ADS-Servier Grant Reports


The following grants were successful under the ADS-Servier Grant Scheme in 2011 for projects commencing in 2012:-

Project Title ‘Prevalence and predictors of an abnormal echocardiogram in type 1 diabetes’

Louise M. Burrell*  
Department of Medicine (Austin Health), University of Melbourne, Heidelberg Repatriation Hospital, Heidelberg, VIC

This is an observational, prospective study that will provide comprehensive information on the prevalence and predictors of an abnormal echocardiogram in 100 adult patients with type 1 diabetes seen in the ambulatory care setting. To date, most echocardiography studies in type 1 diabetes have been in children and adolescents, and there is a knowledge gap in terms of pre-clinical heart disease in the older, adult population. A high proportion of the mortality in type 1 diabetes is due to a cardiac event, and an echocardiogram may serve to more precisely identify those subjects with type 1 diabetes who may be at increased CV risk. The results will provide important pilot data for future grant submissions that assess long-term outcomes in a larger cohort.

Project Title – ‘A Calculator for Personalised HbA1c Targets for Individuals with type 2 diabetes’

Stephen Colagiuri*, Anthony Keech
Boden Institute, University of Sydney, NSW

A key challenge in diabetes care is setting an appropriate individualised blood glucose control (HbA1c) target which minimises risk of complications while minimising risk of treatment associated harm of an unnecessarily low target. Currently there is no objective method for determining an appropriate individual HbA1c target or tools for assisting clinicians to calculate this. The aim of this study is to develop an algorithm for determining an individual’s HbA1c target based on risk of developing complications taking account relevant clinical characteristics. An individual approach to setting an HbA1c target would balance the risk of treatment associated benefits and harms and should assist in negotiating and attaining treatment goals.

Project Title ‘Use of an electronic stethoscope for detection of carotid bruits in patients with type 2 diabetes: Telemedicine to prevent stroke’

Timothy M.E. Davis*, Wendy A Davis, David G. Bruce
University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, WA

Carotid stenosis is a risk factor for stroke that can be detected indirectly by listening through a stethoscope placed over the artery. Electronic stethoscopes can record the presence or absence of the characteristic bruit. This means that a health care worker not skilled in the interpretation of vascular sounds can obtain the recording and then electronically transmit the data for later expert assessment which can then be used as a basis for further management. We aim to see whether the presence of a carotid bruit detected by an electronic stethoscope in patients with type 2 diabetes reflects significant stenosis as assessed by Doppler. If so, this would establish remote recording of carotid sounds as a valuable screening tool, especially in remote settings, which can assist in the prevention of cerebrovascular events by identifying patients who would benefit from intensive vascular risk factor management and perhaps surgical intervention.

 

The following grants were successful under the ADS-Servier Grant Scheme in 2010 for projects commencing in 2011:-

Project Title - 'Health Economics of Diabetes Case Detection through Hospital Emergency Admissions'

N Wah Cheung*, S Middleton, L Campbell, C Pollock, G Fulcher, H Watt
Department of Diabetes & Endocrinology, Westmead Hospital, NSW

Hyperglycaemia in the absence of previously diagnosed diabetes is common in hospital patients. Unfortunately the failure to systematically follow-up patients with newly detected hyperglycaemia is a missed opportunity for the early detection of diabetes. Identification of these patients may reduce hospital costs through better glycaemic control and prevent a broad range of hospital and long-term diabetic complications.

Our project is a cluster randomised trial involving 18 hospitals which aims to determine if routine glucose screening in Emergency, followed by automatic notification of Diabetes Services of patients who are hyperglycaemic, leads to an increase in diabetes detection rate, and better hospital outcomes for these patients.

An additional goal of this study is to conduct an economic evaluation of the process. Demonstration of cost-effectiveness would support this system as routine policy and facilitate early diagnosis of diabetes at the population level, potentially leading to reduced morbidity, mortality, hospital admissions, and decreased utilisation of hospital resources.

Project Title - 'Endothelial dysfunction and neuropathy in adolescents with type 2 diabetes.'

Yoon Hi Cho*, Kim Donaghue, Maria Craig
The Children's Hospital at Westmead, NSW

Type 2 diabetes mellitus (T2DM) now represents more than 10% of incident adolescent diabetes in our population. Previous studies have shown that adolescents with T2DM have significantly higher rates of microalbuminuria and hypertension at shorter disease duration and lower HbA1c than seen in type 1 diabetes (T1DM). Data on the cardiovascular profile of adolescents with T2DM are limited.

In this cross-sectional study, we will assess 50 T2DM patients aged 7-20 years with vascular technology novel for this age group: pulse wave analysis and heart rate variability to detect subclinical changes in arterial stiffness and cardiac autonomic function respectively. The association with conventional indicators of microvascular complications (retinopathy, nephropathy and peripheral neuropathy) and vascular inflammatory markers will also be examined.

Characterising early vascular changes and factors associated with accelerated vascular pathology will help guide the intensity of early management and optimise long-term consequences for a young person with T2DM entering adulthood.

Project Title - ' Widening the net – the impact of web based diabetes counselling on wellbeing and diabetes related distress of men living in rural and remote regions of Australia'

Helen Edwards*, Timothy Skinner
Diabetes Counselling Online Inc, Tranmere North, SA

The aim of this project is to examine the impact of a web based diabetes counselling and support programme on the wellbeing, diabetes related distress and motivation for self-care in men in rural and remote regions of Australia. In this study we are interested in the outcomes for men with diabetes in rural and remote regions and hypothesise that we will:

-          reduce some of the barriers men face in accessing counselling services;

-          reduce the reluctance men feel in seeking health care;

-          increase awareness of preventable health problems and suitable management of diabetes;

-          connect men to others with diabetes and in particular other males, to increase their social support networks; and

-          increase wellbeing and motivation to manage health and diabetes.

Project Title - 'Initiating Insulin in General Practice: What are the outcomes after one year?'

John Furler*
Department of General Practice, The University of Melbourne, VIC

This proposal is to undertake a 12 month follow up evaluation of participants (GPs, Practice Nurses and Patients) from a pilot study of an innovative model of care that supports the timely initiation of insulin with a General Practice setting for patients with poorly controlled type 2 diabetes. The study will answer key questions about sustainability and generalisability of the intervention and model of care that we have successfully piloted in 2009-10. It will have important implications for changed funding models of GP based diabetes care being proposed to commence in 2012.

Project Title - A'Diabetes Tips’ Website – A Diabetes Education Support Program.

Alicia Jenkins*, David O’Neal, Chris Ryan, Suresh Bohra, Gloria Kilmartin, John Kilmartin, Sven Bursell, Sybil McAuley, Doris Young, James Best, Marilyn Burgess  
University of Melbourne, Department of Medicine, St Vincent’s Hospital, VIC

Diabetes management requires lifelong adherence to a regimen of medication, diet, physical activity and home and hospital based monitoring. Excellent diabetes related health care should be, but is not always, readily available to people with diabetes both in and outside of major cities. Education time per person seems to be decreasing due to increased patient numbers. Australians with diabetes could benefit from internet-based health care tools. The team will develop, launch and assess an ad-free website and related CD of Diabetes Tips for adults with Type 1 or with Type 2 diabetes. Over 500 tips from 20 categories (e.g. travel, foot care, nutrition, exercise, insulin pumps) will be developed by endocrinologists, other doctors, CDNEs and diabetes nurse practitioners, dietitians, a podiatrist, a psychologist, exercise physiologist, pharmacists and patients.The initial format will be in English, but should the tool be useful adaptation to other languages and cultures would be welcomed.

Project Title - 'The management of blood glucose in patients with type 2 diabetes:  predictors of therapeutic efficacy and evidence based guidelines.'

Sophia Zoungas*, John Chalmers, Anushka Patel, Jonathan Shaw
The George Institute, Camperdown, NSW

Glucose-lowering strategies are the treatment mainstay in the management of diabetes.  The past decade has seen exponential growth in the number of pharmacological and non-pharmacological strategies to lower blood glucose. Despite this growth, major uncertainty surrounds the clinical benefits (and risks) of different glucose-lowering strategies and, as a consequence, the optimal way to manage patients.

The UKPDS demonstrated a gradual rise in HbA1c over time despite increasing therapy in patients with newly diagnosed type 2 diabetes.   This was proposed to be due to progressive beta cell death with increasing duration of disease.

However, this natural deterioration in glycaemic control over time was not observed in ADVANCE, a contemporary cohort of patients with established type 2 diabetes. The reason for the maintained therapeutic efficacy remains unknown.

This observational study of a large cohort of patients with established type 2 diabetes participating in the ADVANCE trial and ADVANCE-ON post-trial follow up will examine the contemporary management of blood glucose control, predictors of therapeutic efficacy (baseline factors and individual patient management issues) and the adherence to treatment guidelines.

 

The following grants were successful under the ADS-Servier Grant Scheme in 2009 for projects commencing in 2010:-

Project Title - 'Behavioural Management of Type 1 Diabetes in Young Adults: An investigation of adherence to medical and lifestyle regimens, metabolic control and psychological wellbeing'

Melanie Burkhardt*, Bu B. Yeap, David J. Leach, Gerry Fegan, Pixie Barrie
Diabetes Education Unit, Department of Endocrinology & Diabetes, Fremantle Hospital, WA

Standard care for young adults with Type 1 diabetes typically involves regular appointments with the doctor, diabetes educator and dietician. However, better health outcomes also depend on the consistency with which patients manage everyday personal behaviours contributing to better metabolic control. For well over 50% of people with chronic health problems, long-term adherence to medical treatment and lifestyle regimens is poor. The central aim of this research project is to establish higher levels of adherence to conventional medical and lifestyle diabetes care regimens via an innovative functional behaviour analytic approach. The approach is packaged as our Back for Action Program (BAP) which has already proven successful in changing patterns of everyday behaviours and routines of older people. By improving adherence levels we aim to improve glycaemic control and thus reduce the risk of acute and chronic diabetes-related health complications in this population. This study will experimentally evaluate the BAP as applied to young adults with Type 1 diabetes who are already receiving conventional multidisciplinary care. If successful, the package will provide a foundation for future research by extending the behaviour analytic approach to optimize diabetes care for a wider population of adults with Type 1 and Type 2 diabetes.

Project Title: ‘A randomized control trial of continuous subcutaneous insulin infusion (CSII) therapy and its impact upon cognition and behaviour in children and adolescents with type 1 diabetes’

Fergus Cameron*, Elisabeth Northam, Geoffrey Ambler, Alicia Jenkins, Susan Donath
Murdoch Children’s Research Institute, Department of Endocrinology & Diabetes, Melbourne, VIC

Type 1 diabetes in childhood is associated with impaired cognition and externalizing behaviour during childhood and adolescence, which in turn is predictive of poor mental health and functional outcomes in young adulthood (1,2).

Thus, cognition and externalizing behaviour in childhood and adolescence are important clinical determinants of
subsequent long-term diabetes outcomes.

We previously conducted a non-controlled, pilot study investigating consistent parental reports of improved cognition and behaviour of youth with type 1 diabetes following commencement of continuous subcutaneous insulin infusion (CSII) (3). This study documented significantly better performance on perceptual reasoning, selective attention, divided attention, cognitive flexibility and working memory after the commencement of CSII. In addition CSII resulted in fewer mood-related symptoms (internalising problems) and fewer behavioural problems (externalising problems).

These data are consistent with parent perception; however their wider interpretation is limited by the absence of a control group. The aim of this current study therefore, is to further examine the impact of CSII on cognition and behaviour in the robust setting of a randomized controlled trial. If CSII impacts positively upon these determinants, then its benefits are potentially greater than direct glycaemic effects. Such a finding would have significant implications for diabetes management during childhood and adolescence.

1) Northam EA, et al.Diabetes Care 2009; 32:445-50.
2) Northam EA, et al. Diabet Med 2005; 22:152-7.
3) Knight S, et al. Diabetologia 2009;52:193-8.

Project Title - 'Dietetic Intervention to Minimize Excessive Weight Gain in Early Pregnancy'   

Jeff Flack*, Robyn Barnes, Jane Hardman
Diabetes Centre, Bankstown-Lidcombe Hospital, Bankstown, NSW

Gestational Diabetes Mellitus identifies an at-risk pregnancy, as well as an increased long-term risk of Type 2 diabetes in the mother. Excessive weight gain in pregnancy is a known independent predictor of fetal macrosomia and contributes to maternal obesity. Aim: To establish an early intervention to achieve optimal weight gain in pregnancy in all women presenting to the antenatal clinic [ANC]. Methods: Introduce and evaluate a dietetic service involving the following components: development of a written resource for all women booked into the antenatal clinic [translated and printed in 3 languages]; distribution of this resource at the first ANC appointment; and provision of group dietetic education. This service will be trialed for a 6 months period, with all women receiving the intervention being followed up until delivery. Evaluation will involve assessing the following: attendance at group education sessions; pre and post knowledge; weight gain in pregnancy; number who develop GDM; delivery method; infant birth weight.

Project Title - 'Stepping Up Insulin Initiation in GP study' 

John Furler*, Irene Blackberry
Department of General Practice, The University of Melbourne, VIC

Most patients with T2D will require insulin yet this is often delayed in general practice. This project aims to pilot and evaluate the implementation of the “Stepping Up” program in general practice (see below) to help patients with poorly controlled type 2 diabetes (T2D) for whom insulin is indicated move onto insulin in a timely, evidence-based manner. The “Stepping Up” program involves supportive education for GP and practice nurse and a reorientation of the way GP and PN work together in working with patients towards starting insulin. This model of care is sustainable and potentially has wide application for improving patient diabetes outcomes in General Practice.  

GPs and Practice Nurses from three participating General Practices will attend a 2 hour evening training session about initiating insulin, identify 2-3 patients who are eligible to start insulin in their practice and develop their own “in-practice” system for linking those patients with the practice nurse to discuss intensifying their diabetes treatment. GP and PN will attend a final two hour evening session two months later to discuss their experience of the project and patients will attend a focus group.