Medicine (Austin & Northern Health) - Research Publications
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ItemUsing Automated HbA1c Testing to Detect Diabetes Mellitus in Orthopedic Inpatients and Its Effect on Outcomes (vol 12, e0168471, 2017)(PUBLIC LIBRARY SCIENCE, 2017-02-13)[This corrects the article DOI: 10.1371/journal.pone.0168471.].
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ItemRelationship Between Glycated Hemoglobin and Stroke Risk: A Systematic Review and Meta-Analysis(WILEY, 2018-06-05)BACKGROUND: Diabetes mellitus is a major risk factor for ischemic stroke. Rising hemoglobin A1c (HbA1c) levels are associated with microvascular diabetes mellitus complication development; however, this relationship has not been established for stroke risk, a macrovascular complication. METHODS AND RESULTS: We conducted a systematic review and meta-analysis of observational cohort and nested case-control cohort studies assessing the association between rising HbA1c levels and stroke risk in adults (≥18 years old) with and without type 1 or type 2 diabetes mellitus. Random-effects model meta-analyses were used to calculate pooled adjusted hazard ratios (HRs) and their precision. The systematic review yielded 36 articles, of which 29 articles (comprising n=532 779 participants) were included in our meta-analysis. Compared to non-diabetes mellitus range HbA1c (<5.7%), diabetes mellitus range HbA1c (≥6.5%) was associated with an increased risk of first-ever stroke with average HR (95% confidence interval) of 2.15 (1.76, 2.63), whereas pre-diabetes mellitus range HbA1c (5.7-6.5%) was not (average HR [95% confidence interval], 1.19 [0.87, 1.62]). For every 1% HbA1c increment (or equivalent), the average HR (95% confidence interval) for first-ever stroke was 1.12 (0.91, 1.39) in non-diabetes mellitus cohorts and 1.17 (1.09, 1.25) in diabetes mellitus cohorts. For every 1% HbA1c increment, both non-diabetes mellitus and diabetes mellitus cohorts had a higher associated risk of first-ever ischemic stroke with average HR (95% confidence interval) of 1.49 (1.32, 1.69) and 1.24 (1.11, 1.39), respectively. CONCLUSIONS: A rising HbA1c level is associated with increased first-ever stroke risk in cohorts with a diabetes mellitus diagnosis and increased risk of first-ever ischemic stroke in non-diabetes mellitus cohorts. These findings suggest that more intensive HbA1c glycemic control targets may be required for optimal ischemic stroke prevention.
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ItemFeasibility of using a transition diabetes team to commence injectable therapies postdischarge from a tertiary hospital: a pilot, randomised controlled trial(BMJ PUBLISHING GROUP, 2019-09)OBJECTIVES: This study aimed to investigate if the use of a transition team was feasible for patients with diabetes being discharged from hospital on injectable diabetes therapies. DESIGN: Pilot, randomised controlled trial. SETTING: The trial was conducted between 2014 and 2016 conjointly by a tertiary referral hospital and a community healthcare provider. PARTICIPANTS: Hospital inpatients (n=105) on new injectable diabetes therapies were randomised 1:1 to transition team or standard care. The transition team received in-home diabetes education 24-48 hours postdischarge, with endocrinologist review 2-4 weeks and 16 weeks postdischarge. MAIN OUTCOME MEASURES: The primary outcome was feasibility, defined by percentage of patients successfully receiving the intervention. Secondary outcomes included safety, defined by hospital readmission and emergency department presentations within 16 weeks postrandomisation, and treatment satisfaction, measured using Diabetes Treatment Satisfaction Questionnaire (DTSQ). Exploratory outcomes included length of stay (LOS) and change in haemoglobin A1c (HbA1c) throughout the study. RESULTS: The intervention was deemed feasible (85% (95% CI 73% to 94%)). No difference in safety between groups was detected. No difference in change in HbA1c between groups was detected (standard care median HbA1c -1.5% (IQR -3.7% to -0.2%) vs transition team median HbA1c -1.9% (IQR -3.8% to -0.2%), p=0.83). There was a trend towards reduced LOS in the transition team group (per protocol, standard care median LOS 8 (IQR 5.5-12); transition team median LOS 6 (IQR 3-12), p=0.06). There was a significant improvement in patient satisfaction in the transition team (standard care median 10.5 (IQR 8.5-16); transition team DTSQ change version median 15 (IQR 10-17.5), p=0.047), although interpretability is limited by missing data. CONCLUSION: This study demonstrated that the use of a novel transition diabetes team is a feasible alternative model of care.
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ItemDiagnostic performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation at estimating glomerular filtration rate in adults with diabetes mellitus: a systematic review and meta-analysis protocol(BMJ PUBLISHING GROUP, 2019-08)INTRODUCTION: Timely detection leading to the implementation of reno-protective measures reduces the progression of diabetic kidney disease. Estimated glomerular filtration rate (eGFR) is a major surrogate of kidney function. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Equation is a tool to estimate GFR. This protocol outlines a systematic-review, assessing the diagnostic accuracy of the CKD-EPI equation in adults with diabetes. METHODS AND ANALYSIS: MEDLINE, Embase, Cochrane Central Register of Controlled Trials and grey literature will be searched for publications in English, Farsi, Dutch and Chinese from 2009 (when CKD-EPI was first introduced) to January 2019. Bridging searches will be conducted to capture literature published from January 2019 until final review publication. The inclusion criteria will be (1) study participants with diabetes; (2) age ≥18 years; (3) creatinine-based CKD-EPI eGFR as index test; (4) measured GFR using the clearance/plasma disappearance of inulin, iohexol, iothalamate, diethylenetriamine-pentaacetic acid (DTPA) or chromium labelled ethylenediaminetetraacetic acid (Cr-EDTA) as reference test; (5) report of the diagnostic accuracy of the index test. Exclusion criteria will be participants with renal transplant, chronic use of corticosteroids, chronic inflammatory diseases, pregnancy, non-diabetes related kidney disease, thalassaemia, heart failure, pregnancy and potential kidney donors as well as critically ill patients. Screening, eligibility check, risk of bias assessment and data extraction will be carried out by two independent reviewers. Any discrepancies will be discussed, and third-party opinion will be sought. The risk of bias will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A quantitative synthesis of the aggregated-data will be used if the included studies are homogenous. ETHICS AND DISSEMINATION: No ethics approval is required. The outcome will be published in a peer-reviewed journal. The results will help researchers and clinicians evaluate the diagnostic accuracy of the creatinine-based CKD-EPI eGFR in adults with diabetes. PROSPERO REGISTRATION NUMBER: CRD42018108776.
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ItemA longitudinal study of thyroid autoantibodies in pregnancy: the importance of test timing(WILEY, 2015-04)OBJECTIVE: Thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TGAb) are frequently measured to investigate thyroid dysfunction in pregnancy. Despite the recognized fall of these autoantibodies in pregnancy, there is limited guidance on the timing of such testing. We assessed optimal test timing of TPOAb/TGAb for the detection of Hashimoto's thyroiditis and post-partum thyroid dysfunction (PPTD). DESIGN: Prospective longitudinal study with recruitment in Trimester 1. PATIENTS: Healthy women ≤13 weeks' gestation from Mercy Hospital for Women, a tertiary obstetric hospital in Melbourne. MEASUREMENTS: Serum TPOAb, TGAb, TSH and fT4 were measured at Trimester 1 (T1), Trimester 2(T2), Trimester 3(T3) and postpartum (PP) in each participant. Post-partum thyroid dysfunction (PPTD) was defined if TSH deviated from the assay's nonpregnant reference interval. Longitudinal random-effect logistic regression was used to investigate the association between time and positive/negative thyroid autoantibody status. RESULTS: Samples from 140 women at T1 (12·0: 10·3-13·0) (median: IQR weeks' gestation); 95 at T2 (24·3: 23·0-25·9), 79 at T3 (35·9: 34·8-36·7) and 83 at PP (12·4: 10·8-14·6 weeks post-partum) were attained. At T1, 13 (9%) and 15 (11%) women had positive TPOAb and TGAb, respectively. The odds of having a positive TPOAb were 96% lower at T2 [OR = 0·04 (95% CI: 0·02-0·8; P = 0·03)] and 97% lower at T3 [OR = 0·03 (95% CI: 0·001-0·6; P = 0·02)] than at T1. Similarly, the odds of having a positive TGAb were 99·4% lower [OR = 0·006 (95% CI: 0-0·3; P = 0·01)] at T2, and 99·5% lower [OR = 0·005 (95% CI: 0-0·4; P = 0·02)] at T3 than at T1. The ROC analysis diagnostic ORs for a positive TPOAb and/or TGAb to predict PPTD were 7·8 (95% CI: 2·2-27·6), 1·2 (95% CI: 0-8·9), 2·0 (95% CI: 0-16·8), and 12·2 (95% CI: 3·3-44·9) at T1, T2, T3 and post-partum, respectively. CONCLUSIONS: A significant proportion of pregnant women lose their thyroid autoantibody positivity after T1. The gestation-dependent loss of TPOAb/TGAb positivity and reduction in diagnostic accuracy for predicting PPTD limits the value of testing at T2 and T3.
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ItemUsing Routine Hemoglobin A1c Testing to Determine the Glycemic Status in Psychiatric Inpatients(FRONTIERS MEDIA SA, 2017-03-28)AIM: Using routine hemoglobin A1c (HbA1c) testing to describe the prevalence, characteristics, and length of stay (LOS) of psychiatry inpatients with type 2 diabetes compared to those with pre-diabetes and those without diabetes. METHODS: In this prospective observational study, all inpatients aged greater than 30 years admitted to the Austin Health Psychiatry Unit, a major tertiary hospital, affiliated with the University of Melbourne, between February 2014 and April 2015 had routine HbA1c testing as part of the Diabetes Discovery Initiative. Patients were divided into three groups: diabetes (HbA1c ≥ 6.5%, 48 mmol/mol), pre-diabetes (HbA1c 5.7-6.4%, 39-46 mmol/mol), or no diabetes (HbA1c ≤ 5.6%, 38 mmol/mol). Baseline characteristics, co-morbidities, psychiatric illnesses, and treatment were recorded. RESULTS: There were a total of 335 psychiatry inpatients (median age 41 years). The most prevalent diagnoses were schizophrenia, depression, and substance abuse. Of the 335 psychiatric inpatients, 14% (n = 46) had diabetes and 19% (n = 63) had pre-diabetes, a prevalence threefold greater than in the aged matched general population. Compared to inpatients with pre-diabetes and no diabetes, those with diabetes were older and were at least twice as likely to have hypertension, obesity, and hyperlipidemia (all p ≤ 0.002). In multivariable analyses, diabetes was associated with increasing age (p = 0.02), substance abuse (p = 0.04), dyslipidaemia (p = 0.03), and aripiprazole use (p = 0.01). Patients with diabetes also had a 70% longer expected LOS (95% CI: 20-130%; p = 0.001), compared to those with pre-diabetes and no diabetes. CONCLUSION: Despite relative youth, one-third of all psychiatric inpatients above the age of 30 have diabetes or pre-diabetes. Presence of diabetes in psychiatric inpatients is associated with older age, substance abuse, and longer LOS. Routine inpatient HbA1c testing provides an opportunity for early detection and optimization of diabetes care.
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ItemHigher maternal serum prolactin levels are associated with reduced glucose tolerance during pregnancy(WILEY, 2017-09)It is unknown if high prolactin levels during pregnancy contribute to the development of gestational diabetes. We hypothesized that higher prolactin levels are associated with reduced glucose tolerance, as determined by higher 2-h glucose level from an oral glucose tolerance test in pregnancy. The 75-g oral glucose tolerance test was carried out at 28 weeks of gestation in 69 participants. A multiple regression analysis was used to determine the relationship between serum prolactin and 2-h glucose levels. Multivariable regression analysis showed an independent and significant relationship between third trimester prolactin and 2-h glucose levels post oral glucose tolerance test. Higher prolactin levels were associated with higher glucose levels independent of age, body mass index, gravidity and parity. Higher prolactin levels associated with reduced glucose tolerance in the third trimester of pregnancy suggests the possible independent role of prolactin in the pathogenesis of gestational diabetes.
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ItemRoutine use of HbA1c amongst inpatients hospitalised with decompensated heart failure and the association of dysglycaemia with outcomes(NATURE PUBLISHING GROUP, 2018-09-10)Diabetes is an independent risk factor for development of heart failure and has been associated with poor outcomes in these patients. The prevalence of diabetes continues to rise. Using routine HbA1c measurements on inpatients at a tertiary hospital, we aimed to investigate the prevalence of diabetes amongst patients hospitalised with decompensated heart failure and the association of dysglycaemia with hospital outcomes and mortality. 1191 heart failure admissions were identified and of these, 49% had diabetes (HbA1c ≥ 6.5%) and 34% had pre-diabetes (HbA1c 5.7-6.4%). Using a multivariable analysis adjusting for age, Charlson comorbidity score (excluding diabetes and age) and estimated glomerular filtration rate, diabetes was not associated with length of stay (LOS), Intensive Care Unit (ICU) admission or 28-day readmission. However, diabetes was associated with a lower risk of 6-month mortality. This finding was also supported using HbA1c as a continuous variable. The diabetes group were more likely to have diastolic dysfunction and to be on evidence-based cardiac medications. These observational data are hypothesis generating and possible explanations include that more diabetic patients were on medications that have proven mortality benefit or prevent cardiac remodelling, such as renin-angiotensin system antagonists, which may modulate the severity of heart failure and its consequences.
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ItemSystematic review and meta-analysis of prevalence of sarcopenia in post acute inpatient rehabilitation(Springer, 2018-04-01)Summary: Sarcopenia is associated with poor function and increased risk of falls and disability. This work reports a systematic review and meta-analysis of prevalence of sarcopenia in post acute inpatient rehabilitation. Sarcopenia is found to be present in approximately 50% of rehabilitation patients and its prevalence may vary with admission diagnosis. Purpose: To conduct a systematic review and meta-analysis of reported prevalence of sarcopenia in post acute inpatient rehabilitation. Methods: Systematic review conducted according to PRISMA guidelines (PROSPERO registration number CRD42016054135). Databases searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register, and CINAHL. Studies considered the following: published January 1988–February 2017. Key terms are as follows: “sarcopenia” AND “inpatient rehabilitation” OR “rehabilitation” AND/OR “prevalence”. Abstracts and subsequently full studies reporting sarcopenia prevalence in adults admitted to rehabilitation reviewed irrespective of design, provided sarcopenia diagnosis included at least assessment of muscle mass. Random effect meta-analysis was conducted. Methodological quality assessment: Agency for Healthcare Research and Quality, US Department of Health and Human Services tool (MORE tool); Joanna Briggs Institute Prevalence Critical Appraisal Tool. Results: Four hundred twenty-six studies identified during initial search, 399 excluded after reviewing titles and abstracts, 21 full text articles reviewed, and six studies met inclusion criteria. Patient populations: after hip fracture (five studies), general deconditioning (one study). Identified sarcopenia prevalence ranged from 0.28 to 0.69. Pooled sarcopenia prevalence obtained with random effect meta-analysis: 0.56 (95% CI 0.46–0.65), heterogeneity I2 = 92.9%. Main quality shortcomings: lack of reporting of inter- and intra-rater reliability, lack of generalizability to other rehabilitation populations. Conclusions: Original research examining sarcopenia prevalence in inpatient rehabilitation is scarce. Patient populations studied to date are not representative of general rehabilitation population with regard to both age and admission diagnoses. Sarcopenia may be present in approximately half of rehabilitation patients and its prevalence may vary with admission diagnosis.
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ItemDoes left ventricular hypertrophy affect cognition and brain structural integrity in type 2 diabetes? Study design and rationale of the Diabetes and Dementia (D2) study(BMC, 2017-04-07)BACKGROUND: Cognitive impairment is common in type 2 diabetes mellitus, and there is a strong association between type 2 diabetes and Alzheimer's disease. However, we do not know which type 2 diabetes patients will dement or which biomarkers predict cognitive decline. Left ventricular hypertrophy (LVH) is potentially such a marker. LVH is highly prevalent in type 2 diabetes and is a strong, independent predictor of cardiovascular events. To date, no studies have investigated the association between LVH and cognitive decline in type 2 diabetes. The Diabetes and Dementia (D2) study is designed to establish whether patients with type 2 diabetes and LVH have increased rates of brain atrophy and cognitive decline. METHODS: The D2 study is a single centre, observational, longitudinal case control study that will follow 168 adult patients aged >50 years with type 2 diabetes: 50% with LVH (case) and 50% without LVH (control). It will assess change in cardiovascular risk, brain imaging and neuropsychological testing between two time-points, baseline (0 months) and 24 months. The primary outcome is brain volume change at 24 months. The co-primary outcome is the presence of cognitive decline at 24 months. The secondary outcome is change in left ventricular mass associated with brain atrophy and cognitive decline at 24 months. DISCUSSION: The D2 study will test the hypothesis that patients with type 2 diabetes and LVH will exhibit greater brain atrophy than those without LVH. An understanding of whether LVH contributes to cognitive decline, and in which patients, will allow us to identify patients at particular risk. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12616000546459 ), date registered, 28/04/2016.