Cardiovascular risk outcome and program evaluation of a cluster randomised controlled trial of a community-based, lay peer led program for people with diabetes.

BACKGROUND: The 2013 Global Burden of Disease Study demonstrated the increasing burden of diabetes and the challenge it poses to the health systems of all countries. The chronic and complex nature of diabetes requires active self-management by patients in addition to clinical management in order to achieve optimal glycaemic control and appropriate use of available clinical services. This study is an evaluation of a "real world" peer support program aimed at improving the control and management of type 2 diabetes (T2DM) in Australia. METHODS: The trial used a randomised cluster design with a peer support intervention and routine care control arms and 12-month follow up. Participants in both arms received a standardised session of self-management education at baseline. The intervention program comprised monthly community-based group meetings over 12 months led by trained peer supporters and active encouragement to use primary health care and other community resources and supports related to diabetes. Clinical, behavioural and other measures were collected at baseline, 6 and 12 months. The primary outcome was the predicted 5 year cardiovascular disease risk using the United Kingdom Prospective Diabetes Study (UKPDS) Risk Equation at 12 months. Secondary outcomes included clinical measures, quality of life, measures of support, psychosocial functioning and lifestyle measures. RESULTS: Eleven of 12 planned groups were successfully implemented in the intervention arm. Both the usual care and the intervention arms demonstrated a small reduction in 5 year UKPDS risk and the mean values for biochemical and anthropometric outcomes were close to target at 12 months. There were some small positive changes in self-management behaviours. CONCLUSIONS: The positive changes in self-management behaviours among intervention participants were not sufficient to reduce cardiovascular risk, possibly because approximately half of the study participants already had quite well controlled T2DM at baseline. Future research needs to address how to enhance community based programs so that they reach and benefit those most in need of resources and supports to improve metabolic control and associated clinical outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12609000469213 . Registered 16 June 2009.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk.

BACKGROUND: Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

Undifferentiated febrile illnesses amongst British troops in Helmand, Afghanistan.

OBJECTIVES: Undifferentiated febrile illnesses have been a threat to British expeditionary forces ever since the Crusades. The infections responsible were identified during the Colonial Era, both World Wars and smaller conflicts since, but nearly all remain a significant threat today. Undiagnosed febrile illnesses have occurred amongst British troops in Helmand, Afghanistan since 2006 and so a fever study was performed to identify them. METHODS: From May to October 2008, all undifferentiated fever cases seen at the British field hospital in Helmand, Afghanistan were assessed using a standard protocol. Demographic details, clinical features and laboratory results were recorded and paired serum samples were sent for testing at the UK Special Pathogens Reference Unit (SPRU). RESULTS: Over 6 months, there were 26 cases of"Helmand Fever" assessed and 23 diagnoses were made of which 12 (52%) were sandfly fever, 6 (26%) were acute Qfever and 5 (22%) were rickettsial infections. Four cases had co-infections and 7 cases were not diagnosed (mostly due to inadequate samples). The clinical features and laboratory results available at the British field hospital did not allow these diseases to be distinguished from each other. The exact type of rickettsial infection could not be identified at SPRU. CONCLUSIONS: These cases probably represent the "tip of an iceberg" for British and Allied forces. More resources for diagnostic facilities and follow-up of patients are required to improve the management and surveillance of "Helmand Fever" cases; until then doxycycline 100 mg twice daily for 2 weeks should be given to all troops who present with an undifferentiated febrile illness in Helmand, Afghanistan. Patients with acute Q fever should be followed-up for at least 2 years to exclude chronic Q fever. Prevention of these diseases requires a better understanding of their epidemiology, but prophylaxis with doxycycline and possibly Q fever vaccine should be considered.

The MRI appearances of early vertebral osteomyelitis and discitis.

AIM: To describe the magnetic resonance imaging (MRI) appearances in patients with a clinical history suggestive of vertebral osteomyelitis and discitis who underwent MRI very early in their clinical course. MATERIALS AND METHODS: A retrospective review of the database of spinal infections from a spinal microbiological liaison team was performed over a 2 year period to identify cases with clinical features suggestive of spinal infection and an MRI that did not show features typical of vertebral osteomyelitis and discitis. All patients had positive microbiology and a follow up MRI showing typical features of spinal infection. RESULTS: In four cases the features typical of spinal infection were not evident at the initial MRI. In three cases there was very subtle endplate oedema associated with disc degeneration, which was interpreted as Modic type I degenerative endplate change. Intravenous antibiotic therapy was continued prior to repeat MRI examinations. The mean time to the repeat examination was 17 days with a range of 8-22 days. The second examinations clearly demonstrated vertebral osteomyelitis and discitis. CONCLUSION: Although MRI is the imaging method of choice for vertebral osteomyelitis and discitis in the early stages, it may show subtle, non-specific endplate subchondral changes; a repeat examination may be required to show the typical features.

GooD4Mum: A general practice-based quality improvement collaborative for diabetes prevention in women with previous gestational diabetes.

AIMS: Gestational diabetes (GDM) and Type 2 diabetes pose tremendous health and economic burdens as worldwide incidence increases. Primary care-based systematic diabetes screening and prevention programs could be effective in women with previous GDM. GooD4Mum aimed to determine whether a Quality Improvement Collaborative (QIC) would improve postpartum diabetes screening and prevention planning in women with previous GDM in general practice. METHODS: Fifteen general practices within Victoria (Australia) participated in a 12-month QIC, consisting of baseline and four quarterly audits, guideline-led workshops and Plan-Do-Study-Act feedback cycles after each audit. The primary outcome measures were the proportion of women on local GDM registers completing a diabetes screening test and a diabetes prevention planning consultation within the previous 15 months. RESULTS: Diabetes screening increased with rates more than doubled from 26% to 61% and postpartum screening increased from 43%-60%. Diabetes prevention planning consultations did not show the same level of increase (0%-10%). The recording of body mass index improved overall (51%-69%) but the number of women with normal body mass index did not. CONCLUSIONS: GooD4Mum supported increased diabetes screening and the monitoring of high risk women with previous GDM in general practice.

Prevalence, detection and drug treatment of hypertension in a rural Australian population: the Greater Green Triangle risk factor study 2004-2006.

BACKGROUND: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia. AIM: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population. METHODS: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004-2006 using a random population sample (n = 3320, participation rate 49%) aged 25-74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure >or=140 mmHg and/or diastolic blood pressure >or=90 mmHg and/or on antihypertensive drug treatment. RESULTS: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47-60) of men and 71% (95% CI 65-77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54-67 and 55%, 95% CI 47-64) compared with men (42%, 95% CI 36-49 and 35%, 95% CI 26-44). Monotherapy was used by 55% (95% CI 48-61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women. CONCLUSION: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.

Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis.

Post-partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post-partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post-partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self-monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home- or centre-based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta-analysis (1,892 women, age 24-36 years). Studies with self-monitoring had significantly greater weight lost than those without (-4.61 kg [-7.08, -2.15] vs. -1.34 kg [-1.66, -1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (-3.24 kg [-4.59, -1.90] vs. -1.63 kg [-2.16, -1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self-monitoring and take a combined diet-and-exercise approach have significantly greater weight loss in post-partum women.

Rapid prescribing change, how do patients respond?

The cost of prescribed medication is an increasing burden on health care systems. British general practitioners have been encouraged to reduce their prescribing costs through financial incentives within the fundholding scheme. This study reports on one general practice which reduced prescribing expenditure as part of the move to fundholding. Interviews performed with practice staff and patients were analysed and combined with prescribing statistics and questionnaire data to give a picture of the balance between the experience of patients and practitioners. Fifty-three interviews with 17 patients revealed that most were willing to try cheaper treatments and that dissatisfaction was primarily with the communication they received rather than the change itself. Each patient had to decide how to respond to the change in their medication. The decision-making process and the main factors involved are described and discussed. The experience of having long-standing treatment changed can have an impact on the doctor-patient relationship. This was not found to be a large problem and, it is suggested, can be guarded against. Large-scale economies in prescribing are feasible for some practices, and patients will tolerate such changes if attention is paid to sensitive communication.

Biochemical investigation of vitreus: applications in forensic medicine, especially in relation to alcohol.

Vitreus biochemistry is useful in subjects dying with uraemia, dehydration, hyponatraemia; and in the presence of osmotically active substances such as alcohol and drugs. Useful tests include sodium, potassium, chloride, urea, creatinine, osmolality, osmolar gap estimation and ethanol. The significance of calcium, magnesium, zinc, copper, pH, phosphate and urate is still not clear. Transaminases and lactate dehydrogenase are found to be significantly raised; these may be associated with sudden release of hyalocyte contents at death.

Post-mortem estimation of gamma-glutamyl transferase in vitreous humor and its association with chronic abuse of alcohol and road-traffic deaths.

A small survey was undertaken to assess the usefulness of measuring gamma-glutamyl transferase in vitreous. The results show that this enzyme may not be a sensitive test to predict the mortality due to chronic abuse of alcohol in road traffic deaths.

Alcohol consumption, blood alcohol level and the relevance of body weight in experimental design and analysis.

In healthy male subjects, intake of alcohol is not closely related to body weight although there is a significant correlation between consumption and body weight in the younger age group. No association was observed between age and alcohol consumption. Age did show a significant association when expressed in terms of intake per weight. Eight hours after consumption blood alcohol did not vary significantly in people with different body weight; total body water is probably the key factor. This study raises doubts about experimental designs and calculations of blood alcohol whereby assumption is made that correcting alcohol dose for body weight would give precise information. Conclusions from such studies could in fact be misleading.

Vertical strabismus resulting from an anomalous extraocular muscle.

Unusual ocular motility abnormalities have been rarely reported to result from anomalous extraocular structures. These structures, which may be either muscular or fibrotic, attach to the globe and produce a mechanical restriction resulting in incomitant strabismus. To our knowledge, we report the first patient with an anomalous extraocular muscle in whom the clinical, radiologic, surgical, and histopathologic findings are described.

Changing to generic formulary: how one fundholding practice reduced prescribing costs.

OBJECTIVES: To observe one general practice's attempt to reduce prescribing costs on becoming third wave fundholders through the introduction of a generic formulary applied to all new and repeat prescribing. To assess the impact on patients and prescribing patterns. DESIGN: An observational study using interviews with patients and practitioners; questionnaires for patients and prescribing data. SETTING: One urban general practice with five partners in Scotland. It became fundholding in April 1993. SUBJECTS: 71 searches of the register of repeat prescriptions identified 1274 potential changes in drugs. Questionnaires were sent to a stratified random sample of 280 patients four months after the changes were made; 33 interviews were conducted with 17 patients selected by local pharmacists to represent a wide range of opinion. MAIN OUTCOME MEASURES: Changes in prescribing and response and satisfaction of patients. RESULTS: Of intended changes, 129 (70%) were in place after four months. Thirty three (20%) of the 167 patients who returned questionnaires were "very unhappy," though interviews suggested that this was primarily with the communication they received rather than the change itself. Generic prescribing rose from one in three (37%) to over a half (58%). The volume of treatment dispensed (as treatment days) fell by 67,674 (10.7%), and the average cost per day's treatment fell by 3.1 p from 32.3 p per day in 1992 (9.4%), producing a total absolute saving of 24% (137,712 pounds) over the first year. CONCLUSION: This practice has achieved a large reduction in prescribing costs rapidly. These were tolerated by patients, none of whom is thought to have left the practice for this reason. Great care must be taken to inform patients appropriately.

Implementing the North Karelia Project in Scotland.

A comprehensive, determined and theory-based community programme can have a meaningful and positive effect on risk factors and life styles. In much the same way as the North Karelia Project was rolled out to cover the whole of Finland, there is no reason why our intervention schemes could not be rolled out to cover the whole of Scotland. The North Karelia Project proved that a major national demonstration programme can be a strong tool for favourable national development in chronic disease prevention and health promotion.

Integrating clinical pharmacists into the primary health care team: a framework for rational and cost-effective prescribing.

A recent Audit Commission report into general practice prescribing identifies areas where general practitioner and pharmacist collaboration could be beneficial. Two such areas are formulary development and repeat prescribing review. Increased generic prescribing is encouraged in the report and in central priorities for Scottish Health Boards. This study was designed to develop and assess the effects on prescribing, of a practice formulary and a procedure for change to generic name prescribing. A practice formulary, standards for generic name prescribing and an approach to prescribing review were agreed, developed and implemented. Formulary compliance and the extent of prescribing generically and of changes to generic prescriptions were assessed by prospective prescription monitoring. Consultations resulting in a prescription reduced from 69% to 59% and 80% of acute prescribing events were met from 144 formulary medicines. Rapid change to generic name prescriptions was achieved without patient complaints and the overall generic prescribing level increased from 57% to 68%. Eighty percent of all new prescriptions were generic.

A virtual clinic: telemetric assessment and monitoring for rural and remote areas.

This article reports the establishment of a pilot 'virtual clinic' in a rural region of Victoria, Australia. Using low-cost videophones that work across ordinary phone lines, together with off-the-shelf (mostly automatic) clinical tools, local volunteers have been trained to mediate a virtual consultation between simulated patients and local GPs. This system has the potential to save long trips into town by such patients since the traditional 'home visit' is not feasible, as well as to provide regular home monitoring for those with chronic conditions. This in turn should impact favourably on ambulance deployment, sometimes enabling patients to avoid going to hospital or allowing them to come home sooner than otherwise would be the case, and generally to offer a sense of medical security to those living in isolated regions.

Food cost and availability in a rural setting in Australia.

INTRODUCTION: The burden of chronic diseases is rapidly increasing worldwide. In Australia rural populations have a greater burden of disease. Chronic diseases are largely preventable with diet as a key risk factor. With respect to diet-related chronic disease, dietary risk may be due to poor food access, namely, poor availability and/or the high cost of healthy food. It is likely that poor food access is an issue in rural areas. OBJECTIVE: To assess food access in rural south-west (SW) Victoria, Australia. METHODS: A total of 53 supermarkets and grocery stores in 42 towns participated in a survey of food cost and availability in the rural area of SW Victoria. The survey assessed availability and cost of a Healthy Food Access Basket (HFAB) which was designed to meet the nutritional needs of a family of 6 for 2 weeks. RESULTS: Seventy-two percent of the eligible shops in SW Victoria were surveyed. The study found that the complete HFAB was significantly more likely to be available in a town with a chain-owned store (p <0.00). The complete HFAB was less likely to be available from an independently owned store in a town with only one grocery shop (p <0.004). The average cost of the HFAB across SW Victoria was AU380.30 dollars +/- 25.10 dollars (mean +/- SD). There was a mean range in difference of cost of the HFAB of 36.92 dollars. In particular, high variability was found in the cost of fruits and vegetables. CONCLUSIONS: Cost and availability of healthy food may be compromised in rural areas. IMPLICATIONS: Improvements in food access in rural areas could reduce the high burden of disease suffered by rural communities.

Safety and acceptability of practice-nurse-managed care of depression in patients with diabetes or heart disease in the Australian TrueBlue study.

OBJECTIVES: To determine the safety and acceptability of the TrueBlue model of nurse-managed care in the primary healthcare setting. DESIGN: A mixed methods study involving clinical record audit, focus groups and nurse interviews as a companion study investigating the processes used in the TrueBlue randomised trial. SETTING: Australian general practices involved in the TrueBlue trial. PARTICIPANTS: Five practice nurses and five general practitioners (GPs) who had experienced nurse-managed care planning following the TrueBlue model of collaborative care. INTERVENTION: The practice nurse acted as case manager, providing screening and protocol-management of depression and diabetes, coronary heart disease or both. PRIMARY OUTCOME MEASURES: Proportion of patients provided with stepped care when needed, identification and response to suicide risk and acceptability of the model to practice nurses and GPs. RESULTS: Almost half the patients received stepped care when indicated. All patients who indicated suicidal ideations were identified and action taken. Practice nurses and GPs acknowledged the advantages of the TrueBlue care-plan template and protocol-driven care, and the importance of peer support for the nurse in their enhanced role. CONCLUSIONS: Practice nurses were able to identify, assess and manage mental-health risk in patients with diabetes or heart disease.