Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Staff recruitment, development and global mobility

This paper considers issues that relate to staff recruitment, staff development and global mobility of dental academics. Published literature, which has a North American bias, is reviewed. Recommendations, which may be applicable world-wide, are made to address evident and pertinent areas of concern in terms of the availability of quality dental teaching staff in dental teaching institutions so as to sustain the global dental academic enterprise at appropriately high levels of achievement.

Children's understanding of mental illness: an exploratory study

BACKGROUND

This study aimed to investigate children's thinking about mental illness by employing a well-established framework of adult illness understanding.

METHODS

The study adopted a semistructured interview technique and a card selection task to assess children's responses to causes, consequences, timeline and curability of the different types of mental illness. The children were aged between 5 and 11 years.

RESULTS

Results indicated a developmental trend in the children's thinking about mental illness; there was an increase in the children's understanding of the causes, consequences, curability and timeline of mental illness with age. The older children demonstrated a more sophisticated and accurate thinking about mental illness compared with the younger children, who tended to rely on a medical model in order to comprehend novel mental illnesses. Furthermore, the girls exhibited more compassion, showing greater social acceptance compared with the boys.

CONCLUSIONS

The Leventhal model provides a useful framework within which to investigate children's knowledge and understanding of mental illness. Limitations of the study and implications for future research are discussed.

Biphasic insulin aspart given thrice daily is as efficacious as a basal-bolus insulin regimen with four daily injections: a randomised open-label parallel group four months comparison in patients with type 2 diabetes

AIMS

To show that a thrice daily meal-time biphasic insulin aspart (BIAsp) treatment regimen is as efficacious as a 4 times daily basal-bolus regimen with human isophane insulin (NPH) and insulin aspart (IAsp).

METHODS

A multinational, randomised, open-label parallel-group trial in 394 patients with type 2 diabetes on a once or twice daily insulin regimen. Patients were randomised 1:1 to BIAsp or IAsp+NPH for 16 weeks. The BIAsp group was treated according to individual needs using BMI as a surrogate index of insulin resistance. Subjects administered BIAsp 70 (BMI< or =30 kg/m (2)) or BIAsp 50 (BMI>30 kg/m (2)) with breakfast and lunch and BIAsp 30 with dinner. The IAsp+NPH group injected IAsp at meals and NPH at bedtime as basal insulin. HbAlc levels after 16 weeks were compared between treatments using a predefined non-inferiority criterion of 0.4%. The incidence of hypoglycaemic episodes and adverse events was evaluated.

RESULTS

Mean HbAlc (+/-SD) decreased from 9.1+/-0.7% to 7.8+/-1.0% with both treatments. Glycaemic control provided by BIAsp was non-inferior to that obtained by the IAsp+NPH (intention to treat ITT) population: diff, HbAlc -0.05%; 95% CI (-0.24; 0.14); per protocol (PP) population: diff, HbAlc -0.03%; 95% CI (-0.23; 0.16). Similar improvements in glycaemic control in both groups were confirmed by self-measured 8-point plasma glucose (PG) profiles, average and fasting PG concentrations, and average prandial PG increments. The incidence of adverse events and hypoglycaemic episodes was similar in the two treatment groups.

CONCLUSIONS

A thrice daily meal-time BIAsp regimen is a suitable alternative to an intensified insulin regimen in people with inadequately controlled type 2 diabetes mellitus, and requires fewer daily injections than a basal-bolus therapy without compromising efficacy and safety.

Malignancy and mortality in a population-based cohort of patients with coeliac disease or ‘gluten sensitivity’

AIM: To determine the risk of malignancy and mortality in patients with a positive endomysial or anti-gliadin antibody test in Northern Ireland.

METHODS: A population-based retrospective cohort study design was used. Laboratory test results used in the diagnosis of coeliac disease were obtained from the Regional Immunology Laboratory, cancer statistics from the Northern Ireland Cancer Registry and mortality statistics from the General Registrar Office, Northern Ireland. Age standardized incidence ratios of malignant neoplasms and standardized mortality ratios of all-cause and cause-specific mortality were calculated.

RESULTS: A total of 13 338 people had an endomysial antibody and/or an anti-gliadin antibody test in Northern Ireland between 1993 and 1996. There were 490 patients who tested positive for endomysial antibodies and they were assumed to have coeliac disease. There were 1133 patients who tested positive for anti-gliadin antibodies and they were defined as gluten sensitive. Malignant neoplasms were not significantly associated with coeliac disease; however, all-cause mortality was significantly increased following diagnosis. The standardized incidence and mortality ratios for non-Hodgkin’s lymphoma were increased in coeliac disease patients but did not reach statistical significance. Lung and breast cancer incidence were significantly lower and all-cause mortality, mortality from malignant neoplasms, non-Hodgkin’s lymphoma and digestive system disorders were significantly higher in gluten sensitive patients compared to the Northern Ireland population.

CONCLUSION: Patients with coeliac disease or gluten sensitivity had higher mortality rates than the Northern Ireland population. This association persists more than one year after diagnosis in patients testing positive for anti-gliadin antibodies. Breast cancer is significantly reduced in the cohort of patients with gluten sensitivity.

A controlled trial of the impact of exposure to positive images of dentistry on anticipatory dental fear in children

OBJECTIVES

Dental anxiety is common in children. This study sought to determine the impact of viewing positive images of dentistry prior to a dental appointment on the anticipatory dental anxiety levels of children attending for dental treatment.

METHODS

Controlled trial. Assessment of anxiety and analysis of data were conducted blind to experimental condition. Assessment of anxiety was carried out in the waiting room postintervention but before the patient entered the dental surgery for treatment.

PARTICIPANTS

Thirty-eight children and young adults attending a dental clinic in South West England.

INTERVENTION

Participants were randomly assigned to one of two conditions. In both conditions the participant was asked to look at photographs for 2 min in the waiting area prior to their appointment. The intervention consisted of viewing positive images of dentistry and dental treatment, the control condition consisted of dentally neutral images. Positive and neutral images were validated independently by four paediatric dentists. The assessment of anticipatory dental anxiety was made blind to experimental condition and statistical analysis was conducted blind to group membership.

OUTCOME MEASURE

Anticipatory anxiety assessed by the Venham Picture Test.

FINDINGS

A significant difference in anticipatory dental anxiety was found between the two groups (median-positive images = 0, median-neutral images = 3; P < 0.001). Anticipatory anxiety was not correlated to age (rho = 0.04 P > 0.05), there was no difference between male and female participants in their level of anticipatory anxiety (median-males = 0.5, median-females = 1 P > 0.05).

CONCLUSIONS

Viewing positive images of dentistry and dentists results in short-term reductions in anticipatory anxiety in children.

Concurrent end-phase boost high-dose radiation therapy for non-small-cell lung cancer with or without cisplatin chemotherapy

The aim of this study was to audit the results of a high-dose, combined-modality prospective protocol for non-small-cell lung cancer in terms of survival, disease-specific survival and toxicity. One hundred and twenty-one patients with non-small-cell lung cancer were treated with a concurrent, end-phase, boost, high-dose radiotherapy protocol with 65 Gy in 35 fractions for more than 5 weeks. Sixty-six patients received radiotherapy alone (group 1), 29 received concurrent chemoradiation (group 2) and 26 received neoadjuvant and concurrent chemotherapy (group 3). Thirty-four patients had stage I disease, six had stage II and 81 had stage III. Overall median survival was 23 months: 75% at 1 year and 23% at 5 years. Median survivals for patients with stage I and stages II and III disease were 43 and 19 months, respectively. For stages II and III patients by groups 1-3, median survivals were 18, 25 and 18 months, respectively, and 2-year survivals were 36, 52 and 38%, respectively. Toxicity was acceptable. Overall, 9% had symptomatic pneumonitis and 7% had grades 3 and 4 oesophagitis. For those who had the mediastinum included in the volume, grade > or = 3 oesophagitis occurred in 0, 11 and 22% (n = 110, P = 0.001), respectively, for treatment groups 1-3. Overall treatment-related mortality was 3%, consisting of two septic deaths, one pneumonitis and possibly one late cardiac event, all occurring in patients who had chemotherapy (7% of 55 patients). Treatment-related mortality declined over the study period. Accelerated radiotherapy was well tolerated, with only moderate increased acute toxicity when combined with concurrent platinum chemotherapy. Toxicity was enhanced by induction chemotherapy. Overall survival outcomes were excellent for this condition. Continued use of this radiotherapy schedule is recommended as the platform for assessment of other chemotherapy schedules.

Peripheral skin necrosis in the recipient of monochorionic twins complicated by twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) complicates approximately 15% of monochorionic, diamniotic twin pregnancies and if untreated carries a high perinatal loss rate of between 80% and 100%, depending on the stage. The underlying pathology in TTTS appears to be an imbalanced intertwin perfusion difference, secondary to functional unidirectional arteriovenous anastomoses within a monochorionic placenta. We report two cases of monochorionic twin pregnancy complicated by TTTS, in which the pregnancies were treated by serial aggressive amnioreduction. However, the recipient twin in each pregnancy developed 'ischemic damage' to a lower limb.

Linked claims and medical records for case management of breast cancer diagnosis

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Background: Real time linkage of medical records and administrative claims may assist physicians in managing cancer care. Failure to obtain requisite follow-up (f/u) of abnormal mammograms may delay cancer diagnosis and impact outcome with studies showing that up to 20% of women do not get recommened f/u. We tested the accuracy of claims data linked to medical records in identifying women who did not receive f/u for an abnormal mammogram (BI-RADS 0,3,4,5). Methods: Electronic medical records in a staff model practice affiliated with a single payer were scanned to identify the BI-RADS code for all mammograms performed by practice radiologists. For each woman covered by the payer with a BI-RADS 0,3,4 or 5 mammogram, claims were searched for f/u breast procedures (imaging, biopsy, surgery). For women with more than 1 abnormal mammogram in the study period, only f/u of the first abnormal mammogram was studied. Cases were censured if their insurance coverage with the payer terminated before the required period of follow-up. Medical records of cases defined by claims as not having recommended f/u were reviewed to determine the accuracy of claims analysis. Results: 17,329 women covered by the payer had at least one mammogram in the practice from 1/1/2001 to 12/31/2003. The BI-RADS was 0, 3, 4 or 5 in 1,319 (7.5%). Among 1,206 eligible for f/u, 189 (16%) did not receive the BI-RADS recommended f/u (see table ). Medical record review showed that the claims search accurately identified the follow-up care in 95% of these cases. Conclusions: Administrative claims accurately identify care for diagnostic management of abnormal mammograms. Real-time linkage of claims to mammogram BI-RADS data is being tested as a regional case management system to assist physicians in assuring approrpriate follow-up for abnormal mammograms.

[Table: see text]

No significant financial relationships to disclose.

Cholinesterase inhibitors for Parkinson's disease dementia

BACKGROUND

The loss of cholinergic, dopaminergic and noradrenergic innervations seen in Parkinson's Disease Dementia (PDD) suggest a potential role for cholinesterase inhibitors. Concerns have been expressed about a theoretical worsening of Parkinson's disease related symptoms particularly movement symptoms.

OBJECTIVES

To assess the efficacy, safety, tolerability and health economic data relating to the use of cholinesterase inhibitors in PDD.

SEARCH STRATEGY

The trials were identified from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 19 April 2005 using the search term parkinson*This register contains records from major health care databases and many ongoing trial databases and is updated regularly.Comprehensive searches of abstracts from major scientific meetings were performed. Pharmaceutical companies were approached for information regarding additional and ongoing studies.

SELECTION CRITERIA

Randomized, double-blind, placebo-controlled studies assessing the effectiveness of cholinesterase inhibitors in PDD. Inclusion and exclusion criteria were stated to limit bias.

DATA COLLECTION AND ANALYSIS

Two reviewers (IM, CF) independently reviewed the quality of the studies utilising criteria from the Cochrane Collaboration Handbook. Medications were examined separately and as a group. The outcome measures assessed were in the following domains: neuropsychiatric features, cognition, global impression, daily living activities, quality of life, burden on caregiver, Parkinsonian related symptoms, treatment acceptability as determined by withdrawal from trials, safety as determined by the frequency of adverse events, institutionalisation, death and health economic factors.

MAIN RESULTS

A detailed and systematic search of relevant databases identified one published randomized, double-blind, placebo-controlled study (Emre 2004) involving 541 patients that compared rivastigmine with placebo. Rivastigmine produced statistically significant improvements in several outcome measures. On the primary cognitive measure, the ADAS-Cog, rivastigmine was associated with a 2.80 point ADAS-Cog improvement [WMD -2.80, 95% Cl -4.26 to -1.34, P = 0.0002] and a 2.50 point ADCS-ADL improvement [95% Cl 0.43 to 4.57, P = 0.02] relative to placebo. Clinically meaningful (moderate or marked) improvement occurred in 5.3% more patients on rivastigmine, and meaningful worsening occurred in 10.1% more patients on placebo. Tolerability appeared to be a significant issue. Significantly more patients on rivastigmine dropped out of the study due to adverse events [62/362 versus 14/179, OR 2.44, 95% Cl 1.32 to 4.48, P = 0.004]. Nausea [20/179 versus 105/362, OR 3.25, 95% Cl 1.94 to 5.45, P < 0.00001], tremor [7/179 versus 37/362, OR 2.80, 95% Cl 1.22 to 6.41, P = 0.01] and in particular vomiting [3/179 versus 60/362, OR 11.66, 95% Cl 3.60 to 37.72, P < 0.0001] were significantly more common with rivastigmine. However, significantly fewer patients died on rivastigmine than placebo [4/362 versus 7/179, OR 0.27, 95% CI 0.08 to 0.95, P = 0.04]

AUTHORS' CONCLUSIONS

Rivastigmine appears to improve cognition and activities of daily living in patients with PDD. This results in clinically meaningful benefit in about 15% of cases. There is a need for more studies utilising pragmatic measures such as time to residential care facility and both patient and carer quality of life assessments. Future trials should involve other cholinesterase inhibitors, utilise tools to analyse the data that limit any bias and measure health economic factors. It is unlikely that relying solely on the last observation carried forward (LOCF) is sufficient. Publication of the observed case data in the largest trial would assist (Emre 2004). Adverse events were associated with the cholinergic activity of rivastigmine, but may limit patient acceptability as evidenced by the high drop out rate in the active arm.

A review of studies describing the use of acetyl cholinesterase inhibitors in Parkinson's disease dementia

OBJECTIVE

To review the literature relating to the use of acetyl cholinesterase inhibitors in Parkinson's disease dementia (PDD).

METHOD

MEDLINE (1966--December 2004), PsychINFO (1972--December 2004), EMBASE (1980--December 2004), CINHAL (1982--December 2004), and the Cochrane Collaboration were searched in December 2004.

RESULTS

Three controlled trials and seven open studies were identified. Efficacy was assessed in three key domains: cognitive, neuropsychiatric and parkinsonian symptoms.

CONCLUSION

Cholinesterase inhibitors have a moderate effect against cognitive symptoms. There is no clear evidence of a noticeable clinical effect against neuropsychiatric symptoms. Tolerability including exacerbation of motor symptoms--in particular tremor--may limit the utility of cholinesterase inhibitors.