The Kuwait-Scotland eHealth Innovation Network (KSeHIN): a sustainable approach to quality improvement in healthcare.

BACKGROUND: The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country's healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a national informatics platform. In 2010, a Kuwait-Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date. METHODS: The Kuwait-Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensive informatics system. RESULTS: The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. CONCLUSION: KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformation in the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

Impact of health-care accessibility and social deprivation on diabetes related foot disease.

AIMS: To determine whether geography and/or social deprivation influences the occurrence of foot ulcers or amputations in patients with diabetes. METHODS: A population-based cohort of people with diabetes (n = 15 983) were identified between 2004 and 2006. Community and hospital data on diabetes care, podiatry care and onset of ulceration and amputation was linked using a unique patient identifier, which is used for all patient contacts with health-care professionals. Postcode was used to calculate social deprivation and distances to general practice and hospital care. RESULTS: Over 3 years' follow-up 670 patients with diabetes developed new foot ulcers (42 per 1000) and 99 proceeded to amputation (6 per 1000). The most deprived quintile had a 1.7-fold (95% CI 1.2-2.3) increased risk of developing a foot ulcer. Distance from general practitioner or hospital clinic and lack of attendance at community retinal screening did not predict foot ulceration or amputation. Previous ulcer (OR 15.1, 95% CI 11.6-19.6), insulin use (OR 2.7, 95% CI 2.1-3.5), absent foot pulses (5.9: 4.7-7.5) and impaired monofilament sensation (OR 6.5, 95% CI 5.0-8.4) all predicted foot ulceration. Previous foot ulcer, absent pulses and impaired monofilaments also predicted amputation. CONCLUSION: Social deprivation is an important factor, especially for the development of foot ulcers. Geographical aspects such as accessibility to the general practitioner or hospital clinic are not associated with foot ulceration or amputation in this large UK cohort study.

Self-monitoring of blood glucose in Type 2 diabetes: cross-sectional analyses in 1993, 1999 and 2009.

AIM: To characterize the numbers of reagent strips dispensed for self-monitoring of blood glucose to patients with Type 2 diabetes in Tayside, Scotland, in 1993, 1999 and 2009. METHODS: A diabetes clinical information system in Tayside, record-linked to electronic dispensed prescribing records, was used to collate all dispensed prescribing records for three cross-sectional samples of patients with Type 2 diabetes in 1993 (n = 5728), 1999 (n = 8109) and at 1 January 2009 (n = 16,450). The numbers of reagent strips dispensed during the relevant calendar year were calculated and patients stratified by treatment. We also explored whether age, sex or material and social deprivation were associated with whether a patient received strips. RESULTS: Proportions of people who received self-monitoring reagent strips increased from 15.5% in 1993, to 24.2% in 1999 to 29.8% in 2009, as did numbers of strips dispensed. While the proportion of diet-treated patients who received reagent strips was still very low in 2009 (5.6%), the proportion among those treated with oral agents tripled from 9.4 to 27.4% between 1993 and 2009. Over 90% of patients treated with insulin received reagent strips and, among non-insulin-treated patients, this was more common among women, younger people and less deprived groups. CONCLUSIONS: The numbers of reagent strips dispensed for self-monitoring of blood glucose has increased and almost all insulin-treated patients receive strips. While few diet-treated patients receive strips, they are more extensively dispensed to those treated with oral agents. Given that self-monitoring of blood glucose is no longer routinely recommended in non-insulin treated patients, strategies to reduce unnecessary dispensing of reagent strips are needed.

Which people with Type 2 diabetes achieve good control of intermediate outcomes? Population database study in a UK region.

AIMS: To measure quality of vascular risk factor measurement and control in people with Type 2 diabetes after comprehensive pay-for-performance implementation and to examine variation by patient and practice characteristics. METHODS: Multi-level regression analysis of 10 191 patients with Type 2 diabetes registered with 59 practices in the Tayside region. Quality measures examined were recording of glycated haemoglobin (HbA(1c)), blood pressure (BP), cholesterol and smoking status in the last 12 months; achievement of recommended intermediate outcome targets (HbA(1c)< or = 7.4%, BP < 140/80 mmHg, cholesterol < or = 5.0 mmol/l, not smoking); and simple and all-or-none composite measures. RESULTS: Ninety-five per cent of all recommended processes were received by patients, with 88% of patients receiving all four. Half of all intermediate outcomes targets were achieved, but only 16% of patients achieved all four targets. Process and outcome of care were consistently worse for 1523 (15.0%) patients aged < 55 years. HbA(1c) and BP targets were progressively less likely to be achieved as body mass index increased. Women were less likely to achieve cholesterol targets, but apart from smoking status, there were no associations with socio-economic status. CONCLUSION: Under comprehensive pay-for-performance, process of care is remarkably reliable, but intermediate outcome control less so. Previously identified socio-economic variations in diabetes care have been largely eliminated, but gender inequality is persistent. Younger people were considerably less likely to achieve intermediate outcome targets. Mitigating increased vascular risk in younger patients with Type 2 diabetes presents major challenges for health services in the face of the evolving epidemics of obesity and diabetes.

Myofibrillar myopathy with abnormal foci of desmin positivity. I. Light and electron microscopy analysis of 10 cases.

A number of myopathies whose common denominator is abnormal foci of desmin positivity have been described under the rubrics of spheroid body myopathy, cytoplasmic body myopathy, Mallory body myopathy, myopathy with granulofilamentous inclusions, desmin storage myopathy, and intermediate filament myopathy. In this study we reevaluate the light microscopic and ultrastructural features of the myopathy with abnormal foci of desmin positivity. In 10 cases of the disease, ultrastructural analysis reveals 2 major types of lesions: (a) foci of myofibrillar destruction and (b) hyaline structures that appear as spheroidal bodies on electron microscopy. The foci of myofibrillar destruction consist of fiber areas containing disrupted myofilaments, Z-disk-derived bodies, dappled dense structures of Z-disk origin, and streaming Z-disks that are sometimes adjacent to lakes of dense material. The spheroid bodies are composed of compacted and degraded myofibrillar elements. Membrane-bound vacuoles harboring degenerating membranous organelles are a less frequent and probably secondary abnormality. None of the lesions in muscle comprise 8 to 10 nm intermediate filaments. The findings imply that spheroid body myopathy, cytoplasmic body myopathy, Mallory body myopathy, and myopathy with granulofilamentous inclusions are consequences of a single or closely related pathologic processes. Because the common denominator appears to be focal dissolution of the myofibrils followed by accumulation of the products of the degradative process, we propose the term myofibrillar myopathy to cover the observed spectrum of pathologic changes.

Necrotizing myopathy with pipestem capillaries, microvascular deposition of the complement membrane attack complex (MAC), and minimal cellular infiltration.

Three adult patients, two with undifferentiated connective tissue disease and one with carcinoma, had a distinctive pathologic reaction pattern consisting of necrotizing myopathy, minimal cellular infiltration, and a microangiopathy with thick "pipestem" vessels and microvascular deposits of complement membrane attack complex. Quantitative analysis revealed focal capillary depletion. This pattern represents an immune-mediated microangiopathy and is distinct from that observed in other inflammatory myopathies.

1,1'-Ethylidenebis[tryptophan] induces pathologic alterations in muscle similar to those observed in the eosinophilia-myalgia syndrome.

1,1'-Ethylidenebis[tryptophan] (EBT), a derivative of L-tryptophan (LT), is a trace contaminant in batches of LT implicated by epidemiologic evidence in the pathogenesis of the eosinophilia-myalgia syndrome (EMS). We treated female Lewis rats with EBT or unimplicated LT (4 mg per 100 grams daily) by intraperitoneal injection. No rash or weakness occurred in either group. All three EBT rats had a few necrotic muscle fibers. In two rats, perimysium and fascia were abnormally thickened and infiltrated with lymphocytes, macrophages, and sparse eosinophils; two rats had sparse perineurial inflammatory cells. Rats treated with unimplicated LT showed no abnormality. These findings replicate an important feature of human EMS and support the epidemiologic evidence linking EBT to the pathogenesis of the human disease.

Myasthenia, thymoma, presynaptic antibodies, and a continuum of neuromuscular hyperexcitability.

BACKGROUND: Autoantibodies specific for the nicotinic acetylcholine receptor (AChR) of skeletal muscle impair neuromuscular transmission in myasthenia gravis (MG). Autoantibodies specific for alpha3 neuronal AChRs or voltage-gated potassium channels have been reported in patients with Isaacs syndrome, an acquired disorder of continuous muscle fiber activity characterized by neuromyotonia. OBJECTIVE: To report the neuromuscular autoantibody profiles of three patients with a syndrome of MG and neuromuscular hyperexcitability. RESULTS: All three patients reported here had clinical and electrophysiologic evidence of MG and neuromuscular hyperexcitability. None had neuromyotonia. Thymoma was proven in two patients and suspected in the third. One had MG and thymoma and subsequently developed cramp-fasciculation syndrome; MG and rippling muscle syndrome appeared simultaneously in the other two. All patients had muscle and neuronal AChR binding antibodies and striational antibodies. Only one had antibodies reactive with alpha-dendrotoxin-complexed potassium channels. CONCLUSIONS: The coexistence of cramp-fasciculation syndrome and acquired rippling muscle syndrome with MG, thymoma, and neuronal AChR autoantibodies suggests that there is a continuum of autoimmune neuromuscular hyperexcitability disorders related pathogenically to Isaacs syndrome. Manifestations of neuromuscular hyperexcitability may be altered and less apparent in the context of MG because of the coexisting defect of neuromuscular transmission.

Major histocompatibility complex class I antigen expression, immunolocalization of interferon subtypes, and T cell-mediated cytotoxicity in myopathies.

Major histocompatibility complex class I (MHC-I) expression on target cells is a prerequisite for antigen-specific T cell-mediated cytotoxicity (TCMC). Enhanced MHC-I expression has been attributed to interferons (IFNs) released from inflammatory cells. In previous studies, we found evidence of TCMC (invasion of non-necrotic muscle fibers by cytotoxic T cells) in polymyositis (PM) and in inclusion body myositis (IBM). We occasionally found evidence of TCMC in Duchenne dystrophy (DD) but not in dermatomyositis (DM). This study examines the relationships between TCMC, MHC-I expression, and IFN immunoreactivity in these diseases and normal controls. In controls, reactivity for MHC-I was confined to blood vessels. In all diseases, regenerating fibers expressed MHC-I. In IBM, PM and DD, all nonnecrotic muscle fibers invaded by CD8+ cells and some adjacent fibers expressed MHC-I. In DM, myriad muscle fibers expressed MHC-I but none were invaded by CD8+ cells. In all diseases, only a few mononuclear cells and no muscle fiber surfaces were immunoreactive for IFNs. We conclude that MHC-I expression on muscle fibers is necessary but not sufficient for TCMC in myopathy; that the biological significance of increased MHC-I expression in DM remains undefined; and that currently available and appropriately controlled immunocytochemical methods show no relationship between increased MHC-I expression on muscle fibers and local IFN synthesis by mononuclear cells.

Early ultrastructural alterations in adult dermatomyositis. Capillary abnormalities precede other structural changes in muscle.

In 6 adults with dermatomyositis, minimally weak or nonweak muscles that showed inconclusive light-microscopic alterations were examined by electron microscopy. In all 6 specimens, this revealed pathologic changes in endomysial capillaries. The endothelial cells harbored microtubular inclusions and microvacuoles in all cases; pale swollen endothelial cells were observed in 3 specimens. There were no significant ultrastructural changes in the muscle fibers. In all cases, a small proportion of muscle capillaries were immunoreactive for complement membrane attack complex neoantigens. The findings imply that in adult dermatomyositis capillary injury precedes muscle fiber damage and infiltration by inflammatory cells, and that the microvasculature is an early and specific target of the disease process in muscle.

Clinical, biochemical and histological responses to treatment in polymyositis: a prospective study.

Routine methods of monitoring treatment responses in polymyositis patients, such as clinical strength assessments and measurements of ESR and serum creatine kinase, have been compared with functional strength measurements and assay of serum myoglobin levels, in a prospective study of nine cases followed for up to five years. Seven patients also underwent serial muscle biopsies during the first year of treatment in order to document the nature and chronology of histological changes during therapy. Inflammatory and necrobiotic changes indicating active myositis resolved within six months in all cases and no patient developed histological evidence of steroid myopathy. Scores on functional muscle strength assessments improved more slowly than static manual muscle strength test results, reflecting morphometric and architectural abnormalities in the biopsies which persisted throughout the period of observation. Serum creatine kinase levels returned to normal more rapidly than serum myoglobin. No statistical relationship was found between muscle strength measurements and biochemical or histological changes within the patients as a group, but variations in these indices in individual subjects reflected changes in clinical state.

The diabetes audit and research in Tayside Scotland (DARTS) study: electronic record linkage to create a diabetes register. DARTS/MEMO Collaboration.

OBJECTIVES: To identify all patients with diabetes in a community using electronic record linkage of multiple data sources and to compare this method of case ascertainment with registers of diabetic patients derived from primary care. DESIGN: Electronic capture-recapture linkage of records included data on all patients attending hospital diabetes clinics, all encashed prescriptions for diabetes related drugs and monitoring equipment, all patients discharged from hospital, patients attending a mobile unit for eye screening, and results for glycated haemoglobin and plasma glucose concentrations from the regional biochemistry database. Diabetes registers from primary care were from a random sample of eight Tayside general practices. A detailed manual study of relevant records for the 35,144 patients registered with these eight general practices allowed for validation of the case ascertainment. SETTING: Tayside region of Scotland, population 391,274 on 1 January 1996. MAIN OUTCOME MEASURES: Prevalence of diabetes; population of patients identified by different data sources; sensitivity and positive predictive value of ascertainment methods. RESULTS: Electronic record linkage identified 7596 diabetic patients, giving a prevalence of known diabetes of 1.94% (0.21% insulin dependent diabetes, 1.73% non-insulin dependent): 63% of patients had attended hospital diabetes clinics, 68% had encashed diabetes related prescriptions, 72% had attended the mobile eye screening unit, and 48% had biochemical results diagnostic of diabetes. A further 701 patients had isolated hyperglycaemia (plasma glucose > 11.1 mmol/l) but were not considered diabetic by general practitioners. Validation against the eight general practices (636 diabetic patients) showed electronic linkage to have a sensitivity of 0.96 and a positive predictive value of 0.95 for ascertainment of known diabetes. General practice lists had a sensitivity of 0.91 and a positive predictive value of 0.98. CONCLUSIONS: Electronic record linkage was more sensitive than general practice registers in identifying diabetic subjects and identified an additional 0.18% of the population with a history of hyperglycaemia who might warrant screening for undiagnosed diabetes.

Do managed clinical networks improve quality of diabetes care? Evidence from a retrospective mixed methods evaluation.

PROBLEM: System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness. DESIGN AND SETTING: Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998-2005. STRATEGIES FOR CHANGE: Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders. EFFECTS OF CHANGE: Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources. LESSONS LEARNT: Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin.

AIMS/HYPOTHESIS: The aim of this study was to evaluate the risk of adverse cardiovascular outcomes in patients with type 2 diabetes newly treated with sulfonylureas and metformin. SUBJECTS AND METHODS: The Diabetes Audit and Research in Tayside Scotland (DARTS) diabetes information system and the Medicines Monitoring Unit (MEMO) dispensed prescribing database for the population of Tayside, Scotland (400,000 people) were employed. Patients newly prescribed with oral hypoglycaemic agents between 1994 and 2001 were classified into five study cohorts according to the treatment received: metformin only, sulfonylureas only, sulfonylureas added to metformin, metformin added to sulfonylureas, and both drugs simultaneously. In Cox regression analyses, we estimated relative risks for all-cause mortality, cardiovascular mortality and cardiovascular hospital admission for patients in the five study cohorts, with metformin monotherapy as the reference group. RESULTS: Of the 5,730 study patients, 1,000 died during a maximum of 8 years follow-up. Patients in the sulfonylureas only cohort had increased risks of mortality and cardiovascular mortality, with unadjusted relative risks of 3.12 (95% CI 2.54-3.84) and 3.71 (95% CI 2.64-5.22), respectively. After adjusting for differences between groups (age, sex, duration of diabetes, blood pressure, cholesterol, HbA(1c), smoking, previous hospital admission, treatment with cardiovascular medication), these relative risks were 1.43 (95% CI 1.15-1.77) and 1.70 (95% CI 1.18-2.45), respectively. Patients in the combination cohorts had significantly increased risks of cardiovascular hospital admission, as well as increased risks of mortality and cardiovascular mortality. CONCLUSIONS/INTERPRETATION: In this cohort study of patients newly treated with oral hypoglycaemic agents, those treated with sulfonylureas only, or combinations of sulfonylureas and metformin, were at higher risk of adverse cardiovascular outcomes than those treated with metformin alone.

Stratification of foot ulcer risk in patients with diabetes: a population-based study.

This trial assessed whether a simple clinical tool can be used to stratify patients with diabetes, according to risk of developing foot ulceration. This was a prospective, observational follow-up study of 3526 patients with diabetes (91% type 2 diabetes) attending for routine diabetes care. Mean age was 64.7 (range 15-101) years and duration of diabetes was 8.8 (+/-1.5 SD) years. Patients were categorised into 'low' (64%), 'moderate' (23%) or 'high' (13%) risk of developing foot ulcers by trained staff using five clinical criteria during routine patient care. During follow-up (1.7 years), 166 (4.7%) patients developed an ulcer. Foot ulceration was 83 times more common in high risk and six times more in moderate risk, compared with low-risk patients. The negative predictive value of a 'low-risk score' was 99.6% (99.5-99.7%; 95% confidence interval). This clinical tool accurately predicted foot ulceration in routine practice and could be used direct scarce podiatry resources towards those at greatest need.

The annual incidence of diabetic complications in a population of patients with Type 1 and Type 2 diabetes.

AIM: The DARTS diabetes register was used to determine incidence rates of diabetes and related complications in 1997. METHODS: The diabetes register records detailed clinical information for all patients diagnosed with diabetes in Tayside, Scotland. The study population included patients who were alive and registered with a Tayside GP for the duration of 1997 or who died in Tayside during this time. Patients who had diabetes prior to 1997, those who developed diabetes in 1997, and those who developed diabetic complications in 1997, were identified. RESULTS: In the Tayside population of 385 774 at the start of 1997, there were 942 and 6632 patients with Type 1 and Type 2 diabetes, with a further 29 and 744 patients diagnosed in 1997. The incidence rates (with 95% confidence intervals) of diabetic complications per 1000 patients with Type 1 and Type 2 diabetes, respectively, were: angina 8.8 (4.5-17.3) and 38.4 (33.4-44.2); myocardial infarction 8.6 (4.4-16.9) and 21.9 (18.4-25.9); cerebrovascular accident 1.1 (0.3-6.0) and 14.2 (11.6-17.5); lower extremity amputation 3.2 (1.2-9.4) and 3.1 (2.1-4.8); peripheral vascular disease 5.5 (2.4-12.8) and 13.6 (11.0-16.8); registered blindness 1.1 (0.3-5.9) and 1.6 (0.9-2.9); end-stage renal failure 6.4 (3.0-13.8) and 5.0 (3.6-7.0). Mortality was 14.6 per 1000 (9.6-25.7) in Type 1 diabetes and 50.0 per 1000 (45.1-55.3) in Type 2 diabetes. CONCLUSION: This study provides baseline figures for rates of diabetic complications for Type 1 and Type 2 diabetes, and confirms the increased burden of macrovascular disease in Type 2 diabetes.