A systematic review to identify anxiety measures for use in populations undergoing abdominal aortic aneurysm screening.

OBJECTIVE: To identify the most appropriate patient reported outcome measure (PROM) to quantify anxiety of participants in the United Kingdom (UK) National Abdominal Aortic Aneurysm Screening Programme (NAAASP). METHODS: Comprehensive electronic searches were undertaken to identify studies reporting development or validation of PROMs used in the measurement of anxiety in screened populations. Study selection, data extraction and analysis were conducted independently by two reviewers; the "COnsensus-based Standards for the selection of health Measurement INstruments" (COSMIN) classification of measurement properties was used in the evaluation of included PROMs enabling a recommendation to be made for the most appropriate PROM for use in the NAAASP. RESULTS: The systematic review identified three PROMS that met the specified quality criteria and of these the Psychological Consequences of Screening questionnaire (PCQ) was judged to be the most appropriate PROM for use in populations undergoing screening for abdominal aortic aneurysm (AAA). Though the PCQ was developed for use in breast screening the individual items are appropriate to a population undergoing screening for AAA with minimal modification. DISCUSSION: The review was undertaken as part of a wider research initiative aiming to introduce routine measurement of anxiety alongside the UK NAAASP. A significant number of individuals participating in this screening programme will have an AAA that will never progress to a stage where it will directly cause ill health or require treatment. For these individuals the knowledge that they have an AAA could create anxiety that has a significant impact on quality of life, there is a potential for this to outweigh the benefits of screening and surveillance. CONCLUSION: In the absence of a PROM with proven validity and reliability in populations undergoing AAA screening the PCQ is a pragmatic choice as a measure of anxiety in this population and appropriate for the purposes of the NAAASP.

GLP-1 Receptor Agonists for Type 2 Diabetes and Their Role in Primary Care: An Australian Perspective.

The ever-increasing number of drugs available to treat type 2 diabetes and the complexity of patients with this condition present a constant challenge when it comes to identifying the most appropriate treatment approach. The more recent glucagon-like peptide-1 receptor agonists (GLP-1RAs) are non-insulin injectable options for the management of type 2 diabetes. Effective at improving glycaemic control with a low intrinsic risk of hypoglycaemia and the potential for weight reduction, this agent class is an important addition to the prescribing armamentarium. However, understanding their place in therapy may prove confusing for many primary care practitioners, especially given the common belief that 'injectables' are a last-resort treatment option, which puts them at risk of being niched alongside insulin. This review summarises the clinical evidence for GLP-1RAs and how they compare to other glucose-lowering agents in managing type 2 diabetes. It also provides practical and case-driven opinions and recommendations on the optimal use of GLP-1RAs by discussing important patient factors and clinical considerations that will help to identify those who are most likely to benefit from this class of agents.Funding: Eli Lilly Australia.

Complex mixtures, complex responses: Assessing pharmaceutical mixtures using field and laboratory approaches.

Pharmaceuticals are present in low concentrations (<100 ng/L) in most municipal wastewater effluents but may be elevated locally because of factors such as input from pharmaceutical formulation facilities. Using existing concentration data, the authors assessed pharmaceuticals in laboratory exposures of fathead minnows (Pimephales promelas) and added environmental complexity through effluent exposures. In the laboratory, larval and mature minnows were exposed to a simple opioid mixture (hydrocodone, methadone, and oxycodone), an opioid agonist (tramadol), a muscle relaxant (methocarbamol), a simple antidepressant mixture (fluoxetine, paroxetine, venlafaxine), a sleep aid (temazepam), or a complex mixture of all compounds. Larval minnow response to effluent exposure was not consistent. The 2010 exposures resulted in shorter exposed minnow larvae, whereas the larvae exposed in 2012 exhibited altered escape behavior. Mature minnows exhibited altered hepatosomatic indices, with the strongest effects in females and in mixture exposures. In addition, laboratory-exposed, mature male minnows exposed to all pharmaceuticals (except the selective serotonin reuptake inhibitor mixture) defended nest sites less rigorously than fish in the control group. Tramadol or antidepressant mixture exposure resulted in increased splenic T lymphocytes. Only male minnows exposed to whole effluent responded with increased plasma vitellogenin concentrations. Female minnows exposed to pharmaceuticals (except the opioid mixture) had larger livers, likely as a compensatory result of greater prominence of vacuoles in liver hepatocytes. The observed alteration of apical endpoints central to sustaining fish populations confirms that effluents containing waste streams from pharmaceutical formulation facilities can adversely impact fish populations but that the effects may not be temporally consistent. The present study highlights the importance of including diverse biological endpoints spanning levels of biological organization and life stages when assessing contaminant interactions.

Diabetes and the skin - onychomycosis.

Case history - Oliver: Oliver is aged 70 years, has had type 2 diabetes for 18 years, and has been treated with insulin for 4 years. He presents after two episodes of cellulitis of his right lower leg and forefoot, which have cleared on antibiotics. There are no residual skin changes on his leg and forefoot other than some postinflammatory pigmentation.

Association between impaired glucose metabolism and quality of life: results from the Australian diabetes obesity and lifestyle study.

AIMS: We examined the association of quality of life with glucose tolerance status in an Australian population to determine the stage in the development of diabetes that quality of life is impaired. METHODS: The Australian Diabetes, Obesity and Lifestyle study (AusDiab) was a population-based study of 11,247 people from randomly selected areas of Australia. As part of the study, participants underwent an oral glucose tolerance test and completed the SF-36 quality of life questionnaire. RESULTS: Previously diagnosed diabetes was associated with a significantly greater risk of being in the lowest quartile of each dimension of the SF-36 scale (except for mental health) and this association was only partially attenuated by adjustment for age, sex, body mass index (BMI), physical activity and treatment for hypertension and lipid abnormalities (adjusted odds ratios [95% CI]: bodily pain, 1.51 [1.18-1.94]; general health, 2.20 [1.64-2.95]; physical functioning, 1.50 [1.10-2.05]; role limitation (emotional), 1.43 [1.07-1.91]; role limitation (physical), 1.57 [1.13-2.18]; social functioning, 1.93 [1.46-2.54] and vitality, 2.24 [1.56-3.22]. Among those with newly diagnosed diabetes (NDM) and impaired glucose tolerance (IGT), there was also evidence of reduced quality of life on some dimensions of the SF-36 scale (NDM, general health, physical functioning and role limitation (physical); IGT, physical functioning and social functioning) after adjustment for confounders. CONCLUSION: These findings show that diabetes is associated with a reduced quality of life and that this is evident in the early stage of the disease, particularly in relation to the ability to perform physical activities.

Dietary dilemmas in diabetes.

BACKGROUND: Two of the 'f' words summarising predisposition to type 2 diabetes are fixed (family history, age forty years), but the third (fat) can be changed. The diagnosis of diabetes can be the trigger to review lifestyle, 'eat less and walk more' and to lose fat tissue. Initially this is often enough to bring blood glucose into the target range, but later as the metabolic abnormality of type 2 diabetes progresses, oral hypoglycaemic agents will be needed. Nonetheless, lifestyle issues remain important in managing the medical components of the type 2 syndrome (blood glucose, blood pressure, blood fats and blood clotting). OBJECTIVE: This article uses a case based approach to discuss how a dietician can help patients review and modify their lifestyle. DISCUSSION: A coordinated approach by the general practitioner, dietician and diabetes educator will often help to discover the cause of abnormal blood glucose levels, and assist the patient in normalising them.

Diabetes, depression, and quality of life: a population study.

OBJECTIVE: The aim of the study was to assess the prevalence of diabetes and depression and their associations with quality of life using a representative population sample. RESEARCH DESIGN AND METHODS: The study consisted of a representative population sample of individuals aged > or = 15 years living in South Australia comprising 3,010 personal interviews conducted by trained health interviewers. The prevalence of depression in those suffering doctor-diagnosed diabetes and comparative effects of diabetic status and depression on quality-of-life dimensions were measured. RESULTS: The prevalence of depression in the diabetic population was 24% compared with 17% in the nondiabetic population. Those with diabetes and depression experienced an impact with a large effect size on every dimension of the Short Form Health-Related Quality-of-Life Questionnaire (SF-36) as compared with those who suffered diabetes and who were not depressed. A supplementary analysis comparing both depressed diabetic and depressed nondiabetic groups showed there were statistically significant differences in the quality-of-life effects between the two depressed populations in the physical and mental component summaries of the SF-36. CONCLUSIONS: Depression for those with diabetes is an important comorbidity that requires careful management because of its severe impact on quality of life.

One pair must last a lifetime. Case studies of foot care in diabetes.

Neuropathy is the second most important of the four major 'traffic light' warnings for future foot problems (vascular, neuropathy, structural, self care). Peripheral neuropathy is a significant clinical problem in 20% of patients with diabetes. Painful neuropathy can disrupt patients lives but simple effective interventions are available. Painless neuropathy is often not perceived to be a problem by the patient or their doctor but puts the foot at risk from trauma (physical, chemical and thermal). Patients with neuropathy need systematic reassessment of self and professional diabetes care, and education about footwear and foot care. A podiatrist can be invaluable in prescribing appropriate footwear and orthotics to distribute foot pressure and in educating patients about self care. Patients with the 'double whammy' of neuropathy and vascular disease are at extreme risk of limb threatening problems and should have a regular monitoring program by themselves (or their carers) and their professionals as well as an 'action plan' to detect and deal with problems early.

Oral hypoglycaemics. When not to use what.

BACKGROUND: In the 1940s and '50s the first oral hypoglycaemic agents (the sulphonylureas and metformin) became available. These remained the only agents for the next 50 years. Over the last five years three new classes have been released. General practitioners now have a wider range of effective hypoglycaemic agents from which to choose. OBJECTIVES: This article focuses on those patients where particular agents should not be used: i.e. 'when not to use what'. DISCUSSION: In general however, it must be remembered that problems with oral hypoglycaemics are rare. The great majority of patients have no problems with their prescribed hypoglycaemic medication.

One pair must last a lifetime. Misshaped feet.

This article is the fifth in this series examining issues in foot care. This month the authors outline care issues regarding misshaped feet.

Is it dementia? Which one?

BACKGROUND: People fear losing their identity or no longer being themselves. It can be devastating to see someone who spent their life with you turn into someone who looks like your loved one but who no longer recognises you and may be frightened, suspicious, hostile or violent. OBJECTIVE: This article gives practical guidelines with a recognition, definition and differential diagnosis of dementia. DISCUSSION: Dementia may not be obvious to the individual, the family or their family doctor and should not be simply attributed to 'Alzheimer's'. Dementias can be confused with delirium or depression and the different dementias have different prognoses and different interventions.

One pair must last a lifetime. Foot care and vascular disease.

This is the second in a series of articles on foot care relating to various clinical conditions.