Facilitating barriers: Contextual factors and self-management of type 2 diabetes in urban settings

Urban environments create unique challenges for the management of type 2 diabetes (T2D). City living is associated with unhealthy occupational, nutritional, and physical activity patterns. However, it has also been linked to behaviours that promote health, such as walking and cycling for transportation. Our research is situated at the intersection of these contradictory findings. We ask: What aspects of urban living impact the ability of those living with diabetes to reach optimal health? What contextual and structural factors influence how barriers are experienced in the everyday lives of those living with T2D? We conducted semi-structured interviews with 29 individuals living in Toronto and Vancouver. Interviews were recorded, transcribed, and systematically coded for themes and sub-themes. In addition to affirming readily acknowledged barriers to diabetes management, such as accessing healthy, culturally appropriate food and the cost of management, our findings suggest that the unpredictable nature of urban living creates barriers to routinizing self-management practices. As large, cosmopolitan centres with an abundance of activities on offer, cities pulls people away from home, making adherence to self-management recommendations more difficult. Moreover, our findings challenge commonly held assumptions about the mutually exclusive and static nature of barriers and facilitators. Public transit, a readily acknowledged facilitator of healthy living, can be experienced as a barrier to diabetes management. Participants report intentional non-adherence to their medication regimens for fear of hypoglycemia in subway or traffic delays. While the stimulating nature of cities promotes walkability, it produces barriers as well: participants partake in more restaurant eating than they would if they lived in a rural area and were home to cook their own meals. Understanding how barriers are experienced by people living with diabetes will help mitigate some of the unintended consequences associated with various contextual factors. We recommend that healthcare professionals acknowledge and support people with T2D in routinizing self-management and developing contingency plans for the unpredictability and complexity that urban living entails. We suggest further research be carried out to develop contextually-tailored municipal policies and interventions that will support self-management and improve outcomes for individuals living with T2D in urban settings.

Diabetes for Cardiologists: Practical Issues in Diagnosis and Management

Diabetes mellitus (DM), a chronic metabolic disease characterized by hyperglycemia, is a profound cardiovascular (CV) risk factor. It compounds the effects of all other risk factors, leads to premature micro- and macrovascular disease, facilitates development of heart failure, worsens the clinical course of all CV diseases, and shortens life expectancy. Established DM, unrecognized DM, and dysglycemia that may progress to DM are all commonly present at the time of presentation of overt CV disease. Thus, CV specialists and trainees frequently treat patients with dysglycemia. The traditional and proven role of cardiologists in reducing the risk of macrovascular events in this population is through aggressive lipid and blood pressure treatment. However, a more proactive role in the detection and management of DM is likely to become increasingly important as the prevalence continues to increase and therapies continue to improve. The latter include antihyperglycemic therapies with proven cardiovascular safety profiles and CV event reduction properties not yet fully elucidated and not necessarily related to glycemic control. Accordingly, the purpose of this article is to (1) expand the interest of cardiologists in earlier stages of the natural history of DM, when prevention or early detection might help achieve greatest benefit; (2) highlight principles of optimal glycemic management, with an emphasis on add-on choices showing promising reduction of CV events and lacking CV adverse effects; and (3) encourage cardiologists to become proactive partners in the multidisciplinary care needed to ensure optimal lifelong vascular health in patients with, or who are at risk of, DM.

Quality of life after islet transplant: impact of the number of islet infusions and metabolic outcome

The health-related quality of life (HRQL; Health Utilities Index Mark 2) and the fear of hypoglycemia (Hypoglycemia Fear Survey) were assessed after islet transplant; the impact of a single islet infusion and of the metabolic outcome were determined. A control group included 166 patients with type 1 diabetes. Islet transplant had no impact on overall HRQL. Prior to transplant, islet recipients had more fear of hypoglycemia than controls (P<0.000001), but this improved up to 36 months after transplant (P<0.00001, pretransplant vs. each time point). With a single islet infusion, this fear improved substantially (P<0.00001), but improved further with subsequent islet infusions (P</=0.01). Fear of hypoglycemia correlated with the occurrence of hypoglycemia (r=0.47, P=0.01), and even more so with blood glucose stability (r=0.56, P=0.0007) and insulin requirement (r=0.69, P=0.000002).

[Relationships between defense mechanisms and coping strategies, facing exam anxiety performance]

BACKGROUND

Defence mechanisms and coping strategies rely on different theoretical backgrounds and describe distinct psychological processes. Cramer has based a distinction on the following dimensions: conscious processes vs. not; intentionality vs. not; hierarchical conception vs. not. On the contrary to these distinctions, the two notions of defense mechanisms and coping strategies are defined as similar in the Diagnostical and Statistical Manual (DSM IV). This assimilation between coping and defenses in the DSM IV is not confirmed by some researches, namely the one by Callahan and Chabrol. It indeed proves a relationship between adaptive coping and mature defenses, as well as between maladaptive coping and immature defenses. Similarly, Plutchik offered theoretical correspondences between eight defense mechanisms and eight coping strategies: (a) Defenses: repression, isolation, introjection and Coping escape; (b) Defense denial and Coping minimalization; (c) Defense undoing and coping substitution; (d) Defenses: regression, acting out and coping social support; (e) Defenses: compensation, identification, fantasy and coping replacement; (f) Defenses: intellectualization, sublimation, annulation, rationalisation and coping: planification; (g) Defense projection and coping blame; (h) Defense: reactional formation and coping inversion.

METHODS

GOAL

this research aims at testing the relations observed by Callahan and Chabrol and some theoretical correspondences proposed by Plutchik between defences and coping strategies in a population of students similar to the one used by Callahan and Chabrol. It also aims at studying the relationships between coping strategies and conscious derives of defense mechanisms, such as defined by Bond (1995). Defenses were evaluated the first day of the examination week.

POPULATION

the population includes 184 women students in human sciences (sociology and psychology).

INSTRUMENTS

defenses were evaluated with the Defense Style Questionnaire by Bond (DSQ 40). Its French version is made of 40 items and validated by Guelfi et al. It explores 20 defense mechanisms, as well as 3 defense styles: (1) a "mature style", composed by 4 defenses: sublimation, humor, anticipation, repression; (2) a "neurotic style", composed by 4 defenses: annulation, reactional formation, altruism and idealization; (3) an "immature style", composed by 12 defenses. Coping strategies were measured by the French version of the Way of Coping Check-List-Revised, (WCC-R) by Lazarus and Folkman, validated by Graziani et al. It evaluates 10 factors: 1) Problem solving; 2) Evasion; 3) Social support; 4) Self-control; 5) Escape; 6) Responsabilization-Replanification; 7) Resignation; 8)Diplomacy; 9) Confrontation; 10) Personal evolution.

RESULTS

Our results confirm partially Callahan and Chabrol's conclusions in favour of existing relationships between adaptive coping strategies and mature defenses, as well as between maladaptive coping strategies and immature defenses. They demonstrate three positive relationships: 1) a relation between Problem solving resolution coping and two mature defenses (Sublimation, Anticipation); 2) a relation between Evasion coping and nevrotic and immature defenses; 3) a relation between Escaping coping and immature defenses. The correspondences between defense mechanisms and coping strategies, such as proposed by Plutchik psycho-evolutionist emotional model are partly validated. Some links were indeed validated in this research, between: a) Defense Undoing and Escaping or Evasion coping; b) Defense Fantasy and Responzabilization coping, c) Defense Sublimation and Problem solving resolution coping; d) Defense Sublimation and Responsabilization coping or Problem solving resolution coping; e) Défense Annulation and Responzabilisation coping.

Prevention of bleeding after islet transplantation: lessons learned from a multivariate analysis of 132 cases at a single institution

Islet transplantation is being offered increasingly for selected patients with unstable type 1 diabetes. Percutaneous transhepatic portal access avoids a need for surgery, but is associated with potential risk of bleeding. Between 1999 and 2005, we performed 132 percutaneous transhepatic islet transplants in 67 patients. We encountered bleeding in 18/132 cases (13.6%). In univariate analysis, the risk of bleeding in the absence of effective track ablation was associated with an increasing number of procedures (2nd and 3rd procedures with an odds ratio (OR) of 9.5 and 20.9, respectively), platelets count <150,000 (OR 4.4), elevated portal pressure (OR 1.1 per mm Hg rise), heparin dose > or =45 U/kg (OR 9.8) and pre-transplant aspirin (81 mg per day) (OR 2.6, p = 0.05). A multivariate analysis further confirmed the cumulative transplant procedure number (p < 0.001) and heparin dose > or =45 U/kg (p = 0.02) as independent risk factors for bleeding. Effective mechanical sealing of the intrahepatic portal catheter tract with thrombostatic coils and tissue fibrin glue completely prevented bleeding in all subsequent procedures (n = 26, p = 0.02). We conclude that bleeding after percutaneous islet implantation is an avoidable complication provided the intraparenchymal liver tract is sealed effectively.

Suppression of glucose production by GLP-1 independent of islet hormones: a novel extrapancreatic effect

Glucagon-like peptide-1 (GLP-1) is an intestinal hormone that stimulates insulin secretion and decreases glucagon release. It has been hypothesized that GLP-1 also reduces glycemia independent of its effect on islet hormones. Based on preliminary evidence that GLP-1 has independent actions on endogenous glucose production, we undertook a series of experiments that were optimized to address this question. The effect of GLP-1 on glucose appearance (Ra) and glucose disposal (Rd) was measured in eight men during a pancreatic clamp that was performed by infusing octreotide to suppress secretion of islet hormones, while insulin and glucagon were infused at rates adjusted to maintain blood glucose near fasting levels. After stabilization of plasma glucose and equilibration of [3H]glucose tracer, GLP-1 was given intravenously for 60 min. Concentrations of insulin, C-peptide, and glucagon were similar before and during the GLP-1 infusion (115 +/- 14 vs. 113 +/- 11 pM; 0.153 +/- 0.029 vs. 0.156 +/- 0.026 nM; and 64.7 +/- 11.5 vs. 65.8 +/- 13.8 ng/l, respectively). With the initiation of GLP-1, plasma glucose decreased in all eight subjects from steady-state levels of 4.8 +/- 0.2 to a nadir of 4.1 +/- 0.2 mM. This decrease in plasma glucose was accounted for by a significant 17% decrease in Ra, from 22.6 +/- 2.8 to 19.1 +/- 2.8 micromol. kg-1. min-1 (P < 0.04), with no significant change in Rd. These findings indicate that, under fasting conditions, GLP-1 decreases endogenous glucose production independent of its actions on islet hormone secretion.

The development of gender schemata about heterosexual and homosexual others during adolescence

Perceptions of heterosexual and homosexual individuals were investigated among 12-, 16-, and 20-year-old French adolescents. Participants described heterosexual and homosexual males and females with typical masculine and feminine personality traits. Overall, they perceived heterosexual males as having more masculine traits than homosexual males. The 16- and 20-year-olds perceived homosexual males as more feminine than heterosexual males, whereas the reverse was observed in 12-year-olds. Furthermore, the 12-year-olds perceived heterosexual females as more feminine than homosexual females, a difference that disappeared in the older age groups. Results support the view of early adolescence as a crucial period in the development of gender schemata about sexually significant others.

Colonic carcinoma in two adult cystic fibrosis patients

Two adult women with cystic fibrosis (CF) who developed colonic carcinoma, both at age 31, are described. In both patients the carcinoma occurred in the midtransverse colon. The diagnosis had not been suspected, partly because of the patients' relatively young age. In case 1, the symptoms also mimicked the distal intestinal obstruction syndrome. At diagnosis she was shown to have metastases to the regional lymph nodes. In case 2, despite a long history of chronic pulmonary and sinus disorders, CF was not diagnosed until the patient was 36 years old. The incidence of gastrointestinal malignancies has been shown to be significantly increased in patients with CF. As the life expectancy of the CF population increases, vigilance for gastrointestinal cancers in CF patients is important, as illustrated by these two cases.