Contemporary Cardiovascular Risk Assessment for Type 2 Diabetes Including Heart Failure as an Outcome: The Fremantle Diabetes Study Phase II.

Background: Type 2 diabetes (T2D) cardiovascular disease (CVD) risk assessment has limitations. The aim of this study was to develop a risk equation adding heart failure (HF) to conventional major adverse cardiovascular events (MACE, myocardial infarction, stroke, and CVD death) and allowing for non-CVD death. Methods: 1551 community-based people with T2D (mean age 66 years, 52% males) were followed from baseline in 2008-2011 for five years to the first CVD event/death. Cox and competing risk regression identified predictors of three-point MACE and four-point MACE (including HF). Discrimination was assessed by the area under the receiver-operating characteristic curve (AUC) and calibration by the Hosmer-Lemeshow test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for a 10% five-year CVD risk cut-off. Results: 143 participants (9.2%) experienced a three-point MACE during 7,111 person-years of follow-up and 245 (15.8%) a four-point MACE during 6,896 person-years. The best model was the competing risk four-point MACE (221 predicted events (14.3%), AUC 0.82 (95% CI: 0.79-0.85), Hosmer-Lemeshow test, p = 0.17, sensitivity 79.2%, specificity 68.1%, PPV 31.8%, NPV 94.6%) with validation in 177 adults with T2D from an independent population (AUC 0.81 (0.74-0.89). Conclusions: A validated four-point MACE competing risk model reliably predicts key T2D CVD outcomes.

A comparison of obesity indices in relation to mortality in type 2 diabetes: the Fremantle Diabetes Study.

AIMS/HYPOTHESIS: This prospective association study aimed to compare the relationship between each of four obesity indices and mortality risk in people with type 2 diabetes. METHODS: The associations of BMI, waist circumference, WHR and A Body Shape Index (ABSI) with all-cause mortality were analysed in 1282 participants of the Fremantle Diabetes Study, followed for up to 20 years after baseline assessment. Models were adjusted for age and other confounders; assessments as continuous measures and by quintile were carried out for men and women separately. Sensitivity analyses were conducted to minimise reverse causality. RESULTS: When indices were assessed as continuous variables, there were significant bivariate associations with mortality for: ABSI, which was greater in both men and women who died (p < 0.001); WHR, which was greater in women only (p = 0.033); and BMI, which was lower in women only (p < 0.001). When assessed by quintile, there were significant bivariate associations with mortality for ABSI in men and women (p < 0.001) and BMI in women only (p = 0.002). In Cox models of time to death, adjusted for age, diabetes duration, ethnicity and smoking, ABSI quintiles showed a linear trend for both men (p = 0.003) and women (p = 0.035). Men in the fifth ABSI quintile had an increased mortality risk compared with those in the first quintile (HR [95% CI]: 1.74 [1.24, 2.44]) and women in the fifth ABSI quintile had an increased mortality risk that approached statistical significance (1.42 [0.97, 2.08], p = 0.08). Men in the fifth WHR quintile had an increased mortality risk (1.47 [1.05, 2.06]). There was no association between mortality and BMI or waist circumference in either sex. CONCLUSIONS/INTERPRETATION: ABSI was the obesity index most strongly associated with all-cause mortality in Australians with type 2 diabetes. There was no evidence for an obesity paradox with any of the assessed indices. ABSI may be a better index of central obesity than waist circumference, BMI or WHR when assessing mortality risk in type 2 diabetes.

Diagnostic and response assessment FDG PET-CT in neurolymphomatosis.

FDG PET-CT is a useful imaging tool in the diagnosis and response assessment of neurolymphomatosis, especially in cases of otherwise unexplained neuropathy following conventional diagnostic work-up including lumbar puncture, CT, and MRI. The use of a novel PET reconstruction algorithm improves image quality and lesion detection through increased signal-to-noise ratio.

Perspectives of clinical medical directors in child and adolescent psychiatry: diagnostic and treatment needs of migrant families.

Germany is one of many nations characterized by an increasing number of children originating from families with a migration background. Medical treatment modalities will be required to adjust for diversity of social and cultural background. Initiated by the Federal Society of Child and Adolescent Psychiatry (BKJPP), representing mainly those psychiatrists working in private practice, and by the Federal Working Commission of Medical Directors employed in Child and Adolescent Psychiatric Clinics (BAG), a questionnaire was constructed to identify mental health professionals' (psychiatrists') evaluation of the needs and quality of diagnosis and treatment for migrant families. The current study focused on medical directors and deputy chief physicians in clinics for child and adolescent psychiatry. Preliminary results of this survey - implementing descriptive statistics as well as univariate and multivariate statistical analyses - permitted an assessment of the current state of identification and treatment of migrant offspring attending child and adolescent psychiatric practices in Germany. Recommendations and concrete steps are offered, which aim to promote "cultural opening", and assist in health and social policy makers' decisions for improved mental health care.

Practicing physicians' needs for assessment and feedback as part of professional development.

Recently, more is being learned about the linkages among assessment, feedback, and continued learning and professional development. The purpose of this article is to explore these linkages and to understand how assessment and feedback can guide professional development and related practice change. It includes a brief review of conceptual models that guide learning and practice change in general, related to both formally structured continuing professional development (CPD) sessions and to self-directed individual activities, and draws on these to inform learning and change from assessment and feedback. However, evidence and theory show that using assessment and feedback for learning and change are not naturally intuitive activities. We propose a 4-phase facilitated reflective process for enabling engagement with assessment data and feedback and using it for learning and change, and explore the varied personal and contextual factors which are influential and require consideration. We end with practical implications and suggestions.

Health and educational performance among young migrants.

This study is a part replication of an earlier study by on health efficacy, educational attainment and well-being among 30 nations. It includes, however, data from these nations, as well as the latest Pisa results and update socioeconomic data and sociological variables which include divorce rate, number of persons/household, employment rates, and measures of physical and mental health (including new scales of well-being, e.g., mental health index, life satisfaction, suicide rates). More importantly, it includes measures of migrant rates among children and adults in each country, the focus of attention of this article. New material on health and educational expenditure are provided.

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: the Fremantle Diabetes Study.

BACKGROUND: Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes. OBJECTIVE: To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting. DESIGN: Prospective observational study utilising data linkage. SETTING: Postcode defined region in Fremantle, Australia. PARTICIPANTS: All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996. METHODS: Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs. RESULTS: During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9-85] visits, range 1-1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes. CONCLUSIONS: Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.

An effective dietary survey framework for the assessment of total dietary arsenic intake in Bangladesh: part-A--FFQ design.

The accurate assessment of dietary intake patterns is important for the determination of total dietary arsenic (As) exposure in As-contaminated regions of Bangladesh. Food intake questionnaires are a common means of assessing food intake. A food frequency questionnaire (FFQ) was designed to assess the daily intake of frequently consumed food items and was successfully implemented to assess dietary patterns and intake of the rural populations in 18 villages from three Districts of Bangladesh (Comilla, Manikganj Sadar, and Munshiganj). The FFQ presented in this paper comprises a complete set of tools which allowed not only collection of information on dietary patterns but also information on the spatial characteristics of the landscape, socio-demographic indicators, and geographic locations of the identified environmental media of the contaminants, which resulted in As exposure to humans. The FFQ was designed in three sections: (1) general household information, (2) household water and rice information, and (3) individual dietary intake of other foods. The dietary intake of other food was then further subdivided into five different food subgroups: (i) grain intake, (ii) protein intake, (iii) fruit intake (iv), vegetable intake, and (v) dal (pulse) intake. During the design and development of the FFQ, emphasis was given to the source of food, the frequency (day/week/month) of consumption, and the daily amount of food consumed by each adult male, adult female, and child to accurately determine the dietary pattern and intake of arsenic in the rural population of Bangladesh.

Human arsenic exposure and risk assessment at the landscape level: a review.

Groundwater contaminated with arsenic (As), when extensively used for irrigation, causes potentially long term detrimental effects to the landscape. Such contamination can also directly affect human health when irrigated crops are primarily used for human consumption. Therefore, a large number of humans are potentially at risk worldwide due to daily As exposure. Numerous previous studies have been severely limited by small sample sizes which are not reliably extrapolated to large populations or landscapes. Human As exposure and risk assessment are no longer simple assessments limited to a few food samples from a small area. The focus of more recent studies has been to perform risk assessment at the landscape level involving the use of biomarkers to identify and quantify appropriate health problems and large surveys of human dietary patterns, supported by analytical testing of food, to quantify exposure. This approach generates large amounts of data from a wide variety of sources and geographic information system (GIS) techniques have been used widely to integrate the various spatial, demographic, social, field, and laboratory measured datasets. With the current worldwide shift in emphasis from qualitative to quantitative risk assessment, it is likely that future research efforts will be directed towards the integration of GIS, statistics, chemistry, and other dynamic models within a common platform to quantify human health risk at the landscape level. In this paper we review the present and likely future trends of human As exposure and GIS application in risk assessment at the landscape level.

Implementation of food frequency questionnaire for the assessment of total dietary arsenic intake in Bangladesh: part B, preliminary findings.

Dietary intake of water and food has been identified as one of the major pathways for arsenic (As) exposure in the rural population of Bangladesh. Therefore, realistic assessment and measurement of dietary intake patterns are important for the development of an accurate estimate of As exposure and human health risk assessment. One important consideration is to identify an appropriate tool for measuring dietary intake. In this study an interviewer-administered Food Frequency Questionnaire (FFQ) was implemented to determine age and gender specific dietary intake. The developed FFQ was unique because it developed a synergy between field dietary assessment and As concentration measurements in various environmental media. The resulting integrated database provided an accurate framework for the process of As exposure and human health risk assessment. The preliminary results reported here from the FFQ demonstrated that this technique could be used in rural areas as a tool to assess As exposure and the associated human health risk.

The reliability of workplace-based assessment in postgraduate medical education and training: a national evaluation in general practice in the United Kingdom.

To investigate the reliability and feasibility of six potential workplace-based assessment methods in general practice training: criterion audit, multi-source feedback from clinical and non-clinical colleagues, patient feedback (the CARE Measure), referral letters, significant event analysis, and video analysis of consultations. Performance of GP registrars (trainees) was evaluated with each tool to assess the reliabilities of the tools and feasibility, given raters and number of assessments needed. Participant experience of process determined by questionnaire. 171 GP registrars and their trainers, drawn from nine deaneries (representing all four countries in the UK), participated. The ability of each tool to differentiate between doctors (reliability) was assessed using generalisability theory. Decision studies were then conducted to determine the number of observations required to achieve an acceptably high reliability for "high-stakes assessment" using each instrument. Finally, descriptive statistics were used to summarise participants' ratings of their experience using these tools. Multi-source feedback from colleagues and patient feedback on consultations emerged as the two methods most likely to offer a reliable and feasible opinion of workplace performance. Reliability co-efficients of 0.8 were attainable with 41 CARE Measure patient questionnaires and six clinical and/or five non-clinical colleagues per doctor when assessed on two occasions. For the other four methods tested, 10 or more assessors were required per doctor in order to achieve a reliable assessment, making the feasibility of their use in high-stakes assessment extremely low. Participant feedback did not raise any major concerns regarding the acceptability, feasibility, or educational impact of the tools. The combination of patient and colleague views of doctors' performance, coupled with reliable competence measures, may offer a suitable evidence-base on which to monitor progress and completion of doctors' training in general practice.

Workplace-based assessment for general practitioners: using stakeholder perception to aid blueprinting of an assessment battery.

CONTEXT: The implementation of an assessment system may be facilitated by stakeholder agreement that appropriate qualities are being tested. This study investigated the extent to which stakeholders perceived 8 assessment formats (multiple-choice questions, objective structured clinical examination, video, significant event analysis, criterion audit, multi-source feedback, case analysis and patient satisfaction questionnaire) as able to assess varying qualities of doctors training in UK general practice. METHODS: Educationalists, general practice trainers and registrars completed a blueprinting style of exercise to rate the extent to which each evaluation format was perceived to assess each of 8 competencies derived primarily from the General Medical Council document 'Good Medical Practice'. RESULTS: There were high levels of agreement among stakeholders regarding the perceived qualities tested by the proposed formats (G = 0.82-0.93). Differences were found in participants' perceptions of how well qualities were able to be assessed and in the ability of the respective formats to test each quality. Multi-source feedback (MSF) was expected to assess a wide range of qualities, whereas Probity, Health and Ability to work with colleagues were limited in terms of how well they could be tested by the proposed formats. DISCUSSION: Awareness of the perceptions of stakeholders should facilitate the development and implementation of workplace-based assessment (WPBA) systems. These data shed light on the acceptability of various formats in a way that will inform further investigation of WPBA formats' validity and feasibility, while also providing evidence on which to base educational efforts regarding the value of each format.

Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study.

OBJECTIVE: We sought to determine whether self-monitoring of blood glucose (SMBG) is associated with better glycemic control in type 2 diabetes. RESEARCH DESIGN AND METHODS: We used cross-sectional and longitudinal data from type 2 diabetic participants in the observational, community-based Fremantle Diabetes Study (FDS) who reported SMBG status at study entry (n = 1,286) and annual reviews over 5 years (n = 531). RESULTS: At study entry, 70% of patients performed SMBG, with a median of four tests per week (interquartile range two to seven). Patients with shorter diabetes duration; who were attending diabetes education, diabetes-related clinics, or medical specialists; who were taking insulin with or without oral hypoglycemic agents (OHAs); and who were self-reporting hypoglycemic events were more likely to use SMBG. Both cross-sectional and longitudinal FDS data showed that HbA(1c) (A1C) was not significantly different between SMBG users and nonusers, either overall or within diabetes treatment groups (diet, OHAs, and insulin with or without OHAs). There was also no independent cross-sectional relationship between A1C and SMBG frequency. The average annual societal cost of using SMBG (in year 2000 Australian dollars [Adollars], excluding glucometers) was 162 Australian dollars per type 2 diabetic patient or 51 million Australian dollars when projected to the Australian diagnosed type 2 diabetic population. CONCLUSIONS: Neither SMBG testing nor its frequency was associated with glycemic benefit in type 2 diabetic patients regardless of treatment. Our data did not include methods of SMBG delivery and application, factors that require further assessment in the evaluation of SMBG utility in non-insulin-treated type 2 diabetes. SMBG may be still of value in the identification and prevention of hypoglycemia and in dose adjustment in insulin-treated patients.

Hand-assisted laparoscopic living-donor nephrectomy as an alternative to traditional laparoscopic living-donor nephrectomy.

The benefits of laparoscopic living-donor nephrectomy (LDN) are well described, while similar data on hand-assisted laparoscopic living-donor nephrectomy (HALDN) are lacking. We compare hand-assisted laparoscopic living-donor nephrectomy with open donor nephrectomy. One hundred consecutive hand-assisted laparoscopic living-donor nephrectomy (10/98-8/01) donor/recipient pairs were compared to 50 open donor nephrectomy pairs (8/97-1/00). Mean donor weights were similar (179.6 +/- 40.8 vs. 167.4 +/- 30.3 lb; p = NS), while donor age was greater among hand-assisted laparoscopic living-donor nephrectomy (38.2 +/- 9.5 vs. 31.2 +/- 7.8 year; p < 0.01). Right nephrectomies was fewer in hand-assisted laparoscopic living-donor nephrectomy [17/100 (17%) vs. 22/50 (44%); p < 0.05]. Operative time for hand-assisted laparoscopic living-donor nephrectomy (3.9 +/- 0.7 vs. 2.9 +/- 0.5 h; p < 0.01) was longer; however, return to diet (6.9 +/- 2.8 vs. 25.6 +/- 6.1 h; p < 0.01), narcotics requirement (17.9 +/- 6.3 vs. 56.3 +/- 6.4h; p < 0.01) and length of stay (51.7 +/- 22.2 vs. 129.6 +/- 65.7 h; p < 0.01) were less than open donor nephrectomy. Costs were similar ($11072 vs. 10840). Graft function and 1-week Cr of 1.4 +/- 0.9 vs. 1.6 +/- 1.1 g/dL (p = NS) were similar. With the introduction of HALDN, our laparoscopic living-donor nephrectomy program has increased by 20%. Thus, similar to traditional laparoscopic donor nephrectomy, hand-assisted laparoscopic living-donor nephrectomy provides advantages over open donor nephrectomy without increasing costs.