Impact of a diabetes disease management program on diabetes control and patient quality of life

The worldwide burden of diabetes is projected to be 5.4% of the adult population by the year 2025. Diabetes is associated with multiple medical complications that both decrease health-related quality of life (HR-QOL) and contribute to earlier mortality. There is growing evidence for the effectiveness of multidisciplinary disease management programs that incorporate self-management principles in improving patients' long-term outcomes. The aim of this project was to evaluate the effectiveness of this approach in improving: (1) glycemic control measured by HbA1c, and (2) HR-QOL measured by the Assessment of Quality of Life (AQOL), at enrollment and at 12-months follow-up. Between 2004 and 2008, a total of 967 patients were enrolled in the program; 545 (56%) of these patients had HbA1c data available at baseline and at 12 months. Mean HbA1c at enrollment was 8.6% (SD 1.9) versus 7.3% (SD 1.2) at 12 months (P<0.001). Overall, 68% of patients experienced improvements in HbA1c. At enrollment, patients reported "fair" HR-QOL, which was significantly lower than age-adjusted population norms who reported "good" HR-QOL. At 12 months, 251 (64%) patients had improved HR-QOL, 27 (7%) had no change, and 114 (29%) deteriorated. Mean utility scores improved by 0.11 (P<0.001), which is almost twice the minimum clinically important difference for the AQOL. This study confirms that a multidisciplinary disease management program for patients with poorly controlled type 2 diabetes can improve both glycemic control and HR-QOL.     

The six-minute walk test: a useful metric for the cardiopulmonary patient

Measurement of exercise capacity is an integral element in assessment of patients with cardiopulmonary disease. The 6-min walk test (6MWT) provides information regarding functional capacity, response to therapy and prognosis across a range of chronic cardiopulmonary conditions. A distance less than 350 m is associated with increased mortality in chronic obstructive pulmonary disease, chronic heart failure and pulmonary arterial hypertension. Desaturation during a 6MWT is an important prognostic indicator for patients with interstitial lung disease. The 6MWT is sensitive to commonly used therapies in chronic obstructive pulmonary disease such as pulmonary rehabilitation, oxygen, long-term use of inhaled corticosteroids and lung volume reduction surgery. However, it appears less reliable to detect changes in clinical status associated with medical therapies for heart failure. A change in walking distance of more than 50 m is clinically significant in most disease states. When interpreting the results of a 6MWT, consideration should be given to choice of predictive values and the methods by which the test was carried out.     

Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline

Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non‐invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence‐based physiotherapy care to people with CF in Australia and New Zealand.     

Updating the Minimal Important Difference for Six-Minute Walk Distance in Patients With Chronic Obstructive Pulmonary Disease

Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT, McDonald CF. Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease.

Objective

To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD).

Design

Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD.

Setting

Outpatient pulmonary rehabilitation program at 2 teaching hospitals.

Participants

Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104m).

Interventions

Not applicable.

Main Outcome Measures

Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD.

Results

The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61m). There was excellent agreement with distribution-based methods (25.5-26.5m, κ=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85).

Conclusions

The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.     

Reduced physical activity associated with work and transport in adults with cystic fibrosis

BackgroundHabitual physical activity (HPA) is believed to contribute to overall fitness in CF, however little is known about HPA patterns in adults.MethodsAdults with CF were recruited from a tertiary hospital outpatient clinic and were compared with controls without CF. HPA was measured as MET·minutes·week^? 1 using the long-form International Physical Activity Questionnaire. The relationship between HPA and lung function was explored.ResultsCF-group, n = 101 [45% females, mean(sd) age = 29(9), FEV1 % pred = 60(23)] and controls, n = 35 [69% females, age 32(10), FEV1 % pred = 101(130)]. Both groups reported similar levels of moderate and vigorous activities but the CF-group accumulated significantly less total HPA than controls, mean(sd) = 5309(6277) vs. 7808(5493), due to less HPA associated with work, 1887(4285) vs. 3707(5292) and transport 613(1018) vs. 1315(1123). Females with CF showed low to moderate correlations of HPA with lung function (R from 0.30 to 0.42, p < 0.05).ConclusionsAdults with CF accumulate less HPA than non-CF peers. Work and transportation form important targets through which physical activity may be accumulated to supplement prescribed exercise. In females with CF, declining physical activity seen in older adolescents carries into adulthood, which may have implications for wellbeing and outcome.     

A scoping review of evaluations of and recommendations for default uncertainty factors in human health risk assessment

Uncertainty factors (UFs) are used to account for uncertainties and variability when setting exposure limits or guidance values. Starting from a proposal of a single UF of 100 to extrapolate from an animal NOAEL to a human acceptable exposure, the aspects of uncertainty and number of UFs have diversified and today there are several risk assessment guidelines that contain schemes of default UFs of varying complexity. In the present work, we scoped the scientific literature on default UFs to map developments regarding recommendations and evaluations of these. We identified 91 publications making recommendations for one or several UFs and 55 publications evaluating UFs without making explicit recommendations about numerical values; these were published between 1954 and 2021. The 2000s was the decade with the largest number of publications, interspecies differences and intraspecies variability being the most frequent topics. The academic sector has been the most active (76 out of 146 publications). Authors from the private sector more often presented UF recommendations, but differences between sectors regarding size of recommendations were not statistically significant. The empirical underpinning of the reviewed recommendations ranges from four to 462 chemicals, that is, relatively low numbers compared with the range of chemicals these default UFs are expected to cover. The recommended UFs have remained remarkably constant, with merely a slight decrease over time. Although chemical specific UFs are preferable, the widespread use of default UFs warrants further attention regarding their empirical and normative basis.