Review and comparison of retinal vessel calibre and geometry software and their application to diabetes, cardiovascular disease, and dementia.

Developments in retinal imaging technologies have enabled the quantitative evaluation of the retinal vasculature. Changes in retinal calibre and/or geometry have been reported in systemic vascular diseases, including diabetes mellitus (DM), cardiovascular disease (CVD), and more recently in neurodegenerative diseases, such as dementia. Several retinal vessel analysis softwares exist, some being disease-specific, others for a broader context. In the research setting, retinal vasculature analysis using semi-automated software has identified associations between retinal vessel calibre and geometry and the presence of or risk of DM and its chronic complications, and of CVD and dementia, including in the general population. In this article, we review and compare the most widely used semi-automated retinal vessel analysis softwares and their associations with ocular imaging findings in common systemic diseases, including DM and its chronic complications, CVD, and dementia. We also provide original data comparing retinal calibre grading in people with Type 1 DM using two softwares, with good concordance.

Prevalence of diabetic retinopathy and reduced vision among indigenous Australians in the nurse-led integrated Diabetes Education and Eye Screening study in a regional primary care clinic.

BACKGROUND: Nationally, Indigenous Australians are more likely to have diabetes and diabetic retinopathy (DR) than non-Indigenous Australians. However, the prevalence of DR and impaired vision in regional primary care settings is unclear. AIM: To describe the prevalence and severity of DR and presenting vision level among Indigenous Australian adults with diabetes attending an indigenous primary care clinic in regional Australia. METHODS: Participants underwent nurse-led retinal imaging and DR screening with offsite retinal grading in the integrated Diabetes Education and Eye Screening (iDEES) project implemented at a regional indigenous primary healthcare setting between January 2018 and March 2020. RESULTS: Of 172 eligible adults, 135 (79%) were recruited and screened for DR and vision level. The median age was 56 (46-67) years, 130 (96%) had type 2 diabetes of median (interquartile range) duration 6 (2-12) years and 48 (36%) were male. Images from 132 (97.8%) participants were gradable. DR was present in 38 (29%) participants: mild non-proliferative in 33 (25%); moderate-severe in three (2.5%); and sight-threatening two (1.5%). Subnormal presenting vision was present in 33%. CONCLUSIONS: A nurse-led model of care integrating diabetes eye screening and education at a single visit was successful at recruiting Indigenous Australian adults with diabetes, screening their vision and acquiring a high rate of gradable images. Even for a short duration of known diabetes, DR was present in three out of 10 patients screened.

No relationship between socioeconomic status, education level and development and progression of diabetic retinopathy in type 2 diabetes: a FIELD trial substudy.

In 6002 Australian adults with type 2 diabetes and a median 5-year follow-up in the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) trial, baseline socioeconomic status (SES) and self-reported education level were not related to development of on-trial sight-threatening diabetic retinopathy. Similarly, in a retinal photography substudy (n = 549), two-step diabetic retinopathy progression was not related to SES or education.

Adherence to the Mediterranean Diet and Successful aging in Greeks living in Greece and abroad: the epidemiological Mediterranean Islands Study (MEDIS).

Background: Whether older immigrant populations from the Mediterranean region, continue to follow the MD long after they immigrated is not known. Aim: Compare adherence to the MD and successful aging levels between Greeks living in Greece (GG) and Greeks living abroad (GA). Methods: Anthropometrical, clinical, psychological, sociodemographic, dietary and lifestyle parameters were assessed in a cross-sectional manner in a sample of 252 GG and 252 GA. Mediterranean Diet Score (MedDietScore range 0-55) was used to assess adherence to the MD. Successful aging was evaluated with the validated successful aging index (SAI range 0-10). Results: GA presented higher adherence to MD (p < 0.001); they were consuming significantly more cereals, legumes, vegetables, and fruits compared to GG. GG consumed significantly more dairy (3.8 ± 2.9 vs. 1.9 ± 2.2, p < 0.001) and potatoes (2.4 ± 1.6 vs. 1.9 ± 1.5, p < 0.001) compared to GA. Meat (p = 0.27), poultry (p = 0.72), fish (p = 0.68), olive oil (p = 0.16) and alcohol consumption (p = 0.05) were comparable between the two groups (all p's > 0.05). MedDietScore was positively associated with SAI among both groups after adjusting for possible confounders (0.041 ± 0.014, p = 0.003 GG and 0.153 ± 0.035, p < 0.001 GA). Also, legumes, cereals, fruits and vegetables were found to be beneficial for successful aging. Conclusion: Adherence to the MD is associated with higher levels of successful aging among people of the same genetic background living in different environments. However, traditional dietary habits are gradually abandoned in their native countries, when, at the same time, are considered cultural heritage and preserved accordingly among immigrants.

Fenofibrate, which reduces risk of sight-threatening diabetic retinopathy in type 2 diabetes, is associated with early narrowing of retinal venules: a FIELD trial substudy.

Retinal vessel calibre metrics were evaluated at baseline and 2 years in a FIELD substudy (n = 208). Central retinal venule calibre was significantly reduced by fenofibrate and unchanged by placebo. Arteriole metrics did not change. Larger studies relating retinal vessel calibre to future diabetes complications and response to therapy are merited.

Nurse-led vascular risk assessment in a regional Victorian Indigenous primary care diabetes clinic: An integrated Diabetes Education and Eye disease Screening [iDEES] study.

AIM: The aim was to describe vascular risk factors in Australian adults with diabetes attending an Indigenous primary care nurse-led diabetes clinic. DESIGN: This was a cross-sectional descriptive single-site study. METHODS: Vascular risk factor data were extracted from the electronic health records of participants in the nurse-led integrated Diabetes Education and Eye disease Screening (iDEES) study at a regional Victorian Indigenous primary health-care clinic between January 2018 and March 2020. RESULTS: Of 172 eligible adults, 135 (79%) provided data. Median (IQR) age was 56 (46-67) years; 89% were Indigenous; 95% had Type 2 diabetes of median (IQR) duration of 6 (2-12) years and 48 (36%) were male. Median HbA1c, blood pressure, cholesterol (total; LDL and HDL), triglycerides, eGFR, CRP and BMI were 8.0% (64 mmol/mol), 127/78 mm Hg, 4.2; 1.9; 1.1 mmol/L, 2.3 mmol/L, 89 ml/min/1.73 m2 , 7.0 mg/L and 32.4 kg/m2 . Of nine clinical risk factors, the median (IQR) number of risk factors at target was 4 (3-5) for women and 3 (2-5) for men, pχ2  = 0.563. Clinical targets for BMI, HbA1c, blood pressure, triglycerides, total cholesterol, LDL cholesterol, urine albumin: creatinine ratio, HDL cholesterol and smoking were met by 14%, 34%, 38%, 39%, 44%, 52%, 54%, 62% and 64%, respectively. CONCLUSION: A nurse-led model of integrated clinical risk factor assessment and diabetes education identified suboptimal levels of clinical risk factor control for avoiding diabetes chronic complications amongst Australian adults with diabetes in an Indigenous primary care setting. IMPACT: A nurse-led model of diabetes care integrating clinical risk factor assessment into a diabetes education service is achievable. Understanding by stakeholders, including people with diabetes, their clinicians and health services, of the importance of regular monitoring of risk factors impacting diabetes complications is important. The novel nurse-managed iDEES primary-care model of care can assist. TRIAL REGISTRATION: This study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001204235).

Health-risk behaviours among Indigenous Australians with diabetes: A study in the integrated Diabetes Education and Eye Screening (iDEES) project.

AIM: To assess the prevalence of modifiable health-risk behaviours among Indigenous Australian adults with diabetes attending a regional Victorian Indigenous primary-care clinic. DESIGN: A cross-sectional observational single-site study. METHODS: As part of a multi-study project we administered the Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional wellbeing (SNAPE) survey tool during the study baseline visit to methodically capture health-related behavioural data in the nurse-led integrated Diabetes Education and Eye Screening (iDEES) project in a regional Indigenous primary healthcare setting between January 2018 and March 2020. This descriptive SNAPE study helps address the lack of health behaviour data for Indigenous people with diabetes. RESULTS: Of 172 eligible adults, 135 (79%) were recruited to the iDEES study, 50 (37%) male. All participated in at least one survey. Median (range) age was 56 (46-67) years; 130 (96%) had Type 2 diabetes of median [IQR] duration 6 (2-12) years. All 135 provided smoking data; 88 (65%) completed all surveys. Forty-nine (36%) and 29 (22%) were current or former smokers, respectively; 5 (6%) met vegetable intake guidelines, 22 (25%) met fruit intake guidelines; 38 [43%] drank alcohol in the past year. On average, participants walked for ≥10 min at a time 4 days/week and sat for an average of 8 h on weekdays; 35 (40%) had minimal-mild, and 30 (34%) had moderate-severe depressive symptoms. CONCLUSION: Suboptimal modifiable health-risk behaviours and depressive symptoms are common in Indigenous Australian adults with diabetes. IMPACT: Orderly assessment and reporting of health-risk behaviours using a single multi-component survey instrument (SNAPE tool) during a nurse-led diabetes education clinical visit is feasible and efficient. Such data may facilitate personalised interventions and improve diabetes management at both individual and health service levels.

Mixed diabetic retinopathy screening coverage results in Indigenous Australian primary care settings: A nurse-led model of integrated diabetes care.

AIMS: To determine eye screening coverage and adherence to national eye screening recommendations of a nurse-led retinal image-based model of diabetes education and eye screening in Indigenous primary care clinics. DESIGN: A pre-post study. METHODS: During January 2018-March 2020 Indigenous Australians with diabetes at three regional Australian clinics were offered eye screening by a nurse-diabetes educator/retinal imager. At the main site the nurse recruited/scheduled participants, and at satellite sites local clinic staff did so. Visual acuity was tested and digital retinal images acquired and graded. Participants were offered rescreening at or before 12-months based on baseline results. RESULTS: In total 203 adults with diabetes attending Indigenous primary care clinics were screened, with divergent results based on the recruitment methods. At the main clinic 135 of 172 eligible adults (79%) were screened. At the satellite sites, 15 of 85 (18%) and 21 of 77 (27%) diabetes patients were screened. Combined coverage 51%. CONCLUSION: A credentialed nurse-educator implemented a model of retinal image-based diabetes education, measured eye screening coverage and adherence to national eye screening guidelines, met the 'acceptable 75% eye screening coverage' benchmark and improved patient eye screening guideline adherence at the one site where the nurse-educator had access to patient recruitment and scheduling. IMPACT: This novel nurse-led primary care iDEES model of retinal image-based diabetes education can improve the currently low Indigenous diabetes eye screening coverage in Australia. Importantly, the nurse-managed iDEES model of integrated diabetes care is readily adaptable to other settings and populations where access to and/or uptake of eye care is suboptimal. CLINICAL TRIAL REGISTRATION: ANZCTRN1261800120435.

Facilitating diabetic retinopathy screening using automated retinal image analysis in underresourced settings.

AIM: To evaluate an automated retinal image analysis (ARIA) of indigenous retinal fundus images against a human grading comparator for the classification of diabetic retinopathy (DR) status. METHODS: Indigenous Australian adults with type 2 diabetes (n = 410) from three remote and very remote primary-care services in the Northern Territory, Australia, underwent teleretinal DR screening. A single, central retinal fundus photograph (opportunistic mydriasis) for each eye was later regraded using a single ARIA and a UK human grader and national DR classification system. The sensitivity and specificity of ARIA were assessed relative to the comparator. Proportionate agreement and a Kappa statistic were also computed. RESULTS: Retinal images from 391 and 393 participants were gradable for 'Any DR' by the human grader and ARIA grader, respectively. 'Any DR' was detected by the human grader in 185 (47.3%) participants and by ARIA in 202 (48.6%) participants (agreement =88.0%, Kappa = 0.76,), whereas proliferative DR was detected in 31 (7.9%) and 37 (9.4%) participants (agreement = 98.2%, Kappa = 0.89,), respectively. The ARIA software had 91.4 (95% CI, 86.3-95.0) sensitivity and 85.0 (95% CI, 79.3-89.5) specificity for detecting 'Any DR' and 96.8 (95% CI, 83.3-99.9) sensitivity and 98.3 (95% CI, 96.4-99.4) specificity for detecting proliferative DR. CONCLUSIONS: This ARIA software has high sensitivity for detecting 'Any DR', hence could be used as a triage tool for human graders. High sensitivity was also found for detection of proliferative DR by ARIA. Future versions of this ARIA should include maculopathy and referable DR (CSME and/or PDR). Such ARIA software may benefit diabetes care in less-resourced regions.

Screening for diabetic retinopathy and reduced vision among Indigenous Australians in Top End primary care health services: a TEAMSnet sub-study.

BACKGROUND: Diabetic retinopathy (DR) prevalence is higher in Indigenous Australians than in other Australians and is a major cause of vision loss. Consequently, timely screening and treatment is paramount, and annual eye screening is recommended for Indigenous Australians. AIMS: To assess the prevalence of DR, reduced vision and DR treatment coverage among Indigenous Australian adults with diabetes attending Top End indigenous primary care health services. METHODS: A cross-sectional DR screening study conducted from November 2013 to December 2015 in two very remote Northern Territory Aboriginal primary healthcare services. RESULTS: In 287 subjects, the prevalence of non-proliferative DR, proliferative DR and clinically significant diabetic macular oedema was 37.3%, 5.4% and 9.0% respectively. Treatment coverage for PDR was 60% (of 10 patients) and for CSMO was 17% (of 23 patients). Vision data were available from 122 participants at one site. The proportion with normal vision, reduced vision, impaired vision and blindness was 31.1%, 52.5%, 15.6% and 0.8% respectively. Overall, ungradable monocular image sets (46%) were associated with poorer quality images and missing protocol images (both P < 0.001). Ungradable images for DR were associated with presence of small pupils/media opacities (P < 0.001). Ungradable images for diabetic macular oedema were associated with poorer image quality (P < 0.001), cataracts (P < 0.001) and small pupils (P = 0.04). CONCLUSIONS: A high prevalence of DR, CSMO and impaired vision was noted in Indigenous Australians with diabetes. Screening in primary care is feasible, but more effective screening methods are needed.

A model of culturally-informed integrated diabetes education and eye screening in indigenous primary care services and specialist diabetes clinics: Study protocol.

AIMS: To improve diabetes management in Indigenous Australians using an integrated nurse-led model of diabetes education and eye screening in indigenous primary care and specialist diabetes clinics. DESIGN: A pre-post study. METHODS: This study will be implemented in indigenous primary care and specialist diabetes clinics in Victoria, Australia. Participants recruited to the study will be existing adult patient with diagnosed diabetes attending study sites. A nurse-credentialled diabetes educator and certified retinal imager will deliver three study components: (a) retinal photography as a diabetic retinopathy screening and patient engagement tool; (b) lifestyle and behaviour surveys, administered at baseline and at the final visit, in 12 months. Findings from the surveys and participants' retinal images will be used to guide; and (c) personalized diabetes education. The primary outcomes are participant adherence to diabetic eye screening recommendations and health service diabetic retinopathy screening coverage. Secondary outcomes are baseline DR prevalence and changes in clinical and lifestyle risk factor levels, diabetes knowledge and satisfaction with diabetes care. DISCUSSION: Compared with non-indigenous Australians, Indigenous Australians have a high prevalence of diabetic retinopathy and blindness, low adherence to eye screening recommendations and suboptimal health literacy. Nurse-credentialled diabetes educators can be trained to incorporate retinal imaging and eye screening into their clinical practice to give image-based diabetes education to facilitate diabetic retinopathy management. IMPACT: Credentialled nurse diabetes educators who integrate eye screening and diabetes education can facilitate timelier diabetic retinopathy screening, referral pathways and treatment of sight-threatening retinopathy. We believe that this model of integrated diabetes education and eye screening will also improve adherence to eye screening recommendations, population screening coverage, health literacy, risk factor levels and diabetes self-care. CLINICAL TRIAL REGISTRATION: ANZCTRN1261800120435.

Integrating diabetic retinopathy screening within diabetes education services in Australia's diabetes and indigenous primary care clinics.

As diabetes occurs in all ethnicities and regions it is essential that retinopathy screening be widely available. Screening rates are lower in Indigenous than in non-Indigenous Australians. Technological advances and Medicare rebates should facilitate improved outcomes. Use of non-ophthalmic clinicians, (general practitioners, diabetes educators, health-workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists would extend retinopathy screening capacity. Diabetes educators are an integral part of diabetes management. Integrating ocular screening and diabetes education in primary care settings has potential to improve synergistically retinopathy screening coverage, patient self-management, risk factor control, care satisfaction, health economics and sustainability of under-resourced services.

Correction to: A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial).

The original version of this paper [1] did not specify that a website was used in the final year of recruitment, in addition to the other stated recruitment methods.

The SMILES trial: an important first step.

The SMILES trial was the first intervention study to test dietary improvement as a treatment strategy for depression. Molendijk et al. propose that expectation bias and difficulties with blinding might account for the large effect size. While we acknowledge the issue of expectation bias in lifestyle intervention trials and indeed discuss this as a key limitation in our paper, we observed a strong correlation between dietary change and change in depression scores, which we argue is consistent with a causal effect and we believe unlikely to be an artefact of inadequate blinding. Since its publication, our results have been largely replicated and our recent economic evaluation of SMILES suggests that the benefits of our approach extend beyond depression. We argue that the SMILES trial should be considered an important, albeit preliminary, first step in the field of nutritional psychiatry research.

The AUStralian MEDiterranean Diet Heart Trial (AUSMED Heart Trial): A randomized clinical trial in secondary prevention of coronary heart disease in a multiethnic Australian population: Study protocol.

The Mediterranean diet was first characterized as a heart-protective diet in the 1960s. The significant cardioprotective effects of the Mediterranean diet in comparison to the standard-care low-fat diet have been established in the primary prevention of cardiovascular disease (CVD); however, there is insufficient evidence in secondary prevention research to influence the current standard of care. Opportunity exists to assess the Mediterranean diet as a therapeutic target for secondary CVD prevention within Australia's ethnoculturally diverse communities. The AUSMED Heart Trial is a multisite randomized controlled trial that will evaluate the efficacy of the Mediterranean diet for secondary prevention of CVD in the Australian health care setting. This trial aims to evaluate the effect of a 6-month Mediterranean diet intervention (delivered by dietitians) versus a "standard-care" low-fat diet in reducing the composite incidence of cardiovascular events at 12 months and at trial end in participants with documented evidence of a previous acute myocardial infarction at trial entry. The quality of the diet at baseline and follow-up will be assessed using comprehensive dietary questionnaires and diaries as well as relevant dietary biomarkers (such as urinary polyphenols and erythrocyte fatty acids). Cardiovascular risk markers, including novel measures of immune and inflammatory status, endothelial function, vascular compliance, platelet activity, and body composition, will be collected to explore possible mechanisms for treatment effect. Cost-effectiveness will also be estimated to support policy translation. We plan to recruit 1,032 participants (516 per arm) from cardiology clinics in major Australian hospitals in Melbourne, Adelaide, and Brisbane.

Economic evaluation of a dietary intervention for adults with major depression (the "SMILES" trial).

BACKGROUND: Recently, the efficacy of dietary improvement as a therapeutic intervention for moderate to severe depression was evaluated in a randomised controlled trial. The SMILES trial demonstrated a significant improvement in Montgomery-Åsberg Depression Rating Scale scores favouring the dietary support group compared with a control group over 12 weeks. We used data collected within the trial to evaluate the cost-effectiveness of this novel intervention. METHODS: In this prospective economic evaluation, sixty-seven adults meeting DSM-IV criteria for a major depressive episode and reporting poor dietary quality were randomised to either seven sessions with a dietitian for dietary support or to an intensity matched social support (befriending) control condition. The primary outcome was Quality Adjusted Life Years (QALYs) as measured by the AQoL-8D, completed at baseline and 12 week follow-up (endpoint) assessment. Costs were evaluated from health sector and societal perspectives. The time required for intervention delivery was costed using hourly wage rates applied to the time in counselling sessions. Food and travel costs were also included in the societal perspective. Data on medications, medical services, workplace absenteeism and presenteesim (paid and unpaid) were collected from study participants using a resource-use questionnaire. Standard Australian unit costs for 2013/2014 were applied. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in average costs between groups divided by the difference in average QALYs. Confidence intervals were calculated using a non-parametric bootstrap procedure. RESULTS: Compared with the social support condition, average total health sector costs were $856 lower (95% CI -1247 to - 160) and average societal costs were $2591 lower (95% CI -3591 to - 198) for those receiving dietary support. These differences were driven by lower costs arising from fewer allied and other health professional visits and lower costs of unpaid productivity. Significant differences in mean QALYs were not found between groups. However, 68 and 69% of bootstrap iterations showed the dietary support intervention was dominant (additional QALYs at less cost) from the health sector and societal perspectives. CONCLUSIONS: This novel dietary support intervention was found to be likely cost-effective as an adjunctive treatment for depression from both health sector and societal perspectives. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820 . Registered on 29 February 2012.

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial).

BACKGROUND: The possible therapeutic impact of dietary changes on existing mental illness is largely unknown. Using a randomised controlled trial design, we aimed to investigate the efficacy of a dietary improvement program for the treatment of major depressive episodes. METHODS: 'SMILES' was a 12-week, parallel-group, single blind, randomised controlled trial of an adjunctive dietary intervention in the treatment of moderate to severe depression. The intervention consisted of seven individual nutritional consulting sessions delivered by a clinical dietician. The control condition comprised a social support protocol to the same visit schedule and length. Depression symptomatology was the primary endpoint, assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) at 12 weeks. Secondary outcomes included remission and change of symptoms, mood and anxiety. Analyses utilised a likelihood-based mixed-effects model repeated measures (MMRM) approach. The robustness of estimates was investigated through sensitivity analyses. RESULTS: We assessed 166 individuals for eligibility, of whom 67 were enrolled (diet intervention, n = 33; control, n = 34). Of these, 55 were utilising some form of therapy: 21 were using psychotherapy and pharmacotherapy combined; 9 were using exclusively psychotherapy; and 25 were using only pharmacotherapy. There were 31 in the diet support group and 25 in the social support control group who had complete data at 12 weeks. The dietary support group demonstrated significantly greater improvement between baseline and 12 weeks on the MADRS than the social support control group, t(60.7) = 4.38, p < 0.001, Cohen's d = -1.16. Remission, defined as a MADRS score <10, was achieved for 32.3% (n = 10) and 8.0% (n = 2) of the intervention and control groups, respectively (χ 2 (1) = 4.84, p = 0.028); number needed to treat (NNT) based on remission scores was 4.1 (95% CI of NNT 2.3-27.8). A sensitivity analysis, testing departures from the missing at random (MAR) assumption for dropouts, indicated that the impact of the intervention was robust to violations of MAR assumptions. CONCLUSIONS: These results indicate that dietary improvement may provide an efficacious and accessible treatment strategy for the management of this highly prevalent mental disorder, the benefits of which could extend to the management of common co-morbidities. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820 . Registered on 29 February 2012.

An evaluation of the telehealth facilitation of diabetes and cardiovascular care in remote Australian Indigenous communities: - protocol for the telehealth eye and associated medical services network [TEAMSnet] project, a pre-post study design.

BACKGROUND: Despite substantial investment in detection, early intervention and evidence-based treatments, current management strategies for diabetes-associated retinopathy and cardiovascular disease are largely based on real-time and face-to-face approaches. There are limited data re telehealth facilitation in type 2 diabetes management. Therefore, we aim to investigate efficacy of telehealth facilitation of diabetes and cardiovascular disease care in high-risk vulnerable Aboriginal and Torres Strait Islanders in remote/very remote Australia. METHODS: Using a pre-post intervention design, 600 Indigenous Australians with type 2 diabetes will be recruited from three primary-care health-services in the Northern Territory. Diabetes status will be based on clinical records. There will be four technological interventions: 1. Baseline retinal imaging [as a real-time patient education/engagement tool and telehealth screening strategy]. 2. A lifestyle survey tool administered at ≈ 6-months. 3. At ≈ 6- and 18-months, an electronic cardiovascular disease and diabetes decision-support tool based on current guidelines in the Standard Treatment Manual of the Central Australian Rural Practitioner's Association to generate clinical recommendations. 4. Mobile tablet technology developed to enhance participant engagement in self-management. Data will include: Pre-intervention clinical and encounter-history data, baseline retinopathy status, decision-support and survey data/opportunistic mobile tablet encounter data. The primary outcome is increased participant adherence to clinical appointments, a marker of engagement and self-management. A cost-benefit analysis will be performed. DISCUSSION: Remoteness is a major barrier to provision and uptake of best-practice chronic disease management. Telehealth, beyond videoconferencing of consultations, could facilitate evidence-based management of diabetes and cardiovascular disease in Indigenous Australians and serve as a model for other conditions. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404 was retrospectively registered on 22/03/2016.

Prediction of fruit and vegetable intake from biomarkers using individual participant data of diet-controlled intervention studies.

Fruit and vegetable consumption produces changes in several biomarkers in blood. The present study aimed to examine the dose-response curve between fruit and vegetable consumption and carotenoid (α-carotene, ß-carotene, ß-cryptoxanthin, lycopene, lutein and zeaxanthin), folate and vitamin C concentrations. Furthermore, a prediction model of fruit and vegetable intake based on these biomarkers and subject characteristics (i.e. age, sex, BMI and smoking status) was established. Data from twelve diet-controlled intervention studies were obtained to develop a prediction model for fruit and vegetable intake (including and excluding fruit and vegetable juices). The study population in the present individual participant data meta-analysis consisted of 526 men and women. Carotenoid, folate and vitamin C concentrations showed a positive relationship with fruit and vegetable intake. Measures of performance for the prediction model were calculated using cross-validation. For the prediction model of fruit, vegetable and juice intake, the root mean squared error (RMSE) was 258.0 g, the correlation between observed and predicted intake was 0.78 and the mean difference between observed and predicted intake was - 1.7 g (limits of agreement: - 466.3, 462.8 g). For the prediction of fruit and vegetable intake (excluding juices), the RMSE was 201.1 g, the correlation was 0.65 and the mean bias was 2.4 g (limits of agreement: -368.2, 373.0 g). The prediction models which include the biomarkers and subject characteristics may be used to estimate average intake at the group level and to investigate the ranking of individuals with regard to their intake of fruit and vegetables when validating questionnaires that measure intake.

Intake patterns of food nutrients and other substances associated with chronic pancreatitis.

BACKGROUND/OBJECTIVES: While alcohol is considered the most common aetiological factor for chronic pancreatitis, the intake of various nutrient and other substances is thought to act as cofactors in the pathogenesis of the disease due to modulation of oxidative stress. This study examined incident cases of acute pancreatitis to determine the dietary and other intakes that characterize those harbouring underlying chronic pancreatitis. METHODS: Cases of acute pancreatitis presenting to a single institution were prospectively recruited (n = 153). The presence of chronic pancreatitis was defined by a composite of clinical, biochemical and radiological criteria. Information was obtained on the intake of dietary macro- and micronutrients, coffee, tobacco and alcohol in the period just prior to the acute exacerbation. Univariate and multivariate analyses of association were undertaken. Principal components analysis (PCA) was employed to elicit patterns of intake. RESULTS: After adjustment for key demographic variables, no individual nutrient or other substance showed a significant association with chronic pancreatitis. However, following PCA there emerged a significant positive association with a so-called "stimulant" intake pattern and a negative association with a so-called "nutritive" pattern. CONCLUSIONS: Preceding an acute exacerbation, patients with underlying chronic pancreatitis are more likely to substitute food-based intake for combinations of other substances, such as tobacco and coffee. This finding may have application in the clinical setting as part of a chronic disease management protocol.