Medicine (Austin & Northern Health) - Research Publications

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    A systematic review: Cost-effectiveness of continuous glucose monitoring compared to self-monitoring of blood glucose in type 1 diabetes.
    Jiao, Y ; Lin, R ; Hua, X ; Churilov, L ; Gaca, MJ ; James, S ; Clarke, PM ; O'Neal, D ; Ekinci, EI (Wiley, 2022-11)
    Continuous glucose monitoring (CGM) is rapidly becoming a vital tool in the management of type 1 diabetes. Its use has been shown to improve glycaemic management and reduce the risk of hypoglycaemic events. The cost of CGM remains a barrier to its widespread application. We aimed to identify and synthesize evidence about the cost-effectiveness of utilizing CGM in patients with type 1 diabetes. Studies were identified from MEDLINE, Embase and Cochrane Library from January 2010 to February 2022. Those that assessed the cost-effectiveness of CGM compared to self-monitored blood glucose (SMBG) in patients with type 1 diabetes and reported lifetime incremental cost-effectiveness ratio (ICER) were included. Studies on critically ill or pregnant patients were excluded. Nineteen studies were identified. Most studies compared continuous subcutaneous insulin infusion and SMBG to a sensor-augmented pump (SAP). The estimated ICER range was [$18,734-$99,941] and the quality-adjusted life year (QALY) gain range was [0.76-2.99]. Use in patients with suboptimal management or greater hypoglycaemic risk revealed more homogenous results and lower ICERs. Limited studies assessed CGM in the context of multiple daily injections (MDI) (n = 4), MDI and SMBG versus SAP (n = 2) and three studies included hybrid closed-loop systems. Most studies (n = 17) concluded that CGM is a cost-effective tool. This systematic review suggests that CGM appears to be a cost-effective tool for individuals with type 1 diabetes. Cost-effectiveness is driven by reducing short- and long-term complications. Use in patients with suboptimal management or at risk of severe hypoglycaemia is most cost-effective.
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    The Association Between Sarcopenia and Functional Improvement in Older and Younger Patients Who Completed Inpatient Rehabilitation: A Prospective Cohort Study.
    Churilov, I ; Churilov, L ; Brock, K ; Murphy, D ; MacIsaac, RJ ; Ekinci, EI (Frontiers Media SA, 2021)
    Objective: To investigate the association between sarcopenia and functional improvement in patients older and younger than 65 years upon completion of an inpatient rehabilitation program. Design: Prospective cohort study. Participants: Adult consecutive patients who completed the inpatient rehabilitation program at a metropolitan tertiary referral hospital general inpatient rehabilitation unit. Methods: Sarcopenia status was determined using the European Working Group on Sarcopenia in Older People 2 algorithm, using muscle mass measured by BioImpedance Analysis and grip strength. Progress in rehabilitation was measured using change in the Functional Independence Measure and Goal Attainment Scaling score. To investigate the age group by sarcopenia status interaction we used quantile regression models with bootstrapped standard error estimation for functional improvement and linear regression model with robust standard error estimation for GAS score. Results: 257 participants [128 (50%) male, median age 63 years (IQR: 52-72)], 33(13%) with sarcopenia, completed inpatient rehabilitation [median length of stay 16 days (IQR: 11-27.5)]. Participants' median Functional Independence Measure change was 24 (IQR 15-33.5) and mean total Goal Attainment Scaling score was 57.6 (SD 10.2). Adjusting for admission Functional Independence Measure score, the median difference in Functional Independence Measure change between participants with and without sarcopenia was: -4.3 (95% CI: -10.6, 1.9); p = 0.17 in participants 65 years and younger, and 4.6 (95% CI: 1.0, 8.2); p = 0.01 in participants older than 65; age-by-sarcopenia interaction p = 0.02. Conclusions: Unlike younger people, older people with sarcopenia have greater functional improvement in inpatient rehabilitation than those without sarcopenia.
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    Evaluation of the diagnostic performance of the creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation in people with diabetes: A systematic review
    Zafari, N ; Churilov, L ; Wong, LY-L ; Lotfaliany, M ; Hachem, M ; Kiburg, KV ; Kong, L ; Torkamani, N ; Baxter, H ; MacIsaac, RJ ; Ekinci, EI (WILEY, 2020-09-29)
    AIMS: GFR estimated with the creatinine-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPICr ) equation is used to screen for diabetic kidney disease and assess its severity. We systematically reviewed the process and outcome of evaluating CKD-EPICr in estimating point GFR or GFR decline over time in adults with type 1 or type 2 diabetes. METHODS: In this systematic review, MEDLINE, Embase and Cochrane Central Register of Controlled Trials were searched up to August 2019. Observational studies comparing CKD-EPICr with measured GFR (mGFR) in adults with diabetes were included. Studies on people with kidney transplant, non-diabetes related kidney disease, pregnancy, potential kidney donors, and those with critical or other systematic illnesses were excluded. Two independent reviewers extracted data from published papers and disagreements were resolved by consensus. Risk-of-bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. (PROSPERO registration number: CRD42018108776). RESULTS: From the 2820 records identified, 29 studies (14 704 participants) were included. All studies were at risk of bias. Bias (eight different forms) ranged from -26 to 35 ml min-1  1.73 m-2 ; precision (five different forms) ranged between 9 and 63 ml min-1  1.73 m-2 ; accuracy (five different forms) ranged between 16% and 96%; the correlation coefficient between CKD-EPICr and mGFR (four different forms) ranged between 0.38 and 0.86; and the reduced major axis regression slope ranged between 0.8 and 1.8. CONCLUSIONS: Qualitative synthesis of data suggested CKD-EPICr was inaccurate in estimating point GFR or GFR decline over time. Furthermore, a lack of consistency in the methods and processes of evaluating the diagnostic performance of CKD-EPICr limits reliable quantitative assessment. The equation needs to be improved in adults with diabetes.
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    The prevalence of sarcopenia in middle‐aged and older patients in post‐acute inpatient rehabilitation: a cross‐sectional study
    Churilov, I ; Churilov, L ; Brock, K ; Curtain, N ; Murphy, D ; Muthukrishnan, K ; MacIsaac, RJ ; Ekinci, EI (Wiley, 2021-01)
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    Using Automated HbA1c Testing to Detect Diabetes Mellitus in Orthopedic Inpatients and Its Effect on Outcomes (vol 12, e0168471, 2017)
    Ekinci, EI ; Kong, A ; Churilov, L ; Nanayakkara, N ; Chiu, WL ; Sumithran, P ; Djukiadmodjo, F ; Premaratne, E ; Owen-Jones, E ; Hart, GK ; Robbins, R ; Hardidge, A ; Johnson, D ; Baker, ST ; Zajac, JD (PUBLIC LIBRARY SCIENCE, 2017-02-13)
    [This corrects the article DOI: 10.1371/journal.pone.0168471.].
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    Relationship Between Glycated Hemoglobin and Stroke Risk: A Systematic Review and Meta-Analysis
    Mitsios, JP ; Ekinci, EI ; Mitsios, GP ; Churilov, L ; Thijs, V (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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    Change in emotional eating after bariatric surgery: systematic review and meta-analysis
    Wong, LY ; Zafari, N ; Churilov, L ; Stammers, L ; Price, S ; Ekinci, EI ; Sumithran, P (OXFORD UNIV PRESS, 2020-07-16)
    BACKGROUND: The effect of bariatric surgery on 'emotional eating' (EE) in people with obesity is unclear. This systematic review and meta-analysis aimed to examine changes in self-reported emotional eating behaviour after bariatric surgery. METHODS: Fifteen electronic databases were searched from inception to August 2019. Included studies encompassed patients undergoing primary bariatric surgery, quantitatively assessed EE, and reported EE scores before and after surgery in the same participants. Studies were excluded if they were not in English or available in full text. The systematic review and meta-analysis were conducted according to the PRISMA guidelines. Random-effects models were used for quantitative analysis. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for before-after (pre-post) studies with no control group. RESULTS: Some 23 studies containing 6749 participants were included in the qualitative synthesis, with follow-up of from 2 weeks to 48 months. EE scores decreased to 12 months after surgery. Results were mixed beyond 12 months. Quantitative synthesis of 17 studies (2811 participants) found that EE scores decreased by a standardized mean difference of 1·09 (95 per cent c.i. 0·76 to 1·42) 4-18 months after surgery, indicating a large effect size. CONCLUSION: Bariatric surgery may mitigate the tendency to eat in response to emotions in the short to medium term.
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    Feasibility of using a transition diabetes team to commence injectable therapies postdischarge from a tertiary hospital: a pilot, randomised controlled trial
    Pyrlis, F ; Ogrin, R ; Arthur, S ; Zhai, C ; Churilov, L ; Baqar, S ; Zajac, JD ; Ekinci, EI (BMJ PUBLISHING GROUP, 2019-09-01)
    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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    Diagnostic 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
    Zafari, N ; Churilov, L ; MacIsaac, RJ ; Torkamani, N ; Baxter, H ; Kiburg, KV ; Ekinci, E (BMJ PUBLISHING GROUP, 2019-08-01)
    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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    Feasibility of once weekly exenatide-LAR and enhanced diabetes care in Indigenous Australians with type 2 diabetes (Long-acting-Once-Weekly-Exenatide laR-SUGAR, 'Lower SUGAR' study)
    Ekinci, E ; Pyrlis, F ; Hachem, M ; Maple-Brown, LJ ; Brown, A ; Maguire, G ; Churilov, L ; Cohen, N (WILEY, 2021-09-01)
    BACKGROUND: Diabetes is 3-4 times more prevalent in Indigenous Australians with blood glucose levels often above target range. Once weekly formulations of exenatide(exenatide-LAR) have demonstrated significantly greater improvements in glycaemic management with no increased risk of hypoglycaemia and with reductions in bodyweight but have not been studied in Indigenous Australians. AIMS: To assess the feasibility and metabolic effects of once weekly supervised injection of exenatide-LAR in addition to standard care in Indigenous Australians with type 2 diabetes. METHODS: Two communities in Central Australia with longstanding specialist clinical outreach services were allocated by random coin toss to receive once-weekly exenatide-LAR injection with weekly nurse review and adjustment of medication for 20 weeks (community with exenatide-LAR) or to weekly nurse review in addition to standard care over 20 weeks (community without exenatide-LAR). The primary outcome was the feasibility of an intensive diabetes management model of care with and without weekly supervised exenatide-LAR. Secondary outcomes included change in HbA1c. RESULTS: Thirteen participants from the community with exenatide-LAR and nine participants from the community without exenatide-LAR were analysed. Eighty-five percent of individuals in the community with exenatide-LAR and 67% in the community without exenatide-LAR attended more than half of clinic visits. Median difference in the change in HbA1c from baseline to final visit, adjusted for baseline HbA1c, between the community with exenatide-LAR and the community without exenatide-LAR was -3.1%, 95% CI (-5.80%, -0.38%; P = 0.03). CONCLUSIONS: Weekly exenatide-LAR combined with weekly nurse review demonstrated greater improvements in HbA1c, highlighting its potential for use in remote communities.