Inequity of healthcare access for patients with diabetic foot disease: a retrospective study in south-east Queensland.

OBJECTIVES: Logan local government area (LGA) in Queensland has the highest diabetes prevalence (6.5%) within Metro South Health (MSH). The study aimed to determine the burden of, and equity of access to secondary healthcare, for diabetic foot disease (DFD) for Logan residents to better inform healthcare services planning. DESIGN: A retrospective analysis of hospital admissions data between January 2018 and December 2021. SETTING, PARTICIPANTS: All episodes of care for DFD provided by MSH hospitals to patients with a residential address in the three LGAs serving the region were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was number of episodes of care for DFD by LGA of residence and hospital of presentation. Secondary outcomes were DFD-related hospital occupied bed days and number of lower extremity amputations. RESULTS: Among residents in the MSH region, almost half of all episodes of care (47%) and bed days (48%) for DFD were for patients residing in Logan LGA. 40% of episodes of care, 57% of bed days and 73% of lower extremity amputations for DFD for these patients occurred outside of Logan LGA. These findings led to the planning of an integrated model of care for DFD at Logan hospital to improve and make care available locally. CONCLUSIONS: Our study suggests that Logan residents with DFD had poor access to care despite the highest burden. Analysing epidemiology of care for DFD with an equity lens and highlighting gaps in service delivery is paramount to addressing the inequity paradigm.

Lower prevalence of elevated liver stiffness measurements in people with type 2 diabetes taking sodium-glucose co-transporter 2 inhibitors or glucagon-like peptide-1 receptor agonists.

INTRODUCTION AND OBJECTIVES: Among people with type 2 diabetes (T2D), non-alcoholic fatty liver disease (NAFLD) is very common and has an increased risk of clinically significant liver disease. The use of sodium-glucose co-transporter 2 (SGLT2i) inhibitors and glucagon-like peptide-1 (GLP-1a) receptor agonists is endorsed to reduce major cardiovascular events and/or progression of chronic kidney disease. Their prevalence of use in people with T2D and co-existent NAFLD remains unclear. We sought to determine the prevalence of use of these medications at two different time periods, and their association with prevalence of clinically significant liver disease. MATERIALS AND METHODS: Consecutive people with type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD) were recruited from diabetes clinics between Jun-2021 and Jun-2022 ('current' cohort). Liver stiffness measurements (LSM) using FibroScan were performed. Medication data were collected prospectively at recruitment and verified with the dispensing pharmacy or general practitioner medical records. Data for a historical cohort with NAFLD and T2D recruited from the same clinics during 2015-2017 ('historical' cohort) were available. Logistic regression was used to evaluate factors associated with LSM <8.0 or ≥8 kPa (clinically significant fibrosis). RESULTS: There were 292 participants, 177 in the historical cohort and 115 in the current cohort. In the current cohort, 57.4% of patients with T2D and NAFLD were taking a GLP-1a and 42.6% were taking a SGLT2i; a 2.6 to 3.4-fold higher prevalence than in 2015-2017. A lower proportion of the current cohort (23.9% compared to 38.4%) had clinically significant fibrosis (LSM ≥8 kPa; p = 0.012). When the cohorts were pooled and differences adjusted for in multivariable logistic regression analysis, patients taking a GLP-1a or a SGLT2i were 2 times more likely to have a lower LSM (<8 kPa) compared to patients not taking these drugs (OR=2.05, 95%CI 1.07-3.94, p = 0.03 and OR 2.07 95%CI 1.04-4.11, p = 0.04, respectively). CONCLUSIONS: The observation of a lower LSM in people taking SGLT2i and/or GLP-1a following adjustment for other relevant clinico-demographic variables provides support for clinical trials to assess their efficacy in reducing the progression of NAFLD.

Access to inpatient diabetes resources: hospital characteristics from the inaugural Queensland Inpatient Diabetes Survey.

BACKGROUND: Diabetes is common in hospitalised patients and despite this inpatient diabetes care in Queensland has not had large scale benchmarking or audit. AIMS: To establish the prevalence of diabetes in Queensland hospitals and assess the availability of specialised diabetes staff, educational resources and policies for inpatient diabetes management, including assessing equity of access to these resources. METHODS: The hospital capacity, prevalence of diabetes, diabetes-related resources and the availability of diabetes-related guidelines were assessed in 25 hospitals medical, surgical, mental health, high-dependency and intensive care wards across Queensland. Dedicated diabetes staffing measured in full-time equivalents (FTE), care delivery resources, access to educational resources, standard policies and procedures for care were assessed. RESULTS: Twenty-five hospitals included 4265 occupied beds. The median prevalence of diabetes was 22.9% (interquartile range (IQR) 17.3-28.5%) with an average 2.9 FTE per 100 patients with diabetes (IQR 0-6.3). There was difficulty in accessing a diabetes educator in 48% (n = 12), diabetes specialist in 44% (n = 11), orthopaedic surgeon in 48% (n = 12), podiatrist in 58% (n = 14) and vascular surgeon in 64% (n = 16) of hospitals. Small hospitals had more difficulty accessing all members of the diabetes team compared with large hospitals including credentialled diabetes educators 33% (n = 4) versus 62% (n = 8) (P < 0.01), diabetes specialists 17% (n = 2) versus 69% (n = 9) (P < 0.01) and vascular surgeons 33% (n = 4) versus 92% (n = 12) (P < 0.01). Diabetes-related staff education and regular nurse training was available in 40% (n = 10) of hospitals. A multi-disciplinary foot care team was available in 28% (n = 7) of hospitals. CONCLUSIONS: Queensland has a high prevalence of diabetes in hospitalised patients and they have limited and inequitable access to inpatient diabetes-related care.

The Queensland Inpatient Diabetes Survey (QuIDS) 2019: the bedside audit of practice.

OBJECTIVES: To assess the quality of care for patients with diabetes in Queensland hospitals, including blood glucose control, rates of hospital-acquired harm, the incidence of insulin prescription and management errors, and appropriate foot and peri-operative care. DESIGN, SETTING: Cross-sectional audit of 27 public hospitals in Queensland: four of five tertiary/quaternary referral centres, four of seven large regional or outer metropolitan hospitals, seven of 13 smaller outer metropolitan or small regional hospitals, and 12 of 88 hospitals in rural or remote locations. PARTICIPANTS: 850 adult inpatients with diabetes mellitus in medical, surgical, mental health, high dependency, or intensive care wards. RESULTS: Twenty-seven of 115 public hospitals that admit acute inpatients participated in the audit, including 4175 of 6652 eligible acute hospital beds in Queensland. A total of 1003 patients had diabetes (24%), and data were collected for 850 (85%). Their mean age was 65.9 years (SD, 15.1 years), 357 were women (42%), and their mean HbA1c level was 66 mmol/mol (SD, 26 mmol/mol). Rates of good diabetes days (appropriate monitoring, no more than one blood glucose measurement greater than 10 mmol/L, and none below 5 mmol/L) were low in patients with type 1 diabetes (22.1 per 100 patient-days) or type 2 diabetes treated with insulin (40.1 per 100 patient-days); hypoglycaemia rates were high for patients with type 1 diabetes mellitus (24.1 episodes per 100 patient-days). One or more medication errors were identified for 201 patients (32%), including insulin prescribing errors for 127 patients (39%). Four patients with type 1 diabetes experienced diabetic ketoacidosis in hospital (8%); 121 patients (14%) met the criteria for review by a specialist diabetes team but were not reviewed by any diabetes specialist (medical, nursing, allied health). CONCLUSIONS: We identified several deficits in inpatient diabetes management in Queensland, including high rates of medication error and hospital-acquired harm and low rates of appropriate glycaemic control, particularly for patients treated with insulin. These deficits require attention, and ongoing evaluation of outcomes is necessary.

A SERIES OF TWO PATIENTS WITH CARDIAC PARAGANGLIOMAS.

OBJECTIVE: The objective of this report is to present 2 cases of cardiac paragangliomas (PGLs), and to outline the presentation, management, and associated genetic mutations. METHODS: Case 1, a 38-year-old female, presented with a 12-month history of paroxysmal palpitations, headaches, and weight loss. Her investigations included plasma free metanephrines and urinary metanephrines, 68-gallium DOTATATE positron emission tomography/computed tomography, and cardiac imaging. Case 2, a 28-year-old male, presented with a hypertensive crisis and abdominal pain on a background of hypertension. Given his abdominal pain, he was investigated with an abdominal computed tomography (CT) scan, followed by plasma free meta-nephrines and urinary metanephrines, echocardiogram, and 123-iodine meta-iodobenzylguanidine single-photon emission CT. RESULTS: Case 1 had an elevated plasma normetadrenaline of 6,750 pmol/L (reference range is <900 pmol/L) and 3-methoxytyramine of 1,845 pmol/L (reference range is <110 pmol/L). 68-gallium DOTATATE positron emission tomography/computed tomography showed an avid cardiac lesion. The lesion was resected, and histopathology confirmed PGL. Genetic studies revealed an SDHC gene mutation. For case 2, abdominal CT revealed a para-spinal mass. Workup for this lesion revealed elevated normetadrenaline of 56,000 pmol/L (reference range is <900 pmol/L). An echocardiogram, arranged for investigation of hypertension, showed an additional cardiac mass. A 123-iodine meta-iodobenzylguanidine single-photon emission CT scan confirmed that both masses were functioning. The lesions were successfully excised. He was found to have an SDHB gene mutation. CONCLUSION: Both patients had long-standing symptoms secondary to catecholamine excess, thus it is important to promptly screen patients with unexplained hypertension or paroxysmal symptoms of palpitations, headaches, and diaphoresis with plasma free metanephrines or urinary metanephrines. All patients with PGLs should be offered genetic testing due to the high incidence of genetic mutations.

Impact of Physician Navigators on productivity indicators in the ED.

OBJECTIVES: We created Physician Navigators in our ED to help improve emergency physician (EP) productivity. We aimed to quantify the effect of Physician Navigators on measures of EP productivity: patient seen per hour (Pt/hr), and turn-around time (TAT) to discharge. Secondary objectives included examining their impact on measures of ED throughput for non-resuscitative patients: ED length of stay (LOS), door-to-physician time and left-without-being-seen rates (LWBS). METHODS: In this retrospective study, 6845 clinical shifts worked by 20 EPs at a community ED in Newmarket, Canada from 1 January 2012 to 31 March 2015 were evaluated. Using a clustered design, we compared productivity measures between shifts with and without Physician Navigators, by physician. We used a linear mixed model to examine mean changes in Pt/hr and TAT to discharge for EPs who employed Physician Navigators. For secondary objectives, autoregressive modelling was performed to compare ED throughput metrics before and after the implementation of Physician Navigators for non-resuscitative patients. RESULTS: Patient volumes increased by 20 patients per day (p<0.001). Mean Pt/hr increased by 1.07 patients per hour (0.98 to 1.16, p<0.001). The mean TAT to discharge decreased by 10.6 min (-13.2 to -8.0, p<0.001). After implementation of the Physician Navigator programme, overall mean LOS for non-resuscitative patients decreased by 2.6 min (p=0.007), and mean door-to-physician time decreased by 7.4 min (p<0.001). LBWS rates decreased from 1.13% to 0.63% of daily patient volume (p<0.001). CONCLUSION: Despite an ED volume increase, the use of a Physician Navigator was associated with significant improvements in EP productivity, and significant reductions in ED throughput times.

Higher free thyroxine levels predict increased incidence of dementia in older men: the Health in Men Study.

CONTEXT: Both hypothyroidism and subclinical hyperthyroidism hinder cognitive function. OBJECTIVE: We aimed to determine whether more subtle alterations of thyroid hormone levels predict increased incidence of dementia in aging men. PARTICIPANTS AND DESIGN: Community-dwelling men aged 70-89 yr participated in this prospective longitudinal study. MAIN OUTCOME MEASURES: The Standardized Mini-Mental State Examination was performed at baseline (2001-2004), and circulating TSH and free T(4) (FT(4)) were assayed. Men with known thyroid disease or dementia, or Standardized Mini-Mental State Examination scores below 24 were excluded from follow-up. New-onset dementia, defined by International Classification of Disease (ICD) codes, was ascertained using data linkage (2001-2009). RESULTS: During follow-up, 145 of 3401 men (4.3%) were diagnosed for the first time with dementia. Men who developed dementia had higher baseline FT(4) (16.5 ± 2.2 vs. 15.9 ± 2.2 pmol/liter, P = 0.004) but similar TSH (2.2 ± 1.4 vs. 2.3 ± 1.6 mU/liter, P = 0.23) compared with men who did not receive this diagnosis. After adjusting for covariates, higher FT(4) predicted new-onset dementia (11% increased risk per 1 pmol/liter increase in FT(4), P = 0.005; quartiles Q2-4 vs. Q1: adjusted hazard ratio = 1.76, 95% confidence interval = 1.03-3.00, P = 0.04). There was no association between TSH quartiles and incident dementia. When the analysis was restricted to euthyroid men (excluding those with subclinical hyper- or hypothyroidism), higher FT(4) remained associated with incident dementia (11% increase per unit increment, P = 0.03; Q2-4 vs. Q1: adjusted hazard ratio = 2.02, 95% confidence interval = 1.10-3.71, P = 0.024). CONCLUSIONS: Higher FT(4) levels predict new-onset dementia in older men, independently of conventional risk factors for cognitive decline. Additional studies are needed to explore potential underlying mechanisms and to clarify the utility of thyroid function testing in older men at risk of dementia.

Effect of phosphate group addition on the properties of denture base resins.

STATEMENT OF PROBLEM: Acrylic resins are prone to microbial adherence, especially by Candida albicans. Surface-charged resins alter the ionic interaction between the denture resin and Candida hyphae, and these resins are being developed as a means to reduce microbial colonization on the denture surface. PURPOSE: The purpose of this study was to investigate the physical and mechanical properties of phosphate-containing polymethyl methacrylate resins for their suitability as a denture material. MATERIAL AND METHODS: Using PMMA with cross-linker (Lucitone 199) as a control, 4 experimental groups containing various levels of phosphate with and without cross-linker were generated. The properties examined were impact strength, fracture toughness, wettability (contact angle), and resin bonding ability to denture teeth. Impact strength was tested in the Izod configuration (n=16), and fracture toughness (n=13) was measured using the single-edge notched bend test. Wettability was determined by calculating the contact angle of water on the material surface (n=12), while ISO 1567 was used for bonding ability (n=12). The data were analyzed by 1- and 2-way ANOVA (alpha=.05). RESULTS: A trend of increased hydrophilicity, as indicated by lower contact angle, was observed with increased concentrations of phosphate. With regard to the other properties, no significant differences were found when compared with the control acrylic resin. CONCLUSIONS: No adverse physical effect due to the addition of a phosphate-containing monomer was found in the acrylic denture resins. Additional mechanical and physical properties, biocompatibility, and clinical efficacy studies are needed to confirm the in vivo anti-Candida activity of these novel resins.

Safety and efficacy of gastrointestinal stents in cancer patients at a community hospital.

OBJECTIVE: Increasing scientific evidence supports the use of self-expanding metallic gastrointestinal (GI) stents. The commonly accepted primary indications are their usefulness as a bridge to surgery and for palliation to avoid surgery. These stents have been shown to have high technical success and low complication rates, leading to improved quality of life for patients. They have also been shown to be cost-effective when compared with alternative therapies. The objective of this study is to present a retrospective review of our local experience. METHODS: Attempts were made to place 23 GI stents in 16 patients for palliative cancer indications. RESULTS: Follow-up was 5-352 days (mean 81.9 d). Presenting symptoms included abdominal distention or pain (81%), nausea or vomiting (69%), constipation (31%) and weight loss (19%). Stents were placed in the colon (11 patients), duodenum (4 patients) or esophagus (1 patient). The technical success rate was 91.3%, the clinical success rate (defined as any improvement in symptoms in patients successfully receiving a stent) was 85.7%, and the complication rate was 21.4% among patients successfully receiving a stent, or 18.8% overall. Of 14 patients successfully receiving at least 1 stent, 10 (71%) were discharged home after a mean of 11.5 days (range 1-26 d). Of patients successfully receiving at least 1 stent, 12 (86%) had passed away at the time of last follow-up. Patients who successfully received a stent but who have since passed away (either in hospital or out of hospital) had their stent(s) in situ for a mean of 57 days (range 5-180 d). CONCLUSION: On the basis of our data, we believe that GI stents may be safely and effectively used in a community hospital setting and that they provide benefit in the palliative care population.

Awareness of interventional radiology among patients referred to the interventional radiology department: a survey of patients in a large Canadian community hospital.

PURPOSE: To quantify the level of knowledge about interventional radiology (IR) among patients referred for an IR procedure and to develop recommendations on how to increase public awareness of IR. MATERIALS AND METHODS: Paper surveys were prospectively administered to consecutive patients scheduled to undergo an IR procedure at a community hospital. The study was terminated at the accrual of 100 completed surveys. RESULTS: Totals of 28% and 6% knew generally the job of a diagnostic radiologist and interventional radiologist, respectively, and 6% had heard of the field of IR before their referral (despite 21% having undergone a procedure previously). Before their arrival in the IR department, 87% had not received any information about IR. Three percent, 0%, 4%, 82%, and 82% had heard about uterine artery embolization, radiofrequency ablation, vertebroplasty, biopsy (any type), and angioplasty, respectively. After the procedures, 84% had a clearer view of what interventional radiologists do, but 98% believed that most others did not know what IR was. When asked how best to educate the public about IR, the responses were: unsure (39%), other (19%), pamphlets (12%), information from physicians (9%), television (8%), and Internet (7%). Overall, the mean satisfaction rate was 8.8 (with 0 representing the minimum and 10 representing the maximum), and 97% would choose IR over surgery for future treatments. CONCLUSIONS: These data quantify and strongly support the views that (1) even among patients specifically referred to IR for a procedure, the majority of people are unaware of what the field is or may offer; and (2) most patients were satisfied with their IR experience. Six results-based recommendations are made to increase public awareness about IR.