A randomised controlled trial of potential for pharmacologic prevention of new-onset albuminuria, hypertension and diabetes in a remote Aboriginal Australian community, 2008–2013

Introduction: We conducted a double-blind randomised controlled trial in a remote-living Australian Aboriginal group at high risk for chronic disease to assess whether pharmacological treatment with angiotensin converting enzyme inhibitor (ACEi) could delay the onset of albuminuria, hypertension or diabetes in people currently free of those conditions. Methods: Eligibility criteria in 2008 were age =18yr, blood pressure =140/90 mm/Hg, urinary albumin creatinine ratio (ACR) < 3.4 mg/mmol, normal levels of glycosylated haemoglobin, and, in females, infertility. A 2011 amendment allowed enrolment of fertile females using long-term contraception. “Treatment” was the ACEi perindopril arginine, or placebo, and participant events were ACR =3.4 mg/mmol and/or blood pressure >140/90 mm Hg and/or haemoglobin A1c >6.5%, and/or cardiovascular events. Results were analysed in 125 randomised participants who commenced treatment. Results: Recruitment was low, especially of women, and dropout rates high: there were finally 60 and 65 people in the ACEi and placebo groups respectively. In females, there were no events among 10 in the ACEi group, versus 5 events among 17 in the placebo group, and longitudinal ACR, HbA1c and blood pressure levels supported probable benefit of ACEi. There was no benefit of ACEi in males, but a probable benefit on diabetes/hypertension events. With the genders combined, there was probable reduction of diabetes (zero vs 4 events, p = 0.068), and of diabetes or hypertension (zero vs 5 events, p = 0.037). Discussion: In this high-risk population, ACEi probably delays development of albuminuria, diabetes and hypertension in females, and of non-ACR events overall. Repeat investigation with a larger sample size is warranted

Aligning an undergraduate psychological medicine subject with the mental health needs of the local region

Abstract Background The James Cook University (JCU) medical school recently revised its Year 2 human development and behaviour module to be more relevant and practical for students, and more aligned with the mental health priorities of the local region (north Queensland). This study reports medical students’ level of preparedness conferred by the re-designed ‘Psychological Medicine and Human Development’ (PMHD) subject for their later 4-week, rural clinical placement in Year 2. Methods Non-randomized, controlled ‘naturalistic’ study with pre- and post-intervention surveys. The patient mental health experiences of Year 2 students who went on clinical placement after undertaking the PMHD subject were compared to those who went on placement before undertaking PMHD. Results A total of 209 JCU Year 2 medical students completed surveys from a possible 217 (response rate = 96%). Compared to students whom had not taken PMHD before going on placement, students going on placement after undertaking PMHD were significantly more likely to report: feeling comfortable discussing mental health issues with patients (p = 0.001); being prepared for mental health discussions with patients (p < 0.001); having an actual mental health discussion with a patient (p < 0.001); and, volunteering an opinion on the appropriateness of their supervising doctor’s response (p < 0.001). Students reported subject content involving information and classroom instruction on assessing and interviewing patients for mental illness to be of most use. Conclusions Providing medical students with psychological medicine information on locally prevalent mental health conditions plus practical classroom experiences in conducting mental state exams better prepares them for interacting with patients experiencing psychological distress. This novel methodology – aligning formal teaching in a subject with an evaluation utilizing a proximate student placement to provide useful feedback on the curriculum content and assess the relevance of the material taught – could be used to revise other content areas of a medical course to be more locally relevant and practically focused, and then to evaluate the success of this revision