Changes in hyperglycaemia-related testing for prediabetes and type 2 diabetes mellitus management: a prospective, cross-sectional survey of 16 years of general practice data from Australia.

BACKGROUND: The rising prevalence of prediabetes increases the population risk of type 2 diabetes mellitus (T2DM), metabolic syndrome and cardiovascular disease. Early identification by General Practitioners (GPs) provides opportunities for lifestyle modifications that can lower these risks. METHODS: This study examined 16 years of hyperglycaemia-related testing for patients in Australia aged 13 years or older with, or at risk of a diagnosis of T2DM. The Bettering the Evaluation and Care of Health (BEACH) study is a national cross-sectional survey, with a single-stage, cluster sampling design. Approximately 1,000 GPs were randomly selected annually (2000/01-20,015/16) from across Australia, who each recorded details of 100 consecutive clinical encounters with consenting patients. Point estimates were adjusted for intracluster correlation and GP characteristics. RESULTS: Fifteen thousand six hundred seventy nine GPs recorded details of 1,387,190 clinical encounters with patients aged 13 + years. Prediabetes and T2DM were managed at 0.25% (95% CI: 0.24-0.27%) and 3.68% (95% CI: 3.62-3.73%) of encounters respectively. By the end of the study, the proportion of encounters where prediabetes was managed was 2.3 times higher and for T2DM, 1.5 times higher. The proportion of prediabetes (55.9%, 95% CI: 53.9-57.8%) and T2DM (27.3%, 95% CI: 26.7-27.9%) management occasions where one or more hyperglycaemia-related tests were requested were relatively stable. However, differences in the types of tests were observed. For prediabetes, glucose tolerance tests were most common but from 2014/15, requests for HbA1c tests began to increase. For T2DM, HbA1c tests were most common, and requests for one or more glucose tests gradually declined. CONCLUSION: The observed 16-year annual trends align with the rising incidence of prediabetes and T2DM. GPs appeared to be strongly influenced by changes to the national insurance scheme and clinical guidelines for hyperglycaemia-related pathology testing. However, some GPs may have been pre-empting policy changes as there was also evidence of 'unendorsed' testing, notably for prediabetes, that warrants further investigation. The increasing proportion of encounters for prediabetes, coupled with a high proportion of management occasions where pathology was requested have substantial resource implications. Calls to lower the risk threshold for prediabetes screening therefore warrant an economic analysis. Ongoing, reliable, up-to-date data is needed to inform clinical practice guidelines and policy in Australia.

The role of hyperinsulinaemia in screening for prediabetes in the adolescent population: A systematic literature review.

BACKGROUND/AIMS: Present screening methods for Type 2 diabetes (T2DM) fall short of detecting prediabetes. This paper summarises the literature on the utility of insulin measurements (hyperinsulinemia) in detecting prediabetes in adolescents. METHODS: A systematic literature review was conducted using EMBASE and Medline. Relevant data on hyperinsulinemia in the adolescent population is narrated. RESULTS: The database search identified 174 potential articles; 106 underwent a full-paper review, and 36 were included. CONCLUSION: Elevated fasting insulin is a marker of impaired insulin resistance and pending beta-cell dysfunction in at-risk adolescents and can be an early indicator of prediabetes.

Annual trends in diabetes screening and management in Australia: A secondary analysis of Medicare Benefits Schedule data.

BACKGROUND AND OBJECTIVES: The increasing incidence of type 2 diabetes (T2D) is a major Australian and worldwide health concern. The aim of this study was to examine trends in T2D pathology testing by Australian doctors, with a focus on screening and early identification. METHOD: A secondary analysis was conducted of publicly available data for eight pathology tests, accessed from the nationally funded Medicare Benefits Schedule (MBS). Descriptive statistics were used to analyse the annual trends, according to age and sex, for the calendar years 2010-19. RESULTS: Over the 10 years, screening rates for T2D had doubled while glycated haemoglobin (HbA1c) tests for management remained constant. At the end of 2014, the MBS introduced HbA1c screening tests. By 2019, the HbA1c screening rates were three times higher than glucose tolerance tests, which had halved. DISCUSSION: A strong adoption of the national screening guidelines introduced in 2015-16 was identified. Limitations in MBS data categorisation, such as no item number specific to fasting glucose or insulin, prevented detailed analysis of other potentially relevant tests that might be used to screen for prediabetes and diabetes.

Person-to-Person Cancer Transmission via Allogenic Blood Transfusion.

Despite the recognized capability of Circulating Tumor Cells (CTCs) to seed tumors, allogenic blood transfusions are not presently screened for the presence of CTCs. Previous research has examined blood transfusions and the associated risk of cancer recurrence, but not cancer of unknown primary (CUP) occurrence. The Hypothesis explored in this paper proposes that there is potential for cancers to be transmitted from donor-to-patient via CTCs in either blood transfusions or organ transplants or both. This proposed haematogenic tumor transmission will be discussed in relation to two scenarios involving the introduction of donor-derived CTC's from allogeneic blood transfusions into either known cancer surgery patients or into non-cancer patients. The source of CTCs arises either from the donor with a 'clinically dormant cancer' or a 'pre-clinical cancer' existing as yet undiagnosed, in the donor. Given the significant number of allogenic blood transfusions that occur worldwide on a yearly basis, allogenic blood transfusions have the potential to expose a substantial number of non-cancer recipients to the transmission of CTCs and associated tumor risk. This risk is greatly amplified in the low-income nations where the blood collection and processing protocols, including exclusion and screening criteria are less stringent than those in high-income countries.

Penile vascular surgery for treating erectile dysfunction: Current role and future direction.

Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal's law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.

Reconstructive surgery for idealising penile shape and restoring erectile function in patients with penile dysmorphology and erectile dysfunction.

OBJECTIVE: To report an innovative combination of two surgical procedures to treat patients with erectile dysfunction and penile deviation, arising from advances in penile anatomy. PATIENTS AND METHODS: From October 1998 to October 2011, 132 men (aged 23-39 years) underwent penile venous stripping and corporoplasty. Of these, 37 were allocated to a transverse and 95 to a longitudinal group, with an infrapubic transverse or pubic median longitudinal approach, respectively. The abridged five-item version of the International Index of Erectile Function (IIEF-5) and cavernosography were used for assessment, as necessary. Under acupuncture-aided local anaesthesia, and after a circumferential incision, the deep dorsal vein and cavernous veins were completely stripped, with 6-0 Nylon sutures for ligation, followed by tunical surgery for correcting the penile shape. RESULTS: In the transverse and longitudinal groups the mean (SD) duration of surgery was 4.6 (0.2) and 4.8 (0.3) h, respectively. Before surgery the mean (SD) IIEF-5 score was 9.4 (2.3) and 9.6 (2.1), which increased to 20.6 (2.4) and 20.8 (2.7), respectively, after surgery. The penile shape (<15°) was deemed satisfactory in 92% (34/37) and 96% (91/95) of patients in the transverse and longitudinal groups, respectively. The cavernosograms consistently showed a good penile shape. There were significant differences in the mean (SD) duration of penile oedema, at 3.2 (1.6) vs. 11.9 (2.1) days, the overall satisfaction rate and the prevalence of hypertrophied scarring (all P < 0.001). CONCLUSION: This combination of unique penile venous stripping with a pubic median longitudinal approach and an anatomy-based corporoplasty is ideally suited to the simultaneous restoration of penile erectile function and morphological reconstruction.

The venous drainage of the corpora cavernosa in the human penis.

OBJECTIVE: To study the drainage proportions from the corpora cavernosa in defrosted human cadavers, as the veins related to penile erection were recently depicted to comprise the deep dorsal vein (DDV), a pair of cavernous veins (CVs) and two pairs of para-arterial veins (PAVs), as opposed to a single DDV between Buck's fascia and the tunica albuginea of the human penis. MATERIALS AND METHODS: With no formalin fixation, 10 defrosted male human cadavers were used for this study. After injecting a 10% solution of colloid, and with the intracavernous pressure (ICP) fixed at 90 mmHg, the perfusion rate was recorded before and after the DDV, CVs and PAVs were removed, respectively. Finally, measurements were again recorded after penile arterial ligation. Cavernosography was used if required. RESULTS: The mean (range) perfusion rate for maintaining the ICP at 90 mmHg was 30.2 (15.5-90.8) mL/min, whereas the arterial perfusion rate was 2.8 (0.3-3.9) mL/min. The mean (range) drainage proportion of the corpora cavernosa was 60.5 (50.3-69.7)%, 11.9 (5.8-22.9)% and 11.4 (5.2-15.0)% via the DDV, CVs and PAVs, respectively. The remaining drainage proportion was 15.6 (14.1-18.1)%. This study shows the separate drainage contributions of the DDV, CVs and PAVs to the corpora cavernosa of the human penis. CONCLUSION: We conclude that the venous drainage system of the corpora cavernosa is much more complex than the previous depictions of it, and the consequent focus on a single DDV. This also shows the independent role of each venous system.

Advances in understanding of mammalian penile evolution, human penile anatomy and human erection physiology: clinical implications for physicians and surgeons.

Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck's fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers.

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Clinical teacher training--maximising the 'ad hoc' teaching encounter.

Classically, the patient is absent when the learner makes an 'ad hoc' corridor enquiry of their supervisor. This teaching encounter challenges the supervisor to ensure that the educational benefit is not limited by the brevity of the encounter. Focusing on some of the critical steps or teaching skills involved in the learning process increases the efficiency and effectiveness of this type of teaching encounter. Educationalists have provided models to optimise this fleeting corridor enquiry. This article presents a range of scripted clinical teaching scenarios that demonstrate the sound educational theory and principles underlying one such model--the 'one minute preceptor' or 'five step microskills model' of clinical teaching.

Identifying and training effective clinical teachers--new directions in clinical teacher training.

Decisions about recruitment of clinical teachers and about the content of clinical teacher training programs are complex. This article aims to identify core components that reflect the characteristics of effective clinical teachers and effective clinical teaching in the ambulatory setting. These are grouped into four thematic categories--personal attributes, educational theory and principles, core clinical teaching skills, and mentored instructional activities.