Expansion and consolidation of fracture liaison service in New Zealand public healthcare setting - Waitemata District Health Board Experience.

AIM: To describe the service delivery of the Fracture Liaison Service (FLS) at Waitemata District Health Board (WDHB) for the year 2020, and to outline how the service evolved in recent years. METHOD: We reviewed and analysed the WDHB FLS database as well as 4-month and 12-month patient follow-up records from the calendar year 2020. RESULTS: In 2020, we identified and assessed 1,225 patients. We either directly initiated anti-osteoporosis medication (AOM) (256), recommended to start AOM with patient's GP (477), or recommended to continue or switch to a different AOM (441) in the vast majority (1174 = 95.8%). In remaining 51 patients, AOM was either deemed unnecessary (owing to relatively young age and good DEXA indices) or patient refused it. Three hundred and thirty dual energy X-ray absorptiometry (DEXA) scans were arranged by FLS, and 79.5% were found to be either osteoporotic (32.9%) or osteopenic (46.6%). At 4-month and 12-month follow-up, 85.1% and 74.4%, respectively, of those expected to be on treatment were on treatment. CONCLUSION: The WDHB FLS has expanded and consolidated considerably in recent years. Nationwide implementation of effective FLSs should significantly reduce the burden of fragility fractures.

Effect of Banded Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy on Diabetes Remission at 5 Years Among Patients With Obesity and Type 2 Diabetes: A Blinded Randomized Clinical Trial.

OBJECTIVE: To determine whether silastic ring laparoscopic Roux-en-Y gastric bypass (SR-LRYGB) or laparoscopic sleeve gastrectomy (LSG) produces superior diabetes remission at 5 years. RESEARCH DESIGN AND METHODS: In a single-center, double-blind trial, 114 adults with type 2 diabetes and BMI 35-65 kg/m2 were randomly assigned to SR-LRYGB or LSG (1:1; stratified by age-group, BMI group, ethnicity, diabetes duration, and insulin therapy) using a web-based service. Diabetes and other metabolic medications were adjusted according to a prespecified protocol. The primary outcome was diabetes remission assessed at 5 years, defined by HbA1c <6% (42 mmol/mol) without glucose-lowering medications. Secondary outcomes included changes in weight, cardiometabolic risk factors, quality of life, and adverse events. RESULTS: Diabetes remission after SR-LRYGB versus LSG occurred in 25 (47%) of 53 vs. 18 (33%) of 55 patients (adjusted odds ratios 4.5 [95% CI 1.6, 15.5; P = 0.009] and 4.2 [1.3, 13.4; P = 0.015] in the intention-to-treat analysis). Percent body weight loss was greater after SR-LRYGB than after LSG (absolute difference 10.7%; 95% CI 7.3, 14.0; P < 0.001). Improvements in cardiometabolic risk factors were similar, but HDL cholesterol increased more after SR-LRYGB. Early and late complications were similar in both groups. General health and physical functioning improved after both types of surgery, with greater improvement in physical functioning after SR-LRYGB. People of Maori or Pacific ethnicity (26%) had lower incidence of diabetes remission than those of New Zealand European or other ethnicities (2 of 25 vs. 41 of 83; P < 0.001). CONCLUSIONS: SR-LRYGB provided superior diabetes remission and weight loss compared with LSG at 5 years, with similar low risks of complications.

Long-term outcomes in gastric bypass patients with and without type 2 diabetes--Waitemata District Health Board experience.

BACKGROUND/OBJECTIVES: Dramatic early postoperative improvement or resolution of type 2 diabetes mellitus (T2DM) has been widely reported after bariatric surgery but there is limited long-term data on T2DM outcome. Moreover, data on long-term weight outcomes of government funded bariatric surgery in New Zealand is lacking. We report weight and glycaemic outcomes in subjects with and without T2DM who underwent gastric bypass surgery (GBP) at Waitemata District Health Board (WDHB). METHODS: Clinical records of those who underwent a GBP (Roux-en-Y gastric bypass or loop gastric bypass) at WDHB between 2001 and 2007 were reviewed. Relevant pre- and postoperative data, including weight and diabetes related parameters, were collected from hospital records and analysed. Missing clinical data was attained by contacting patients, their primary practitioners and local laboratories, and also by performing HbA1c in T2DM subjects in whom latest diabetes status was unclear. RESULTS: Data of 126 subjects was analysed. Their mean age was 43.7 years, 73% were female and 83% were Pakeha/European. Mean preoperative weight was 136.2 kg (SD plus or minus 29.1, range 81.3-241) with a mean BMI of 48.3 kg/m². Postoperative nadir weight was 80.6 kg (SD plus or minus 18.1, range 48.0-132.8) at 20.8 months (SD plus or minus 14.6, range 4-98) (BMI 28.6) with percentage of excess body weight loss (%EBWL) of 84.7%. Latest mean weight was 90.5 kg (SD plus or minus 18.8, range 57-140) (BMI 32.2, %EBWL 70.7%) at a mean of 63.4 months (SD plus or minus 19.7, range 12-109) post-op. Thirty four subjects (27.0%) had preoperative diagnosis of T2DM, of whom 29 (85.3%) had complete remission at some stage postoperatively. At the latest follow-up, 19 of 33 (57.6%) remained in complete remission, and the rest had either never remitted or had evidence of T2DM relapse after an initial remission. Weight loss outcomes were comparable between T2DM and non-T2DM subjects, and also between European and Maori and Pacific Islanders. CONCLUSION: GBP resulted in substantial weight loss in essentially all subjects, and weight loss was well maintained over time. GBP also had dramatic and favourable effect on T2DM but did not uniformly result in prolonged diabetes remission. Long-term glycaemic surveillance is desirable.

Pioglitazone in acromegaly - an open-label, prospective study.

OBJECTIVE: Preclinical studies demonstrate that thiazolidinediones (TZDs) decrease growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels, suggesting that they might be effective treatments for acromegaly. This study investigated the effect of pioglitazone on biochemical indices of disease activity in acromegaly. DESIGN AND PARTICIPANTS: This was a 4-month open-label prospective study in 16 patients with active acromegaly who were attending public hospital endocrinology clinics. METHODS: The intervention was pioglitazone 45 mg/day. The primary outcome was change in serum IGF-1; the secondary outcome was change in area under the curve of glucose-suppressed GH. RESULTS: Serum IGF-1 did not change during treatment with pioglitazone (P = 0·95). After 4 months, the mean (95% CI) change from baseline was -1 µg/l (-51, 49). GH levels following oral glucose loading were unchanged during pioglitazone therapy. After 4 months, the mean (95% CI) change from baseline in area under curve for glucose-suppressed GH was 31 µg/l (-75, 138, P = 0·54). CONCLUSIONS: Short-term treatment with conventional doses of pioglitazone did not improve biochemical measures of disease activity in acromegaly.

Unmasking of undiagnosed pre-existing central diabetes insipidus after renal transplantation.

Acquired central diabetes insipidus (CDI) often occurs abruptly after a cranial event causing hypothalamic or pituitary damage. We present a case of a patient with pre-existing and clinically unapparent CDI which was unmasked after renal transplantation. A 60 year old woman with end-stage renal failure due to autosomal dominant polycystic kidney disease (ADPKD) underwent renal transplantation. She was noted to be markedly polyuric and polydipsic after the transplant. A fluid deprivation test was unequivocally positive for CDI, and desmopressin treatment resulted in immediate symptom relief. Neuroimaging revealed a midline defect in the region of the hypothalamus. She had a history of an intracerebral aneurysm that had ruptured, requiring extensive neurosurgery many years previously. This case demonstrates a rare instance of pre-existing but clinically unapparent CDI unmasked by renal transplantation. It is likely that renal failure due to ADPKD disguised her CDI prior to transplantation. A previous intracerebral insult from an aneurysmal bleed is the likely cause of her vasopressin deficiency.

Hot flushes, hypertension and haemodialysis.

Hypertension is common in patients with end stage renal disease. However, in patients non-responsive to standard measures to control the blood pressure, non-renal causes should be considered. We present the case of a patient on haemodialysis with difficult to control blood pressure.

A survey of thyroid function test abnormalities in patients presenting with atrial fibrillation and flutter to a New Zealand district hospital.

AIM: Subclinical and overt hyperthyroidism is a known trigger of atrial fibrillation and flutter (AF). We wanted to see if thyroid function tests (TFT) were being requested appropriately in patients with atrial fibrillation or flutter at North Shore Hospital, and how common subclinical or overt hyperthyroidism was in our local inpatient population presenting with AF. METHOD: Clinical data on 250 patients admitted to North Shore Hospital with a history of AF was retrospectively analysed, including prior history of thyroid dysfunction, measurement of TFT and their results at the time of admission, subsequent management of subjects with abnormal TFT, and the association of amiodarone treatment or use of radiocontrast with TFT derangements. RESULTS: Of the 250 patients analysed, only a small (7.2%) proportion had known thyroid dysfunction prior to admission, most of whom had hypothyroidism on thyroxine replacement. Although the majority (77%) of AF patients had had TFT checked either at the time of admission or in the prior 6 months, a significant proportion (23%) had not. Of the patients in whom TFT were performed, 82% were normal. Abnormalities included subclinical hyperthyroidism (2.1%), overt hyperthyroidism (3.1%), subclinical hypothyroidism (11%), and overt hypothyroidism (1.6%). CONCLUSION: Despite a relatively low frequency, hyperthyroid conditions in patients presenting to North Shore Hospital with AF were sufficiently prevalent to continue recommending TFT assessment in these patients. Although the majority of AF patients were being adequately screened with TFT, a significant proportion was not, and those with abnormalities were not well followed up.