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Zheng Wang,1,* Dahai Yu,1,2,* Uchechukwu Levi Osuagwu,3,4 Karen Pickering,5 John Baker,5,6 Richard Cutfield,5,7 Yamei Cai,1 Brandon J Orr-Walker,5,6 Gerhard Sundborn,8 Zhanzheng Zhao,1 David Simmons1,4 1Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, People’s Republic of China; 2Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, ST5 5BG, UK; 3Translational Health Research Institute (THRI), Western Sydney University, Campbelltown, Sydney NSW, 2560, Australia; 4School of Medicine, Western Sydney University, Campbelltown, Sydney NSW, 2751, Australia; 5Diabetes Foundation Aotearoa, Otara, New Zealand; 6Department of Diabetes and Endocrinology, Counties Manukau Health, Auckland, New Zealand; 7Department of Diabetes and Endocrinology, Waitemata District Health Board, Auckland, New Zealand; 8Section of Pacific Health, The University of Auckland, Auckland, New Zealand*These authors contributed equally to this workCorrespondence: David Simmons; Zhanzheng Zhao, Department of Nephrology, The First Affiliated Hospital Zhengzhou University, Zhengzhou, 450052, People’s Republic of China, Tel +6124620 3899 ; +86 13938525666, Fax +6124620 3890 ; +863716698 8753, Email Da.Simmons@westernsydney.edu.au; zhanzhengzhao@zzu.edu.cnPurpose: We aimed to examine socioeconomic inequality (SI) in cause-specific outcomes among adults with impaired glucose tolerance (IGT) and/or Impaired fasting glucose (IFG) in New Zealand (NZ) over 25 years.Patients and Methods: A population-based open cohort was derived from Diabetes Care Support Service in NZ with national databases linkage. Patients aged ≥ 18 years with IGT and/or IFG were enrolled between 01/01/1994 and 31/07/2018 and followed up until death or 31/12/2018. Incident outcomes (all-cause, premature, cardiovascular, and cancer death; cardiovascular, myocardial infarction, stroke, heart failure, and end-stage kidney disease hospitalization) by demographic, anthropometric, socioeconomic status, clinical measurements, enrol-time-periods, and IGT/IFG were evaluated. Adjusted incidence rate ratios, absolute risk difference, and SI measurements (slope and relative index of inequality) were estimated using Age-Period-Cohort models.Results: 29,894 patients (58.5 (SD 14.3) years mean age; 52.2% female) were enrolled with 5.6 (IQR: 4.4– 7.4) years of median follow-up. Mortality rates decreased, whereas hospitalization (except myocardial infarction) rates increased. SI was significant for each outcome. Higher mortality and hospitalization rates and worsened SI were common in men, older, the most deprived, and Māori patients, as well as patients with obesity, current smoking, with both IFG and IGT, and greater metabolic derangement (higher systolic blood pressure, lipids, and HbA1c, and lower level of mean arterial pressure).Conclusion: Enhanced management strategies are necessary for people with IGT and/or IFG to address persisting SI, especially for men, older people, current smokers, NZ European and Māori patients, patients with obesity, or with any abnormal metabolic measurements.Keywords: impaired glucose tolerance, impaired fasting glucose, New Zealand, Māori, ethnic disparity, socioeconomic inequality, mortality, cardiovascular diseases, heart failure, cancer, end-stage renal disease

Dahai Yu,1,2 Uchechukwu Levi Osuagwu,3,4 Karen Pickering,5 John Baker,5,6 Richard Cutfield,5,7 Zheng Wang,1 Yamei Cai,1,* Brandon J Orr-Walker,5,6 Gerhard Sundborn,8 Zhanzheng Zhao,1,* David Simmons1,3,4,* 1Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, People’s Republic of China; 2Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK; 3Translational Health Research Institute (THRI), Western Sydney University, Sydney, NSW, Australia; 4School of Medicine, Western Sydney University, Sydney, NSW, Australia; 5Diabetes Foundation Aotearoa, Auckland, New Zealand; 6Department of Diabetes and Endocrinology, Counties Manukau Health, Auckland, New Zealand; 7Department of Diabetes and Endocrinology, Waitemata District Health Board, Auckland, New Zealand; 8Section of Pacific Health, The University of Auckland, Auckland, New Zealand*These authors contributed equally to this workCorrespondence: David Simmons; Zhanzheng Zhao, Department of Nephrology, The First Affiliated Hospital Zhengzhou University, Zhengzhou, 450052, People’s Republic of China, Tel +61 2 4620 3899 ; +86 139 3852 5666, Fax +61 2 4620 3890 ; +86 371 6698 8753, Email Da.Simmons@westernsydney.edu.au; zhanzhengzhao@zzu.edu.cnPurpose: The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).Patients and Methods: A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.Results: Among 36,267 patients, adjusted population AFs indicated 6.6(− 30.8– 33.3)% of PM, 17.1(5.8– 27.0)% of MI, 35.3(22.6– 46.0)% of stroke, 14.3(3.2– 24.2)% of HF, and 15.9(6.7– 24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3– 25.4)% of PM, − 3.3(− 8.3– 1.5)% of MI, − 0.5(− 6.7– 5.3)% of stroke, 4.7(0.3– 8.8)% of HF, 13.3(9.9– 16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.Conclusion: Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.Keywords: stroke, myocardial infarction, heart failure, end-stage renal disease, premature mortality, Māori

Purpose: Thiazide diuretics reduce urine calcium excretion and might therefore reduce postmenopausal bone loss. In some, but not all, case-control studies, their use has been associated with a reduced incidence of hip fractures. We studied the effects of hydrochlorothiazide on bone loss in normal postmenopausal women.Subjects and Methods: We performed a randomized, double-blind, 2-year trial of the effects of hydrochlorothiazide (50 mg per day) and placebo on bone mineral density in normal postmenopausal women. Participants were not required to have either low bone mineral density or hypertension. Bone mineral density was measured using dual-energy x-ray absorptiometry.Results: One hundred eighty-five women entered the study, of whom 138 completed 2 years of follow-up. In an intention-to-treat analysis, hydrochlorothiazide produced significant benefits on bone mineral density of the total body (between-group difference at 2 years of 0.8%, 95% confidence interval [CI]: 0.3% to 1.3%, P <0.0001), legs (0.9%, 95% CI: 0.2% to 1.7%, P <0.0001), mid-forearm (1.2%, 95% CI: 0.2% to 2.2%, P = 0.02), and ultradistal forearm (1.7%, 95% CI: 0.1% to 3.2%, P = 0.04). There was no effect in the lumbar spine (0.5%, 95% CI: -0.5% to 1.6%) or femoral neck (0.2%, 95% CI: 1.3% to 1.7%). The between-group changes tended to be greatest during the first 6 months, except in the mid-forearm where there appeared to be a progressive divergence. An as-treated analysis produced similar results. Urine calcium excretion and indices of bone turnover decreased in the thiazide group, but parathyroid hormone concentrations did not differ between the groups. Treatment was tolerated well.Conclusions: Hydrochlorothiazide (50 mg per day) slows cortical bone loss in normal postmenopausal women. It may act directly on bone as well as on the renal tubule. The small size of the effect suggests that thiazides may have a role in the prevention of postmenopausal bone loss, but that they are not an appropriate monotherapy for treating osteoporosis. [ABSTRACT FROM AUTHOR]

Aims: To assess whether diabetes treatment satisfaction differs by ethnicity among participants with insufficient glycaemic control of type 2 diabetes mellitus in a clinical trial involving additional oral diabetes medications. Patient satisfaction is used as an indicator of healthcare quality. However, data on patients' diabetes treatment satisfaction in the context of insufficient glycaemic control is limited., Methods: Individuals with type 2 diabetes and an HbA1c of 58-110mmol/mol (7.5-12.5%) were recruited across Aotearoa New Zealand to participate in an 8-month randomised crossover study of vildagliptin and pioglitazone as add-on therapy to metformin and/or sulfonylurea. Participants completed the Diabetes Treatment Satisfaction Questionnaire (DTSQ) at baseline pre-randomisation. Treatment satisfaction scores were compared between ethnic groups and other characteristics using the analysis of variance and linear regression. Perceived hyper- and hypoglycaemia were summarised separately., Results: Between February 2019 and March 2020, 346 participants (41% women, 32% Pacific peoples, 23% Māori, 26% European) completed the DTSQ. Mean (SD) age was 57.5 (10.9) years, diabetes duration was 9 (6.3) years and HbA1c was 75 (12)mmol/mol (9.0[3.2]%). At study entry, 40% were receiving monotherapy for diabetes. Treatment satisfaction was rated highly, with a score of 29(6) (interquartile range 25-33). Pacific peoples and older people reported greater treatment satisfaction than other groups (p<0.001)., Conclusions: Diabetes treatment satisfaction was high, particularly among Pacific peoples, despite suboptimal glycaemic control and insufficient glucose-lowering therapy., Competing Interests: RM has participated in industry sponsored meetings and received speaking honoraria from Sanofi, Lilly, Novonordisk, Novartis, Astra Zeneca, Boeringer Ingelheim. This study received funding from the Health Research Council of New Zealand (Grant 18-861)., (© PMA.)

Background: Understanding which group of patients with type 2 diabetes will have the most glucose lowering response to certain medications (which target different aspects of glucose metabolism) is the first step in precision medicine., Aims: We hypothesized that people with type 2 diabetes who generally have high insulin resistance, such as people of Māori/Pacific ethnicity, and those with obesity and/or hypertriglyceridemia (OHTG), would have greater glucose-lowering by pioglitazone (an insulin sensitizer) versus vildagliptin (an insulin secretagogue)., Methods: A randomised, open-label, two-period crossover trial was conducted in New Zealand. Adults with type 2 diabetes, HbA1c>58mmol/mol (>7.5%), received 16 weeks of either pioglitazone (30mg) or vildagliptin (50mg) daily, then switched to the other medication over for another 16 weeks of treatment. Differences in HbA1c were tested for interaction with ethnicity or OHTG, controlling for baseline HbA1c using linear mixed models. Secondary outcomes included weight, blood pressure, side-effects and diabetes treatment satisfaction., Results: 346 participants were randomised (55% Māori/Pacific) between February 2019 to March 2020. HbA1c after pioglitazone was lower than after vildagliptin (mean difference -4.9mmol/mol [0.5%]; 95% CI -6.3, -3.5; p<0.0001). Primary intention-to-treat analysis showed no significant interaction effect by Māori/Pacific vs other ethnicity (1.5mmol/mol [0.1%], 95% CI -0.8, 3.7), and per-protocol analysis (-1.2mmol/mol [0.1%], 95% CI -4.1, 1.7). An interaction effect (-4.7mmol/mol [0.5%], 95% CI -8.1, -1.4) was found by OHTG status. Both treatments generated similar treatment satisfaction scores, although there was greater weight gain and greater improvement in lipids and liver enzymes after pioglitazone than vildagliptin., Conclusions: Comparative glucose-lowering by pioglitazone and vildagliptin is not different between Māori/Pacific people compared with other New Zealand ethnic groups. Presence of OHTG predicts greater glucose lowering by pioglitazone than vildagliptin., Clinical Trial Registration: www.anzctr.org.au, identifier (ACTRN12618001907235)., Competing Interests: Authors RP and RM have received speaking honoraria from Lilly, Boehringer Ingelheim, Astra Zeneca, Sanofi, Novo Nordisk, also Novartis (RM) and Inova pharmaceuticals (RP). RP is a member of the Lilly, Novo Nordisk and Dexcom New Zealand advisory boards. Authors KAM, RD, PC were employed by Ventures/Pinnacle Incorporated, a primary health care organisation which has no relevant commercial or financial relationships. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Brandon, Jiang, Yeu, Tweedie-Cullen, Smallman, Doherty, Macaskill-Smith, Doran, Clark, Moffitt, Merry, Nehren, King, Hindmarsh, Leask, Merriman, Orr-Walker, Shepherd, Paul and Murphy.)

Aim: To review the Fracture Liaison Service (FLS) recommendations for bone protection therapy and assess treatment implementation in the community., Method: All patients screened from 1 January to 31 March 2019 at Counties Manukau District Health Board were evaluated. Exclusion criteria included death within six months following sentinel fracture, and hip fractures, which are studied elsewhere. Patient risk factors assessed included age, gender, type of fracture, history of previous fracture, and dual X-ray absorptiometry scan results if performed. If bone protection therapy was recommended, electronic dispensing records were utilised as a proxy for treatment initiation., Results: One hundred and sixty-nine of the 238 patients referred were included. Thirty-seven patients had evidence of a previous fragility fracture, with thirteen patients not on bone protection treatment following their prior fracture. Of the 99 patients in the study recommended bone protection therapy, 31.3% (n=31) did not have this dispensed at six months following written FLS assessment. Three of thirteen patients with a previous fragility fracture and not on bone protection treatment, still did not have this dispensed at 6 months., Conclusion: A high proportion of patients recommended bone protection therapy did not receive this in a timely manner, including patients with a history of repeated fracture., Competing Interests: Nil., (© PMA.)

Background: Until recently, most patients with diabetes worldwide have been diagnosed when symptomatic and have high cardiovascular risk, meaning most should be prescribed cardiovascular preventive medications. However, in New Zealand, a world-first national programme led to approximately 90% of eligible adults being screened for diabetes by 2016, up from 50% in 2012, identifying many asymptomatic patients with recent-onset diabetes. We hypothesised that cardiovascular risk prediction equations derived before widespread screening would now significantly overestimate risk in screen-detected patients., Methods: New Zealanders aged 30-74 years with type 2 diabetes and without known cardiovascular disease, heart failure, or substantial renal impairment were identified from the 400 000-person PREDICT primary care cohort study between Oct 27, 2004, and Dec 30, 2016, covering the period before and after widespread screening. Sex-specific equations estimating 5-year risk of cardiovascular disease were developed using Cox regression models, with 18 prespecified predictors, including diabetes-related and renal function measures. Equation performance was compared with an equivalent equation derived in the New Zealand Diabetes Cohort Study (NZDCS), which recruited between 2000 and 2006, before widespread screening., Findings: 46 652 participants were included in the PREDICT-1° Diabetes subcohort, of whom 4114 experienced first cardiovascular events during follow-up (median 5·2 years, IQR 3·3-7·4). 14 829 (31·8%) were not taking oral hypoglycaemic medications or insulin at baseline. Median 5-year cardiovascular risk estimated by the new equations was 4·0% (IQR 2·3-6·8) in women and 7·1% (4·5-11·2) in men. The older NZDCS equation overestimated median cardiovascular risk by three times in women (median 14·2% [9·7-20·0]) and two times in men (17·1% [4·5-20·0]). Model and discrimination performance measures for PREDICT-1° Diabetse equations were also significantly better than for the NZDCS equation (eg, for women: R 2 =32% [95% CI 29-34], Harrell's C=0·73 [0·72-0·74], Royston's D=1·410 [1·330-1·490] vs R 2 =24% [21-26], C=0·69 [0·67-0·70], and D=1·147 [1·107-1·187])., Interpretation: International treatment guidelines still consider most people with diabetes to be at high cardiovascular risk; however, we show that recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand. Many of these patients have normal renal function, are not dispensed glucose-lowering medications, and have low cardiovascular risk. These findings have clear international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events. Cardiovascular risk prediction equations derived from contemporary diabetes populations, with multiple diabetes-related and renal function predictors, will be required to better differentiate between low-risk and high-risk patients in this increasingly heterogeneous population and to inform appropriate non-pharmacological management and cost-effective targeting of expensive new medications., Funding: Health Research Council of New Zealand, Heart Foundation of New Zealand, and Healthier Lives National Science Challenge., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: There is emerging evidence for stratified glucose-lowering responses to certain oral medications for type 2 diabetes (T2D) by individual characteristics. The objective of this study was to test whether glycaemic response to representative treatments of dipeptidyl peptidase-4 inhibitors (vildagliptin) and thiazolidinediones (pioglitazone) varies according to ethnicity, gender, baseline obesity, triglyceride level or genetic variation., Methods: This is a multicentre, two-period, two-treatment, open-label, randomised cross-over trial of vildagliptin and pioglitazone as second-line or third-line therapy in patients with T2D who have suboptimal glycaemic control on metformin and/or sulfonylurea therapy. It is conducted in New Zealand with a target of 300 patients (40% with Māori or Pacific ancestry) eligible if aged ≥18 and ≤80 years, with T2D for more than 1 year, on stable doses of metformin and/or sulfonylurea for at least 3 months, with HbA1c between 59 and 110 mmol/mol inclusive. Participants are assigned to complete 4 months of vildagliptin 50 mg per day or pioglitazone 30 mg per day, followed by 4 months of the other medications in randomly allocated sequences. Participant characteristics, including ethnicity, obesity, lipid profile and candidate genotypes are collected at baseline. Primary outcome variable is on treatment HbA1c. Secondary outcomes include weight change, frequency of side effects and patient preference., Ethics and Dissemination: Ethical approval of the trial has been obtained from the New Zealand Health and Disability Ethics Committee (18/STH/242). The trial commenced in February 2019 and recruitment is expected to be completed by March 2020. Results will be reported in articles submitted to peer-reviewed journals, as well as in presentations at national and international meetings., Trial Registration Number: ACTRN12618001907235., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Premix insulin analogs are a well-established treatment for type 2 diabetes (T2D). However, there is a lack of simple, clear guidance on some aspects of their use. These include choosing a regimen for insulin initiation, recognizing when patients need intensification of therapy, and switching from basal-bolus to a premix insulin analog when appropriate., Methods: An independent expert panel formulated recommendations on the use in T2D of the premix insulin analog formulations widely available in Australasia, based on the available evidence and their own experience., Results: Results from trials in both initiation and intensification of insulin show that no single insulin or regimen is best on all endpoints, and that improved glycemic control can be expected regardless of which regimen is used. Thus, individual patient factors and preferences become more important. Guidance is presented to help the clinician choose between a premix insulin analog or basal analog for insulin initiation, and to intensify insulin therapy using premix insulin analogs. Recommendations are made on dosing, titration, the concomitant use of non-insulin glucose-lowering drugs, and other practical issues, and on the special case of switching from basal-bolus to premix insulin analog therapy., Conclusion: This guidance is intended to help both general and specialist practitioners make informed choices and provide optimal care for patients with T2D. It emphasizes the importance of taking into account individual patient factors and preferences so that the choice of insulin regimen is individualized to the patient in the same way that glycemic targets are now individualized., Funding: Novo Nordisk Region IO A/S.

Aim: Standardised reporting of thyroid cytology is recommended but not universally practiced. We compared agreement between clinicians categorising non-standardised thyroid cytology reports, and determined malignancy rates in clinician-assigned cytology categories., Methods: We identified all thyroid cytology reports from 2008-9 and any reports prior to histology samples from 2008-9 at Middlemore Hospital. Two clinicians independently classified these cytology reports using the Bethesda System, and we assessed agreement between their classifications. We classified histology results following the cytology sample as benign or malignant according to the primary diagnosis in the histology report, and calculated malignancy rates for each cytology category., Results: Agreement between the classifications of 259 cytology results from 227 patients was moderate (kappa=0.67, 95% confidence interval 0.61-0.74), with good agreement (>80%) for only 3 of the 6 Bethesda categories. 122 patients had subsequent thyroid histology samples. 88% had benign primary diagnoses, with 15 (12%) primary thyroid cancers and an additional 11 (9%) incidental cancers. Malignancy rates for each Bethesda category varied from published rates for the majority of clinician-assigned categories., Conclusions: Low agreement between interpretation of non-standardised thyroid cytology reports suggests that standardised reporting should be universally adopted. Malignancy rates for thyroid cytology categories should be reported to inform local clinical practice.

Objectives: Weight loss leads to reduced serum urate (SU) in people with obesity. However, the clinical relevance of such reductions in SU is unknown. This study examined the impact of non-surgical weight loss and bariatric surgery on SU targets in people with morbid obesity and diabetes., Methods: The study was a single-centre, prospective study of 60 people with type 2 diabetes and body mass index ≥35 kg/m(2). Following 6 months of non-surgical weight loss, all participants had laparoscopic sleeve gastrectomy, with a further 1 year of follow-up. Serial SUs were measured throughout the study., Results: Participants experienced mean (SD) weight loss of 5.5 (4.1) kg prior to surgery and 34.3 (11.1) kg following surgery. SU did not change following non-surgical weight loss (0.38 (0.09) mmol/L at baseline and 0.38 (0.10) mmol/L at follow-up), but increased to 0.44 (0.15) mmol/L in the immediate postoperative period and reduced to 0.30 (0.08) mmol/L 1 year after surgery (p<0.05 for both compared with baseline). Baseline SU, cessation of diuretics, female sex and change in creatinine independently predicted change in SU at the final visit. In participants without gout, SU above saturation levels (≥0.41 mmol/L) were present in 19/48 (40%) at baseline and 1/48 (2%) 1 year after surgery (p<0.0001). In participants with gout, SU above therapeutic target levels (≥0.36 mmol/L) were present in 10/12 (83%) at baseline and 4/12 (33%) 1 year after surgery (p=0.031)., Conclusions: Clinically relevant reductions in SU occur following bariatric surgery in people with diabetes and WHO class II or higher obesity.

Objectives: To determine the diabetes screening levels and known glycaemic status of all individuals by age, gender and ethnicity within a defined geographic location in a timely and consistent way to potentially facilitate systematic disease prevention and management., Design: Retrospective observational study., Setting: Auckland region of New Zealand., Participants: 1 475 347 people who had utilised publicly funded health service in New Zealand and domicile in the Auckland region of New Zealand in 2010. The health service utilisation population was individually linked to a comprehensive regional laboratory repository dating back to 2004., Outcome Measures: The two outcomes measures were glycaemia-related blood testing coverage (glycated haemoglobin (HbA1c), fasting and random glucose and glucose tolerance tests), and the proportions and number of people with known dysglycaemia in 2010 using modified American Diabetes Association (ADA) and WHO criteria., Results: Within the health service utilisation population, 792 560 people had had at least one glucose or HbA1c blood test in the previous 5.5 years. Overall, 81% of males (n=198 086) and 87% of females (n=128 982) in the recommended age groups for diabetes screening had a blood test to assess their glycaemic status. The estimated age-standardised prevalence of dysglycaemia was highest in people of Pacific Island ethnicity at 11.4% (95% CI 11.2% to 11.5%) for males and 11.6% (11.4% to 11.8%) for females, followed closely by people of Indian ethnicity at 10.8% (10.6% to 11.1%) and 9.3% (9.1% to 9.6%), respectively. Among the indigenous Maori population, the prevalence was 8.2% (7.9% to 8.4%) and 7% (6.8% to 7.2%), while for 'Others' (mainly Europeans) it was 3% (3% to 3.1%) and 2.2% (2.1% to 2.2%), respectively., Conclusions: We have demonstrated that the data linkage between a laboratory repository and national administrative datasets has the potential to provide a systematic and consistent individual level clinical information that is relevant to medical auditing for a large geographically defined population.

Objective: Diabetes has become the leading cause of end-stage renal disease (ESRD). Renal risk stratification could assist in earlier identification and targeted prevention. This study aimed to derive risk models to predict ESRD events in type 2 diabetes in primary care., Research Design and Methods: The nationwide derivation cohort included adults with type 2 diabetes from the New Zealand Diabetes Cohort Study initially assessed during 2000-2006 and followed until December 2010, excluding those with pre-existing ESRD. The outcome was fatal or nonfatal ESRD event (peritoneal dialysis or hemodialysis for ESRD, renal transplantation, or death from ESRD). Risk models were developed using Cox proportional hazards models, and their performance was assessed in a separate validation cohort., Results: The derivation cohort included 25,736 individuals followed for up to 11 years (180,497 person-years; 86% followed for ≥5 years). At baseline, mean age was 62 years, median diabetes duration 5 years, and median HbA1c 7.2% (55 mmol/mol); 37% had albuminuria; and median estimated glomerular filtration rate (eGFR) was 77 mL/min/1.73 m2. There were 637 ESRD events (2.5%) during follow-up. Models that included sex, ethnicity, age, diabetes duration, albuminuria, serum creatinine, systolic blood pressure, HbA1c, smoking status, and previous cardiovascular disease status performed well with good discrimination and calibration in the derivation cohort and the validation cohort (n=5,877) (C-statistics 0.89-0.92), improving predictive performance compared with previous models., Conclusions: These 5-year renal risk models performed very well in two large primary care populations with type 2 diabetes. More accurate risk stratification could facilitate earlier intervention than using eGFR and/or albuminuria alone.

In New Zealand laboratories the measurement of glycated haemoglobin (HbA1c) for diagnosis of diabetes is now only reported in SI units of mmol/mol. HbA1c is now recommended as the preferred test to diagnose diabetes in most circumstances. The requirement for a second positive test in asymptomatic individuals is retained. An HbA1c greater than and equal to 50 mmol/mol (repeated on a second occasion in asymptomatic patients) is diagnostic of diabetes and a value less than and equal to 40 mmol/mol represents normal glucose tolerance. For patients with an initial HbA1c result of 41-49 mmol/mol, cardiovascular risk assessment and lifestyle interventions are recommended with repeat HbA1c screening in 6-12 months. For patients whose HbA1c is less than and equal to 40 mmol/mol, repeat screening (including for CVD risk) at intermittent intervals is recommended as per published guidelines.

Aims: To determine the co-prevalence of gout, diabetes and cardiovascular disease (CVD) in the entire Aotearoa New Zealand adult population to inform clinical practice., Methods: Algorithms based on hospital admissions, outpatient visits, drug dispensing, laboratory test data and mortality for the Aotearoa New Zealand Health Tracker (ANZHT) population aged ≥20 years (n = 3,036,093) were used to estimate the prevalence of those identified with gout, diabetes and CVD in 2009., Results: The crude prevalence in the adult ANZHT population of gout was 3.9%, of diabetes was 6.6%, and of CVD was 5.4%. For those identified with gout, 25.6% had diabetes and 22.7% had CVD. Both diabetes and CVD were more prevalent in those identified with gout, compared with those without gout (age-standardised rate (ASR) ratio 3.5 for diabetes and 2.7 for CVD, p for both <0.001)., Conclusion: By applying algorithms based on hospital coding, community drug dispensing and laboratory test data sets, we have demonstrated a high co-prevalence of gout, diabetes and CVD in the adult population of Aotearoa New Zealand. Health service presentation with gout can be an important opportunity to assess risk and manage co-morbid disease. Prevention and management strategies are reinforcing for these metabolic conditions.

Aim: This study estimated diabetes prevalence and utilisation of healthcare services in Counties Manukau using routinely collected administrative data and compared estimates with findings for three other district health boards (DHBs) in close geographic proximity., Method: Records of subsidy claims for pharmaceuticals and laboratory investigations were linked to records in a national hospital admissions database to 'reconstruct' populations of four DHBs--Counties Manukau, Northland, Waitemata and Auckland. Individuals were included in reconstructed populations if they had health events recorded between January 2006 and December 2007. Diabetes cases were identified using an algorithm based on claims for monitoring tests and pharmaceuticals, as well as clinical codes for diabetes in hospital admissions., Results: Reconstructed populations were only 6% lower than census population counts indicating that the vast majority of the population use health services in a two year period. The age- and sex-standardised prevalence of diabetes was 7.1% in Counties Manukau and 5.2% in the other three DHBs combined. Prevalence of diabetes was highest amongst Māori (10.6% in women and 12.2% in men) and Pacific peoples (15.0% for women and 13.5% for men). Maori diabetes cases had the highest hospital discharge rate of any ethnic group. Community pharmaceutical prescribing patterns and laboratory test frequency were similar between diabetes cases by ethnicity and deprivation., Conclusion: Estimates of diabetes prevalence using linkage of routinely collected administrative data were consistent with epidemiological surveys, suggesting that linkage of pharmaceutical and laboratory subsidy databases with hospital admissions data can be used as an alternative to traditional surveys for estimating the prevalence of some long-term conditions. This study demonstrated substantial differences in the prevalence of diabetes and in hospitalisation rates by ethnicity, but measures of community diabetes care were similar by ethnicity and deprivation.

Aim: To identify the extent to which people with diabetes are admitted as inpatients to Counties Manukau District Health Board (CMDHB) hospitals compared to all New Zealand, and the costs of these admissions., Method: Search of National Minimum Dataset for inpatient public hospital discharges with any mention of Type 1 or Type 2 diabetes from 1996-2007., Results: Overall 13% of all CMDHB inpatient discharges mentioned diabetes in 2007 compared with 12% nationally. There were differences by ethnicity among those discharges aged 45 to 64 years, with Pacific (38%), Indian (31%) and Maori (31%) being more than three times as likely as European/Other people (10%) to experience a diabetes-recorded admission. There was a substantial increase in the rate of admission per 1000 where diabetes was recorded over 1996-2007, with Maori (31%) and Pacific (52%) people aged 45-64 years showing the largest increases. Findings from Counties Manukau tended to be comparable with total New Zealand data in terms of the percentage of people with diabetes who were inpatients in 2007, but relatively more inpatients in Counties Manukau had diabetes recorded (consistent with its high population of people with diabetes). Costs of admissions, laboratory investigations, and pharmaceuticals for people with diabetes were estimated to be $66 million per annum higher than for people without diabetes, in Counties Manukau alone., Conclusion: The findings give support to balanced system-wide strategies (such as the Let's Beat Diabetes programme in Counties Manukau) that focus on both upstream (prevention) and downstream (management and coordinated care) responses to diabetes. The study points to a long-term and significant capacity challenge for secondary care services to respond to the forecast growth in the incidence of Type 2 diabetes, particularly in Counties Manukau. The findings also pose challenges for transfer of care to primary care providers after a hospital episode and the flow of information between care settings.

People of Indian origin develop type 2 diabetes at a relatively young age and low body mass index compared to people of other racial groups, possibly because of preferential accumulation of abdominal fat. We examined the relationship between abdominal fat and body mass index (BMI) in healthy premenopausal women of different racial groups, and compared abdominal fat measurements at different ages. Women of Chinese, European, Indian or Polynesian origin (50 of each, mean age 31) had dual energy x-ray absorptiometry of the lumbar spine, with estimation of the percentage fat in the abdominal area. Polynesian women had a significantly greater mean BMI (P< 0.001) than all other groups, and a higher abdominal fat than European and Chinese woman (P< 0.001). Although the Indian women had a similar mean BMI to the European and Chinese women, they had a significantly greater abdominal fat (P<0.001). When examined by age tertile, the Indian women had significantly more abdominal fat than Chinese or European women at all ages (P<0.001), with marked differences evident even in the youngest group (mean age 23 years). Compared to other racial groups, women of Indian origin preferentially accumulate abdominal fat--a trait that is well established in young adulthood.

Aim: Treatment of vitamin D deficiency is an important aspect of the management of osteoporosis, particularly in the elderly. Most well-described regimens in current use involve daily dosing and thus require long-term compliance to be effective. In New Zealand, no preparation containing only low-dose vitamin D suitable for daily use is available. We describe a high-dose regimen for rapid correction of vitamin D deficiency, which makes use of the calciferol 50 000 international unit (IU) tablets available in this country., Methods: Thirty two women (mean age 76 +/- 4 years; range 67-84 years) with serum 25-hydroxyvitamin D concentrations = or <10 microg/l were treated with oral calciferol 50 000 IU daily for 10 days., Results: At an average time after treatment of four months, serum 25-hydroxyvitamin D increased from 8 +/- 1 microg/l to 21 +/- 5 microg/l, bringing all but one patient within the reference range (14-76 microg/l). Serum parathyroid hormone level decreased after treatment by 0.7 +/- 1.7 pmol/l (p <0.05), and alkaline phosphatase activity decreased by 5 +/- 11 u/l (p <0.05). Serum calcium increased by 0.06 +/- 0.08 mmol/l (p <0.001), but all values were within the reference range. Data collected from a separate cohort of elderly inpatients showed that similar increases could be achieved with a single 300 000 IU dose, and suggested that serum 25-hydroxyvitamin D levels decline with a half-life of 90 days., Conclusions: This regimen provides a simple, safe and effective way of managing vitamin D deficiency. Its short-term nature may result in higher compliance than daily dosing regimens.

Purpose: To determine the effect of supplementation with calcium citrate on circulating lipid concentrations in normal older women., Subjects and Methods: As part of a study of the effects of calcium supplementation on fractures, we randomly assigned 223 postmenopausal women (mean [+/- SD] age, 72 +/- 4 years), who were not receiving therapy for hyperlipidemia or osteoporosis, to receive calcium (1 g/d, n = 111) or placebo (n = 112) for 1 year. Fasting serum lipid concentrations, including high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol, were obtained at baseline, and at 2, 6, and 12 months., Results: After 12 months, HDL cholesterol levels and the HDL cholesterol to LDL cholesterol ratio had increased more in the calcium group than in the placebo group (mean between-group differences in change from baseline: for HDL cholesterol, 0.09 mmol/L (95% confidence interval [CI]: 0.02 to 0.17; P = 0.01); for HDL/LDL cholesterol ratio, 0.05 (95% CI: 0.02 to 0.08; P = 0.001). This was largely due to a 7% increase in HDL cholesterol levels in the calcium group, with a nonsignificant 6% decline in LDL cholesterol levels. There was no significant treatment effect on triglyceride level (P = 0.48)., Conclusion: Calcium citrate supplementation causes beneficial changes in circulating lipids in postmenopausal women. This suggests that a reappraisal of the indications for calcium supplementation is necessary, and that its cost effectiveness may have been underestimated.

Background: Long-term treatment of patients with asymptomatic primary hyperparathyroidism remains controversial, but the presence of osteoporosis is regarded as an indication for parathyroidectomy. Hormone replacement therapy (HRT) is a possible alternative therapy in osteopenic postmenopausal women with the disorder, and results of short-term studies suggest a beneficial effect on bone mass comparable to that achieved by parathyroidectomy. Longer-term data are required to further assess the efficacy of this treatment in chronic stable primary hyperparathyroidism., Methods: We report the results of the extension from 2 to 4 years of a randomized, placebo-controlled trial of HRT in postmenopausal women with primary hyperparathyroidism. Of 23 postmenopausal women with primary hyperparathyroidism, 11 received active HRT with conjugated equine estrogen, 0.625 mg/d, and medroxyprogesterone acetate, 5 mg/d, and 12 received placebo. Bone mineral density was measured throughout the skeleton at 6-month intervals using dual-energy x-ray absorptiometry in these women and in 50 normocalcemic age-matched control subjects. None of the 23 patients withdrew during the extension period., Results: Changes in bone mineral density were more positive in those taking HRT than placebo, with the between-group differences at 4 years being 4.6% in the total body, 7.5% in the lumbar spine, 7.4% in the femoral neck, 8.2% in the femoral trochanter, 6.8% in the legs, and 7.0% in the forearm (P<.01). At skeletal sites composed predominantly of cortical bone, there was a progressive divergence of the 2 groups. Biochemical markers of bone turnover remained lower throughout the study in women taking HRT. When rates of bone loss were compared between the placebo group and healthy women of comparable age, bone loss tended to be more marked throughout the skeleton in women with hyperparathyroidism, but only in the total body and its legs subregion was this difference significant., Conclusions: Hormone replacement therapy is efficacious in the long-term management of osteopenia in postmenopausal women with primary hyperparathyroidism and thus represents an important new therapeutic option for asymptomatic patients who do not have other indications for surgery. Bone loss seems to be accelerated in untreated primary hyperparathyroidism.

Objective: Depot medroxyprogesterone acetate (DMPA), an injectable progestogen, is a widely used contraceptive acting primarily by inhibiting secretion of pituitary gonadotrophins, thus producing oestrogen deficiency. Cross-sectional and prospective studies in pre-menopausal women have shown DMPA use to be associated with reduced bone density, but bone density increases following discontinuation of the drug. Because fracture rates are low in pre-menopausal women, the principal concern arising from the effects of DMPA on bone is that there may be residual osteopenia in former users such that their post-menopausal fracture risk is increased. The present study addresses this question., Design: Cross-sectional study of bone density in post-menopausal former users of DPMA and controls., Subjects: Three hundred and forty-six normal post-menopausal women, of whom 34 had previously used DMPA. The median age at which DMPA use began was 41 years and the median duration of use was 3.0 years., Measurements: Bone density was measured in the spine, proximal femur and total body by dual-energy, X-ray absorptiometry., Results: There were no significant differences in bone density at any site between the women who had previously used DMPA and the others in the cohort. However, in those who had used DMPA for > 2 years there was a trend towards bone densities being lower in the former users, the differences from non-users being 1.6% in the lumbar spine (P = 0.6), 3.1% in the femoral neck (P = 0.4) and 0.5% in the total body (P = 0.8). There was no correlation between bone densities and the duration of DMPA use, the age at discontinuation of DMPA, or the time between DMPA discontinuation and the menopause., Conclusions: Any residual effects of depot medroxyprogesterone acetate use on post-menopausal bone density are small and therefore unlikely to have a substantial impact on fracture risk in the post-menopausal years.