Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand.

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist. SLEEP DISORDERS: MORE ASSESSMENTS, SHORTER WAITS WITH COMMUNITY SLEEP SERVICE: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.

A regional programme to improve skin cancer management.

BACKGROUND AND CONTEXT: In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives. ASSESSMENT OF PROBLEM: There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care. RESULTS: The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians. STRATEGIES FOR IMPROVEMENT: The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors. LESSONS: Skin cancer management can be improved by a coordinated approach between primary and secondary care.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery.

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Fibrates plus betaine: a winning combination?

Because most of the cardiac risk remains despite successful statin therapy there has been renewed interest in fibrate therapy for persisting hyperlipidaemia. Fibrate therapy lowers triglycerides but causes the urinary loss of betaine, which is an essential metabolite that is involved in osmoregulation, in methyl group metabolism, and which also affects lipid partitioning in the body. Loss of betaine is associated with an elevation of homocysteine and may compromise the potential benefits of fibrate therapy. However, betaine deficiency could be easily and inexpensively corrected by concurrent betaine supplementation. Clinical trials of combinations of betaine and fibrate, to complement statin therapy, are needed to determine the value of these agents in reducing the residual cardiovascular disease risk.

Comparison of insulin resistance, metabolic syndrome and adiponectin in overweight bipolar patients taking sodium valproate and controls.

OBJECTIVE: Metabolic abnormalities in patients with bipolar disorder may be secondary to obesity, aspects of the disorder or its treatment. To investigate this further, the purpose the present study was to compare insulin resistance, components of the metabolic syndrome and adiponectin levels in a group of overweight bipolar patients taking sodium valproate and a group of non-psychiatric control subjects. METHODS: Data were collected from 60 overweight bipolar patients who had experienced clinically significant weight gain thought to be related to sodium valproate treatment and from 60 control subjects without psychiatric illness matched for age, gender, body mass index and ethnicity. RESULTS: The frequency of the metabolic syndrome was high in both groups (50% and 32%, respectively), although not significantly different between groups (p = 0.06). Similar frequencies of insulin resistance (HOMA-IR), abdominal obesity, hypertriglyceridaemia, hypertension and fasting hyperglycaemia were found in both groups. High-density lipoprotein cholesterol levels were lower in patients (p = 0.006), while adiponectin was unexpectedly higher than in control subjects (9.6+/-5.9 microg mL(-1) vs 7.4+/-4.3 microg mL(-1), p = 0.03). The frequencies of insulin resistance (HOMA-IR), the metabolic syndrome and its individual components were not significantly different in patients taking atypical antipsychotic medication and patients not on these medications. CONCLUSIONS: Frequencies of insulin resistance and the metabolic syndrome were similar in bipolar patients taking sodium valproate and matched control subjects, but dyslipidaemia was more frequent. Adiponectin levels were higher in patients. Further research is required to clarify the reasons for these findings.

Plasma retinol-binding protein is not a marker of insulin resistance in overweight subjects: a three year longitudinal study.

OBJECTIVES: This longitudinal study investigated whether or not plasma retinol-binding protein (RBP), recently referred to as RBP4, was a marker of insulin resistance in overweight subjects. METHODS: We measured anthropometric markers as well as RBP, fasting glucose and insulin in 206 overweight subjects and repeated these measurements 36 months later. Subjects were grouped according to fasting plasma glucose concentration at baseline and 36 months. RESULTS: Subjects (n=51) with a normal basal fasting glucose (<5.6 mmol/L) who developed impaired fasting glucose (IFG) 3 years later (>or=5.6 mmol/L) showed a highly significant increase in both fasting insulin and insulin resistance, but importantly no change in plasma RBP. This group had a significant increase in body mass index (BMI). Subjects (n=101) with a normal fasting glucose at both baseline (<5.6 mmol/L) and 36 months showed no significant change in fasting insulin, insulin resistance, RBP or BMI. The remaining subjects had impaired basal fasting glucose and were not analysed on a group-wise basis. Overall, RBP correlated significantly, but inversely, with anthropometric measures, but not with fasting glucose, insulin or insulin resistance. CONCLUSIONS: This is the first report of a long-term longitudinal study on RBP and the major finding is that subjects who developed insulin resistance showed no change in plasma RBP. On the basis of our results we consider that RBP cannot be construed as a marker of insulin resistance in overweight humans.

Plasma retinol-binding protein is unlikely to be a useful marker of insulin resistance.

To assess whether plasma retinol-binding protein (RBP) is a marker of insulin resistance we measured RBP, insulin and glucose in 285 fasting subjects attending a Lipid Disorders Clinic as outpatients. They were grouped as either subjects without diabetes mellitus and with varying degrees of insulin resistance or subjects with diabetes mellitus according to the WHO criteria. We show that there was no association between plasma RBP and insulin-resistance, insulin, glucose, % body fat, waist circumference or BMI whether analysed together or in groups. We confirm, using the largest study cohort to date, that plasma RBP is unlikely to be a useful marker of insulin resistance.

An ELISA for plasma retinol-binding protein using monoclonal and polyclonal antibodies: plasma variation in normal and insulin resistant subjects.

OBJECTIVES: Plasma retinol-binding protein (RBP) has been linked to insulin resistance and cardiovascular risk, yet little is know of its natural variation in plasma. We examined this in normal subjects and compared plasma levels and variability in lean subjects and subjects with the metabolic syndrome. METHODS: We established an "in house" ELISA for plasma RBP and measured levels in 20 normal subjects over daylight hours and 2 subject groups, either lean or classified with the metabolic syndrome. RESULTS: Plasma RBP in normal subjects did not vary over the day with no differences between males and females. There was also no difference in plasma RBP levels and between the age- and sex-matched lean subjects compared to the metabolic syndrome group. CONCLUSION: The lack of variation in plasma RBP in normal subjects and the lack of difference between plasma RBP in normal and metabolic syndrome subjects suggest the link between plasma RBP and insulin resistance is tenuous. Investigating a large cohort over the diabetic non-diabetic spectrum may clarify this issue.

Comparative effects of enzogenol and vitamin C supplementation versus vitamin C alone on endothelial function and biochemical markers of oxidative stress and inflammation in chronic smokers.

Chronic smoking is associated with endothelial dysfunction and inflammation, with oxidative stress contributing to both these processes. In this study, we investigated the effect of combined antioxidant treatment with Enzogenol, a flavonoid extract from the bark of Pinus radiata and vitamin C, over and above vitamin C alone, on endothelial function, plasma markers of inflammation and oxidative stress, blood pressure (BP) and anthropometrics. Forty-four chronic smokers without established cardiovascular disease were assigned randomly to receive either 480 mg Enzogenol and 60 mg vitamin C, or 60 mg vitamin C alone daily for 12 weeks. Endothelial function in the brachial artery was assessed by flow-mediated vasodilation (FMD). FMD improved in both treatment groups (p < 0.001), with no significant difference between the two groups (p = 0.84). In the group receiving Enzogenol and vitamin C, protein carbonyl levels were significantly reduced compared to the group taking vitamin C alone (p = 0.03). Enzogenol and vitamin C resulted in a significant reduction in fibrinogen levels in heavy smokers compared with vitamin C alone (p < 0.009). These findings demonstrated that co-supplementation with Enzogenol and vitamin C in smokers conferred no additional beneficial effect on macrovascular endothelial function over and above that seen in the vitamin C alone group. However, Enzogenol did demonstrate additional favourable effects on protein oxidative damage and fibrinogen levels.