Expanding the clinical and radiological phenotypes of leukoencephalopathy due to biallelic HMBS mutations.

Pathogenic heterozygous variants in HMBS encoding the enzyme hydroxymethylbilane synthase (HMBS), also known as porphobilinogen deaminase, cause acute intermittent porphyria (AIP). Biallelic variants in HMBS have been reported in a small number of children with severe progressive neurological disease and in three adult siblings with a more slowly, progressive neurological disease and distinct leukoencephalopathy. We report three further adult individuals who share a distinct pattern of white matter abnormality on brain MRI in association with biallelic variants in HMBS, two individuals with homozygous variants, and one with compound-heterozygous variants. We present their clinical and radiological features and compare these with the three adult siblings previously described with leukoencephalopathy and biallelic HMBS variants. All six affected individuals presented with slowly progressive spasticity, ataxia, peripheral neuropathy, with or without mild cognitive impairment, and/or ocular disease with onset in childhood or adolescence. Their brain MRIs show mainly confluent signal abnormalities in the periventricular and deep white matter and bilateral thalami. This recognizable pattern of MRI abnormalities is seen in all six adults described here. Biallelic variants in HMBS cause a phenotype that is distinct from AIP. It is not known whether AIP treatments benefit individuals with HMBS-related leukoencephalopathy. One individual reported here had improved neurological function for 12 months following liver transplantation followed by decline and progression of disease.

Impact of weekend admission and changes in treating team on patient flow and outcomes in adults admitted to hospital with community-acquired pneumonia.

BACKGROUND: The effect of workflow factors, such as timing of admission and changes in treating team, on patient outcomes remains inconclusive. AIMS: To investigate the impact of weekend admission and changes in treating team on four pre-defined outcomes in patients admitted to hospital with community-acquired pneumonia (CAP). METHODS: We performed an observational cohort study by utilising prospective longitudinal data collected during the IMPROVE-GAP trial, a stepped-wedge randomised study investigating an evidence-based bundle of care in the management of CAP. We assessed the effect of two exposure variables, day of admission and change of treating team, on four pre-specified outcomes: (i) length of stay; (ii) time to clinical stability; (iii) readmission within 30 days; and (iv) mortality at 30 days. Our analysis was restricted to patients with a primary diagnosis of CAP and employed multivariable Cox regression and logistic regression to adjust for potential measured confounders. RESULTS: Of 753 participants, 224 (29.7%) were admitted on the weekend and 71 (9.4%) changed treating team during admission. Weekend admissions had significantly longer hospital stays than weekday admissions (hazard ratio (95% confidence interval; P-value) 0.82 (0.70-0.98; 0.03)) and took longer to reach clinical stability (0.80 (0.68-0.95; 0.01)). Change of treating team doubled the odds of readmission at 30 days (odds ratio 1.95 (1.08-3.58; 0.03)). CONCLUSIONS: These results suggest workflow factors can negatively impact both health service and patient outcomes. Systems interventions aimed at improving out of hours service and reducing changes in treating team should be considered.

Gaps in the Care of Familial Hypercholesterolaemia in Australia: First Report From the National Registry.

BACKGROUND: Familial hypercholesterolaemia (FH) is under-diagnosed and under-treated worldwide, including Australia. National registries play a key role in identifying patients with FH, understanding gaps in care and advancing the science of FH to improve care for these patients. METHODS: The FH Australasia Network has established a national web-based registry to raise awareness of the condition, facilitate service planning and inform best practice and care services in Australia. We conducted a cross-sectional analysis of 1,528 FH adults enrolled in the registry from 28 lipid clinics. RESULTS: The mean age at enrolment was 53.4±15.1 years, 50.5% were male and 54.3% had undergone FH genetic testing, of which 61.8% had a pathogenic FH-causing gene variant. Only 14.0% of the cohort were family members identified through cascade testing. Coronary artery disease (CAD) was reported in 28.0% of patients (age of onset 49.0±10.5 years) and 64.9% had at least one modifiable cardiovascular risk factor. The mean untreated LDL-cholesterol was 7.4±2.5 mmol/L. 80.8% of patients were on lipid-lowering therapy with a mean treated LDL-cholesterol of 3.3±1.7 mmol/L. Among patients receiving lipid-lowering therapies, 25.6% achieved an LDL-cholesterol target of <2.5 mmol/L without CAD or <1.8 mmol/L with CAD. CONCLUSION: Patients in the national FH registry are detected later in life, have a high burden of CAD and risk factors, and do not achieve guideline-recommended LDL-cholesterol targets. Genetic and cascade testing are under-utilised. These deficiencies in care need to be addressed as a public health priority.

The effect of a diabetes prevention program on dietary quality in women with previous gestational diabetes.

BACKGROUND: Women with gestational diabetes have low diet quality. We evaluated the effectiveness of a group-based lifestyle modification program for improvement of dietary quality in women with previous gestational diabetes predominantly within their first postnatal year. METHODS: Women were randomised to intervention (n = 284) or usual care (n = 289). Dietary data was collected at baseline and twelve months using a food frequency questionnaire and recoded into the Australian Recommended Food Score (ARFS). Mixed model analyses investigated the intervention effect on ARFS (per-protocol-set (PPS) excluded women without the minimum intervention exposure). RESULTS: Baseline mean total ARFS was low (31.8 ± 8.9, maximum score = 74) and no significant changes were seen in total ARFS (Cohen's D = - 0.06). 2% reduction in alcohol for intervention (0.05, 0.26) compared with - 1% for usual care (Odds ratio: 0.68; 95%CI 0.46, 0.99). Dairy ARFS sub-category significantly improved (low fat/saturated fat foods) in the intervention group over time compared with usual care for the PPS analysis (dairy + 0.28 in intervention (95%CI 0.08, 0.48) compared with + 0.02 in usual care (95%CI -0.14, 0.18) (group-by-treatment interaction p = 0.05, Cohen's D = 0.14)). CONCLUSIONS: Engaging with the intervention improved aspects of diet quality that aligned with minimum intervention exposure, but the total diet quality remains low. Further research is needed to improve diabetes prevention program engagement. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTRN12610000338066 , April 2010.

Changes in Statin Prescription Patterns in Patients Admitted to an Australian Geriatric Subacute Unit.

BACKGROUND: Assessment of demographic and clinical factors influencing the decision of statin discontinuation in the elderly population admitted to subacute geriatric unit. The aim of this study is to assess the clinical factors impacting the decision-making process of statin discontinuation in the elderly. METHODS: We retrospectively assessed changes in statin discontinuation and prescription among patients (≥60 years old) discharged from a geriatric evaluation and management unit by reviewing hospital digital medical records at Western Health - The Williamstown Hospital over a 12-month period from 4 February 2012 until 4 February 2013 inclusive. The main outcome of the study was to determine the independent predictors of statin discontinuation using logistic regression analysis. RESULTS: Of the studied population, 46% were already prescribed statins prior to their admission. Statins were discontinued in 17.5% of patients at discharge. Predictors of statin de-prescription included octogenarian status, primary prevention indication, poor functional recovery, residential care facility discharge destination and lower cognitive function. The presence of previous cardiovascular disease history and the burden of comorbidities were not predictors of statin discontinuation. CONCLUSIONS: We observed that factors that conveyed poor prognosis such as advanced age, poor functional recovery, worse cognitive function, being discharged to a residential care facility as well as primary prevention indication for statin prescription are predictors of statin discontinuation in the geriatric unit.

International statistical classification of diseases and related health problems coding underestimates the incidence and prevalence of acute kidney injury and chronic kidney disease in general medical patients.

BACKGROUND: The international classification of diseases (ICD) code is frequently used to identify renal impairment in epidemiological research. However, Australian studies examining accuracy of this administrative data in coding kidney injury are lacking. AIMS: To compare the ICD 10 coding with the kidney disease: improving global outcomes (KDIGO) criteria in diagnosing acute kidney injury (AKI) and/or chronic kidney disease (CKD). METHODS: A retrospective study of 325 patients admitted to general medicine during January 2012 was performed. Sensitivity and specificity of ICD 10 in identifying AKI and CKD were calculated using KDIGO as gold standard. RESULTS: The sensitivities of ICD 10 in identifying AKI and CKD were low for both (59.5% and 54.1%), but the specificities were high (86.2% and 90.2%). Using KDIGO criteria, we identified 72 AKI (22%), 56 CKD (17%), 64 AKI on CKD (19%) and 133 controls (40%). Compared to the control group, patients with AKI and AKI on CKD had longer length of stay (3.2 vs 4.9 days and 3.2 vs 4.8 days, P = 0.20). Renal impairment groups had increased in-hospital mortality rate (5% control, 6% AKI, 10% CKD, 9% AKI on CKD) and re-admission rate within 30 days (13% control, 20% AKI, 25% CKD, 26% AKI on CKD). After adjusting for age, gender and comorbidities, the difference in outcomes was not statistically significant. CONCLUSION: This study shows that ICD 10 fails to identify almost half of the patients with AKI (40.5%) and CKD (45.9%) in our cohort. A total of 60% had evidence of renal impairment as defined by KDIGO.

Quantifying the hidden healthcare cost of diabetes mellitus in Australian hospital patients.

BACKGROUND: Diabetes mellitus in hospital inpatients is most commonly present as a comorbidity rather than as the primary diagnosis. In some hospitals, the prevalence of comorbid diabetes mellitus across all inpatients exceeds 30%, which could add to complexity of care and resource utilisation. However, whether and to what extent comorbid diabetes mellitus contributes indirectly to greater hospitalisation costs is ill-defined. AIM: To determine the attributable effect of comorbid diabetes mellitus on hospital resource utilisation in a General Internal Medical service in Melbourne, Australia. METHODS: We extracted data from a database of all General Internal Medical discharge episodes from July 2012 to June 2013. We fitted multivariable regression models to compare patients with diabetes mellitus to those without diabetes mellitus with respect to hospitalisation cost, length of stay, admissions per year and inpatient mortality. RESULTS: Of 4657 patients 1519 (33%) had diabetes mellitus, for whom average hospitalisation cost (AUD9910) was higher than those without diabetes mellitus (AUD7805). In multivariable analysis, this corresponded to a 1.22-fold (95% confidence interval (CI) 1.12-1.33, P < 0.001) higher cost. Mean length of stay for those with diabetes was 8.2 days versus 6.8 days for those without diabetes, with an adjusted 1.19-fold greater odds (95% CI 1.06-1.33, P = 0.001) of staying an additional day. Number of admissions and mortality were similar. CONCLUSION: Comorbid diabetes mellitus adds significantly to hospitalisation duration and costs in medical inpatients. Moreover, diabetes mellitus patients with chronic complications had a greater-still cost and hospitalisation duration compared to those without diabetes mellitus.

Mothers after Gestational Diabetes in Australia (MAGDA): A Randomised Controlled Trial of a Postnatal Diabetes Prevention Program.

BACKGROUND: Gestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for type 2 diabetes. We evaluated the effectiveness of a group-based lifestyle modification program in mothers with prior GDM within their first postnatal year. METHODS AND FINDINGS: In this study, 573 women were randomised to either the intervention (n = 284) or usual care (n = 289). At baseline, 10% had impaired glucose tolerance and 2% impaired fasting glucose. The diabetes prevention intervention comprised one individual session, five group sessions, and two telephone sessions. Primary outcomes were changes in diabetes risk factors (weight, waist circumference, and fasting blood glucose), and secondary outcomes included achievement of lifestyle modification goals and changes in depression score and cardiovascular disease risk factors. The mean changes (intention-to-treat [ITT] analysis) over 12 mo were as follows: -0.23 kg body weight in intervention group (95% CI -0.89, 0.43) compared with +0.72 kg in usual care group (95% CI 0.09, 1.35) (change difference -0.95 kg, 95% CI -1.87, -0.04; group by treatment interaction p = 0.04); -2.24 cm waist measurement in intervention group (95% CI -3.01, -1.42) compared with -1.74 cm in usual care group (95% CI -2.52, -0.96) (change difference -0.50 cm, 95% CI -1.63, 0.63; group by treatment interaction p = 0.389); and +0.18 mmol/l fasting blood glucose in intervention group (95% CI 0.11, 0.24) compared with +0.22 mmol/l in usual care group (95% CI 0.16, 0.29) (change difference -0.05 mmol/l, 95% CI -0.14, 0.05; group by treatment interaction p = 0.331). Only 10% of women attended all sessions, 53% attended one individual and at least one group session, and 34% attended no sessions. Loss to follow-up was 27% and 21% for the intervention and control groups, respectively, primarily due to subsequent pregnancies. Study limitations include low exposure to the full intervention and glucose metabolism profiles being near normal at baseline. CONCLUSIONS: Although a 1-kg weight difference has the potential to be significant for reducing diabetes risk, the level of engagement during the first postnatal year was low. Further research is needed to improve engagement, including participant involvement in study design; it is potentially more effective to implement annual diabetes screening until women develop prediabetes before offering an intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000338066.

False economies in home-based parenteral antibiotic treatment: a health-economic case study of management of lower-limb cellulitis in Australia.

OBJECTIVES: The majority of healthcare costs accrued managing cellulitis can be attributed to the small proportion of patients treated with parenteral antibiotics. Hospital in the home (HITH) instead of or following initial inpatient treatment is a safe and effective alternative, but there are few data evaluating its cost-effectiveness for cellulitis. PATIENTS AND METHODS: Our retrospective cohort study included all treatment episodes (by either HITH or an inpatient service for >24 h) with an ICD-10 primary diagnosis code of lower-leg cellulitis at a tertiary-level health service in Melbourne, Australia over 12 months (2012-13). Data included demography, social factors and ICD-10 codes mapped to major comorbidities constituting the Charlson comorbidity index (CCI). Differences in length of stay (LOS) and individual clinical costing (ICC) between HITH- and non-HITH-treated patients were tested with univariable and multivariable (generalized linear model) analyses. RESULTS: For 328 admissions in 294 patients, the average per-day costs were AU$431 for HITH and AU$761 for inpatient care. For 124 patients (38%) treated in HITH, both LOS [mean (95% CI) 7.48 days (6.76-8.20 days) versus 5.82 days (3.45-8.18 days)] and ICC [mean (95% CI) AU$5873 (AU$5212-AU$6534) versus AU$5196 (AU$4567- AU$5824)] were higher than those for patients with solely inpatient care. In multivariable analysis controlling for age, comorbidity, carer support and language, HITH remained associated with significantly longer LOS [1.63-fold (95% CI: 1.24- to 2.13-fold): P < 0.001] and non-significantly with higher cost [1.14-fold (95% CI: 0.97- to 1.34-fold): P = 0.11]. CONCLUSIONS: Management of cellulitis represents a substantial cost burden for hospital services. Modest per-day cost savings from HITH can be offset by much longer HITH LOS.

Association of weight misperception with weight loss in a diabetes prevention program.

BACKGROUND: Weight misperception may have an impact on perceived risk and susceptibility for chronic diseases. Little has been reported on the long term effects of this misperception in chronic disease interventions, particularly in field of diabetes prevention. The aim of this study was to investigate the relationship between weight misperception and weight loss during a diabetes prevention project conducted in south-east Australia with individuals at moderate to high risk of developing diabetes. METHODS: A total of n=251 at risk individuals provided self-reported weight during recruitment from 2004-2006. Objectively measured weight was assessed at baseline (0-21 days after recruitment), and subsequently at three months and 12 months after the intervention. Differences between self-reported and actual weight status are presented as percentages. Linear regression was used to investigate the relationship between weight misperception and weight loss, adjusting for baseline weight and BMI. RESULTS: Those who had high levels of under-reporting at baseline had greater weight loss at three and 12 months compared with those who under-reported to some degree, and those over-reporting their weight. A significant association was found between weight misperception and weight loss at the three and the 12 month time points. Baseline weight was not associated with weight loss. CONCLUSIONS: Weight misperception should be acknowledged as a factor to be addressed when screening and identifying individuals at risk for diabetes. Screening and giving feedback is important in terms of awareness of participants' actual weight status and may have an effect on program outcomes.

The potential for measuring ethnicity and health in a multicultural milieu--the case of type 2 diabetes in Australia.

OBJECTIVE: Ethnicity influences health in many ways. For example, type 2 diabetes (T2DM) is disproportionately prevalent among certain ethnic groups. Assessing ethnicity is difficult, and numerous proxy measures are used to capture its various components. Australian guidelines specify a set of variables for measuring ethnicity, and how such parameters should be categorised. Using T2DM data collections as an illustrative example, this study sought to examine how ethnicity is measured in Australian health databases and, by comparing current practice with Australia's existing benchmark recommendations, to identify potential areas for improvement of the health data landscape. DESIGN: We identified databases containing information from which ethnic group-specific estimates of T2DM burden may be gleaned. For each database, details regarding ethnicity variables were extracted, and compared with the Australian guidelines. RESULTS: Data collection instruments for 32 relevant databases were reviewed. Birthplace was recorded in 27 databases (84%), but mode of birthplace assessment varied. Indigenous status was commonly recorded (78%, n=25), but only nine databases recorded other aspects of self-perceived race/ethnicity. Of 28 survey/audit databases, 14 accommodated linguistic preferences other than English, and 11 either excluded non-English speakers or those for whom a translator was not available, or only offered questionnaires in English. CONCLUSIONS: Considerable variation exists in the measurement of ethnicity in Australian health data-sets. While various markers of ethnicity provide complementary information about the ethnic profile within a data-set, non-uniform measurement renders comparison between data-sets difficult. A standardised approach is necessary, and identifying the ethnicity variables that are particularly relevant to the health sector is warranted. Including self-identified ethnicity in Australia's set of recommended indicators and as a core component of the national census should be considered. Globalisation and increasing migration mean that these findings have implications internationally, including for multi-ethnic countries throughout North America and Europe.

Type 2 diabetes prevalence varies by socio-economic status within and between migrant groups: analysis and implications for Australia.

BACKGROUND: Ethnic diversity is increasing through migration in many developed countries. Evidence indicates that type 2 diabetes mellitus (T2DM) prevalence varies by ethnicity and socio-economic status (SES), and that in many settings, migrants experience a disproportionate burden of disease compared with locally-born groups. Given Australia's multicultural demography, we sought to identify groups at high risk of T2DM in Victoria, Australia. METHODS: Using population data from the Australian National Census and diabetes data from the National Diabetes Services Scheme, prevalence of T2DM among immigrant groups in Victoria in January 2010 was investigated, and prevalence odds versus Australian-born residents estimated. Distribution of T2DM by SES was also examined. RESULTS: Prevalence of diagnosed T2DM in Victoria was 4.1% (n = 98671) in men and 3.5% (n = 87608) in women. Of those with T2DM, over 1 in 5 born in Oceania and in Southern and Central Asia were aged under 50 years. For both men and women, odds of T2DM were higher for all migrant groups than the Australian-born reference population, including, after adjusting for age and SES, 6.3 and 7.2 times higher for men and women born in the Pacific Islands, respectively, and 5.2 and 5.0 times higher for men and women born in Southern and Central Asia, respectively. Effects of SES varied by region of birth. CONCLUSIONS: Large socio-cultural differences exist in the distribution of T2DM. Across all socio-economic strata, all migrant groups have higher prevalence of T2DM than the Australian-born population. With increasing migration, this health gap potentially has implications for health service planning and delivery, policy and preventive efforts in Australia.

Occupational differences, cardiovascular risk factors and lifestyle habits in South Eastern rural Australia.

BACKGROUND: In rural and remote Australia, cardiovascular mortality and morbidity rates are higher than metropolitan rates.This study analysed cardiovascular and other chronic disease risk factors and related health behaviours by occupational status, to determine whether agricultural workers have higher cardiovascular disease (CVD) risk than other rural workers. METHODS: Cross-sectional surveys in three rural regions of South Eastern Australia (2004-2006). A stratified random sample of 1001 men and women aged 25-74 from electoral rolls were categorised by occupation into agricultural workers (men = 214, women = 79), technicians (men = 123), managers (men = 148, women = 272) and 'home duties' (women = 165). Data were collected from self-administered questionnaire, physical measurements and laboratory tests. Cardiovascular disease (CVD) and coronary heart disease (CHD) risk were assessed by Framingham 5 years risk calculation. RESULTS: Amongst men, agricultural workers had higher occupational physical activity levels, healthier more traditional diet, lower alcohol consumption, lower fasting plasma glucose, the lowest proportion of daily smokers and lower age-adjusted 5 year CVD and CHD risk scores.Amongst women, managers were younger with higher HDL cholesterol, lower systolic blood pressure, less hypertension, lower waist circumference, less self-reported diabetes and better 5 year CVD and CHD risk scores.Agricultural workers did not have higher cardiovascular disease risk than other occupational groups. CONCLUSIONS: Previous studies have suggested that farmers have higher risks of cardiovascular disease but this is because the risk has been compared with non-rural populations. In this study, the comparison has been made with other rural occupations. Cardiovascular risk reduction programs are justified for all. Programs tailored only for agricultural workers are unwarranted.

Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial.

Background: Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases. Methods: Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts. Results: At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables. Conclusions: This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.

Plasma concentration of pigment epithelium-derived factor is closely associated with blood pressure and predicts incident hypertension in Chinese: a 10-year prospective study.

OBJECTIVES: Pigment epithelium-derived factor (PEDF) is secreted from the adipose tissue. It circulates at high concentrations, and was reported to play a causal role in obesity-induced insulin resistance and metabolic dysfunctions in mice. Previous cross-sectional studies also demonstrated plasma PEDF concentration correlated positively with systolic blood pressure (BP) and pulse pressure, and inversely with small artery elasticity. Here we investigated the relationship of plasma PEDF concentration with BP and incident hypertension in a 10-year prospective study. METHODS: Baseline plasma PEDF concentrations were measured by ELISA in 520 Chinese subjects, aged 51 ± 12 years, followed up long-term from the population-based Hong Kong Cardiovascular Risk Factor Prevalence Study. The association between plasma PEDF concentration and BP was investigated in both cross-sectional and prospective studies, using multiple linear regression and path analyses. Cox proportional hazards analysis was used to determine whether baseline PEDF concentration was independently related to the subsequent development of hypertension over 10 years. RESULTS: Baseline plasma concentrations of PEDF were higher in men (P < 0·001), and were directly related to systolic BP at 2 and 5 years, and to diastolic BP at 2 years, after adjustment for covariates. Of the 386 normotensive subjects at baseline, high baseline PEDF concentration was predictive of incident hypertension, independent of the effects of age, sex, baseline BP and obesity parameters (hazard ratio: 1·135; 95% CI: 1·039-1·241; P = 0·005). CONCLUSION: Our data suggest that plasma PEDF concentration is significantly associated with BP, and incident hypertension. PEDF may be involved in the pathogenesis of hypertension in humans.

A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: the PAART CVD pilot project.

BACKGROUND: There is insufficient evidence for the efficacy of comprehensive multiple risk factor interventions by pharmacists in the primary prevention of cardiovascular disease (CVD). Given the proven benefits of pharmacist interventions for individual risk factors, it is essential that evidence for a comprehensive approach to care be generated so that pharmacists remain key members of the health care team for individuals at risk of initial onset of CVD. OBJECTIVE: To establish the feasibility of an intervention delivered by community pharmacists to reduce the risk of primary onset of CVD. METHODS: A single-cohort intervention study was undertaken in 2008-2009. Twelve community pharmacists from 10 pharmacies who were trained to provide lifestyle and medicine management support to reduce CVD risk recruited 70 at-risk participants aged 50-74 years who were free from diabetes or CVD. Participants received a baseline assessment to establish CVD risk and health behaviors. An assessment report provided to patients and pharmacists was used to collaboratively establish treatment goals and, over 5 sessions, implement treatment strategies. Follow-up assessment at 6 months measured changes in baseline parameters. The primary outcome was the average change to overall 5-year risk of CVD onset. RESULTS: Sixty-seven participants were included in the analysis. The mean participant age was 60 years and 73% were female. We observed a 25% (95% CI 17 to 33) proportional risk reduction in overall CVD risk. Significant reductions also occurred in mean blood pressure (-11/-5 mm Hg) and waist circumference (-1.3 cm), with trends toward improvement for most other observed risk factors. CONCLUSIONS: Findings support previous evidence of positive cardiovascular health outcomes following pharmacist intervention in other patient groups; we recommend generating randomized controlled trial evidence for a primary prevention population.

Recruitment into diabetes prevention programs: what is the impact of errors in self-reported measures of obesity?

BACKGROUND: Error in self-reported measures of obesity has been frequently described, but the effect of self-reported error on recruitment into diabetes prevention programs is not well established. The aim of this study was to examine the effect of using self-reported obesity data from the Finnish diabetes risk score (FINDRISC) on recruitment into the Greater Green Triangle Diabetes Prevention Project (GGT DPP). METHODS: The GGT DPP was a structured group-based lifestyle modification program delivered in primary health care settings in South-Eastern Australia. Between 2004-05, 850 FINDRISC forms were collected during recruitment for the GGT DPP. Eligible individuals, at moderate to high risk of developing diabetes, were invited to undertake baseline tests, including anthropometric measurements performed by specially trained nurses. In addition to errors in calculating total risk scores, accuracy of self-reported data (height, weight, waist circumference (WC) and Body Mass Index (BMI)) from FINDRISCs was compared with baseline data, with impact on participation eligibility presented. RESULTS: Overall, calculation errors impacted on eligibility in 18 cases (2.1%). Of n = 279 GGT DPP participants with measured data, errors (total score calculation, BMI or WC) in self-report were found in n = 90 (32.3%). These errors were equally likely to result in under- or over-reported risk. Under-reporting was more common in those reporting lower risk scores (Spearman-rho = -0.226, p-value < 0.001). However, underestimation resulted in only 6% of individuals at high risk of diabetes being incorrectly categorised as moderate or low risk of diabetes. CONCLUSIONS: Overall FINDRISC was found to be an effective tool to screen and recruit participants at moderate to high risk of diabetes, accurately categorising levels of overweight and obesity using self-report data. The results could be generalisable to other diabetes prevention programs using screening tools which include self-reported levels of obesity.