Temporal variation in cardiovascular disease risk predicted by albuminuria: an opportunity for clinical intervention?

Albuminuria predicts cardiovascular disease (CVD) events but it is likely to vary over time in a nonlinear fashion. The aim of this study was to estimate the potentially differing predictive effect of albuminuria on the risk of CVD or related death over time. Data were from a cohort study of 3505 predominately indigenous adults from remote communities in Queensland, Australia, 1999-2006. Cox Proportional Hazards model analysis of the predictive effects of urinary albumin creatinine ratio on the risk of CVD or CVD-related death was undertaken for incident and prevalent CVD. Analyses sequentially removed those who had a cardiovascular event or related death for the first year through to six years. The baseline prevalence of microalbuminuria was 21.2% and for macroalbuminuria 6.7%. The incidence of CVD was 92 in 13,812 person-years. Microalbuminuria predicted incident CVD with a Hazard Ratio (HR) of 3.0 (95% CI 1.83 - 4.96) and for macroalbuminuria HR 10.8 (95% CI 6.58 - 17.68) and for those with pre-existing CVD, HR 2.6 (95% CI 1.65 - 3.97) and HR 9.7 (95% CI 6.38 - 14.82) respectively. People with macroalbuminuria who survived the first three years had a crude HR of an incident cardiovascular event or death of 13.0 (95% CI 6.45 - 26.39) to a peak of 32.3 (95% CI 8.55 - 121.77) for those who survived the first five years. The hazard appeared to drop in the 6th year although this is based on small numbers.The first three years after finding macroalbuminuria provide a potential window opportunity to actively manage the risk of incident CVD before the risk elevates

Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

Background: Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. Methods: The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered ‘clusters’ each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. Results: Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. Conclusions: While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured

Are there multiple kinds of episodic memory? An fMRI investigation comparing autobiographical and recognition memory tasks

What brain regions underlie retrieval from episodic memory? The bulk of research addressing this question with fMRI has relied upon recognition memory for materials encoded within the laboratory. Another, less dominant tradition has used autobiographical methods, whereby people recall events from their lifetime, often after being cued with words or pictures. The current study addresses how the neural substrates of successful memory retrieval differed as a function of the targeted memory when the experimental parameters were held constant in the two conditions (except for instructions). Human participants studied a set of scenes and then took two types of memory test while undergoing fMRI scanning. In one condition (the picture memory test), participants reported for each scene (32 studied, 64 nonstudied) whether it was recollected from the prior study episode. In a second condition (the life memory test), participants reported for each scene (32 studied, 64 nonstudied) whether it reminded them of a specific event from their preexperimental lifetime. An examination of successful retrieval (yes responses) for recently studied scenes for the two test types revealed pronounced differences; that is, autobiographical retrieval instantiated with the life memory test preferentially activated the default mode network, whereas hits in the picture memory test preferentially engaged the parietal memory network as well as portions of the frontoparietal control network. When experimental cueing parameters are held constant, the neural underpinnings of successful memory retrieval differ when remembering life events and recently learned events

Does It Matter What You Call It? Lay Beliefs for Overcoming Chronic Fatigue Syndrome, Myalgic Encephalomyelitis, and Post-Viral Fatigue Syndrome

The study reported here examines variation in beliefs about how best to overcome a health complaint when it is nominally designated in one of 3 different ways, namely, as chronic fatigue syndrome (CFS), myalgic encephalomyelitis (ME), or as post-viral fatigue syndrome (PVFS). In a repeated measures design, the participant sample (n = 140) was presented with an adapted version of Knapp and Karabenick's (1985) questionnaire which asks respondents to rate the degree to which single-item coping strategies would be most useful for overcoming each of the 3 designated complaints. Factor analysis of the coping items produces 3 groups of items as belief components: "self-reliance," "seeking help," and "external control." The chronic fatigue syndrome appellation invoked significantly higher scores on the self-reliance factor and on external control than did the other two diagnostic labels. However, seeking help was considered to be the most important strategy for overcoming all three of the designated incarnations of the condition. In conclusion, "chronic fatigue syndrome" is the linguistic construction that bestows the most beneficial outlook for assisting individuals to overcome this complaint. Thereby, the use of this descriptor in current medical nomenclatures arguably is well placed

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol]

Background: Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. Methods/Design: The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month's duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. Discussion: This project responds to a need for robust evidence of the clinical and economic effectiveness of coordinated care for the management of diabetes in the Australian primary care setting. The outcomes of the study will have implications not only for diabetes management, but also for the management of other chronic diseases, both in Australia and overseas

Using health check data to understand risks for dementia and cognitive impairment among Torres Strait Islander and Aboriginal peoples in northern Queensland—a data linkage study

Objective: High rates of dementia are evident in First Nations populations, and modifiable risk factors may be contributing to this increased risk. This study aimed to use a longitudinal dataset to gain insights into the long-term risk and protective factors for dementia and cognitive impairment not dementia (CIND) in a Torres Strait Islander and Aboriginal population in Far North Queensland, Australia. Study Design and Setting: Probabilistic data linkage was used to combine baseline health check data obtained in 1998/2000 and 2006/2007 for 64 residents in remote communities with their results on a single dementia assessment 10–20 years later (2015–2018). The relationship between earlier measures and later CIND/dementia status was examined using generalized linear modeling with risk ratios (RRs). Due to the small sample size, bootstrapping was used to inform variable selection during multivariable modeling. Results: One third of participants (n = 21, 32.8%) were diagnosed with dementia (n = 6) or CIND (n = 15) at follow-up. Secondary school or further education (RR = 0.38, 95% CI 0.19–0.76, p = 0.006) and adequate levels of self-reported physical activity (RR = 0.26, 95% CI 0.13–0.52, p < 0.001) were repeatedly selected in bootstrapping and showed some evidence of protection against later CIND/dementia in final multivariate models, although these had moderate collinearity. Vascular risk measures showed inconclusive or unexpected associations with later CIND/dementia risk. Conclusions: The preliminary findings from this small study highlighted two potential protective factors for dementia that may be present in this population. A tentative risk profile for later CIND/dementia risk is suggested, although the small sample size limits the applicability of these findings

Dementia Risk Models in an Australian First Nations Population: Cross-Sectional Associations and Preparation for Follow-Up

Background: Reducing the burden of dementia in First Nations populations may be addressed through developing population specific methods to quantify future risk of dementia. Objective: To adapt existing dementia risk models to cross-sectional dementia prevalence data from a First Nations population in the Torres Strait region of Australia in preparation for follow-up of participants. To explore the diagnostic utility of these dementia risk models at detecting dementia. Methods: A literature review to identify existing externally validated dementia risk models. Adapting these models to cross-sectional data and assessing their diagnostic utility through area under the receiver operating characteristic curve (AUROC) analyses and calibration using Hosmer-Lemeshow Chi2. Results: Seven risk models could be adapted to the study data. The Aging, Cognition and Dementia (AgeCoDe) study, the Framingham Heart Study (FHS), and the Brief Dementia Screening Indicator (BDSI) had moderate diagnostic utility in identifying dementia (i.e., AUROC >0.70) before and after points for older age were removed. Conclusion: Seven existing dementia risk models could be adapted to this First Nations population, and three had some cross-sectional diagnostic utility. These models were designed to predict dementia incidence, so their applicability to identify prevalent cases would be limited. The risk scores derived in this study may have prognostic utility as participants are followed up over time. In the interim, this study highlights considerations when transporting and developing dementia risk models for First Nations populations

Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study

BACKGROUND Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland. METHODS Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy. RESULTS Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17). CONCLUSIONS Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.Sandra K Campbell, John Lynch, Adrian Esterman and Robyn McDermot

Potentially preventable dementia in a First Nations population in the Torres Strait and Northern Peninsula Area of North Queensland, Australia: A cross sectional analysis using population attributable fractions

Dementia is highly prevalent among Australia's First Nations peoples, including Torres Strait Islander and Aboriginal peoples in Far North Queensland (FNQ). It is likely that historically recent exposure to modifiable risk factors underlies these rates, and a large proportion of dementia may be potentially preventable. Data from two adult community health checks (2015-2018) were analyzed to determine the prevalence of 11 modifiable dementia risk factors among the First Nations residents of the Torres Strait and Northern Peninsula Area of FNQ. Population attributable fractions (PAF%) for dementia were calculated using age-standardized prevalence estimates derived from these health checks and relative risks obtained from previous meta-analyses in other populations. PAF% estimates were weighted for communality to account for overlap of risk factors. Half (52·1%) of the dementia burden in this population may be attributed to 11 potentially modifiable risk factors. Hypertension (9·4%), diabetes mellitus (9·0%), obesity (8·0%), and smoking (5·3%) were the highest contributing risk factors. The contribution of depression (2·0%) and alcohol (0·3%) was lower than other global and national estimates. While the adjusted PAF% for social isolation was low based on the adult community health check data (1·6%), it was higher (4·2%) when official census data were analyzed. These results suggest that a substantial proportion of dementia in FNQ First Nations peoples could potentially be prevented. Government investment in preventative health now is essential to reduce the future burden of dementia