Gestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for type 2 diabetes. We evaluated the effectiveness of a group-based lifestyle modification program in mothers with prior ...GDM within their first postnatal year.
In this study, 573 women were randomised to either the intervention (n = 284) or usual care (n = 289). At baseline, 10% had impaired glucose tolerance and 2% impaired fasting glucose. The diabetes prevention intervention comprised one individual session, five group sessions, and two telephone sessions. Primary outcomes were changes in diabetes risk factors (weight, waist circumference, and fasting blood glucose), and secondary outcomes included achievement of lifestyle modification goals and changes in depression score and cardiovascular disease risk factors. The mean changes (intention-to-treat ITT analysis) over 12 mo were as follows: -0.23 kg body weight in intervention group (95% CI -0.89, 0.43) compared with +0.72 kg in usual care group (95% CI 0.09, 1.35) (change difference -0.95 kg, 95% CI -1.87, -0.04; group by treatment interaction p = 0.04); -2.24 cm waist measurement in intervention group (95% CI -3.01, -1.42) compared with -1.74 cm in usual care group (95% CI -2.52, -0.96) (change difference -0.50 cm, 95% CI -1.63, 0.63; group by treatment interaction p = 0.389); and +0.18 mmol/l fasting blood glucose in intervention group (95% CI 0.11, 0.24) compared with +0.22 mmol/l in usual care group (95% CI 0.16, 0.29) (change difference -0.05 mmol/l, 95% CI -0.14, 0.05; group by treatment interaction p = 0.331). Only 10% of women attended all sessions, 53% attended one individual and at least one group session, and 34% attended no sessions. Loss to follow-up was 27% and 21% for the intervention and control groups, respectively, primarily due to subsequent pregnancies. Study limitations include low exposure to the full intervention and glucose metabolism profiles being near normal at baseline.
Although a 1-kg weight difference has the potential to be significant for reducing diabetes risk, the level of engagement during the first postnatal year was low. Further research is needed to improve engagement, including participant involvement in study design; it is potentially more effective to implement annual diabetes screening until women develop prediabetes before offering an intervention.
Australian New Zealand Clinical Trials Registry ACTRN12610000338066.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Gestational Diabetes Mellitus (GDM) increases the risk of type 2 diabetes. A register can be used to follow-up high risk women for early intervention to prevent progression to type 2 diabetes. We ...evaluate the performance of the world's first national gestational diabetes register.
Observational study that used data linkage to merge: (1) pathology data from the Australian states of Victoria (VIC) and South Australia (SA); (2) birth records from the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM, VIC) and the South Australian Perinatal Statistics Collection (SAPSC, SA); (3) GDM and type 2 diabetes register data from the National Gestational Diabetes Register (NGDR). All pregnancies registered on CCOPMM and SAPSC for 2012 and 2013 were included-other data back to 2008 were used to support the analyses. Rates of screening for GDM, rates of registration on the NGDR, and rates of follow-up laboratory screening for type 2 diabetes are reported.
Estimated GDM screening rates were 86% in SA and 97% in VIC. Rates of registration on the NGDR ranged from 73% in SA (2013) to 91% in VIC (2013). During the study period rates of screening at six weeks postpartum ranged from 43% in SA (2012) to 58% in VIC (2013). There was little evidence of recall letters resulting in screening 12 months follow-up.
GDM Screening and NGDR registration was effective in Australia. Recall by mail-out to young mothers and their GP's for type 2 diabetes follow-up testing proved ineffective.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Context Evidence-based approaches are needed to improve the delivery of specialized palliative care. Objectives The aim of this trial was to improve on current models of service provision. ...Methods This 2 × 2 × 2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations. Results There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori -defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 SE 0.10 vs. control 1.70 SE 0.13, P = 0.0069) and better maintained performance status (AKPS case conferences 57.3 SE 1.5 vs. control 51.7 SE 2.3, P = 0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 SE 2.1 vs. control 46.5 SE 2.9, P = 0.0143; patient/caregiver education 54.7 SE 2.8 vs. control 46.8 SE 2.1, P = 0.0206). Pain was unchanged. GP education did not change outcomes. Conclusion A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective.
Currently, there is a lack of guidelines for the use of short-acting bronchodilators (SABD) in people admitted to hospital for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), ...despite routine use in practice and risk of cardiac adverse events.
To review the evidence that underpins use and optimal dose, in terms of risk versus benefit, of SABD for inpatient management of AECOPD and collate the results for future guidelines.
Medline, Embase, the Cochrane Central Register of Controlled Trials, clinicaltrials.gov and International Clinical Trials Registry Platform were searched (inception to November 2017) for published and ongoing studies. Included studies were randomised controlled trials or controlled clinical trials investigating the effect of SABD (β2-agonist and/or ipratropium) on inpatients with a diagnosis of AECOPD. This review was undertaken in accordance with PRISMA guidelines and a pre-defined protocol. Due to heterogeneous methodologies, meta-analysis was not possible so the results were synthesised qualitatively.
Of 1378 studies identified, 10 met inclusion criteria. Narrative synthesis of 10 studies revealed no significant differences in most outcomes of interest relative to dose, delivery via inhaler or nebuliser, and type of β2-agonist used. However, some evidence demonstrated significantly increased cardiac side effects with increased dosage of β2-agonist (45% versus 24%), P<0.05).
This review identified a paucity of methodologically rigorous evidence evaluating use of SABD among AECOPD. The available evidence did not identify any additional benefits for participants receiving higher doses of short-acting β2-agonists compared to lower doses, or based on type of delivery method or β2-agonists used. However, there was a small increase in some adverse events for participants using higher doses of β2-agonists.
Cognitive-Experiential Self Theory assumes that reasoning conforms to a parallel dual processing model (comprising rational and experiential systems), through which we make sense of the world. The ...Rational Experiential Inventory was developed to measure an individual’s preference for rational (need for cognition) and experiential (faith in intuition) thinking, with individual differences proposed to influence the respective dominance of each. While small but consistent gender effects have been found previously, age effects have rarely been reported or investigated across the lifespan. We examine both age and gender differences in Rational Experiential Inventory scores, using combined data from five studies involving adult participants (
n
=
520, 61.9% male) with a mean age of 41.45
years (
SD
=
11.73, range 20–74
years). Results suggest a convergence of the rational and experiential systems in adulthood, although the timing may be different for women and men. In later adulthood, the relationship appears to diverge again.
Objective: To determine the prevalence of completion of advance directives (ADs) and wills by South Australians aged 15 years and over.
Design, setting and participants: Statewide population‐based ...survey of a single member (aged 15 years and over) of 3055 South Australian households between 4 September and 12 December 2012.
Main outcome measures: Prevalence and sociodemographic determinants of completion of the four recognised legal ADs in South Australia (enduring power of attorney EPA for finance, enduring power of guardianship EPG for health care/lifestyle, medical power of attorney MPA for medical treatment and anticipatory direction for end‐of‐life care) and wills.
Results: Nearly half the 3055 survey participants had not completed any AD document or will. Financial documents were more likely to be completed than health care documents. In multivariate analysis, the odds of not having completed any AD was higher among those aged 15–24 years compared with those aged over 65 years (odds ratio OR, 55.3; 95% CI, 31.3–97.7) and 25–44 years (OR, 24.9; 95% CI, 17.3–36.1). Similarly, the odds were higher for those born in another country (OR, 2.0; 95% CI, 1.6–2.4); those never married (OR, 3.1; 95% CI, 2.3–4.2) or in de facto relationships (OR, 2.8; 95% CI, 2.1–3.8) or separated/divorced (OR, 1.8; 85% CI, 1.3–2.4) compared with those married; those who left school in Year 12 or before (OR, 1.5; 95% CI, 1.1–1.9) or with a bachelor degree (OR, 1.5; 95% CI, 1.1–2.0) compared with those who had completed a trade/apprenticeship, certificate/diploma; and those in blue collar occupations (OR 1.6; 95% CI, 1.3–2.2) or not employed (OR, 2.2; 95% CI, 1.4–3.6) versus professionals. The odds of not having completed any AD were lower for those living in rural or regional areas (OR, 0.8, 95% CI, 0.6–1.0) compared with the metropolitan area, and for those in the highest income bracket earning more than $80 000 (OR, 0.6; 95% CI, 0.5–0.8) compared with those in the middle bracket earning $40 000–$80 000.
Conclusion: Completion rates of ADs among South Australians remain low, with financial instruments more likely to be completed than health care and lifestyle instruments. The odds of not completing ADs were associated with age and socioeconomic characteristics. General practitioners are in a good position to target advance care planning towards relevant patient groups, which would likely improve rates of decision making in future health care.
Completion of Advance Directives (ADs), being financial and healthcare proxy or instructional documents, is relatively uncommon in Australia. Efforts to increase completion rates include online ...education and prompting which past literature suggests may be effective. The aim of this randomized controlled trial was to assess computer-based online AD information and email prompting for facilitating completion of ADs by Australian Baby Boomers (b.1946-1965) as well as factors which may impede or assist completion of these documents by this generation when using the online environment.
Two hundred eighty-two men and women aged 49-68 years at the time of the trial were randomly assigned to one of 3 intervention groups: education module only; email prompt only; email prompt and education module; and a control group with no education module and no email prompt. The randomized controlled trial was undertaken in participants' location of choice. Randomization and allocation to trial group were carried out by a central computer system. The primary analysis was based on a final total of 189 participants who completed the trial (n = 52 education module only; n = 44 email prompt only; n = 46 email prompt and education module; and n = 47 control). The primary outcome was the number of individuals in any group completing any of the 4 legal ADs in South Australia within 12 months or less from entry into the trial. Frequency analysis was conducted on secondary outcomes such as reasons for non-completion.
Mean follow-up post-intervention at 12 months showed that 7% of overall participants completed one or more of the 4 legal ADs but without significant difference between groups (delta = 1%, p = .48 Prompt/Non-Prompt groups, delta = 5%, p = .44 education/non-education groups). Reasons offered for non-completion were too busy (26%) and/or it wasn't the right time (21%).
Our results suggest that neither email prompting nor provision of additional educational material online were sufficient to significantly impact AD completion rates for this generational cohort. Research with this cohort over longer periods of time exploring online preferences for engagement with ADs as they age may provide better insight into using this environment for ADs with this group.
Australian New Zealand Clinical Trials Registry ACTRN12616000425493 .
Background The World Health Organization has identified cognitive determinants of hand hygiene as an outstanding research question. This study investigated whether doctors' preferences for a rational ...thinking style or an experiential thinking style are associated with hand hygiene compliance. Methods This was an observational study of hand hygiene practices of 32 doctors in 2 teaching hospitals in South Australia. Compliance rates were correlated with self-reported thinking styles. The doctors were observed by a trained observer during a ward round or outpatient clinic and were unaware that hand hygiene was under observation. The main outcome measures were hand hygiene compliance (hand hygiene compliance tool) and thinking style (Rational-Experiential Inventory). Results An overall mean compliance rate of 7.6% (standard deviation ± 7.2%) was found. Compliance was significantly positively correlated with experiential/automatic thinking ( r = .46; P = .004) and the observational setting of ward rounds (vs clinics) ( r = -.47; P = .003). No significant relationship was found between compliance and a rational/deliberate thinking style ( r = -.01; P = .472). Conclusions Hand hygiene is more experiential than rational. Findings suggest that certain promotional strategies appealing to the experiential thinking mode may improve compliance, and that traditional approaches based on logic and reasoning alone probably will not work.
We used a pragmatic randomised controlled trial to evaluate a behavioural change strategy targeting carers of chronically hypoxaemic patients using long-term home oxygen therapy. Intervention group ...carers participated in personalised educational sessions focusing on motivating carers to take actions to assist patients. All patients received usual care. Effectiveness was measured through a composite event of patient survival to hospitalisation, residential care admission or death to 12 months. Secondary outcomes at baseline, 3, 6 and 12 months included carer and patient emotional and physical well-being. No difference between intervention (n = 100) and control (n = 97) patients was found for the composite outcome (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 0.89, 1.68; p = 0.22). Improved fatigue, mastery, vitality and general health occurred in intervention group patients (all p values < 0.05). No benefits were seen in carer outcomes. Mortality was significantly higher in intervention patients (HR = 2.01, 95% CI = 1.00, 4.14; p = 0.05; adjusted for Australia-modified Karnofsky Performance Status), with a significant diagnosis–intervention interaction (p = 0.028) showing higher mortality in patients with COPD (HR 4.26; 95% CI = 1.60, 11.35) but not those with interstitial lung disease (HR 0.83; 95% CI = 0.28, 2.46). No difference was detected in the primary outcome, but patient mortality was higher when carers had received the intervention, especially in the most disabled patients. Trials examining behavioural change interventions in severe disease should stratify for functionality, and both risks and benefits should be independently monitored. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000177459).
Measurement of safety and quality is fundamental to health care delivery.
A variety of measures are needed to fully understand the system; quantitative and qualitative measures are both useful in ...different ways.
Measures need to be valid, reliable, accurate, timely, collectable, meaningful, relevant and important to those who will use them.
Clinicians value appropriate measures and respond to them.
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