Outcomes of telehealth in the management of Type 2 Diabetes — a systematic review and meta-analysis of randomised controlled trials

Background: The outcomes of telehealth in the management of type 2 diabetes (T2DM) have not been evaluated since the publication of recent clinical trials. Objective: To conduct a systematic review and meta-analysis of recently published randomized controlled trials (RCTs) to assess the biochemical, clinical and psychosocial outcomes of telehealth in subjects with T2DM. Methods: Electronic databases, MEDLINE, CINAHL, INFORMIT, SCOPUS and the Cochrane Central Register of Controlled Trials and reference lists of existing systematic reviews were searched until August 2017 to identify relevant studies. Study search and selection were performed by two independent reviewers. 4791 articles were retrieved of which 11 RCTs (n=3772) were included. A meta-analysis with random effects model was applied to estimate the pooled results. Results: Telehealth was associated with a statistically significant and clinically relevant absolute decline in glycosylated haemoglobin (HbA1c) compared to usual care (mean difference -0.17%; 95% CI -0.25 to -0.09%; p<0.0001), especially if participants had a mean baseline HbA1c≥8.0%; were less than sixty years of age or received telehealth for less than one year. There was no clinically significant reduction in LDL-cholesterol (LDL-c), body mass index (BMI), systolic (SBP) or diastolic blood pressure (DBP). Conclusion: Telehealth interventions were associated with improved glycaemic control (HbA1c) in T2DM diabetic patients. However, no clinically relevant impact was observed on lipid profile, blood pressure, body mass index and psychosocial well-being. Future studies should seek to evaluate the effect of intervention duration on HbA1c, psychosocial outcomes and the effectiveness of telehealth in rural and underserved populations

Diagnostic utility and outcomes of inpatient investigations for syncope in a regional setting

Background: Syncope is a common presentation to the emergency department with a wide spectrum of aetiology. The identification of the underlying cause can be diagnostically challenging, as are the choice of investigations and the decision for inpatient versus outpatient disposition. Aims: This study aimed to evaluate the aetiology of syncope as documented, the diagnostic yield of inpatient investigations and outcomes for adult patients admitted for syncope. Methods: A single-centred, retrospective cohort study was conducted in adult patients admitted for syncope within a 2-year period. A total of 386 patients were identified after exclusion. Information regarding syncope aetiology, investigations and outcomes were established via chart review of electronic records. Results: The most common cause of syncope was neural-mediated (43%), followed by orthostatic (36.5%) and cardiogenic (20.5%). The investigations performed in order of frequency included: telemetry electrocardiogram (ECG) (75.4%), computed tomography head non-contrast (58.8%), transthoracic echocardiogram (TTE) (20.2%), computed tomography pulmonary angiogram (CTPA) (6.5%), MR brain (3.9%), electroencephalogram (1.3%) and carotid ultrasound (0.3%). Telemetry ECG, TTE and CTPA led to the diagnosis of syncope in a minority of patients only. As a result, 17.5% of patients had a new intervention on discharge, 5.4% were readmitted for syncope and 9.6% of patients died. Conclusions: In the context of the inpatient evaluation of syncope, this study supports the use of telemetry ECG and TTE. Neuroimaging demonstrates a low diagnostic yield for the cause of syncope, but it may have a role to play in excluding other pathologies. Our study does not support the routine use of CTPA, EEG or carotid ultrasound in the evaluation of syncope

Head and neck cancers: monitoring quality and reporting outcomes

Introduction: Head and neck cancers (HNC) require high level multidisciplinary care to achieve optimal outcomes. Reporting of quality indicators (QIs) has been instigated by some health services in an effort to improve quality of care. The aim of this study was to determine the quality of care provided to patients with HNC at a single institution by analysing compliance with QIs and to explore the feasibility and utility of collecting this data. Methods: This was a single institution retrospective chart review of all patients with squamous cell HNC at Townsville Hospital who were treated with curative intent between June 2011 and June 2019. Data was entered into a RedCap database and then exported to Stata V16 for analysis. Results: A total of 537 patients were included in the overall study, with six patients who had a synchronous non-HNC and two patients who received previous radiotherapy (RT) to the head and neck region excluded from the outcome analysis. Overall, compliance with pre-treatment, treatment and post-treatment QIs was high, with the exception of smoking cessation support (66%), post-treatment dental review and time to post-operative RT (33% of patients within 6 weeks). The 5-year overall survival was 69.4% (CI; 64–73.2%). The cumulative incidence of locoregional relapse for the overall study cohort was 18% (CI; 14.8–21.4%). Conclusion: Collecting and evaluating quality metrics is feasible and helps identify areas for improvement. Centres treating HNC patients should strive towards monitoring quality against benchmarks and demonstrate transparency in outcome data

Pott's puffy tumour in an immunosuppressed adult: case report and systematic review of literature

This case is of a 34-year-old immunocompromised male with Pott's puffy tumour, which was treated with antibiotics and endoscopic sinus surgery. Pott's puffy tumour is typically a complication of frontal sinusitis in children and immunocompromise can be a precipitating factor. A search was conducted of Embase, Medline, CINAHL, Cochrane, Google Scholar, Informit and Scopus of 'Pott's Puffy' and variations of this phrase. Initial 804 records were reviewed by title, abstract and full text. Of the unique papers identified, 155 only included paediatric patients and 128 included adult patients. After title, abstract and full-text review of 13 papers were identified describing Pott's puffy tumour in immunocompromised patients. Immunosuppression was noted as a risk factor in only a small number of cases, with diabetes mellitus being the most common. A few cases did note immunosuppression due to newer immunomodulatory agents being used for treatment of autoimmune conditions

Protocol for an open randomised controlled trial investigating Fibrin Glue in Skin grafts for Skin cancer (FiGSS)

Introduction: Skin cancer is a common disease in the tropics, and oncological resection typically requires reconstruction with skin grafts. Fibrin glue, initially established as a haemostatic agent, has been studied extensively as an adhesive for skin grafts in burns. This study aims to investigate the use of fibrin as an adhesive for split skin grafts in skin cancers. Methods and analysis: The study design is a prospective randomised controlled trial with the aim of investigating the impact of two different methods of split skin graft fixation. The intervention of fibrin glue will be compared with the control of staples or sutures. The trial will be conducted at two sites, a public hospital and a private hospital in Townsville, Australia, over a 24-month period with 334 participants to be recruited. Consecutive patients presenting for skin excisions and grafting will be eligible to participate in this study. Randomisation will be on the level of the patient. The primary outcome is graft take based on wound healing at 1 month. Secondary outcomes will be pain on dressing changes and operative time. Ethics and dissemination: The study has been approved by The Townsville University Hospital Human Research Ethics Committee. Findings will be disseminated in conference presentations and journals and through online electronic media

Characterising patients and clinician experiences in comprehensive conservative care for kidney failure in Northern Queensland

Background: Comprehensive conservative care (CCC) is an emerging treatment option in kidney failure (KF), but its implementation has been restricted by a limited understanding of KF populations, outcomes and clinician experiences. Aims: This pilot study aimed to investigate the characteristics of patients who are opting for (CCC) in North Queensland, Australia. It also aimed to highlight clinician factors impacting treatment discussions. Methods: It was an observational study facilitated through an online cross-sectional survey to nephrologists, nephrology advanced trainees and nurse practitioners working across North Queensland. Results: Study participants disagreed with the statement that patients commencing dialysis are more likely to have cardiac co-morbidities (46.7%), diabetes (40.0%), stroke (60.0%), liver disease (60.0%), chronic lung disease (53.3%), cognitive impairment (60.0%) and use of mobility aids (80.0%) than those commencing CCC. Conversely, they agreed that patients commencing dialysis are more likely to be independent (66.7%) and living in their private residence (40.0%). The median frailty score in patients choosing dialysis was 3.0 (interquartile range (IQR) 2.8–3.3), while that of patients selecting CCC was 4.5 (IQR 3.8–7.0). Our participants were aware of at least one clinical prognostication tool, and the one most frequently used was the ‘Surprise Question’ (46.2%, n = 6). Overall, our participants demonstrated low confidence (median 8.0%, IQR 6.0–8.0%) in facilitating CCC discussions. Conclusion: Patients who are highly co-morbid and frail and have functional impairment are suitable candidates for CCC. More focus needs to be placed on objective prognostication of patients and the upskilling of clinicians to advocate for, and deliver, CCC

Electromechanical therapy in diabetic foot ulcers patients: A systematic review and meta-analysis

Purpose: Diabetic foot ulcer (DFU) is one of the most devastating and troublesome consequences of diabetes. The current therapies are not always effective because of the complicated aetiology and interactions of local and systemic components in DFU. However, adjunctive therapy (electromechanical therapy) has become the latest modality in recent years, although there is a lack of significant research to support its utilization as a treatment standard. The purpose of this systematic research was to review the literature on the application of electromechanical therapies in the healing of DFUs. Methods: For this systematic review, we searched PubMed, Medline, EmBase, the Cochrane library, and Google Scholar for the most current research (1990–2022) on electromechanical therapies for DFUs. We used the PICO method (where P is population, I is intervention, C is comparator/control, and O is outcome for our study) to establish research question with the terms [Electromechanical therapy OR Laser therapy OR photo therapy OR Ultrasound therapy OR Shockwave therapy] AND [diabetic foot ulcers OR diabetes] were used as search criteria. Searches were restricted to English language articles only. Whereas, Cochrane handbook of “Systematic Reviews of Interventions” with critical appraisal for medical and health sciences checklist for systematic review was used for risk of bias assessment. There were 39 publications in this study that were deemed to be acceptable. All the suitably selected studies include 1779 patients. Results: The meta-analysis of 15 included research articles showed the overall effect was significant (P = 0.0002) thus supporting experimental groups have improvement in the DFUs healing in comparison to the control group. Conclusion: This systematic review and meta-analysis revealed electromechanical treatments are significantly viable options for patients with DFUs. Electromechanical therapy can considerably reduce treatment ineffectiveness, accelerate healing, and minimize the time it takes for complete ulcer healing

Prevalence and risk factors for diabetic lower limb amputation: a clinic-based case control study

Objective: The aim of the study was to evaluate the prevalence of and risk factors for lower limb amputation in a specialist foot clinic-based setting. Methods: A retrospective quantitative study was conducted, using clinical and biochemical profiles of diabetic foot patients attending the High Risk Foot Clinic at The Townsville Hospital, Australia, between January 1, 2011, and December 31, 2013. Results: The total study sample included 129 subjects, comprising 81 males and 48 females with M : F ratio of 1.7 : 1. Twenty-three subjects were Indigenous Australians, representing 17.8% of the study population. The average age of the cohort was 63.4 years ± 14.1 years [CI 90.98–65.89]. Lower limb amputation was identified as a common and significant outcome (n = 44), occurring in 34.1%, more commonly amongst the Indigenous Australians (56.5% versus 29.2%; p = 0.94, OR 0.94). Risk factors most closely associated with amputation included diabetic retinopathy (p = 0.00, OR 4.4), coronary artery bypass graft (CABG) surgery (p = 0.01, OR 4.1), Charcot's arthropathy (p = 0.01, OR 2.9), and Indigenous ethnicity (p = 0.01, OR 3.4). Although average serum creatinine, corrected calcium, and glycosylated haemoglobin A1c (Hba1c) levels were higher amongst amputees they were statistically insignificant. Conclusions: Lower limb amputation is a common outcome and linked to ethnicity and neurovascular diabetic complications amongst subjects with diabetic foot ulcer. Further research is needed to identify why risk of lower limb amputation seems to differ according to ethnicity

NOD.Cd1-/- mice have increased numbers of CD4+CD25+Foxp3+ T regulatory cells in the periphery

Recent studies indicate Natural Killer T (NKT) lymphocytes and Regulatory T (Treg) cells interact to regulate immune responses. NOD mice bearing a targeted deletion of the NKT cell restriction molecule, CD1d, lack NKT cells. To determine whether absence of NKT cells has an effect on Treg numbers, NOD/Lt and NOD.Cd1-/- mice were examined for differences in their Treg population. Flow cytometric analysis of 10-week old female mice of both strains revealed that NOD.Cd1-/- mice have a higher number of CD4+CD25+Foxp3+ T cells in both the spleen and liver. Further studies on differences in regulatory T cells between these strains at different ages and the effect of adoptive transfer of NKT cells on Treg cells would give us a better understanding about interactions of these two populations

High rate of diabetes in the Asia-Pacific Island: possible role of rapid urbanization: a hospital based study

Asia-Pacific countries are experiencing lifestyle-related non-communicable disease crises. Kimbe, one of Papua New Guinea's provincial capitals is noted as the fastest growing city in the South Pacific subcontinent yet its impact on diabetes mellitus (DM) is not known. To determine pattern of newly diagnosed DM, we conducted a retrospective review of Kimbe General Hospital medical admissions from January 2009 to December 2012. 125 patients were diagnosed with diabetes with male: female ratio of 1.1: 1. Overall, number of patients diagnosed with DM at the hospital increased rapidly from 16 in 2009 to 49 in 2012; p <0.05. Majority of the patients were of young population aged <50 years representing 72 % of the cohort and predominantly of coastal province of origin. Almost 3/4th of the study population was based in Kimbe town and its suburb with only 32 subjects (25.6%) identified as rural residents; p<0.05. This study suggests that subjects living in Asia-Pacific area of rapid urbanization are at higher risk of diabetes compared to residents of rural areas. It highlights the need for adequate health planning and education as part of urbanization program in the DM-prone Asia-Pacific population. Further prospective studies are needed to verify our findings