Endocrinology

Targeted follow-up during the initial 14 days after discharge may reduce re-admission rates

Gillian E Caughey · Nicole L Pratt · John D Barratt · Sepehr Shakib · Anna R Kemp-Casey · Elizabeth E Roughead

Most Australian children and adolescents with type 1 diabetes are not meeting the HbA1c target

Helen Phelan · Helen Clapin · Loren Bruns · Fergus J Cameron · Andrew M Cotterill · Jennifer J Couper · Elizabeth A Davis · Kim C Donaghue · Craig A Jefferies · Bruce R King · Richard O Sinnott · Elaine B Tham · Jerry K Wales · Timothy W Jones · Maria E Craig

The physical health of patients with schizophrenia requires serious national attention

Leonard Kritharides · Vincent Chow · Tim JR Lambert

Non-mydriatic photography may be the key to accessible eye care

Hugh R Taylor AC

Maturity onset diabetes of the young (MODY), the most common monogenic form of diabetes, accounts for 1–2% of all diabetes diagnoses. Glucokinase (GCK)-MODY (also referred to as MODY2) constitutes 10–60% of all MODY cases and is inherited as an autosomal dominant heterozygous mutation, resulting in loss of function of the GCK gene. Patients with GCK-MODY generally have mild, fasting hyperglycaemia that is present from birth, are commonly leaner and diagnosed at a younger age than patients with type 2 diabetes, and rarely develop complications from diabetes. Hence, treatment is usually unnecessary and may be ceased. Therefore, genetic screening is recommended in all young patients (< 40 years) with an autosomal dominant family history of diabetes and who lack features of the metabolic syndrome and type 1 diabetes. Further, treatment discontinuation should be discussed with the patient as part of the informed consent process, as the realisation that prior treatment may have not been necessary — or that it could have been less burdensome — may have psychological implications for the patient. This is true for other forms of MODY, such as hepatocyte nuclear factor 1A mutations (MODY3) where hyperglycaemia is managed with low dose sulfonylurea rather than insulin. Patients with GCK-MODY, in line with trends in the general population, are becoming older and more overweight and obese, and are concomitantly developing features of insulin resistance and glucose intolerance. Therefore, controversy exists as to whether such “treatment-exempt” patients should be reassessed for treatment later in life. As testing becomes more accessible, clinicians and patients are likely to embrace genetic screening earlier in the course of diabetes, which may avert the consequences of delayed testing years after diagnosis and treatment initiation.

Ramy H Bishay · Jerry R Greenfield

Better care coordination, e-health tools and funding systems are essential for chronic disease management

Tim Fountaine · Christine C Bennett

n/a

Lynn M Weekes

Older adults with sarcopenia are at risk of developing type 2 diabetes, while those with diabetes show accelerated loss of muscle mass and function

David Scott · Barbora de Courten · Peter R Ebeling

Part 2 of a position statement to update the 2000 guidelines and inform the recommended management of men with androgen deficiency

Bu B Yeap · Mathis Grossmann · Robert I McLachlan · David J Handelsman · Gary A Wittert · Ann J Conway · Bronwyn GA Stuckey · Douglas W Lording · Carolyn A Allan · Jeffrey D Zajac · Henry G Burger

Policy, research and clinical practice need a paradigm shift, focused on human behaviour and psychology

Jane Speight

Studies are inconclusive about the benefits of the Paleo diet in patients with type 2 diabetes

Sofianos Andrikopoulos

Improved doctor–patient communications and more research are necessary

Jeffrey D Zajac

Individualised multifactorial treatment strategies are required to optimise outcomes

Aidan McElduff

Good glycaemic control is not sufficient for avoiding adverse outcomes for mother and child

Sally K Abell · Jacqueline A Boyle · Barbora de Courten · Michelle Knight · Sanjeeva Ranasinha · John Regan · Georgia Soldatos · Euan M Wallace · Sophia Zoungas · Helena J Teede

Diabetes rapid access clinics (DRACs) have been identified by the New South Wales Agency for Clinical Innovation as a key component of an integrated diabetes model of care.1 This cost-effective model provides fast and comprehensive outpatient review and has been shown to circumvent hospital admission, decrease hospital length of stay and improve patient outcomes.2-5 Based on this approach, a nurse practitioner-led DRAC was established in February 2015 at Royal North Shore Hospital (RNSH) in Sydney as a pilot program to assess the suitability of the DRAC for scalability across the Northern Sydney Local Health District (NSLHD). The DRAC is an outpatient clinic, operating on weekdays, which adopts the principle that high-risk patients who present to the emergency department (ED) could be diverted from hospitalisation if they were well enough for outpatient management of their condition (Appendix). Patients are referred from general practice, the ED or the endocrinologist on call and require rapid review (within 72 hours) of complex diabetes problems, such as an episode (or episodes) of severe hypoglycaemia, recurring mild hypoglycaemia or hyperglycaemia not needing hospitalisation. We prospectively collected data during the first year since inception of the DRAC, with a particular focus on reasons for referral and cost evaluation. The study was approved by the NSLHD Human Research Ethics Committee (RESP/16/62). Within the first year of the DRAC pilot program at RNSH, 61 patients attended the clinic. About a quarter of these patients (n = 15) would have been hospitalised had they not been reviewed at the DRAC and they were successfully managed as outpatients. Although these patients met the criteria for admission, they were deemed appropriate for the DRAC by the endocrinologist on call. In addition, 26% of the patients were referred back to general practice, while the remainder required ongoing endocrinologist review. Most patients presented with hyperglycaemia-related problems (n = 40; 66%; Box), including 15 patients with newly diagnosed diabetes. A further 11 patients presented with severe hypoglycaemia. Within 30 days of review at the DRAC, one patient presented to the ED and required hospitalisation. Using a conservative costing approach, whereby patients were assumed to be uncomplicated with an average length of stay of 2.5 days (based on data from the NSLHD Performance Unit), the cost analysis demonstrated that for 15 patients for whom hospitalisation was avoided, about $46 700 would have been incurred in their inpatient stay. The DRAC was established through a restructure of existing services; however, if nursing costs associated with running the DRAC were included (about $23 400), the analysis showed that the cost of management in the clinic was half the cost of an inpatient stay (Box). A nurse practitioner-led DRAC was successfully established at a tertiary referral hospital in NSW. Our preliminary evaluation has demonstrated improved patient outcomes and assistance for general practice in managing ongoing outpatient diabetes-related problems. In addition, for a quarter of patients presenting to the DRAC, hospitalisation was prevented. Future directions include the expansion of the DRAC across the local health district and the incorporation of a “hotline” to assist general practitioners with urgent and complex diabetes management. Box – Royal North Shore Hospital Diabetes Rapid Access Clinic (DRAC) evaluation: overview of patient demographics and cost analysis data Patient demographic No. of patients* Patients seen (February – December 2015) 61 Male 42 Mean age, years (SD) 56 ± 16 Mean glycated haemoglobin value (SD) 9.7% ± 2.5% Mean duration of diabetes, years (SD) 13 ± 13 Type 1 diabetes 14 (23%) Type 2 diabetes 47 (77%) Reason for referral to DRAC Newly diagnosed type 1 diabetes 2 Newly diagnosed type 2 diabetes 13 Hyperglycaemia 25 Hypoglycaemia (severe) 11 Other 10 Cost analysis No. of hospitalisations prevented† 15 (25%) Hospitalisation cost per day $1245 Average length of stay, days 2.5 Total hospitalisation cost that would have been incurred $46 687.50 Cost of nursing at DRAC $23 339.52 Cost management difference $23 347.98 * Data are number of patients unless otherwise indicated. † One patient sent to the emergency department via DRAC — not diabetes related.

Neroli Newlyn · Rachel T McGrath · Gregory R Fulcher

Part 1 of a position statement to update the 2000 guidelines and inform the recommended management of men with androgen deficiency

Bu B Yeap · Mathis Grossmann · Robert I McLachlan · David J Handelsman · Gary A Wittert · Ann J Conway · Bronwyn GA Stuckey · Douglas W Lording · Carolyn A Allan · Jeffrey D Zajac · Henry G Burger

Management is often straightforward, but there are pitfalls which may lead to misdiagnosis, overdiagnosis and inappropriate treatment

John P Walsh

Effective treatment is available, but under-used, for a common and very costly health problem

Frances Milat · Peter R Ebeling

Scalable interventions for PTSD that target mental health and comorbid cardiometabolic health are urgently required

Simon Rosenbaum BSc, PhD · Zachary Steel PhD, MClinPsych