Recent temporal trends, characteristics and outcomes of patients with non-COVID-19 community-acquired pneumonia at two tertiary hospitals in Australia: an observational study.

BACKGROUND: Community-acquired pneumonia (CAP) leads to considerable morbidity and mortality globally. However, data on CAP burden in Australia, especially during the coronavirus disease 2019 (COVID-19) pandemic, are limited. AIMS: We characterised and assessed clinical outcomes of non-COVID-19 CAP hospitalisations over a 6-year period at two major hospitals in South Australia. METHODS: All non-COVID-19 CAP hospitalisations were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian modification (ICD-10-AM) codes, between 1 January 2018 and 31 December 2023, at two tertiary hospitals in Adelaide. Clinical outcomes included in-hospital and 30-day mortality, length of stay (LOS) in, intensive care unit (ICU) admission and 30-day readmissions. Multilevel regression models were utilised to identify predictors of clinical outcomes. RESULTS: Over the 6-year period, there were 7853 non-COVID-19 CAP hospitalisations, with a temporal increase from 100 per 100 000 population in 2018 to 208 per 100 000 population in 2023 (P < 0.001). The mean (SD) age was 75.1 (17.6) years, and 54.6% were males. The mean age declined over time (P < 0.05), while other characteristics remained stable. Streptococcus pneumoniae was the most commonly identified bacterium (21.8% of cases). In-hospital mortality occurred in 7.8% of patients, with 30-day mortality and readmission rates of 14.3% and 16.9% respectively. LOS declined significantly during the pandemic years; however, mortality remained stable over time. Frailty status, malnutrition and number of comorbidities significantly predicted 30-day mortality and LOS, in addition to pneumonia severity and ICU admission. CONCLUSIONS: There has been an increasing trend of hospitalisations for non-COVID-19 CAP during the COVID-19 pandemic, with a concomitant trend towards shorter LOS and no significant shift in other clinical outcomes.

The value of distinguishing patients with isolated subsegmental pulmonary embolism presenting to two tertiary hospitals in Australia: an observational study.

Isolated-subsegmental-pulmonary-embolism (SSPE) is increasingly diagnosed with the use of computed-tomography-pulmonary-angiogram (CTPA). There remains clinical equipoise for management of SSPE with previous studies not accounting for frailty while determining clinical outcomes. Clinical outcomes among patients with isolated SSPE were compared with those with a more proximal PE after accounting for frailty and other risk-factors. This study included all patients with a positive CTPA for pulmonary embolism (PE) admitted between 2017 and 2021 to two Australian-tertiary-hospitals. Frailty was determined by use of the hospital-frailty-risk-score (HFRS). Competing-risk-analysis and Cox-proportional hazard models determined the cumulative-risk of VTE and mortality within 3 months and 1 year of index PE event after adjustment for frailty and other variables. Of 334 patients with positive CTPA for PE, 111 (33.2%) had isolated-SSPE. The mean (SD) age was 64.3 (17.7) years, 50.9% were males and 9.6% were frail. The risk of recurrent VTE within 3-months (0.9% vs. 1.8%, P = 0.458) and within 1-year of follow-up (2.7% vs. 6.3%, P = 0.126) did not differ significantly between patients with isolated SSPE and those with more proximal PE. After adjusted analyses, the cumulative-incidence of recurrent VTE was not different among patients with isolated SSPE within 1 year of index event [subdistribution-hazard-ratio (HR) 0.84, 95% CI 0.19 to 3.60]. Similarly, mortality within 1 year of index event was also not different between the two groups (aHR 1.72, 95% CI 0.92-3.23). The prevalence of SSPE was 33.2% and even after adjustment for frailty these patients had no different clinical outcomes than those with proximal PE.

Weight loss with subcutaneous semaglutide versus other glucagon-like peptide 1 receptor agonists in type 2 diabetes: a systematic review.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) reduce elevated blood glucose levels and induce weight loss. Multiple GLP-1 RAs and one combined GLP-1/glucose-dependent insulinotropic polypeptide agonist are currently available. This review was conducted with the aim of summarising direct comparisons between subcutaneous semaglutide and other GLP-1 RAs in individuals with type 2 diabetes (T2D), particularly with respect to efficacy for inducing weight loss and improving other markers of metabolic health. This systematic review of PubMed and Embase from inception to early 2022 was registered on PROSPERO and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Of the 740 records identified in the search, five studies fulfilled the inclusion criteria. Comparators included liraglutide, exenatide, dulaglutide and tirzepatide. In the identified studies, multiple dosing regimens were utilised for semaglutide. Randomised trials support the superior efficacy of semaglutide over other GLP-1 RAs with respect to weight loss in T2D, but tirzepatide is more effective than semaglutide.

Impact of Malnutrition on Clinical Outcomes of Acutely Hospitalised Heart Failure Patients at Two Tertiary Hospitals in Australia: An Observational Study.

BACKGROUND: Malnutrition is common in patients with heart failure (HF) but is often neglected, despite guidelines suggesting that all hospitalised patients should undergo nutritional screening within 24-hours of admission. AIMS: This study investigated the nutritional screening rates and determined the immediate and long-term clinical outcomes in patients with HF admitted at two tertiary hospitals in Australia. METHODS: Nutritional screening was assessed by the Malnutrition Universal Screening Tool (MUST) completion rates. Patients were classified into two categories based on their MUST scores (0=low malnutrition risk and ≥1=at risk of malnutrition). Propensity-score-matching (PSM) was used to match 20 variables depending upon the risk of malnutrition. Clinical outcomes included the days-alive-and-out-of-hospital at 90 days of discharge (DAOH90), length of hospital stay, in-hospital, 30-day and 180-day mortality and 30-day readmissions. RESULTS: There were 5,734 HF admissions between 2013-2020, of whom, only 789 (13.8%) patients underwent MUST screening. The mean (SD) age was 76.2 (14.0) years and 51.9% were males. Five-hundred and fifty-four (554) (70.2%) patients were at low malnutrition risk and 235 (29.8%) at risk of malnutrition. In HF patients, who were at risk of malnutrition, the DAOH90 were lower by 5.9 days (95% CI -11.49 to -0.42, p=0.035) and 180-day mortality was significantly worse (coefficient 0.10, 95% CI 0.02-0.18, p=0.007) compared to those who were at low risk of malnutrition. However, other clinical outcomes were similar between the two groups. CONCLUSION: Nutrition screening is poor in hospitalised HF patients and long-term but not short-term clinical outcomes were worse in malnourished HF patients.

Predictive value of a tiered escalation response system: A case control study.

OBJECTIVE: Rapid response systems designed to detect and respond to clinical deterioration often incorporate a multitiered, escalation response. We sought to determine the 'predictive strength' of commonly used triggers, and tiers of escalation, for predicting a rapid response team (RRT) call, unanticipated intensive care unit admission, or cardiac arrest (events). DESIGN: This was a nested, matched case-control study. SETTING: The study setting involved a tertiary referral hospital. PARTICIPANTS: Cases experienced an event, and controls were matched patients without an event. OUTCOME MEASURES: Sensitivity and specificity and area under the receiver operating characteristic curve (AUC) were measured. Logistic regression determined the set of triggers with the highest AUC. RESULTS: There were 321 cases and 321 controls. Nurse triggers occurred in 62%, medical review triggers in 34%, and RRT triggers 20%. Positive predictive value of nurse triggers was 59%, that of medical review triggers was 75%, and that of RRT triggers was 88%. These values were no different when modifications to triggers were considered. The AUC was 0.61 for nurses, 0.67 for medical review, and 0.65 for RRT triggers. With modelling, the AUC was 0.63 for the lowest tier, 0.71 for next highest, and 0.73 for the highest tier. CONCLUSION: For a three-tiered system, at the lowest tier, specificity of triggers decreases, sensitivity increases, but the discriminatory power is poor. Thus, there is little to be gained by using a rapid response system with more than two tiers. Modifications to triggers reduced the potential number of escalations and did not affect tier discriminatory value.

Designing the ultimate general medicine model.

The ideal model of care in general medicine remains elusive, perhaps because of interhospital heterogeneity in patient population and resource allocation to both general medicine and the medical subspecialties. We explain why successful interventions at one site are not easily applied in another and recommend a nationally coordinated examination of the best general medicine departments' methods of clinical practice improvement.

Modular structures and the delivery of inpatient care in hospitals: a Network Science perspective on healthcare function and dysfunction.

BACKGROUND: Reinforced by the COVID-19 pandemic, the capacity of health systems to cope with increasing healthcare demands has been an abiding concern of both governments and the public. Health systems are made up from non-identical human and physical components interacting in diverse ways in varying locations. It is challenging to represent the function and dysfunction of such systems in a scientific manner. We describe a Network Science approach to that dilemma. General hospitals with large emergency caseloads are the resource intensive components of health systems. We propose that the care-delivery services in such entities are modular, and that their structure and function can be usefully analysed by contemporary Network Science. We explore that possibility in a study of Australian hospitals during 2019 and 2020. METHODS: We accessed monthly snapshots of whole of hospital administrative patient level data in two general hospitals during 2019 and 2020. We represented the organisations inpatient services as network graphs and explored their graph structural characteristics using the Louvain algorithm and other methods. We related graph topological features to aspects of observable function and dysfunction in the delivery of care. RESULTS: We constructed a series of whole of institution bipartite hospital graphs with clinical unit and labelled wards as nodes, and patients treated by units in particular wards as edges. Examples of the graphs are provided. Algorithmic identification of community structures confirmed the modular structure of the graphs. Their functional implications were readily identified by domain experts. Topological graph features could be related to functional and dysfunctional issues such as COVID-19 related service changes and levels of hospital congestion. DISCUSSION AND CONCLUSIONS: Contemporary Network Science is one of the fastest growing areas of current scientific and technical advance. Network Science confirms the modular nature of healthcare service structures. It holds considerable promise for understanding function and dysfunction in healthcare systems, and for reconceptualising issues such as hospital capacity in new and interesting ways.

Effects of very low-carbohydrate vs. high-carbohydrate weight loss diets on psychological health in adults with obesity and type 2 diabetes: a 2-year randomized controlled trial.

AIMS: Very low-carbohydrate (LC) diets are popular for type 2 diabetes (T2DM) management; however, long-term effects on psychological health remain largely unknown. This study reports the effects of a LC diet on mood and cognitive function after 2 years and explores the potential predictors of changes in psychological health. METHODS: 115 adults (57% males; age: 58.5 ± 7.1 years) with obesity and T2DM were randomized to consume an energy reduced (~ 500 to 1000 kcal/day deficit), LC diet [14% energy as carbohydrate, 28% protein, 58% fat (< 10% saturated fat)] or an isocaloric high unrefined carbohydrate, low-fat diet [HC: 53% carbohydrate, 17% protein, 30% fat (< 10% saturated fat)] for 2 years. Both diets were combined with aerobic/resistance exercise (1 h, 3 days/week). Mood/well-being [Beck Depression Inventory (BDI), Spielberger State Anxiety Inventory (SAI), Profile of Mood States (POMS)], diabetes-related quality of life [Diabetes-39 (D-39)] and distress [Problem Areas in Diabetes (PAID) Questionnaire], and cognitive function were assessed during and post-intervention. RESULTS: 61 (LC: 33, HC: 28) participants completed the study. Weight loss was 9.1% after 12 months and 6.7% after 2 years with no difference between diet groups. There were no differences between the groups for the changes in any psychological health outcome (smallest p ≥ 0.19 for all time x diet interactions). Overtime, improvements in BDI, POMS [Total Mood Disturbance (TMD); four subscales], PAID, and D-39 (three subscales) scores occurred (p ≤ 0.05, time). Stepwise regression analysis showed improvements in BDI, POMS (TMD; two subscales), D-39, SAI, and PAID scores were significantly (p < 0.05) correlated with reductions in body weight and glycated hemoglobin. CONCLUSION: In adults with obesity and T2DM, energy-restricted LC and HC diets produced comparable long-term improvements on a comprehensive range of psychological health outcomes. The findings suggest both diets can be used as a diabetes management strategy as part of a holistic lifestyle modification program without concern of negative effects on mental well-being or cognition. TRIAL REGISTRATION: ACTRN12612000369820, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362168&isReview=true . Data described in the manuscript, code book, and analytic code will not be made available because approval has not been granted by participants.

The overlap of frailty and malnutrition in older hospitalised patients: An observational study.

BACKGROUND AND OBJECTIVES: Frailty and malnutrition are geriatric syndromes with common risk-factors. Limited studies have investigated these two conditions simultaneously in hospitalised patients. This study investigated the overlap of frailty and malnutrition in older hospitalised patients. METHODS AND STUDY DESIGN: This prospective study enrolled 263 patients ≥65 years in a tertiary-teaching hospital in Australia. Frailty status was assessed by use of the Edmonton-Frail-Scale (EFS) and malnutrition risk was determined by use of the Malnutrition Universal Screening Tool (MUST). Patients were divided into four categories for comparison: normal, at malnutrition- risk only, frail-only and both frail and at malnutrition risk. Multivariable regression models compared clinical outcomes: length of hospital stay (LOS), in-hospital mortality, health-related quality of life (HRQoL) and 30- day readmissions after adjustment for age, sex, Charlson comorbidity index (CCI) and living-status. RESULTS: The mean (SD) age was 84.1 (6.6) years and 51.2% were females. The prevalence of patients who were at malnutrition- risk only was 14.8%, frailty only 27.8% and 33.5% were both frail and at malnutrition-risk. Frail-only patients were more likely to be older, from a nursing home and with a higher CCI than malnourished only patients. Frail patients had a worse HRQoL (coefficient -0.08, 95% -0.0132--0.031, p=0.002) and were more likely to have a longer LOS (coefficient 5.91, 95% CI 0.77-11.14, p=0.024) than patients at-risk of malnutrition. Other clinical outcomes were similar between the two groups. CONCLUSIONS: There is a substantial overlap of frailty and malnutrition in older hospitalised patients and frailty is associated with worse clinical outcomes than malnutrition.

Nutritional risk assessed by the Malnutrition Universal Screening Tool as a predictor of frailty in acutely hospitalised older patients: An observational study.

BACKGROUND AND OBJECTIVES: Frailty and malnutrition are overlapping geriatric syndromes and leads to poor clinical outcomes in older patients. This study determined whether Malnutrition Universal Screening Tool (MUST) can predict frailty in older hospitalised patients. METHODS AND STUDY DESIGN: This prospective study recruited 243 patients ≥65 years in a tertiary-teaching hospital in Australia. Frailty assessment was performed by use of the Edmonton-Frail-Scale (EFS), while malnutrition-risk was determined by use of the MUST. Patients with an EFS score >8 were classified as frail, while patients with a MUST score of 1 as at moderate malnutritionrisk and ≥2 as at high malnutrition-risk. Multivariable logistic regression determined whether malnutrition-risk predicts frailty after adjustment for various co-variates. RESULTS: The mean (SD) age was 83.9 (6.5) years) and 126 (51.9%) were females. One-hundred and forty-nine (61.3%) patients were classified as frail, while 66 (27.2%) were found to be at high malnutrition-risk according to the MUST. Frail patients were more likely to be older with a higher Charlson-index and on polypharmacy than non-frail patients. Patients who were at high malnutrition- risk were more likely to be living alone and on vitamin D supplementation than those at low malnutritionrisk. Patients who were at a high malnutrition-risk but not those who were at moderate malnutrition-risk, were more likely to be deemed frail (aOR 2.6, 95% CI 1.2-5.5, p=0.015) when compared to those who were at low malnutrition-risk. CONCLUSIONS: Only patients who were classified as at high malnutrition-risk according to the MUST are more likely to be deemed frail.

Very Low and Higher Carbohydrate Diets Promote Differential Appetite Responses in Adults with Type 2 Diabetes: A Randomized Trial.

BACKGROUND: Effects of very low carbohydrate (VLC) diets on appetite response in individuals with type 2 diabetes remain unclear. OBJECTIVE: A secondary analysis was conducted to determine appetite responses to an energy-restricted [30% of energy (%E) deficit] very low carbohydrate (VLC) diet compared with a higher carbohydrate (HC) diet in adults who were overweight or obese with type 2 diabetes. METHODS: Forty-four men and 40 women (mean ± SD, age: 58.7 ± 6.6 y; weight: 100.4 ± 15.5 kg; BMI: 34.5 ± 4.1 kg/m2; glycated hemoglobin: 7.3 ± 1.0%; duration of diabetes: 6.7 ± 5.6 y) were randomly assigned to diets categorized as VLC [14%E carbohydrate (<50 g/d), 28%E protein, 58%E fat (<10%E saturated fat)], or energy-matched HC [53%E carbohydrate, 17%E protein, 30%E fat (<10%E saturated fat)] combined with progressive multicomponent exercise (60 min; 3 d/wk). Body weight, average weekly "daily fasting" and "daily overall" appetite perceptions (hunger, fullness, prospective consumption, and desire to eat-visual analog scales) were assessed at baseline and after 4 and 16 wk. Changes between diets over time were assessed using repeated measures ANOVA. RESULTS: Significant decreases in body weight did not differ between groups (VLC: -11.0 ± 5.4 kg/16 wk compared with HC: -10.1 ± 4.3 kg/16 wk, P = 0.40). Compared with HC, VLC had greater decreases in "daily overall" ratings of fullness (P time × diet < 0.01), such that scores were higher in HC at Week 4 (VLC:48 ± 3 vs HC:56 ± 3 mm, P = 0.001) and 16 (VLC:51 ± 2 vs HC:57 ± 3 mm, P = 0.019). Compared with HC, VLC had greater increases in prospective consumption ratings (P time × diet = 0.03), such that scores were lower in HC at Week 4 (VLC:33 ± 2 vs HC:28 ± 2 mm, P = 0.008), but not at Week 16 (VLC:33 ± 2 vs HC 31 ± 2 mm, P = 0.289). CONCLUSIONS: In the context of energy restriction, both HC and VLC energy-matched diets promoted comparable effects on fasting perceptions of appetite, but the HC diet resulted in greater "daily overall" fullness and reduced prospective consumption. Further research is required to evaluate the effects of ad libitum diets differing in amounts of carbohydrate on appetite response in populations with type 2 diabetes. This trial was registered at www.anzctr.org.au as ACTRN12612000369820.

Clinical characteristics and outcomes of influenza A and B virus infection in adult Australian hospitalised patients.

BACKGROUND: Influenza B is often perceived as a less severe strain of influenza. The epidemiology and clinical outcomes of influenza B have been less thoroughly investigated in hospitalised patients. The aims of this study were to describe clinical differences and outcomes between influenza A and B patients admitted over a period of 4 years. METHODS: We retrospectively collected data of all laboratory confirmed influenza patients ≥18 years at two tertiary hospitals in South Australia. Patients were confirmed as influenza positive if they had a positive polymerase-chain-reaction (PCR) test of a respiratory specimen. Complications during hospitalisation along with inpatient mortality were compared between influenza A and B. In addition, 30 day mortality and readmissions were compared. Logistic regression model compared outcomes after adjustment for age, Charlson index, sex and creatinine levels. RESULTS: Between January 2016-March 2020, 1846 patients, mean age 66.5 years, were hospitalised for influenza. Of whom, 1630 (88.3%) had influenza A and 216 (11.7%) influenza B. Influenza B patients were significantly younger than influenza A. Influenza A patients were more likely be smokers with a history of chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) than influenza B. Complications, including pneumonia and acute coronary syndrome (ACS) were similar between two groups, however, septic shock was more common in patients with influenza B. Adjusted analyses showed similar median length of hospital stay (LOS), in hospital mortality, 30-day mortality and readmissions between the two groups. CONCLUSIONS: Influenza B is less prevalent and occurs mostly in younger hospitalised patients than influenza A. Both strains contribute equally to hospitalisation burden and complications. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry (ANZCR) no ACTRN12618000451202 date of registration 28/03/2018.

Optimising the response to acute clinical deterioration: the role of observation and response charts.

We sought the role of the hospital inpatient observation and response chart (ORC) in reducing adverse outcomes. We sourced articles written in English and published in PubMed. Track, trigger and response systems can be tiered and use single parameter or aggregate scoring systems; the latter being more prone to error. The documentation and detection of abnormal vital signs can be affected by choice of trigger and response and by ORC design. There is considerable variation in the design of ORC and of rapid response systems (RRS) in general, and this impairs assessment of their efficacy. A high rate of modification of pre-determined triggers and poor sensitivity of measured outcomes further compromise systematic review. The best-designed ORC and RRS should optimise the frequency of response team activation to minimise adverse patient outcomes without excess resource utilisation. The role and the risks of electronic data recording are under-explored. Detecting and responding to deteriorating patients relies upon accurate and clear documentation of vital signs. ORC design and staff education on ORC implementation and usage are integral to minimising ALF and optimising patient outcomes. Standardisation of the design of both the ORC and the hospital RRS are overdue.

Similar outcomes for general medicine patients discharged on any day of the week.

BACKGROUND: Hospital congestion is worsened by fewer patients being discharged on the weekend than on weekdays. Weekend admissions fare worse in hospital than weekday admissions. Understanding the fate of patients discharged on the weekend, or any particular weekday, may help optimise hospital discharge processes. AIM: To determine the effects of weekend and specific weekday discharges on adverse outcomes (mortality and readmission to hospital). METHODS: Electronic records were used to identify unplanned admissions to two large public hospitals across a 5-year period. Day of week of discharge, the inpatient length of stay, unplanned readmissions and mortality rate were determined. RESULTS: There was a significant reduction in discharges on the weekend (49%), particularly for patients who were older or with significant comorbidity (P < 0.001). Adjusting for these differences, there was no difference in readmission and mortality between weekday and weekend discharges within two (OR 0.97; 95% CI 0.83-1.14; P < 0.76) or seven (OR 0.91; 95% CI 0.82-1.01; P < 0.07) days of discharge. By 30 days, there were significantly fewer adverse outcomes for those discharged on the weekend (OR 0.89; 95% CI 0.83-0.96; P < 0.001). There was no difference in adverse outcome rates for patients discharged on Mondays, Wednesdays or Fridays. CONCLUSION: Fewer patients are discharged on the weekend and these are typically younger, less complex patients. Patients discharged on the weekend fare similarly or better than those discharged on a weekday. Therefore, a push to discharge more patients on the weekend could improve hospital efficiency without compromising patient care.

Vitamin C deficiency in Australian hospitalised patients: an observational study.

BACKGROUND: Vitamin C has anti-oxidant properties and acts as a cofactor for several enzymes. Hypovitaminosis C has been associated with bleeding, endothelial dysfunction and death. The prevalence of hypovitaminosis C is unknown in Australian hospitalised patients, and its clinical relevance is uncertain. AIMS: To determine the prevalence, characteristics and clinical outcomes of hospitalised patients with hypovitaminosis C. METHODS: This observational study included general-medical inpatients in a tertiary-level hospital in Australia. High-performance liquid chromatography (HPLC) was used to determine plasma vitamin C levels. As per Johnston's criteria, vitamin C levels of ≥28 µmol/L were classified as normal and <28 µmol/L as low. Clinical outcomes determined included length of hospital stay (LOS), nosocomial complications, intensive care unit admission and in-hospital mortality. RESULTS: A total of 200 patients participated in this study, and vitamin C levels were available for 149 patients, of whom 35 (23.5%) had normal vitamin C levels, and 114 (76.5%) had hypovitaminosis C. Patients with hypovitaminosis C were older and had higher C-reactive protein (CRP) levels. Median LOS was 2 days longer in patients with hypovitaminosis C (6 days (interquartile range (IQR) 4, 8) vs 4 days (IQR 3, 6), P = 0.02), and they had fourfold higher odds of staying in hospital for >5 days than those with normal vitamin C levels. Other clinical outcomes were similar between the two groups. CONCLUSIONS: Hypovitaminosis C is common in hospitalised patients and is associated with prolonged LOS. Further research is needed to ascertain the benefits of vitamin C supplementation in vitamin C-depleted patients.

Effects of an energy-restricted low-carbohydrate, high unsaturated fat/low saturated fat diet versus a high-carbohydrate, low-fat diet in type 2 diabetes: A 2-year randomized clinical trial.

AIM: To examine whether a low-carbohydrate, high-unsaturated/low-saturated fat diet (LC) improves glycaemic control and cardiovascular disease (CVD) risk factors in overweight and obese patients with type 2 diabetes (T2D). METHODS: A total of 115 adults with T2D (mean [SD]; BMI, 34.6 [4.3] kg/m2 ; age, 58 [7] years; HbA1c, 7.3 [1.1]%) were randomized to 1 of 2 planned energy-matched, hypocaloric diets combined with aerobic/resistance exercise (1 hour, 3 days/week) for 2 years: LC: 14% energy as carbohydrate, 28% as protein, 58% as fat (<10% saturated fat); or low-fat, high-carbohydrate, low-glycaemic index diet (HC): 53% as CHO, 17% as protein, 30% as fat (<10% saturated fat). HbA1c, glycaemic variability (GV), anti-glycaemic medication effect score (MES, calculated based on the potency and dosage of diabetes medication), weight, body composition, CVD and renal risk markers were assessed before and after intervention. RESULTS: A total of 61 (LC = 33, HC = 28) participants completed the study (trial registration: http://www.anzctr.org.au/, ANZCTR No. ACTRN12612000369820). Reductions in weight (estimated marginal mean [95% CI]; LC, -6.8 [-8.8,-4.7], HC, -6.6 [-8.8, -4.5] kg), body fat (LC, -4.3 [-6.2, -2.4], HC, -4.6 [-6.6, -2.7] kg), blood pressure (LC, -2.0 [-5.9, 1.8]/ -1.2 [-3.6, 1.2], HC, -3.2 [-7.3, 0.9]/ -2.0 [-4.5, 0.5] mmHg), HbA1c (LC, -0.6 [-0.9, -0.3], HC, -0.9 [-1.2, -0.5] %) and fasting glucose (LC, 0.3 [-0.4, 1.0], HC, -0.4 [-1.1, 0.4] mmol/L) were similar between groups (P ≥ 0.09). Compared to HC, the LC achieved greater reductions in diabetes medication use (MES; LC, -0.5 [-0.6, -0.3], HC, -0.2 [-0.4, -0.02] units; P = 0.03), GV (Continuous Overall Net Glycemic Action calculated every 1 hour (LC, -0.4 [-0.6, -0.3], HC, -0.1 [-0.1, 0.2] mmol/L; P = 0.001), and 4 hours (LC, -0.9 [-1.3, -0.6], HC, -0.2 [-0.6, 0.1] mmol/L; P = 0.02)); triglycerides (LC, -0.1 [-0.3, 0.2], HC, 0.1 [-0.2, 0.3] mmol/L; P = 0.001), and maintained HDL-C levels (LC, 0.02 [-0.05, 0.1], HC, -0.1 [-0.1, 0.01] mmol/L; P = 0.004), but had similar changes in LDL-C (LC, 0.2 [-0.1, 0.5], HC, 0.1 [-0.2, 0.4] mmol/L; P = 0.85), brachial artery flow mediated dilatation (LC, -0.5 [-1.5, 0.5], HC, -0.4 [-1.4, 0.7] %; P = 0.73), eGFR and albuminuria. CONCLUSIONS: Both diets achieved comparable weight loss and HbA1c reductions. The LC sustained greater reductions in diabetes medication requirements, and in improvements in diurnal blood glucose stability and blood lipid profile, with no adverse renal effects, suggesting greater optimization of T2D management.

Economic evaluation of an extended nutritional intervention in older Australian hospitalized patients: a randomized controlled trial.

BACKGROUND: Prevalence of malnutrition in older hospitalized patients is 30%. Malnutrition is associated with poor clinical outcomes in terms of high morbidity and mortality and is costly for hospitals. Extended nutrition interventions improve clinical outcomes but limited studies have investigated whether these interventions are cost-effective. METHODS: In this randomized controlled trial, 148 malnourished general medical patients ≥60 years were recruited and randomized to receive either an extended nutritional intervention or usual care. Nutrition intervention was individualized and started with 24 h of admission and was continued for 3 months post-discharge with a monthly telephone call whereas control patients received usual care. Nutrition status was confirmed by Patient generated subjective global assessment (PG-SGA) and health-related quality of life (HRQoL) was measured using EuroQoL 5D (EQ-5D-5 L) questionnaire at admission and at 3-months follow-up. A cost-effectiveness analysis was conducted for the primary outcome (incremental costs per unit improvement in PG-SGA) while a cost-utility analysis (CUA) was undertaken for the secondary outcome (incremental costs per quality adjusted life year (QALY) gained). RESULTS: Nutrition status and HRQoL improved in intervention patients. Mean per included patient Australian Medicare costs were lower in intervention group compared to control arm (by $907) but these differences were not statistically significant (95% CI: -$2956 to $4854). The main drivers of higher costs in the control group were higher inpatient ($13,882 versus $13,134) and drug ($838 versus $601) costs. After adjusting outcomes for baseline differences and repeated measures, the intervention was more effective than the control with patients in this arm reporting QALYs gained that were higher by 0.0050 QALYs gained per patient (95% CI: -0.0079 to 0.0199). The probability of the intervention being cost-effective at willingness to pay values as low as $1000 per unit improvement in PG-SGA was > 98% while it was 78% at a willingness to pay $50,000 per QALY gained. CONCLUSION: This health economic analysis suggests that the use of extended nutritional intervention in older general medical patients is likely to be cost-effective in the Australian health care setting in terms of both primary and secondary outcomes. TRIAL REGISTRATION: ACTRN No. 12614000833662 . Registered 6 August 2014.

Treatment of prednisolone-induced hyperglycaemia in hospitalized patients: Insights from a randomized, controlled study.

AIM: Prednisolone causes hyperglycaemia predominantly between midday and midnight. Consequently, glargine-based basal-bolus insulin regimens may under treat daytime hyperglycaemia and cause nocturnal hypoglycaemia. We investigated whether an isophane-based insulin regimen is safer and more effective than a glargine-based regimen in hospitalized patients. MATERIALS AND METHODS: Fifty inpatients prescribed ≥20 mg/day prednisolone acutely with (1) finger prick blood glucose level (BGL) ≥15 mmol/L or (2) BGLs ≥10 mmol/L within the previous 24 hours were randomized to either insulin isophane or glargine before breakfast and insulin aspart before meals. The initial daily insulin dose was 0.5 U/kg bodyweight or 130% of the current daily insulin dose. Glycaemic control was assessed using a continuous glucose monitoring system. RESULTS: On Day 1, there were no significant differences in percentage of time outside a target glucose range of 4 to 10 mmol/L (41.3% ± 5.5% vs 50.0% ± 5.7%, P = .28), mean daily glucose (10.2 ± 0.7 vs 10.8 ± 0.8 mmol/L, P = .57) or glucose <4 mmol/L (2.2% ± 1.1% vs 2.0% ± 1.3%, P = .92) in patients randomized to isophane and glargine. In patients treated for 3 days, the prednisolone dose was reduced ( P = .02) and the insulin dose was increased over time ( P = .02), but the percentage of time outside the 4 to 10 mmol/L glucose range did not differ over time ( P = .45) or between groups ( P = .24). CONCLUSIONS: There were no differences in the efficacy or safety of the isophane and glargine-based insulin regimens. We recommend an initial daily insulin dose of 0.5 units/kg bodyweight if not on insulin, a greater than 30% increase in pre-prednisolone insulin dose and larger insulin dose adjustments in patients with prednisolone-induced hyperglycaemia.

Hospital occupancy and discharge strategies: a simulation-based study.

BACKGROUND: Increasing demand for hospital services has resulted in more arrivals to emergency department (ED), increased admissions, and, quite often, access block and ED congestion, along with patients' dissatisfaction. Cost constraints limit an increase in the number of hospital beds, so alternative solutions need to be explored. AIMS: To propose and test different discharge strategies, which, potentially, could reduce occupancy rates in the hospital, thereby improving patient flow and minimising frequency and duration of congestion episodes. METHODS: We used a simulation approach using HESMAD (Hospital Event Simulation Model: Arrivals to Discharge) - a sophisticated simulation model capturing patient flow through a large Australian hospital from arrival at ED to discharge. A set of simulation experiments with a range of proposed discharge strategies was carried out. The results were tabulated, analysed and compared using common hospital occupancy indicators. RESULTS: Simulation results demonstrated that it is possible to reduce significantly the number of days when a hospital runs above its base bed capacity. In our case study, this reduction was from 281.5 to 22.8 days in the best scenario, and reductions within the above range under other scenarios considered. CONCLUSION: Some relatively simple strategies, such as 24-h discharge or discharge/relocation of long-staying patients, can significantly reduce overcrowding and improve hospital occupancy rates. Shortening administrative and/or some treatment processes have a smaller effect, although the latter could be easier to implement.

Glycemic Variability: Assessing Glycemia Differently and the Implications for Dietary Management of Diabetes.

The primary therapeutic target for diabetes management is the achievement of good glycemic control, of which glycated hemoglobin (HbA1c) remains the standard clinical marker. However, glycemic variability (GV; the amplitude, frequency, and duration of glycemic fluctuations around mean blood glucose) is an emerging target for blood glucose control. A growing body of evidence supports GV as an independent risk factor for diabetes complications. Several techniques have been developed to assess and quantify intraday and interday GV. Additionally, GV can be influenced by several nutritional factors, including carbohydrate quality, quantity; and distribution; protein intake; and fiber intake. These factors have important implications for clinical nutrition practice and for optimizing blood glucose control for diabetes management. This review discusses the available evidence for GV as a marker of glycemic control and risk factor for diabetes complications. GV quantification techniques and the influence of nutritional considerations for diabetes management are also discussed.