Impact of patient level factors on the improvement of the ABCs of diabetes

OBJECTIVE

To determine which patient factors contribute to improvements in the ABCs of diabetes following a multi-faceted diabetes care intervention.

METHODS

A multi-level, cluster design, randomized controlled trial examined the effectiveness of a Chronic Care Model (CCM) intervention in an underserved community (n=119).

RESULTS

Improvements in glycemic control were experienced among older subjects (p=0.02), those with higher scores on the WHO-10 Quality of Well-Being Subscale 1 (p=0.05), and those in the CCM group (p=0.04). Insulin use was associated with greater improvements in SBP and DBP. Those taking insulin (p=0.07), and those more satisfied with their diabetes care and ready to make a behavior change (p=0.08) experienced larger improvements in Non-HDLc. Medication treatment intensification (TI) did not significantly impact the ABCs.

CONCLUSION

Psychosocial and sociodemographic factors explained more of the variation in the ABCs than TI, and are important contributors to clinical improvement.

PRACTICE IMPLICATIONS

Providers may be able to identify and intervene on patients who are at risk for developing diabetes complications and improve the consistency, quality, and effectiveness of patient care.

Patient empowerment: myths and misconceptions

OBJECTIVE

The purpose of this article is to clarify the concept of empowerment and to correct common misconceptions about its use in diabetes care and education.

METHODS

The patient empowerment approach is well suited to helping patients make self-selected changes related to weight, nutrition, and physical activity. Although the concept of patient empowerment has become an integral part of diabetes education, an accurate understanding and authentic application of empowerment has not occurred as readily. The empowerment approach is clarified and common misconceptions have been corrected.

RESULTS

Embracing empowerment means making a paradigm shift that is often difficult because the traditional approach to care is embedded in the training and socialization of most health care professionals (HCPs).

CONCLUSION

Unlike the traditional approach, empowerment is not something one does to patients. Rather, empowerment begins when HCPs acknowledge that patient are in control of their daily diabetes care. Empowerment occurs when the HCPs goal is to increase the capacity of patients to think critically and make autonomous, informed decisions. Empowerment also occurs when patients are actually making autonomous, informed decisions about their diabetes self-management.

PRACTICE IMPLICATIONS

Clarity about all aspects of the empowerment approach is essential if it is to be used effectively.

3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial

PURPOSE

The purpose of this study was to determine if improvements observed in clinical, behavioral, and psychosocial outcomes measured at 12 months following a multifaceted diabetes care intervention were sustained at 3-year follow-up.

METHODS

This study was a multilevel, nonblinded, cluster design, randomized controlled trial that took place in an underserved suburb of Pittsburgh, Pennsylvania, between 1999 and 2005. Eleven primary care practices, and their patients, were randomly assigned to 3 groups: chronic care model (CCM) intervention (n = 30), provider education only (PROV) (n = 38), and usual care (UC) (n = 51). Subjects were followed for 3 years.

RESULTS

Improvements observed at 12-month follow-up in glycemic (-0.5%) and blood pressure control (-4.8 mm Hg), and the proportion of participants who self-monitor their blood glucose (86.7%-100%), were sustained at 3-year follow-up in the CCM group. Additional improvements occurred in non-HDLc levels in all study groups and quality of well-being scores in the CCM intervention group. All associations remained after controlling for medication treatment intensification.

CONCLUSIONS

We have demonstrated that improvements in outcomes can be sustained over time following a multifaceted diabetes care intervention. Future research in this area is necessary to understand if improvements in outcomes can be sustained following diabetes self-management education (DSME) and what type of patient fares the best from multifaceted diabetes care interventions.

Evaluating the Efficacy of an Empowerment-Based Self-Management Consultant Intervention: Results of a Two-Year Randomized Controlled Trial

OBJECTIVES: This study was conducted to determine if an empowerment-based Diabetes Self-Management Consultant (DSMC) was more effective than a group receiving Mailed metabolic Assessments Only (MAO) in improving diabetes-related quality of life and blood glucose control. MATERIALS AND METHODS: A two-year clinical trial, in which 310 patients with type 2 diabetes were randomized to the DSMC intervention or the MAO group. The DSMC met with the patient to review the baseline assessments, then met with this review was patient and the patient's physician. Subsequently patients received monthly telephone calls from the DSMC who used the empowerment approach to help patients identify self-management problems, consider options, set goals and make adjustments to their diabetes self-management plans. RESULTS: The Diabetes Self-Management Consultant (DSMC) intervention resulted in improvements in diabetes related quality of life (PAID) p= .008, the Empowerment Scale p= .024, A1C p= .016, Perceived understanding of diabetes p= .001 and satisfaction with diabetes care p= .019 as compared to the MAO group. DISCUSSION/CONCLUSION: The DSMC the intervention resulted in a broad array of modest diabetes related improvements. A promising area for future research would be to test the efficacy of combining an empowerment-based DSMC intervention with case management using algorithm-based medication adjustments for higher risk patients.

Development and testing of the Diabetes Self-management Instrument: a confirmatory analysis

The purpose of this study was to develop and psychometrically test a new instrument for measuring self-management of adults with type 2 diabetes. Data were collected from 634 diabetic adults recruited from three teaching hospitals in Taiwan. Construct validity was determined by confirmatory factor analysis (CFA). Tests of internal consistency and test-retest were used to assess the reliability of the diabetes self-management instrument (DSMI). Initial results of CFA did not fully support the proposed five-factor model. After the model was modified, the fit indices indicated that this model fits the data best. This model was further cross validated in a second sample. Cronbach's alpha coefficient of the DSMI total scale was .94. The test-retest correlations for the DSMI total scale were acceptable (r = .73, p < .01).

Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes

PURPOSE

The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and self-care behaviors in African Americans with type 2 diabetes.

METHODS

The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing diabetes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support.

RESULTS

Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and self-care behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = -.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = -.348, P < .01).

CONCLUSIONS

Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

The art and science of diabetes education: a culture out of balance

In the past 20 years, behavioral science has helped create a growing body of theoretically derived, evidenced-based approaches to diabetes patient education. Health care professionals in all disciplines are being required to demonstrate that their practice is evidence based. For diabetes educators, behavioral science is the source of much of that evidence. However, effective diabetes education involves a combination of art and science. Establishing a therapeutic alliance with patients is an art. Diabetes educators must have the interpersonal skills, values, and personal traits needed to cultivate relationships with patients that are characterized by trust, respect, and acceptance. They must feel and be able to express compassion, empathy, and warmth. However, if someone outside the field were reviewing diabetes education evaluation research, they would probably conclude that diabetes educators are interchangeable cogs in a wheel. The positive impact of the therapeutic alliance is well documented in the counseling, psychotherapy, education, and nursing literature. However, evidence to support the important role of the diabetes educator's values, interpersonal skills, and ability to establish a therapeutic alliance with patients is absent from that literature. Valid and reliable measures used to document the impact of interpersonal skills counselors and teachers could be used in diabetes education with little or no adaptation. The evidence and tools exist; we now need to determine if the will exists.

Patient-provider perceptions of diabetes and its impact on self-management: a comparison of African-American and White patients

AIMS

To compare patient-provider differences in diabetes-related perceptions between African-American and White patients and to examine its association with self-care behaviours.

METHODS

One hundred and thirty patient-provider pairs were recruited from the greater Detroit area. Patients and providers completed a survey assessing perceptions about diabetes-related concepts and demographic background. The Diabetes Semantic Differential Scale was used to measure diabetes-related perceptions. Patients also reported the frequency of performing self-care behaviours, including following a healthy eating plan, engaging in physical activity, blood glucose monitoring, and taking medication and/or insulin.

RESULTS

There were a greater number of patient-provider differences in diabetes-related perceptions for the African-American patients (nine of 18 concepts) compared with the White patients (four of 18 concepts). Stepwise regression analyses found patients' semantic differential scores to be significantly associated with five self-care behaviours for African-American patients and two self-care behaviours for White patients. Providers' semantic differential scores emerged as predictors of self-care behaviours for African-American patients, but not for White patients.

CONCLUSIONS

Our findings suggest that compared with White patients, African-Americans differ in a greater number of diabetes-related perceptions than their providers. Patients' and providers' perceptions of diabetes care concepts have a significant impact on a greater number of self-care behaviours for African-American patients than White patients.

Distribution of prion protein genotypes in breeds of sheep in New Zealand

AIM

To use an established high through-put genotyping procedure to gain an estimate of the frequency of alleles of the prion protein (PrP) gene in some common sheep breeds in New Zealand.

METHODS

Using a genotyping procedure based on matrix-assisted laser desorption ionisation-time of flight (MALDI-TOF), DNA samples from 3,024 sheep from New Zealand, including breeds such as Romney, Texel, Coopworth, Merino and mixed breed, were isolated, genotyped and the results analysed.

RESULTS

The 15 scrapie genotypes commonly reported, and derived from the five commonly reported allelic variants (ARR, ARQ, AHQ, ARH and VRQ), were all observed in the samples analysed. The estimates were indicative of the frequencies in the population of alleles present in breeds of sheep in New Zealand. There was a significant difference between the frequencies of alleles between breeds, but the ARQ, followed by the ARR allele, were, except in Carwell sheep, the most common alleles present.

CONCLUSION

This study gave an indication of the percentages of PrP gene alleles in sheep in New Zealand, including data previously unreported from breeds in this country. It is of interest because of the relatively large size of the sheep population in New Zealand compared with many countries, and it provides some useful information on the genetic susceptibility or resistance of the sheep population in New Zealand to scrapie. The frequencies of the alleles can be different for an individual breed compared between countries.

Evaluating large-scale HIV prevention interventions: study design for an integrated mathematical modelling approach

BACKGROUND

There is an urgent need to evaluate HIV prevention interventions, thereby improving our understanding of what works, under what circumstances and what is cost effective.

OBJECTIVES

To describe an integrated mathematical evaluation framework designed to assess the population-level impact of large-scale HIV interventions and applied in the context of Avahan, the Indian AIDS Initiative, in southern India. The Avahan Initiative is a large-scale HIV prevention intervention, funded by the Bill & Melinda Gates Foundation, which targets high-risk groups in selected districts of the six states most affected by the HIV/AIDS epidemic (Maharashtra, Karnataka, Tamil Nadu, Andhra Pradesh, Nagaland and Manipur) and along the national highways.

METHODS

One important component of the monitoring and evaluation of Avahan relies on an integrated mathematical framework that combines empirical biological and behavioural data from different subpopulations in the intervention areas, with the use of tailor-made transmission dynamics models embedded within a Bayesian framework.

RESULTS

An overview of the Avahan Initiative and the objectives of the monitoring and evaluation of the intervention is given. The rationale for choosing this evaluation design compared with other possible designs is presented, and the different components of the evaluation framework are described and its advantages and challenges are discussed, with illustrated examples.

CONCLUSIONS

This is the first time such an approach has been applied on such a large scale. Lessons learnt from the CHARME project could help in the design of future evaluations of large-scale interventions in other settings, whereas the results of the evaluation will be of programmatic and public health relevance.

A QTL study of growth and body shape in the inter-species hybrid of Père David's deer (Elaphurus davidianus) and red deer (Cervus elaphus)

An interspecies deer hybrid resource population developed from a cross of Père David's and red deer was used to detect QTL that account for species differences. A genome scan, coupled with composite interval mapping, was conducted to search for QTL controlling body measurements at pre-pubescent age (6 months of age) and puberty (15 months of age) in this interspecies hybrid. Five linkage groups that harbour QTL affecting morphology were identified. A joint-traits analysis was used to search for putative pleiotropic QTL on four of these linkage groups, and three were significantly associated with pleiotropic QTL for nose width and foot length (metacarpal and phalanges), which collectively accounted for 29-58% of the phenotypic difference between the two deer species. This study suggests that a few loci with large pleiotropic effects may be responsible for species-specific differences in growth and structure-related traits.

Adherence to antiretroviral therapy and its impact on clinical outcome in HIV-infected patients

We analyse data on patient adherence to prescribed regimens and surrogate markers of clinical outcome for 168 human immunodeficiency virus infected patients treated with antiretroviral therapy. Data on patient adherence consisted of dose-timing measurements collected for an average of 12 months per patient via electronic monitoring of bottle opening events. We first discuss how such data can be presented to highlight suboptimal adherence patterns and between-patient differences, before introducing two novel methods by which such data can be statistically modelled. Correlations between adherence and subsequent measures of viral load and CD4+T-cell counts are then evaluated. We show that summary measures of short-term adherence, which incorporate pharmacokinetic and pharmacodynamic data on the monitored regimen, predict suboptimal trends in viral load and CD4+T-cell counts better than measures based on adherence data alone.

A study of certified diabetes educators: influences and barriers

PURPOSE

There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators.

METHODS

A 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis.

RESULTS

This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings.

CONCLUSIONS

Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

Chromosome breakpoint distribution of damage induced in peripheral blood lymphocytes by densely ionizing radiation

PURPOSE

To assess the chromosomal breakpoint distribution in human peripheral blood lymphocytes (PBL) after exposure to a low dose of high linear energy transfer (LET) alpha-particles using the technique of multiplex fluorescence in situ hybridization (m-FISH).

MATERIALS AND METHODS

Separated PBL were exposed in G0 to 0.5 Gy 238Pu alpha-particles, stimulated to divide and harvested approximately 48 - 50 hours after exposure. Metaphase cells were assayed by m-FISH and chromosome breaks identified. The observed distribution of breaks were then compared with expected distributions of breaks, calculated on the assumption that the distribution of breaks is random with regard to either chromosome volume or chromosome surface area.

RESULTS

More breaks than expected were observed on chromosomes 2 and 11, however no particular region of either chromosome was identified as significantly contributing to this over-representation. The identification of hot or cold chromosome regions (pter,p,cen,q,qter) varied depending on whether the data were compared according to chromosome volume or surface area.

CONCLUSIONS

A deviation from randomness in chromosome breakpoint distribution was observed, and this was greatest when data were compared according to the relative surface area of each individual chromosome (or region). The identification of breaks by m-FISH (i.e., more efficient observation of interchanges than intrachanges) and importance of territorial boundaries on interchange formation are thought to contribute to these differences. The significance of the observed non-random distribution of breaks on chromosomes 2 and 11 in relation to chromatin organization is unclear.

Comparative neuropathology of Kuru with the new variant of Creutzfeldt-Jakob disease: evidence for strain of agent predominating over genotype of host

The three major influences on the phenotype of the transmissible spongiform encephalopathies are believed to be strain of agent, route of infection and host genotype. We have compared the pathologic profiles and genotypes of the new variant of Creutzfeldt-Jakob disease (vCJD) and kuru. The comparison reveals that there are distinct lesional differences particularly in the prion protein (PrP) load and distribution as seen by immunohistochemistry. The clinico-pathologic phenotypes and the genotypes of these two diseases are sufficiently different to suggest that the strain of agent may play a greater role than any presumptive common route of peripherally acquired infection.

Seroprevalence of IgG antibodies to SARS-coronavirus in asymptomatic or subclinical population groups

We systematically reviewed the current understanding of human population immunity against SARS-CoV in different groups, settings and geography. Our meta-analysis, which included all identified studies except those on wild animal handlers, yielded an overall seroprevalence of 0.10% [95% confidence interval (CI) 0.02-0.18]. Health-care workers and others who had close contact with SARS patients had a slightly higher degree of seroconversion (0.23%, 95% CI 0.02-0.45) compared to healthy blood donors, others from the general community or non-SARS patients recruited from the health-care setting (0.16%, 95% CI 0-0.37). When analysed by the two broad classes of testing procedures, it is clear that serial confirmatory test protocols resulted in a much lower estimate (0.050%, 95% CI 0-0.15) than single test protocols (0.20%, 95% CI 0.06-0.34). Potential epidemiological and laboratory pitfalls are also discussed as they may give rise to false or inconsistent results in measuring the seroprevalence of IgG antibodies to SARS-CoV.

Vitamin D-dependent rickets type II in a cat

A cat with clinical signs Indicating rickets was diagnosed as having a defect of vitamin D receptors. Clinical signs had been seen from four months of age. Treatment with calcium supplementation and various forms of vitamin D did not alter plasma calcium levels or reverse skeletal lesions of lateral antebrachial bowing, lumbar spinal lordosis and costochondral beading. Analgesics were effective for relieving skeletal pain during the bone growth phase and were withdrawn when the animal reached skeletal maturity. Therapy for hip osteoarthritis was given from five years of age until the cat was euthanased at nine years of age as a result of refractory hip pain.

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe

AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15-18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p = 0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80-3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58-11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17-18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p = 1.000) or STI symptoms (2.7% versus 1.6%; p = 0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease.

Increased complexity of radiation-induced chromosome aberrations consistent with a mechanism of sequential formation

Complex chromosome aberrations (any exchange involving three or more breaks in two or more chromosomes) are effectively induced in peripheral blood lymphocytes (PBL) after exposure to low doses (mostly single particles) of densely ionising high-linear energy transfer (LET) alpha-particle radiation. The complexity, when observed by multiplex fluorescence in situ hybridisation (m-FISH), shows that commonly four but up to eight different chromosomes can be involved in each rearrangement. Given the territorial organisation of chromosomes in interphase and that only a very small fraction of the nucleus is irradiated by each alpha-particle traversal, the aim of this study is to address how aberrations of such complexity can be formed. To do this, we applied theoretical "cycle" analyses using m-FISH paint detail of PBL in their first cell division after exposure to high-LET alpha-particles. In brief, "cycle" analysis deconstructs the aberration "observed" by m-FISH to make predictions as to how it could have been formed in interphase. We propose from this that individual high-LET alpha-particle-induced complex aberrations may be formed by the misrepair of damaged chromatin in single physical "sites" within the nucleus, where each "site" is consistent with an "area" corresponding to the interface of two to three different chromosome territories. Limited migration of damaged chromatin is "allowed" within this "area". Complex aberrations of increased size, reflecting the path of alpha-particle nuclear intersection, are formed through the sequential linking of these individual sites by the involvement of common chromosomes.

Gender difference in HIV-1 RNA viral loads

OBJECTIVES

To test and characterize the dependence of viral load on gender in different countries and racial groups as a function of CD4 T-cell count.

METHODS

Plasma viral load data were analysed for > 30,000 HIV-infected patients attending clinics in the USA [HIV Insight (Cerner Corporation, Vienna, VA, USA) and Plum Data Mining LLC (East Meadow, NY, USA) databases] and the Netherlands (Athena database; HIV Monitoring Foundation, Amsterdam, Netherlands). Log-normal regression models were used to test for an effect of gender on viral load while adjusting for covariates and allowing the effect to depend on CD4 T-cell count. Sensitivity analyses were performed to test the robustness of conclusions to assumptions regarding viral loads below the lower limit of quantification (LLOQ).

RESULTS

After adjusting for covariates, women had (nonsignificantly) lower viral loads than men (HIV Insight: -0.053 log(10) HIV-1 RNA copies/mL, P = 0.202; Athena: -0.005 log(10) copies/mL, P = 0.667; Plum: -0.072 log(10) copies/mL, P = 0.273). However, further investigation revealed that the gender effect depended on CD4 T-cell count. Women had consistently higher viral loads than men when CD4 T-cell counts were at most 50 cells/microL, and consistently lower viral loads than men when CD4 T-cell counts were greater than 350 cells/microL. These effects were remarkably consistent when estimated independently for the racial groups with sufficient data available in the HIV Insight and Plum databases.

CONCLUSIONS

The consistent relationship between gender-related differences in viral load and CD4 T-cell count demonstrated here explains the diverse findings previously published.

Methods for estimating the case fatality ratio for a novel, emerging infectious disease

During the course of an epidemic of a potentially fatal disease, it is important that the case fatality ratio be well estimated. The authors propose a novel method for doing so based on the Kaplan-Meier survival procedure, jointly considering two outcomes (death and recovery), and evaluate its performance by using data from the 2003 epidemic of severe acute respiratory syndrome in Hong Kong, People's Republic of China. They compare this estimate obtained at various points in the epidemic with the case fatality ratio eventually observed; with two commonly quoted, naïve estimates derived from cumulative incidence and mortality statistics at single time points; and with estimates in which a parametric mixture model is used. They demonstrate the importance of patient characteristics regarding outcome by analyzing subgroups defined by age at admission to the hospital.

Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm

Diabetes is a self-managed illness in which the decisions most affecting the health and well being of patients are made by the patients themselves. Many of these decisions involve routine activities of daily living (e.g., nutrition, physical activity). Effective diabetes care requires patients and health care professionals to collaborate in the development of self-management plans that integrate the clinical expertise of health care professionals with the concerns, priorities and resources of the patient. Collaborative diabetes care requires a new "empowerment" paradigm that involves a fundamental redefinition of roles and relationships of health care professionals and patients. The challenges of fostering the adoption of a new paradigm differ substantially from those associated with the introduction of new technology. Those challenges are discussed in this paper.