Biomedical subjects

David G Bruce

Publications and source records attributed to David G Bruce.

14 recordsLinked to original sources

PubMed2006

Glycaemic levels triggering intensification of therapy in type 2 diabetes in the community: the Fremantle Diabetes Study.

OBJECTIVE: To assess the effectiveness of the management of type 2 diabetes in an urban Australian setting. DESIGN AND SETTING: The Fremantle Diabetes Study (FDS), a community-based longitudinal observational study. PATIENTS: 531 FDS participants with type 2 diabetes, with mean age, 62.4 years (95% CI, 40.9-79.3 years), 54% male, median diabetes duration 3.0 years (interquartile range [IQR], 0.7-7.0 years), with valid data from the baseline FDS assessment and five subsequent annual reviews between 1993 and 2001. MAIN OUTCOME MEASURES: Glycated haemoglobin (HbA(1c)) levels at annual review visits before and after change in blood glucose-lowering therapy. RESULTS: Over 2893 patient-years of follow-up, 97 patients (18%) progressed from dietary management to therapy with oral hypoglycaemic agents (OHA), and 45 (9%) progressed from OHA to insulin therapy, after a median duration of diabetes of 4.0 years (IQR, 2.9-5.5 years) and 8.1 years (IQR, 5.5-13.0 years), respectively. Median HbA(1c) concentrations (IQR) at the review before OHA or insulin were started were 7.7% (6.9%-8.8%) and 9.4% (8.0%-10.7%), respectively. At the next annual review, HbA(1c) levels in the two groups had fallen to 7.4% (6.5%-8.1%) and 7.9% (7.2%-9.5%), respectively (P < or = 0.001). Intensification of therapy was associated with beneficial changes in serum lipid profiles, but not with an increase in frequency of hypoglycaemia. CONCLUSIONS: Most Australian patients with type 2 diabetes may be spending most of the duration of their disease with suboptimal glycaemic control (HbA(1c) > 7.0%), despite the availability of a range of effective therapies, including insulin.

Adult↗

PubMed2006

Is self-monitoring of blood glucose appropriate for all type 2 diabetic patients? The Fremantle Diabetes Study.

OBJECTIVE: We sought to determine whether self-monitoring of blood glucose (SMBG) is associated with better glycemic control in type 2 diabetes. RESEARCH DESIGN AND METHODS: We used cross-sectional and longitudinal data from type 2 diabetic participants in the observational, community-based Fremantle Diabetes Study (FDS) who reported SMBG status at study entry (n = 1,286) and annual reviews over 5 years (n = 531). RESULTS: At study entry, 70% of patients performed SMBG, with a median of four tests per week (interquartile range two to seven). Patients with shorter diabetes duration; who were attending diabetes education, diabetes-related clinics, or medical specialists; who were taking insulin with or without oral hypoglycemic agents (OHAs); and who were self-reporting hypoglycemic events were more likely to use SMBG. Both cross-sectional and longitudinal FDS data showed that HbA(1c) (A1C) was not significantly different between SMBG users and nonusers, either overall or within diabetes treatment groups (diet, OHAs, and insulin with or without OHAs). There was also no independent cross-sectional relationship between A1C and SMBG frequency. The average annual societal cost of using SMBG (in year 2000 Australian dollars [Adollars], excluding glucometers) was 162 Australian dollars per type 2 diabetic patient or 51 million Australian dollars when projected to the Australian diagnosed type 2 diabetic population. CONCLUSIONS: Neither SMBG testing nor its frequency was associated with glycemic benefit in type 2 diabetic patients regardless of treatment. Our data did not include methods of SMBG delivery and application, factors that require further assessment in the evaluation of SMBG utility in non-insulin-treated type 2 diabetes. SMBG may be still of value in the identification and prevention of hypoglycemia and in dose adjustment in insulin-treated patients.

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PubMed2006

Peripheral arterial disease and risk of cardiac death in type 2 diabetes: the Fremantle Diabetes Study.

OBJECTIVE: The purpose of this study was to examine the natural history of peripheral arterial disease (PAD) complicating type 2 diabetes, in particular the influence of PAD on the risk of cardiac death and the adequacy of PAD risk factor management. RESEARCH DESIGN AND METHODS: The Fremantle Diabetes Study (FDS) was a prospective community-based observational study of diabetic patients recruited between 1993 and 1996. The present sample comprised the 1,294 FDS type 2 diabetic patients and a subgroup of 531 of these who had valid data at baseline and five or more subsequent consecutive annual reviews. Assessments consisted of a range of clinical and biochemical variables including the ankle/brachial index (ABI). PAD was defined as an ABI < or =0.90 at two consecutive reviews or any PAD-related lower-extremity amputation. RESULTS: The prevalence of PAD at study entry was 13.6% and the incidence of new PAD was 3.7 per 100 patient-years. Both prevalent and incident PAD was strongly and independently associated with increasing age, systolic blood pressure, total serum cholesterol, and especially smoking. Risk factor management improved but remained suboptimal during follow-up. An ABI of < or =0.90 was independently associated with an increased risk of cardiac death of 67%. CONCLUSIONS: Measurement of the ABI is a simple means of identifying PAD in diabetic patients. PAD is common in diabetic patients and predicts cardiac death. These data further support the role of regular screening for PAD in diabetes so that intensive management of vascular risk factors can be pursued.

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PubMed2005

Interaction between testosterone and apolipoprotein E epsilon4 status on cognition in healthy older men.

CONTEXT: Reduced testosterone levels have been implicated as a potential causative factor in cognitive decline with older age. Men who possess the apolipoprotein E (APOE) epsilon4 allele have an increased risk of developing Alzheimer's disease; however, no studies have examined whether the influence of testosterone on cognition in healthy older men may be modulated by this genetic predisposition. OBJECTIVE: The objective of the study was to investigate the association between serum testosterone concentrations and cognitive performance in healthy older men, taking into account APOE epsilon4 status. DESIGN: This was a cross-sectional study conducted from 2003 to 2004. SETTING: The study population consisted of community-dwelling males residing in Perth, Western Australia. PARTICIPANTS: Healthy men over 55 yr, free of cognitive impairment and dementia (n = 45), were included in the study. MAIN OUTCOME MEASURES: Participants had fasting early morning blood samples for testosterone and SHBG and were assessed for mood as well as indices of general cognition, verbal and visual memory, executive functioning, working memory, and attention. RESULTS: There was a significant interaction between calculated free testosterone (FT) and APOE epsilon4 on general cognition (P = 0.01) and executive functioning, working memory, and attention (P < 0.01). Higher levels of FT were associated with better general cognition in non-epsilon4 carriers (P = 0.01). By contrast, in epsilon4 carriers higher FT levels were associated with lower scores on tests of executive functioning, working memory, and attention (P = 0.02). In men at increased risk for Alzheimer's disease, higher testosterone levels were not associated with better cognitive function. CONCLUSIONS: Cross-sectional and prospective studies of testosterone and cognition in older men should take into account APOE epsilon4 status.

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PubMed2005

Lack of meal intake compensation following nutritional supplements in hospitalised elderly women.

Undernutrition contributes to poor clinical outcomes in hospitalised elderly patients but the potential impact of oral nutritional supplements may be reduced by suppressing subsequent food intake. We investigated this possibility in elderly female patients recovering mainly from hip fracture by studying the effect of oral supplements on subsequent food intake during an ad libitum buffet luncheon meal. We tested the effect in seven women by giving the supplement 90 min before the meal and compared energy and macronutrient intake with a control water pre-load condition. A similar study was carried out in another seven women with the supplement or water drink given 30 min beforehand. Both self-rated appetite and energy intake were low in these women. The nutritional supplement did not alter ratings of hunger, fullness or prospective consumption or subsequent energy and macronutrient consumption whether given 90 or 30 min before the meal. There were significant independent correlations between the lack of adequate compensation of energy intake at meals and chronic undernutrition (as assessed by skinfold thickness) and energy intake during the control meal. We conclude that elderly women during the recovery phase after major fractures have low appetites and energy intakes and markedly impaired adjustment of energy intake following liquid oral nutritional supplements. The reasons for this are unknown but are related to anorexia and undernutrition. The consumption of liquid oral supplements given up to 30 min before a meal does not suppress subsequent energy intake from meals.

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PubMed2005

Physical disability contributes to caregiver stress in dementia caregivers.

BACKGROUND: Previous findings of studies on the impact of physical illness on caregiver health have been inconsistent. The authors wanted to determine whether physical disability, as determined by the SF-12 survey that provides information on both physical and mental health problems, contributes to caregiver stress. METHODS: The authors interviewed 91 primary caregivers (aged 38-85 years) of persons with dementia who had been referred by their family physicians for the first time for formal support services or memory evaluation. Caregivers completed the SF-12 version of the Medical Outcomes Study Short Form Health Survey that generates Mental Component Summary (MCS) and Physical Component Summary (PCS) scores and reported on caregiver stress and concurrent medical conditions and medications. RESULTS: Most caregivers reported stress (76.9%), having medical conditions (72.4%), or taking medications (67%). The MCS but not the PCS scores were significantly lower than community norms, indicating an excess of disability due to mental health problems. Nevertheless, 40.7% had PCS scores indicating some degree of physical disability. Using multiple logistic regression analysis, PCS scores but not the presence of medical problems were independently associated with caregiver stress. CONCLUSIONS: Chronic disability as assessed by SF-12 PCS scores is independently associated with caregiver stress. These data suggest that caregivers of persons with dementia should be assessed for disabling physical conditions and mental health problems. In addition, reducing the impact of physical disability could ameliorate caregiver stress.

Adult↗

PubMed2005

Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes: the Fremantle Diabetes Study.

OBJECTIVE: The purpose of this study was to determine longitudinal predictors of impaired mobility and physical disability in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We studied patients with type 2 diabetes who participated in a prospective, community-based study. A wide range of baseline variables were examined to determine whether they predicted future difficulties with 1) mobility and 2) basic activities of daily living (ADLs) in patients free of ADLs difficulty at baseline. To study mobility impairment, subjects with baseline mobility problems were also excluded. RESULTS: After an average 4.6 +/- 2.3 and 4.8 +/- 2.3 years of follow-up in 818 and 934 patients, respectively, 28.5% of subjects had developed new mobility impairment and 18.1% had developed new ADL disability. In Cox proportional hazards models, the risk of mobility impairment was significantly increased by older age (6%/year), peripheral neuropathy (40% increase), stroke history (123%), insulin treatment (117%), albuminuria, and arthritis (82%); taking exercise and being married lowered the risk (by 39 and 32%, respectively). The risk of new ADL disability was increased by baseline mobility problems (222% increase), stroke (92%), claudication (67%), and depression (41%) and was also influenced by age, smoking, lack of exercise, non-fluency in English, and indigenous Australian ethnicity. CONCLUSIONS: Both mobility impairment and ADL disability in type 2 diabetes have multiple causes that are due to diabetes complications and common comorbidities. The specific causes of each functional problem are largely distinct, and different approaches may be required to prevent their onset or progression.

Activities of Daily Living↗

PubMed2004

Greater use of insulin by southern European compared with Anglo-Celt patients with type 2 diabetes: the Fremantle Diabetes Study.

OBJECTIVE: To investigate the relationship between blood glucose-lowering therapy, glycaemia and ethnicity in urban Australians with type 2 diabetes. DESIGN: Prospective observational community-based study of diabetes care, control and complications. METHODS: We analysed cross-sectional data from 1057 patients, 238 from a southern European (SE) migrant background and 819 Anglo-Celts (AC). Follow-up data were available for 539 patients (113 SE, 426 AC) who had annual reviews over 4 years. RESULTS: The SE patients were of similar age to the AC patients but had longer diabetes duration, were less fluent in English and had less formal education. After adjustment for diabetes duration, glycosylated haemoglobin and glutamic acid decarboxylase antibody positivity in a logistic regression model, insulin use at study entry was approximately twice as frequent amongst SE as AC patients (odds ratio (95% confidence interval); 1.90 (1.20-3.02)). In the prospective arm, progression to insulin increased in both groups, from 18.0% at baseline to 22.1% at 4 years in SE and from 7.1% to 14.4% in AC patients. beta-cell function (%B) and insulin sensitivity (%S) using the homoeostasis model assessment in a subset of diet-treated patients at baseline showed that SE ethnicity was associated with lower %B and greater %S than in the AC group. CONCLUSIONS: SE patients with early non-antibody-mediated beta-cell failure progress to insulin requirement within the first 4-5 years of type 2 diabetes. This could reflect either a longer period of undiagnosed diabetes or a more rapid loss of beta-cell function after diagnosis.

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PubMed2003

Prospective evaluation of carotid bruit as a predictor of first stroke in type 2 diabetes: the Fremantle Diabetes Study.

BACKGROUND AND PURPOSE: We sought to examine prospectively the relationship between asymptomatic carotid bruit and stroke in type 2 diabetes. METHODS: We studied 1181 (91.3%) of a community-based sample of 1294 patients with type 2 diabetes. These patients had no history of cerebrovascular disease at recruitment during 1993-1996 and were followed until the end of January 2002. Hospital morbidity and death register data relating to cerebrovascular events were also available. Cox proportional hazards models were used to determine whether carotid bruit status was an independent predictor of stroke and to identify other significant cerebrovascular risk factors. RESULTS: One hundred thirty-four patients (11.3%) suffered a first stroke during 6.5+/-2.2 (mean+/-SD) years of follow-up. In the first 2 years after study entry, first stroke (n=45/1181; 3.8%) was strongly predicted by the presence of carotid bruit(s) after adjustment for known cardiovascular risk factors and other potentially confounding variables (hazard ratio, 6.7; 95% CI, 3.0 to 14.9; P<0.001). Between 2 years and census, first stroke (n=89/1083; 8.2%) was not associated with carotid bruit(s) (P=0.97). Age and diastolic blood pressure were other determinants of stroke in the first 2 years, while age, atrial fibrillation/flutter, and microalbuminuria were independent predictors of subsequent stroke. CONCLUSIONS: Type 2 diabetic patients found to have incidental carotid bruits have >6 times the risk of first stroke in the first 2 years than patients without a bruit and should receive intensified management of vascular risk factors. Carotid imaging with a view to surgical intervention in these patients remains controversial.

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PubMed2003

Cognitive impairment, physical disability and depressive symptoms in older diabetic patients: the Fremantle Cognition in Diabetes Study.

OBJECTIVE: To determine whether the prevalence of dementia, depression and/or disability in older diabetic subjects warrants an active screening approach by diabetes health care workers. PATIENTS AND METHODS: The initial 223 members of a cohort of 529 eligible diabetic subjects, aged 70 years or over, were screened for cognitive impairment (using the Mini-Mental State Examination (MMSE) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE)), physical impairments and depressive symptoms. RESULTS: Virtually all subjects were community-dwelling (99%) and mobile (86%) and relatively few had moderate or severe deficits in activities of daily living (ADL) (17.5%). The prevalences of cognitive impairment and probable dementia estimated from the screening tests were high (range 10.8-17.5%) compared with population studies. Any deficit with ADL was reported by 53% of the subjects and common problems included urinary and faecal incontinence. Scores consistent with clinical depression were reported by 14.2% of the sample but 50.2% of the remainder reported one or more depressive symptoms below the cut-off point for clinical depression. Only 36% of the study subjects were free of deficits in any domain. CONCLUSIONS: Community-living older diabetic subjects have high rates of cognitive impairment, deficits in physical function and depressive symptomatology suggesting that screening programs for functional impairments and depression may be beneficial in health care systems that manage older diabetic patients.

Activities of Daily Living↗

PubMed2002

Communication problems between dementia carers and general practitioners: effect on access to community support services.

OBJECTIVES: To investigate the circumstances that led general practitioners to refer dementia sufferers and their carers to community support services. DESIGN: Qualitative study using semi-structured interviews, carried out between 1 September 1999 and 30 April 2000. SETTING AND PARTICIPANTS: 21 live-in carers of patients with dementia referred for the first time to a Western Australian metropolitan Aged Care Assessment Team, and 19 of their referring general practitioners. RESULTS: Most referrals occurred after the carers had been experiencing carer stress, and were precipitated by crisis situations. Carers failed to discuss their difficulties with the referring GP for a variety of reasons, including the belief that they should cope because it was their duty. The doctors found it difficult to know how the carers were coping or when to intervene, and some carers tended to resist their attempts to help. Time constraints were a significant problem for both groups. CONCLUSION: Attitudinal barriers in both carers of patients with dementia and GPs, combined with time constraints, often lead to inadequate assessment of carer problems. While it is important that strategies to improve communication between carers and GPs are developed, it would be sensible for GPs to assume that dementia carers are at risk of carer stress and should be encouraged to use community care services.

Aged↗

PubMed2002

Primary hyperparathyroidism in an elderly woman: surgical reversibility of profound mental state problems due to mild hypercalcaemia.

BACKGROUND: Clinical case of primary hyperparathyroidism in an 89 year old woman causing profound neuropsychiatric symptoms associated with relatively mild increases in serum calcium levels. OBJECTIVES: To demonstrate that lowering of serum calcium levels by medical treatment (biphosphonate), provided a scientific basis from which to treat a very elderly woman with neuropsychiatric symptoms with definitive surgery. METHOD: Case report. RESULTS: The use of biphosphonate therapy led to marked but temporary improvements in her mental state. CONCLUSION: A trial of reducing serum calcium levels with biphosphonate appears to be indicated in elderly patients with mild primary hyperparathyroidism and neuropsychiatric disorders.

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PubMed2002

Recreational physical activity levels in healthy older women: the importance of fear of falling.

OBJECTIVES: To examine whether fear of falling is a probable cause of reduced recreational physical activity levels in healthy older women. DESIGN: Cross-sectional analysis of baseline data from a longitudinal study. PARTICIPANTS: One thousand five hundred older, ambulatory women (aged 70-85), selected at random from the electoral roll. MEASUREMENTS: Self-reported recreational physical activity levels and fear of falling, demographic variables, anthropometric variables and measures of disability, and physical and cognitive function. RESULTS: The study subjects had low levels of physical and cognitive impairments; 24.1% of the group was obese (body mass index> 30). Twenty-six percent of the women did not participate in recreational physical activity; 39% participated in sufficient activity to gain probable health benefits. Although the women who did not participate in recreational activities were most likely to report fear of falling (45.2%), it was common in the group as a whole (33.9%), including the most active women (27.0%). Independent risk factors for nonparticipation in physical activity were fear of falling (odds ratio (OR)=0.70, 95% confidence interval (CI)=0.54-0.90, P=.006), obesity (OR=0.50, 95% CI=0.38-0.66, P=.001), and slower times on the timed up-and-go test (OR=0.88, 95% CI=0.84-0.92, P=.001). Fear of falling was also independently associated with lower recreational physical activity levels in women who were active (beta=-0.09, P=.003). Subgroup analysis suggested that fear of falls affected activity levels at a predisability stage in women with mildly impaired mobility. CONCLUSIONS: Fear of falling is common in healthy, high-functioning older women and is independently associated with reduced levels of participation in recreational physical activity. Fear of falling is an important psychological barrier that may need to be overcome in programs attempting to improve activity levels in older women.

Accidental Falls↗

PubMedDate not supplied

Diabetes education and knowledge in patients with type 2 diabetes from the community: the Fremantle Diabetes Study.

BACKGROUND: Diabetic patients obtain knowledge of the condition from a variety of sources. These include education programs and encounters with health-care staff such as during instruction on self-monitoring of blood glucose (SMBG). OBJECTIVE: To assess whether diabetes knowledge is related to prior attendance at diabetes education programs, visits to dieticians or the current use of SMBG in a community-based cohort of subjects with type 2 diabetes. PATIENTS: 1264 type 2 patients from the Fremantle Diabetes Study (FDS) cohort. METHODS: Subjects answered 15 standard multiple-choice questions about diabetes and its management. Recall of past diabetes education, dietician consultations, and use of SMBG were recorded. Analysis of variance was used to determine whether these activities or other social and demographic factors predicted diabetes knowledge. RESULTS: Attendance at education programs, visits to dieticians, and SMBG were independently associated with greater diabetes knowledge. Subjects who were older, whose schooling was limited, who were not fluent in English and/or who were from Southern European or indigenous Australian ethnic groups had significantly lower knowledge scores. Patients who were older, not fluent in English or from an indigenous Australian background were significantly less likely to have received diabetes education, dietetic advice or to be performing SMBG. CONCLUSIONS: Diabetes education programs, diabetes-related visits to dieticians and SMBG are associated with, and may be important sources of, improved diabetes knowledge in patients with type 2 diabetes. Our data provide evidence that barriers to access or utilization of contemporary diabetes education confront older patients, minority groups and those with language difficulties. These groups are likely to benefit from specialized programs.

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