From design to implementation - The Joint Asia Diabetes Evaluation (JADE) program: A descriptive report of an electronic web-based diabetes management program

<p>Abstract</p> <p>Background</p> <p>The Joint Asia Diabetes Evaluation (JADE) Program is a web-based program incorporating a comprehensive risk engine, care protocols, and clinical decision support to improve ambulatory diabetes care.</p> <p>Methods</p> <p>The JADE Program uses information technology to facilitate healthcare professionals to create a diabetes registry and to deliver an evidence-based care and education protocol tailored to patients' risk profiles. With written informed consent from participating patients and care providers, all data are anonymized and stored in a databank to establish an Asian Diabetes Database for research and publication purpose.</p> <p>Results</p> <p>The JADE electronic portal (e-portal: <url>http://www.jade-adf.org</url>) is implemented as a Java application using the Apache web server, the mySQL database and the Cocoon framework. The JADE e-portal comprises a risk engine which predicts 5-year probability of major clinical events based on parameters collected during an annual comprehensive assessment. Based on this risk stratification, the JADE e-portal recommends a care protocol tailored to these risk levels with decision support triggered by various risk factors. Apart from establishing a registry for quality assurance and data tracking, the JADE e-portal also displays trends of risk factor control at each visit to promote doctor-patient dialogues and to empower both parties to make informed decisions.</p> <p>Conclusions</p> <p>The JADE Program is a prototype using information technology to facilitate implementation of a comprehensive care model, as recommended by the International Diabetes Federation. It also enables health care teams to record, manage, track and analyze the clinical course and outcomes of people with diabetes.</p

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Determination and regulation of body composition in elite athletes

In 2011, the International Association of Athletics Federations (IAAF) and IOC introduced a 'hyperandrogenism' rule that excluded women with a serum testosterone &gt;10 nmol/L from participating in elite sport. This rule was based on the false premise that the greater lean body mass in men was a consequence of their higher serum testosterone. This rule did not have scientific backing and the Court of Arbitration for Sport subsequently rescinded the rule following an appeal from an Indian athlete barred from the Commonwealth Games. This review covers the scientific knowledge about the development and regulation of body composition in humans but also considers the lessons learnt from evolution and breeding in animals. The importance of heredity has been documented in family and twin studies. The roles of growth hormone and sex steroids are reviewed. The Androgen Insensitivity Syndrome (AIS) is considered as a model of the role of testosterone in development of body composition and also as evidence of the importance of other factors carried on the Y-chromosome that are of prime importance but have been systematically ignored. Finally the key factors determining body composition are considered and placed in a suggested order of importance.</p

The effects of recombinant human insulin-like growth factor-I/Insulin-like growth factor binding protein-3 administration on body composition and physical fitness in recreational athletes

Context:Insulin-like growth factor-I (IGF-I) is thought to mediate many of the anabolic actions of growth hormone (GH) and there are anecdotal reports that IGF-I is misused by elite athletes. There is no published evidence regarding the effects of IGF-I administration on athletic performance.Objective:To investigate the effects of IGF-I administration on body composition and physical fitness in recreational athletes.Design and Setting:Randomised, double-blind, placebo-controlled rhIGF-I/rhIGFBP-3 administration study at Southampton General Hospital, UK.Participants:56 recreational athletes (30 men, 26 women)Intervention:Participants were randomly assigned to receive placebo, low dose rhIGF-I/rhIGFBP-3 (30 mg/day) or high dose rhIGF-I/rhIGFBP-3 (60 mg/day) for 28 days. Body composition (assessed by Dual Energy X-ray Absorptiometry) and cardiorespiratory fitness (assessed by incremental treadmill test), were measured before and immediately after treatment. Within-individual changes after treatment were analysed using paired t-tests.Results:There were no significant changes in body fat mass or lean body mass in women or men after administration of rhIGF-I/rhIGFBP-3 complex. There was a significant increase in maximal oxygen consumption (VO2 max) after treatment. When women and men and low and high dose treatment groups were combined, mean VO2 max increased by approximately 7% (P = 0.001). No significant change in VO2 max was observed in the placebo group.Conclusions:rhIGF-I/rhIGFBP-3 administration for 28 days improves aerobic performance in recreational athletes but there are no effects on body composition.<br/

Aging and physical fitness are more important than obesity in determining exercise-induced generation of GH

Exercise is a potent stimulus for GH secretion. Aging and obesity are associated with a diminution of GH secretion. We wanted to determine whether age or fat mass is more important in regulating the GH response to exercise. Four groups of healthy men were studied: seven lean young men [age, &lt;40 yr; body mass index (BMI), &lt;25 kg/m2], six overweight young men (age, &lt;40 yr; BMI, &gt;27.5), seven lean older men (age, &gt;60 yr; BMI, &lt;25), and 6 overweight older men (age, 60 yr; BMI, &gt;27.5). The men performed a maximal exercise test. GH secretion was higher in the younger men than in the older men. Peak GH was higher in the older lean men than in the older overweight men. There was no difference between the young groups. Fitness correlated negatively with age and positively with peak GH. In young men, there was no relation between BMI, bioimpedance, or leptin and GH secretion. In contrast, in older men there was an inverse correlation between measures of fat mass and GH secretion. Age and physical fitness are more important than body fat in regulating exercise-induced GH secretion. These findings have important clinical implications if we are to prevent the frailty and morbidity associated with aging. <br/