This was independent of the type of diabetes. CONCLUSIONS: This is the largest study of young people with diabetes undertaken in New Zealand. The results confirm the difficulty of achieving good glycaemic control in children and young adults. Microvascular complications were common, particularly in those of long duration, and cardiovascular risk factors were present in many young adults. The difference in average HbA1c% between centres was highly significant and independent of other factors. Type 2 diabetes mellitus in young people was associated with early onset nephropathy and dyslipidaemia (almost from diagnosis), thus suggesting the need for earlier diagnosis.