Constructing evidence-based clinical intrapartum care algorithms for decision-support tools

AIM

To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours.

POPULATION

Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility.

SETTING

Health facilities in low- and middle-income countries.

SEARCH STRATEGY

Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google.

CASE SCENARIOS

Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes.

CONCLUSIONS

Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts.

TWEETABLE ABSTRACT

Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

The information-motivation-behavioral skills model explains physical activity levels for adults with type 2 diabetes across all weight classes

Physical activity is an evidence-based, effective treatment for type 2 diabetes mellitus (T2D), yet insufficient numbers of adults achieve recommended daily levels, particularly amongst higher weight classes. This cross-sectional study assessed whether the Information-Motivation-Behavioural Skills (IMB) Model explained physical activity levels in adults with T2D across different body mass index (BMI) levels (N = 381). Measures included the American Adults Knowledge of Exercise Recommendations (AAKER), Behavioural Regulation in Exercise Questionnaire (BREQ-2), Barriers Specific Self-Efficacy Scale (BARSE) and the outcome measure, International Physical Activity Questionnaire (IPAQ-short form). Analyses included structural equation modelling (SEM) and ordinal logistic regression models. SEM demonstrated a good fit of the IMB Model to the data, accounting for 44% of variance in physical activity levels. Both motivation and self-efficacy had a direct effect, and motivation indirectly predicted physical activity through self-efficacy. Further analyses found the effect of the IMB predictors did not vary according to BMI status. This study supports the application of the IMB Model in explaining physical activity behavior in adults with T2D. In particular, the contribution of motivation and self-efficacy as substantive and modifiable predictors of physical activity will facilitate the development of targeted and evidence-based interventions for individuals of all BMI classes.

Positive reinforcement by general practitioners is associated with greater physical activity in adults with type 2 diabetes

Objective

In a sample of adults with type 2 diabetes mellitus (T2DM), the aim of this study was to examine whether self-reported physical activity level is associated with recall of specific physical activity-related interactions used by general practitioners (GP).

Research design and methods

Adults with T2DM completed an online survey reporting physical activity behaviors and recall of 14 GP-patient interactions about physical activity, mapped onto discrete behavior change techniques (BCT). Stepped logistical regression examined associations between recommended physical activity (≥600 MET-min/week) and GP-patient interactions, controlling for body mass index, diabetes-related comorbidities, depressive symptoms and self-efficacy.

Results

In total, 381 respondents (55% men, mean±SD age: 62±10 years and T2DM duration 8±8 years) provided complete data. Most (73%) reported receiving 'general advice', while interactions related to goal setting, monitoring, and relapse prevention were least commonly reported (all <20%). Self-reported achievement of the recommended physical activity level was significantly associated with recall of GP interactions involving praise for 'efforts to be active' (OR 2.1; 95% CI 1.24 to 3.53), 'lost weight' (OR 1.81; 95% CI 1.05 to 3.12) or lowering 'glucose levels as a result of being active' (OR 1.75; 95% CI 1.03 to 2.96).

Conclusions

Findings suggest GPs can be somewhat effective in promoting physical activity with simple, positive, reinforcing messages/interactions. Future research to develop and evaluate very brief primary care BCT-based physical activity interventions is needed.

Comorbid elevated symptoms of anxiety and depression in adults with type 1 or type 2 diabetes: Results from the International Diabetes MILES Study

AIMS

We examined: (a) the prevalence of comorbid elevated symptoms of anxiety/depression; (b) its demographic/clinical correlates; (c) associations with self-care behaviors, by diabetes type.

METHODS

Cross-sectional self-report data of 6590 adults with diabetes (42% type 1; 58% type 2) from the Australian and Dutch Diabetes MILES studies were used. Elevated symptoms of anxiety/depression were defined as GAD-7 ≥ 10/PHQ-9 ≥ 10.

RESULTS

In both diabetes types, comorbid elevated symptoms of anxiety/depression were present in 9% and symptoms of anxiety alone in 2%; symptoms of depression alone were present in 8% of adults with type 1 diabetes and 11% with type 2 diabetes. Shorter diabetes duration (type 1 only) was the only characteristic that distinguished those with comorbid elevated symptoms of anxiety/depression but not those with symptoms of anxiety/depression alone from the reference group (no/minimal symptoms of anxiety/depression). Those with comorbid elevated symptoms of anxiety/depression had increased odds of sub-optimal diabetes self-care behaviors compared with the reference group, with higher odds than those with symptoms of anxiety or depression alone.

CONCLUSIONS

Comorbid elevated symptoms of anxiety/depression affected one in ten respondents, who also had increased odds of suboptimal diabetes self-care. Those with shorter type 1 diabetes duration may be at increased risk.

Views and preferences of medical professionals and pregnant women about a novel primary prevention intervention for hypertensive disorders of pregnancy: a qualitative study

Background

Calcium and low-dose aspirin are two potential approaches for primary prevention of hypertensive disorders of pregnancy (HDP). This study aimed to explore the acceptability, views and preferences of pregnant women and primary healthcare providers for a fixed-dose combined preparation of aspirin and calcium (a polypill) as primary prevention of HDP in an unselected pregnant population.

Methods

In this qualitative study eight in-depth semi-structured interviews were conducted with Dutch primary care midwives and general practitioners. Seven focus group discussions were organised with women with low-risk pregnancies. Topics discussed were: perceptions of preeclampsia; information provision about preeclampsia and a polypill; views on the polypill concept; preferences and needs regarding implementation of a polypill. Thematic analysis of the data transcripts was carried out to identify emerging themes.

Results

Two major themes shaped medical professionals’ and women’s views on the polypill concept: ‘Informed Choice’ and ‘Medicalisation’. Both could be divided into subthemes related to information provision, personal choice and discussions with regard to the balance between ‘unnecessary medicalisation’ and ‘scientific progress’.

Conclusions

In general, women and healthcare practitioners expressed a positive attitude towards a polypill intervention as primary prevention strategy with aspirin and calcium, providing some conditions are met. The most important conditions for implementation of such a strategy were safety, effectiveness and the possibility to make a well-informed autonomous decision.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0707-8) contains supplementary material, which is available to authorized users.

A call for inclusion of work-related diabetes distress in the spectrum of diabetes management: Results from a cross-sectional survey among working people with type 1 diabetes

AIM

Diabetes distress captures a range of emotional responses and reactions to life with diabetes and is considered a part of the experience of managing diabetes and its treatment. Given the importance of the social context of work life for people of working age we set out to explore whether work-related diabetes distress is a distinct and important dimension of diabetes-related emotional distress in working people with type 1 diabetes.

METHODS

A questionnaire with self-reported measures of psychosocial health and well-being at work was completed by 1126 working people with type 1 diabetes from a specialist diabetes clinic in Denmark. Work-related diabetes distress was assessed with two questions about worry and exhaustion related to reconciling work life and diabetes. Diabetes-related emotional distress was assessed with the Problem Areas in Diabetes scale (PAID-5), a short form version of the full PAID scale. We performed inter-item correlation analyses, exploratory factor analysis, and hierarchical multiple regression analyses.

RESULTS

Inter-item correlations and exploratory factor analysis indicated that work-related diabetes distress was distinct from diabetes-related emotional distress. Further, work-related diabetes distress was found to be a unique contributor to work ability, quality of life, intentional hyperglycaemia at work, and absenteeism, after adjusting for covariates and diabetes-related emotional distress.

CONCLUSIONS

The findings suggest that work-related diabetes distress captures an aspect of distress so far unaccounted for in workers with type 1 diabetes. Further studies are needed to strengthen the conceptual basis of work-related diabetes distress, explore its clinical usefulness and clarify its risk factors.

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

BACKGROUND

Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes.

METHODS

Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6).

RESULTS

Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet.

CONCLUSIONS

This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

Diabetes stigma is associated with negative treatment appraisals among adults with insulin-treated Type 2 diabetes: results from the second Diabetes MILES - Australia (MILES-2) survey

AIM

To explore factors associated with negative insulin appraisals among adults with Type 2 diabetes, including perceived and experienced diabetes stigma.

METHODS

The second Diabetes MILES - Australia study (MILES-2) is a national survey of adults with diabetes, focused on behavioural and psychosocial issues. Subgroup analyses were conducted on the responses of 456 adults with insulin-treated Type 2 diabetes (38% women; mean ± sd age: 61.2 ± 8.8 years; diabetes duration: 14.5 ± 7.5 years; years using insulin: 6.4 ± 5.5). Participants completed validated measures of perceived and experienced diabetes stigma (Type 2 Diabetes Stigma Assessment Scale), insulin appraisals [Insulin Treatment Appraisal Scale (ITAS)] and known correlates of insulin appraisals: diabetes-specific distress (Problem Areas In Diabetes scale) and diabetes-specific self-efficacy (Confidence in Diabetes Self-care scale). A multiple linear regression was conducted (N = 279) to determine the contribution of those variables found to be associated with ITAS Negative scores.

RESULTS

Univariable analyses revealed negative insulin appraisals were associated with demographic and self-care characteristics (age, employment status, BMI, years using insulin, injections per day), self-efficacy, diabetes-specific distress and diabetes stigma (all P < 0.01). Number of injections per day [regression coefficient [95% confidence interval]: 0.74 [0.08, 1.40]; P = 0.028], self-efficacy [-0.12 [-0.19, -0.06]; P < 0.001] and diabetes stigma [0.39 (0.31, 0.46); P < 0.001) significantly and independently contributed to the final multivariable model, explaining 58% of the variance in ITAS Negative scores. The independent contribution of diabetes-specific distress was suppressed following the inclusion of diabetes stigma.

CONCLUSIONS

This study represents the first step in understanding the relationship between perceived and experienced diabetes stigma and negative insulin appraisals, and provides quantitative evidence for the strong, independent relationship between these two important constructs.

Stigma Perceived and Experienced by Adults with Type 1 Diabetes: Linguistic Adaptation and Psychometric Validation of the Danish Version of the Type 1 Diabetes Stigma Assessment Scale (DSAS-1 DK)

OBJECTIVES

We aimed to (a) culturally and linguistically adapt the Type 1 Diabetes Stigma Assessment Scale (DSAS-1) from English (for Australia) into Danish and (b) examine psychometric properties of the measure among Danish adults with type 1 diabetes.

METHODS

We performed a forward-backward translation, face validity interviews with experts and cognitive debriefing of the Danish version (DSAS-1 DK) with ten adults from the target group. The DSAS-1 DK was then completed by 1594 adults with type 1 diabetes. Electronic clinical records provided age, diabetes duration, diabetes-related complications, and glycemic control [glycated hemoglobin (HbA1c)]. We examined internal consistency, construct validity and structural validity of the DSAS-1 DK using exploratory and confirmatory factor analysis in a cross-validation design.

RESULTS

The translated measure was found acceptable by the experts and target group, with only minor adaptations required for the Danish context. The DSAS-1 DK structure was best represented by a three-factor model representing the subscales 'Treated Differently,' 'Blame and Judgement,' and 'Identity Concern' (α = 0.88-0.89). The results also provided some support for calculation of a total score (19-item scale; α = 0.75). The subscales and total scale demonstrated satisfactory convergent and discriminant validity. Good structural validity was demonstrated for the three-factor model for four out of five indices [normed χ ² = 4.257, goodness-of-fit index (GFI) = 0.923, root mean square error of approximation (RMSEA) = 0.065, standardized root mean square residual (SRMSR) = 0.0567, comparative fit index (CFI) = 0.93].

CONCLUSION

The DSAS-1 DK has a confirmed three-factor structure, consistent with the original Australian English version. The measure is now validated and available to advance research into the stigma perceived and experienced by adults with type 1 diabetes in a Danish context.

The Use of Mobile Applications Among Adults with Type 1 and Type 2 Diabetes: Results from the Second MILES-Australia (MILES-2) Study

BACKGROUND

While the number of diabetes-specific mobile applications (apps) continues to grow, there is a lack of knowledge about their actual use.

METHODS

The second MILES (Management and Impact for Long-term Empowerment and Success)-Australia study was a national cross-sectional survey of the psychological, behavioral, and social aspects of diabetes for adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). Associations between diabetes-specific app usage and demographic, clinical, and psychosocial variables were examined.

RESULTS

Of the 1589 respondents responding to the diabetes-specific app questions, 795 had T1D (mean ± standard deviation age 43 ± 14 years; 61% women; diabetes duration 19 ± 14 years) and 794 had T2D (age 60 ± 9 years; 40% women; diabetes duration 11 ± 7 years). Among adults with T1D, 24% (n = 188) reported using apps, with carbohydrate counting (74%; n = 139) as the most common cited purpose. App usage was significantly associated with shorter diabetes duration, more frequent glucose monitoring, and lower self-reported HbA1c. Among adults with T2D, 8% (n = 64) reported using apps, with glucose monitoring (62%; n = 39) as the most common purpose. For all respondents, the most commonly reported reason for not using apps was a belief that they could not help with diabetes self-management.

CONCLUSIONS

A minority of adults with T1D and T2D use apps to support their self-management. App use among adults with T1D is associated with a more recent T1D diagnosis, more frequent glucose monitoring, and lower self-reported HbA1c. Future efforts should focus on this association and determine the mechanisms by which app use is related to better clinical outcomes.

Measuring Type 1 diabetes stigma: development and validation of the Type 1 Diabetes Stigma Assessment Scale (DSAS-1)

AIMS

To develop and validate a self-report measure designed to assess perceived and experienced stigma for adults with Type 1 diabetes: the Type 1 Diabetes Stigma Assessment Scale (DSAS-1).

METHODS

A large item-pool (64 items) was drafted based on qualitative data from interviews with 27 adults with Type 1 diabetes. Eleven adults with Type 1 diabetes completed the draft questionnaire (responding to items using a five-point Likert scale), and participated in cognitive debriefing interviews. Based on their feedback, the item-pool was reduced and refined. Adults with Type 1 diabetes (N=898) completed an online survey including the draft stigma questionnaire (41 items) and other validated measures. Psychometric validation included principal components analysis and confirmatory factor analysis (split samples), internal consistency reliability assessment and Spearman's rho correlations.

RESULTS

Scale reduction techniques resulted in 19 items (α=0.93). An unforced three-factor solution suggested three subscales: Treated Differently (six items, α=0.89); Blame and Judgement (six items, α=0.88); and Identity Concerns (seven items, α=0.89). This was corroborated with a confirmatory factor analysis, which demonstrated reasonable model fit with the three factors; less so for a single-factor model. Satisfactory concurrent, convergent and discriminant validity were demonstrated.

CONCLUSIONS

The 19-item DSAS-1 is a valid and reliable measure of the perceptions and experiences of Type 1 diabetes stigma. This novel, relatively brief measure has satisfactory psychometric properties. The DSAS-1 is now available for investigations into the nature and magnitude of the relationships between diabetes stigma and diabetes self-care behaviours and outcomes.

Validation of the WHO-5 as a first-step screening instrument for depression in adults with diabetes: Results from Diabetes MILES - Australia

AIMS

Screening for depression is recommended internationally. The World Health Organization's 5-item Well-being Index (WHO-5) is used clinically to screen for depression but its empirical suitability for this purpose is not well documented. We investigated the psychometric properties of the WHO-5 and its suitability for identifying likely depression in Australian adults with diabetes.

METHODS

The Diabetes MILES - Australia study dataset provided a sample of N=3249 who completed the WHO-5 (positively-worded 5-item measure of emotional well-being) and the PHQ-9 (9-item measure of depressive symptoms). Analyses were conducted for the full sample, and separately by diabetes type and treatment (type 1, non-insulin-treated type 2, and insulin-treated type 2 diabetes). Construct (convergent and factorial) validity and reliability of the WHO-5 were examined. ROC analyses were used to examine the sensitivity and specificity of the WHO-5 as a depression screening instrument, comparing two commonly used WHO-5 cut-off values (≤7 and <13) with the PHQ-9.

RESULTS

For the whole sample, the WHO-5 demonstrated satisfactory internal consistency reliability (α=0.90) and convergent validity with the PHQ-9 (r=-0.73, p<0.001). Confirmatory factor analysis partially supported factorial validity: Χ²(5)=834.94, p<0.001; RMSEA=0.23, 90% CI 0.21-0.24; CFI=0.98, TLI=0.96; factor loadings=0.78-0.92. The AUC was 0.87 (95% CI: 0.86-0.89, p<0.001). The sensitivity/specificity of the WHO-5 for detecting likely depression was 0.44/0.96 for the ≤7 cut-off, and 0.79/0.79 for the <13 cut-off, with similar findings by diabetes type and treatment.

CONCLUSIONS

These findings support use of a WHO-5 cut-point of <13 to identify likely depression in Australian adults with diabetes, regardless of type/treatment.

What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework

AIMS

Young adults with type 2 diabetes (T2D, 18-39years) face increased risk of vision loss from diabetic retinopathy (DR). Retinal screening is essential to detect DR, yet screening rates for this group are low and little is known about the underlying factors influencing this important behavior. Using the theoretical domains framework (TDF) to guide data collection and analysis, we explored screening barriers and facilitator, contrasting them with a comparator group of older adults with T2D (40+ years).

METHODS

Thirty semi-structured telephone interviews (10 younger, 20 older adults) were conducted. Data were coded into TDF domains with salience identified by "frequency" of reference. Screening facilitators and barriers were systematically compared between groups.

RESULTS

Although many screening facilitators and barriers were shared by younger and older adults, additional factors highly relevant to the former included: social comparison with others ('social influences'); concern for the impact on the family unit, unrealistic optimism and perceived invulnerability ('beliefs about consequences'); lack of time and financial resources ('environmental context and resources'), and DR misconceptions ('knowledge').

CONCLUSIONS

This study demonstrated that young adult retinal screening behavior was influenced by additional social cognitive factors compared to older adults, providing a first-step evidence base for clinicians and other health professionals, and potential targets for future eye health and retinal screening interventions.

Cohort profiles of the cross-sectional and prospective participant groups in the second Diabetes MILES-Australia (MILES-2) study

PURPOSE

More research into the psychosocial aspects of diabetes is needed so that the health and quality of life of people with the condition can be improved. To fill this gap, we conducted the second Diabetes MILES-Australia study (MILES-2), a survey focused on psychological, behavioural and social aspects of diabetes. The aim of the MILES-2 study was to provide a (1) longitudinal follow-up of the original MILES 2011 study cohort; (2) cross-sectional assessment of a new cohort.

PARTICIPANTS

Eligible participants were English-speaking Australians with type 1 or type 2 diabetes, aged 18-75 years. Longitudinal cohort participants were mailed/emailed study invitations directly by researchers. Random sampling (stratified by diabetes type, insulin use, state) of the National Diabetes Services Scheme (NDSS) database and nationwide advertisements were used to recruit new cohort participants. The final sample included N=2342 eligible respondents (longitudinal cohort: n=504; 2015 new cohort: n=1838); 54% had type 2 diabetes.

FINDINGS TO DATE

Survey respondents were from an advantaged socioeconomic background compared to the general population. Respondents with type 1 diabetes were over-represented in the new cohort (45%) relative to the planned stratification (40% type 1 diabetes, 60% type 2 diabetes). Respondents with insulin-treated type 2 diabetes were under-represented in the new cohort relative to the stratified sampling (42% invited vs 50% response). Participants who completed both the 2011 and 2015 surveys were more likely than those completing the 2011 survey only to have type 1 diabetes, report a higher education and annual income, and live in metropolitan areas. Participant feedback indicated that the survey was perceived as relevant and valuable.

FUTURE PLANS

The depth and breadth of the data available in this large sample will highlight unmet needs and priority areas for future investigation and, crucially, will inform policy, programme and intervention development and evaluation in Australia.

The Use of Mobile Applications Among Adolescents with Type 1 Diabetes: Results from Diabetes MILES Youth-Australia

BACKGROUND

The use of mobile applications ("apps") for diabetes management is a rapidly developing area and has relevance to adolescents who tend to be early technology adopters. Apps may be useful for supporting self-management or connecting young people with type 1 diabetes (T1D) with their peers. However, outside controlled trials testing the effectiveness of apps, little is known about app usage in this population. Our aim was to explore app usage among adolescents with T1D.

METHODS

Diabetes MILES Youth-Australia is a national, online cross-sectional survey focused on behavioral and psychosocial aspects relevant to adolescents with T1D. Associations between app usage and demographic, clinical, and psychosocial variables were analyzed using logistic regression.

RESULTS

In total, 425 adolescents with T1D responded to the app questions (mean age, 16 ± 2 years; 62% female; diabetes duration 7 ± 4 years). Overall, 21% (n = 87) indicated that they used an app for diabetes management. Of these, 89% (n = 77) reported carbohydrate counting as the most common purpose. Of those not using apps, 44% (n = 149) indicated that this was due either to no awareness of suitable apps or a belief that apps could not help. App usage was associated significantly with shorter T1D duration, higher socioeconomic status, and at least seven daily blood glucose checks.

CONCLUSIONS

Only one in five respondents were using apps to support their diabetes management; most apps used were not diabetes specific. App users can be characterized as having a more recent T1D diagnosis, checking blood glucose more frequently, and being from a middle-to-high socioeconomic background.

Measuring the Stigma Surrounding Type 2 Diabetes: Development and Validation of the Type 2 Diabetes Stigma Assessment Scale (DSAS-2)

OBJECTIVE

To develop and validate a self-report measure of perceived and experienced stigma for use with adults with type 2 diabetes: the Type 2 Diabetes Stigma Assessment Scale (DSAS-2).

RESEARCH DESIGN AND METHODS

An item pool was drafted based on qualitative data from 25 adults with type 2 diabetes and content from other health-related stigma questionnaires. Thirteen adults with type 2 diabetes completed 57 draft diabetes stigma items and participated in cognitive debriefing interviews. Based on participant feedback, the pool was reduced to 48 items with a 5-point Likert scale (strongly disagree to strongly agree). A total of 1,064 adults with type 2 diabetes completed a survey including these 48 items and other validated measures. Data were subject to principal components analysis and Spearman ρ correlations.

RESULTS

The scale was reduced to 19 items, with an unforced three-factor solution indicative of three subscales: Treated Differently (6 items, α = 0.88), Blame and Judgment (7 items, α = 0.90), and Self-stigma (6 items, α = 0.90). A forced one-factor solution supported the calculation of a total score (α = 0.95). Satisfactory concurrent, convergent, and discriminant validity were demonstrated.

CONCLUSIONS

The 19-item DSAS-2 is a reliable and valid measure of type 2 diabetes stigma. A rigorous design and validation process has resulted in a relatively brief measure of perceived and experienced stigma in type 2 diabetes. The novel scale has satisfactory psychometric properties and is now available to facilitate much-needed research in this field.

Suicidal ideation reported by adults with Type 1 or Type 2 diabetes: results from Diabetes MILES-Australia

AIMS

To examine the prevalence and correlates of suicidal ideation (SI) in a community-based sample of adults with Type 1 or Type 2 diabetes.

METHODS

Participants were 3338 adults aged 18-70 years with Type 1 diabetes (n = 1376) or Type 2 diabetes (non-insulin: n = 1238; insulin: n = 724) from a national survey administered to a random sample registered with the National Diabetes Services Scheme. Depression and SI were assessed using the Patient Health Questionnaire, and diabetes-specific distress with the Problem Areas In Diabetes scale. Separate logistic regression analyses by diabetes type/treatment were used to determine relative contribution to SI.

RESULTS

Overall, we observed a SI rate of 14% in our sample. Participants with Type 2 diabetes using insulin reported more frequent depressive symptoms, and were more likely to report recent SI (19%) compared with those with either Type 1 diabetes or Type 2 diabetes not using insulin (14 and 12%, respectively). After controlling for depression, there was little difference in the prevalence of SI between diabetes types/treatments, but higher diabetes-specific distress significantly increased the odds of SI.

CONCLUSIONS

As SI is a significant risk factor for a suicide attempt, the findings have implications for healthcare professionals, pointing to the importance of adequate screening and action plans for appropriate follow-up of those reporting depression. Our findings are also indicative of the psychological toll of diabetes more generally, and the need to integrate physical and mental healthcare for people with diabetes.

The impact of insulin therapy and attitudes towards insulin intensification among adults with type 2 diabetes: A qualitative study

BACKGROUND

As type 2 diabetes (T2DM) is a progressive chronic condition, regular clinical review and treatment intensification are critical for prevention of long-term complications. Our aim was to explore the personal impact of insulin therapy, both positive and negative consequences, and attitudes towards future insulin intensification.

METHODS

Twenty face-to-face interviews were conducted, and transcripts were analysed using thematic inductive analysis. Eligible participants were adults with T2DM, using insulin injections for <4years. Participants were mostly men (n=13, 65%), (median (range)) aged 65 (43-76) years, living with T2DM for 11.5 (2-27) years.

RESULTS

Five themes emerged regarding the consequences (positive and negative) of insulin therapy, including: physical impact, personal control, emotional well-being, freedom/flexibility, (concerns about) others' reactions. Increased inconvenience and the perceived seriousness of using fast-acting insulin were both reported as barriers to future insulin intensification, despite most participants being receptive to the idea of administering additional injections.

CONCLUSIONS

Positive and negative experiences of insulin therapy were reported by adults with T2DM and most were receptive to insulin intensification despite reported barriers. These findings may inform clinical interactions with people with T2DM and interventions to promote receptiveness to insulin initiation and intensification.

What is the best measure for assessing diabetes distress? A comparison of the Problem Areas in Diabetes and Diabetes Distress Scale: results from Diabetes MILES–Australia

This study used Rasch analysis to examine the psychometric validity of the Diabetes Distress Scale and the Problem Areas in Diabetes scale to assess diabetes distress in 3338 adults with diabetes (1609 completed the Problem Areas in Diabetes scale ( n = 675 type 1 diabetes; n = 934 type 2 diabetes) and 1705 completed the Diabetes Distress Scale ( n = 693 type 1 diabetes; n = 1012 type 2 diabetes)). While criterion and convergent validity were good, Rasch analysis revealed suboptimal precision and targeting, and item misfit. Unresolvable multidimensionality within the Diabetes Distress Scale suggests a total score should be avoided, while suboptimal precision suggests that the Physician-related and Interpersonal distress subscales should be used cautiously.

‘Are you sure you’re going to have another one of those?’: A qualitative analysis of the social control and social support models in type 2 diabetes

While there is evidence that spouses can impact the self-management of adults with type 2 diabetes mellitus, less is known about the influence of the wider social network. This qualitative study explored the perceived impact of the family as well as friends and work colleagues on type 2 diabetes mellitus self-management. A total of 25 adults with type 2 diabetes mellitus participated in semi-structured interviews regarding their social experiences of living with diabetes. Deductive thematic analysis was applied to the data. Pre-existing themes of health-related social control and social support were identified in the wider social network, with additional themes of non-involvement and unintentional undermining also emerging.

Building the evidence for integrated care for type 2 diabetes: a pilot study

Integrated care models have the potential to reduce fragmentation in the health system and improve outcomes for people with type 2 diabetes. A pilot evaluation of an integrated care model for people with type 2 diabetes in Melbourne, Australia, is reported on. Two studies were conducted: (1) a 6-month pilot randomised controlled trial (n=56) evaluating the impact of the integrated care model relative to hospital outpatient clinics; and (2) a cross-sectional study (n=92) of patients attending the two services. The primary outcome was diabetes-specific distress; secondary outcomes were perceived quality of diabetes care, diabetes-specific self-efficacy and glycated haemoglobin (HbA1c). There was no effect of service setting on diabetes-specific distress. Participants from the integrated care setting perceived the quality of diabetes care to be higher than did participants from the hospital clinics. Significant HbA1c improvements were observed over time, but with no effect of service setting. The model holds promise for people with type 2 diabetes who need more specialist/multidisciplinary care than can be provided in primary care. Patients’ evaluations of the quality of diabetes care received at the integrated care service are very positive, which is likely to be one of the key strengths of the integrated model.

Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract

OBJECTIVE

To establish the accuracy of three-dimensional ultrasound (3D-US), compared with magnetic resonance imaging (MRI), for diagnosing uterine anomalies, using the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) consensus on the classification of congenital anomalies of the female genital tract.

METHODS

Sixty women with uterine anomalies suspected after examination by conventional two-dimensional ultrasound were evaluated with 3D-US and MRI. These data were analyzed retrospectively to confirm the presence and type of uterine malformation in accordance with the ESHRE-ESGE consensus. Sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were calculated, using MRI as the gold standard, and agreement between the two methods was evaluated by kappa index.

RESULTS

Compared with MRI, for the diagnosis of normal uteri, 3D-US had a sensitivity of 83.3%, specificity of 100%, PPV of 100%, NPV of 98.2% and kappa index of 0.900. For dysmorphic uteri and for hemi-uteri, the sensitivity, specificity, PPV and NPV were all 100%, and kappa was 1.00. For septate uteri, the sensitivity was 100%, specificity was 88.9%, PPV was 95.5%, NPV was 100% and kappa was 0.918. For bicorporeal uteri, the sensitivity was 83.3%, specificity was 100%, PPV was 100%, NPV was 98.2% and kappa was 0.900.

CONCLUSIONS

3D-US is highly accurate for diagnosing uterine malformations, having a good level of agreement with MRI in the classification of different anomaly types based on the ESHRE-ESGE consensus.

Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting

OBJECTIVE

The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub-Saharan African setting.

METHODS

A prospective cohort study of 1010 women of less than 17 weeks of gestation was conducted at two antenatal clinics in Accra, Ghana, between July 2012 and March 2014. Information about hypertensive disorders was available for analysis on 789 pregnancies. The main outcomes were pre-term birth, birthweight, Apgar scores, small for gestational age and mortality. Relative risk (RR, 95% confidence interval (CI)) for the association between hypertensive disorders of pregnancy and perinatal outcomes was assessed using logistic regression adjusting for potential confounders.

RESULTS

A total of 88.7% of women remained normotensive, 7.5% developed pregnancy-induced hypertension, 2.0% had chronic hypertension, and 1.7% developed (pre-)eclampsia. No adverse effects were observed in women with pregnancy-induced hypertension. Women with chronic hypertension were more likely to have a lower gestational age at delivery (38.0 ± 2.3 weeks vs. 39.0 ± 1.9 weeks, P = 0.04) and higher risk of pre-term delivery (aRR 4.63, 95% CI 1.35-15.91). Women with pre-eclampsia had emergency Caesarean section significantly more often (88.9% vs. 50%, P = 0.04), with a higher risk for low birthweight infants (aRR 7.95, 95% CI 1.41-44.80) and a higher risk of neonatal death (aRR 18.41, 95% CI 1.20-283.22).

CONCLUSION

Comparable to high-income countries, in Accra hypertensive disorders during pregnancy were associated with increased risk of adverse perinatal outcomes necessitating maternal and newborn care.

Dried blood spot measurement of pregnancy-associated plasma protein A (PAPP-A) and free β-subunit of human chorionic gonadotropin (β-hCG) from a low-resource setting

OBJECTIVES

The objectives of the article is to compare pregnancy-associated plasma protein A (PAPP-A) and free β-subunit of human chorionic gonadotropin (β-hCG) concentrations in dried blood spots (DBSs) with serum of samples obtained from a public hospital in a low-resource setting and to evaluate their stability.

METHODS

Serum and DBS samples were obtained by venipuncture and finger prick from 50 pregnant participants in a cohort study in a public hospital in Accra, Ghana. PAPP-A and β-hCG concentrations from serum and DBS were measured with an AutoDELFIA® (PerkinElmer, PerkinElmer, Turku, Finland) automatic immunoassay. Correlation and Passing-Bablok regression analyses were performed to compare marker levels.

RESULTS

High correlation (>0.9) was observed for PAPP-A and β-hCG levels between various sampling techniques. The β-hCG concentration was stable between DBS and serum, PAPP-A concentration consistently lower in DBS.

CONCLUSION

Our findings suggest that β-hCG can be reliably collected from DBS in low-resource tropical settings. The exact conditions of the clinical workflow necessary for reliable PAPP-A measurement in these settings need to be further developed in the future. These findings could have implications for prenatal screening programs feasibility in low-income and middle-income countries, as DBS provides an alternative minimally invasive sampling method, with advantages in sampling technique, stability, logistics, and potential application in low-resource settings.

Depression, anxiety and self-care behaviours of young adults with Type 2 diabetes: results from the International Diabetes Management and Impact for Long-term Empowerment and Success (MILES) Study

AIM

Young adults with Type 2 diabetes have higher physical morbidity and mortality than other diabetes sub-groups, but differences in psychosocial outcomes have not yet been investigated. We sought to compare depression and anxiety symptoms and self-care behaviours of young adults with Type 2 diabetes with two matched control groups.

METHODS

Using cross-sectional survey data from the Australian and Dutch Diabetes Management and Impact for Long-term Empowerment and Success (MILES) studies, we matched 93 young adults (aged 18-39 years) with Type 2 diabetes (case group) with: (i) 93 older adults ( ≥ 40 years) with Type 2 diabetes (Type 2 diabetes control group; matched on country, gender, education, diabetes duration and insulin use) and (ii) 93 young adults with Type 1 diabetes (Type 1 diabetes control group; matched on country, gender, age and education). Groups were compared with regard to depression symptoms (nine-item Patient Health Questionnaire), anxiety symptoms (seven-item Generalised Anxiety Disorder questionnaire) and frequency of selected self-care behaviours (single item per behaviour).

RESULTS

Participants in the case group had higher depression scores (Cohen's d = 0.40) and were more likely to have clinically meaningful depressive symptoms (Cramer's V = 0.23) than those in the Type 2 diabetes control group. Participants in the case group had statistically equivalent depression scores to the Type 1 diabetes control group. The groups did not differ in anxiety scores. Those in the case group were less likely than both control groups to take insulin as recommended (Cramer's V = 0.24-0.34), but there were no significant differences between the groups in oral medication-taking. The case group were less likely than the Type 2 diabetes control group to eat healthily (Cramer's V = 0.16), and less likely than the Type 1 diabetes control group to be physically active (Cramer's V = 0.15).

CONCLUSIONS

Our results suggest that Type 2 diabetes is as challenging as Type 1 diabetes for young adults and more so than for older adults. Young adults with Type 2 diabetes may require more intensive psychological and self-care support than their older counterparts.

Vaginal delivery after hemipelvectomy and pelvic radiotherapy for chondrosarcoma

Chondosarcoma of the proximal femur is a rare malignant disorder in women of (pre-) childbearing age, for which a radical resection through a hemipelvectomy could be indicated. We describe a case of a 36-year-old primigravida with a hemipelvectomy (2004) who had a history of radiotherapy of the pelvic and uterine regions after an atypical cartilaginous tumour. After an uncomplicated pregnancy, she had a spontaneous rupture of the membranes at 41+2 weeks and an uncomplicated vaginal delivery with physiological development of the infant. On the basis of the literature review, vaginal delivery after hemipelvectomy should be advocated and discussed with the patient and involved care providers. Women with radiotherapy in the pelvic and uterine areas have an increased risk of stillbirth, placental attachment disorders, impaired fetal growth, fetal malposition and preterm labour, but no association with prolonged rupture of the membranes has been described.

'I'm not a druggie, I'm just a diabetic': a qualitative study of stigma from the perspective of adults with type 1 diabetes

OBJECTIVES

While health-related stigma has been the subject of considerable research in other conditions (eg, HIV/AIDS, obesity), it has not received substantial attention in diabetes. Our aim was to explore perceptions and experiences of diabetes-related stigma from the perspective of adults with type 1 diabetes mellitus (T1DM).

DESIGN

A qualitative study using semistructured interviews, which were audio recorded, transcribed and subject to thematic analysis.

SETTING

All interviews were conducted in non-clinical settings in metropolitan areas of Victoria, Australia.

PARTICIPANTS

Adults aged ≥18 years with T1DM living in Victoria were eligible to take part. Participants were recruited primarily through the state consumer organisation representing people with diabetes. A total of 27 adults with T1DM took part: 15 (56%) were women; median IQR age was 42 (23) years and diabetes duration was 15 (20) years).

RESULTS

Australian adults with T1DM perceive and experience T1DM-specific stigma as well as stigma-by-association with type 2 diabetes. Such stigma is characterised by blame, negative social judgement, stereotyping, exclusion, rejection and discrimination. Participants identified the media, family and friends, healthcare professionals and school teachers as sources of stigma. The negative consequences of this stigma span numerous life domains, including impact on relationships and social identity, emotional well-being and behavioural management of T1DM. This stigma also led to reluctance to disclose the condition in various environments. Adults with T1DM can be both the target and the source of diabetes-related stigma.

CONCLUSIONS

Stigmatisation is part of the social experience of living with T1DM for Australian adults. Strategies and interventions to address and mitigate this diabetes-related stigma need to be developed and evaluated.

Associations between economic hardship and markers of self-management in adults with type 2 diabetes: results from Diabetes MILES - Australia

OBJECTIVE

A socioeconomic gradient exists in Australia for type 2 diabetes mellitus (T2DM). It remains unclear whether economic hardship is associated with T2DM self-management behaviours.

METHODS

Cross-sectional data from a subset of the Diabetes MILES - Australia study were used (n=915). The Economic Hardship Questionnaire was used to assess hardship. Outcomes included: healthy eating and physical activity (Diabetes Self-Care Inventory - Revised), medication-taking behaviour (Medication Adherence Rating Scales) and frequency of self-monitoring of blood glucose (SMBG). Regression modelling was used to explore the respective relationships.

RESULTS

Greater economic hardship was significantly associated with sub-optimal medication-taking (Coefficient: -0.86, 95%CI -1.54, -0.18), and decreased likelihood of regular physical activity (Odds Ratio: 0.47, 0.29, 0.77). However, after adjustments for a range of variables, these relationships did not hold. Being employed and higher depression levels were significantly associated with less-frequent SMBG, sub-optimal medication-taking and less-regular healthy eating. Engaging in physical activity was strongly associated with healthy eating.

CONCLUSIONS

Employment, older age and depressive symptoms, not economic hardship, were commonly associated with diabetes self-management.

IMPLICATIONS

Work-based interventions that promote T2DM self-management in younger, working populations that focus on negative emotions may be beneficial.

Severe obesity and diabetes self-care attitudes, behaviours and burden: implications for weight management from a matched case-controlled study. Results from Diabetes MILES--Australia

AIMS

To investigate whether diabetes self-care attitudes, behaviours and perceived burden, particularly related to weight management, diet and physical activity, differ between adults with Type 2 diabetes who are severely obese and matched non-severely obese control subjects.

METHODS

The 1795 respondents to the Diabetes MILES--Australia national survey had Type 2 diabetes and reported height and weight data, enabling BMI calculation: 530 (30%) were severely obese (BMI ≥ 35 kg/m(2); median BMI = 41.6 kg/m(2)) and these were matched with 530 control subjects (BMI < 35 kg/m(2); median BMI = 28.2 kg/m(2)). Diabetes self-care behaviours, attitudes and burden were measured with the Diabetes Self-Care Inventory-Revised. Within-group and between-group trends were examined.

RESULTS

The group with BMI ≥ 35 kg/m(2) was less likely to achieve healthy diet and exercise targets, placed less importance on diet and exercise recommendations, and found the burden of diet and exercise recommendations to be greater than the group with BMI < 35 kg/m(2). The group with BMI ≥ 35 kg/m(2) was more likely to be actively trying to lose weight, but found weight control a greater burden. These issues accentuated with increasing obesity and were greatest in those with BMI > 45 kg/m(2). There were no between-group differences in other aspects of diabetes self-care: self-monitoring of blood glucose, use of medications and smoking. Moderate-to-severe symptoms of depression were independently associated with reduced likelihood of healthy diet and physical activity, and with greater burden associated with diet, physical activity and weight management.

CONCLUSIONS

Severely obese people with diabetes demonstrated self-care attitudes, behaviours and burdens that infer barriers to weight loss. However, other important diabetes self-care behaviours are supported equally by severely obese and non-severely obese individuals.

'I call it the blame and shame disease': a qualitative study about perceptions of social stigma surrounding type 2 diabetes

OBJECTIVES

While health-related stigma has been the subject of considerable research in other conditions (obesity and HIV/AIDS), it has not received substantial attention in diabetes. The aim of the current study was to explore the social experiences of Australian adults living with type 2 diabetes mellitus (T2DM), with a particular focus on the perception and experience of diabetes-related stigma.

DESIGN

A qualitative study using semistructured interviews, which were audio recorded, transcribed and subject to thematic analysis.

SETTING

This study was conducted in non-clinical settings in metropolitan and regional areas in the Australian state of Victoria. Participants were recruited primarily through the state consumer organisation representing people with diabetes.

PARTICIPANTS

All adults aged ≥18 years with T2DM living in Victoria were eligible to take part. Twenty-five adults with T2DM participated (12 women; median age 61 years; median diabetes duration 5 years).

RESULTS

A total of 21 (84%) participants indicated that they believed T2DM was stigmatised, or reported evidence of stigmatisation. Specific themes about the experience of stigma were feeling blamed by others for causing their own condition, being subject to negative stereotyping, being discriminated against or having restricted opportunities in life. Other themes focused on sources of stigma, which included the media, healthcare professionals, friends, family and colleagues. Themes relating to the consequences of this stigma were also evident, including participants' unwillingness to disclose their condition to others and psychological distress. Participants believed that people with type 1 diabetes do not experience similar stigmatisation.

CONCLUSIONS

Our study found evidence of people with T2DM experiencing and perceiving diabetes-related social stigma. Further research is needed to explore ways to measure and minimise diabetes-related stigma at the individual and societal levels, and also to explore perceptions and experiences of stigma in people with type 1 diabetes.

Severely obese people with diabetes experience impaired emotional well-being associated with socioeconomic disadvantage: results from diabetes MILES - Australia

AIM

To examine the emotional well-being of severely obese Australians with type 2 diabetes, along with markers of social and economic disadvantage, using the Diabetes MILES - Australia dataset.

METHODS

Diabetes MILES - Australia was a national survey of 3338 adults with diabetes that focused on psychosocial issues; 1795 had type 2 diabetes and reported BMI. We extracted data regarding depression (PHQ-9), anxiety (GAD-7), obesity- and diabetes-related comorbidities, and demographics. The severely obese group (SOG) (BMI ≥ 35; median BMI=41.6) constituted 530 (30%) of the type 2 diabetes respondents and was matched with 530 controls (CG) (BMI<35; median BMI=28.2). Within- and between-group trends were examined.

RESULTS

The SOG had higher depression scores (median (IQR) 6.0 (3-12)) than CG (5.0 (2-10)); p<0.001, and were more likely to report moderate-severe depressive symptoms (37% versus 27%; p<0.001). The groups did not differ on anxiety. The SOG, compared with the CG, were more likely to live alone (21% versus 17%), receive a disability pension (21% versus 15%), earn ≤$40.000/year (51% versus 41%; all p<0.05), and were less likely to be employed (46% versus 53%), university or higher educated (17% versus 26%), or have health insurance (50% versus 60%; all p ≤ 0.01). Moderate-severe depression was positively associated with cumulative stressors of severe obesity, socioeconomic disadvantage, and obesity- and diabetes-related comorbidity.

CONCLUSIONS

Severely obese people living with type 2 diabetes have cumulative stressors related to health, disability, demographic and socioeconomic factors, and impaired emotional well-being.

Does the shortage of diabetes specialists in regional and rural Australia matter? Results from Diabetes MILES--Australia

AIM

To investigate differences in access to services and health outcomes between people living with Type 1 (T1DM) and Type 2 (T2DM) diabetes in rural/regional and metropolitan areas.

METHODS

Diabetes MILES--Australia was a national postal/online survey of persons registered with the National Diabetes Services Scheme. Selected variables, including utilisation of health care services and self-care indicators, were analysed for 3338 respondents with T1DM (41%) or T2DM (59%).

RESULTS

Respondents from rural/regional (n=1574, 48%) and metropolitan areas were represented equally (n=1700, 52%). After adjusting for diabetes duration, demographic and socioeconomic variables, rural/regional respondents with T1DM (RR 0.90, 95% CI 0.83-0.97) and T2DM (RR 0.69, 95% CI 0.59-0.81) were less likely to report consulting an endocrinologist during the past 12 months. Rural/regional respondents with T1DM were more than twice as likely to have accessed a community/practice nurse for diabetes care (RR 2.22, 95% CI 1.25-3.93) while those with T2DM were more likely to have accessed a diabetes educator (RR 1.21, 95% CI 1.07-1.36) or dietician (RR 1.17, 95% CI 1.07-1.36). For the T1DM and T2DM groups were no differences between rural/regional and metropolitan respondents in self-reported hypoglycaemic events during past week and the majority of self-care indicators.

CONCLUSIONS

Despite a lack of access to medical specialists, respondents with T1DM and T2DM living in rural/regional areas did not report worse health or self-care indicators. The results suggest that multidisciplinary primary services in rural areas may be providing additional care for people with diabetes, compensating for poor access to specialists.

The needs, concerns, and characteristics of younger Australian adults with Type 2 diabetes

AIMS

The mean age of onset of Type 2 diabetes mellitus is decreasing in Australia and internationally. We conducted an internet-based survey to improve our understanding of the emotional well-being and unmet needs of younger adults with Type 2 diabetes, and to inform service provision for this group.

METHODS

A random sample of National Diabetes Services Scheme registrants (n = 1,417) with Type 2 diabetes, aged 18-39 years, living in the Australian state of Victoria received an invitation to complete the online survey. The study was also advertised state-wide. The survey included validated scales (PAID-5: diabetes-related distress; WHO-5: general emotional well-being) and study-specific items. A total of 149 eligible respondents participated.

RESULTS

Almost two-thirds (63%) of respondents reported severe-diabetes related distress; more than a quarter (27%) had impaired general emotional well-being. Most (82%) were overweight or obese (BMI ≥ 25); most (77%) had at least one other co-morbidity. Lack of motivation, feeling burned out, and being time-poor were identified as top barriers to self-management. More than half (59%) of respondents had not participated in structured diabetes education. Respondents perceived that younger adults with Type 2 diabetes had different health-care needs than their older counterparts (68%), and that most Type 2 diabetes information/services were aimed at older adults (62%). Of a range of potential new services, respondents indicated greatest interest in an online forum specifically for younger adults with Type 2 diabetes.

CONCLUSIONS

Younger adults with Type 2 diabetes have impaired emotional well-being and physical health. Population-based research is needed to confirm the current findings, to further inform service delivery and optimise outcomes for this group.

Social stigma in diabetes : a framework to understand a growing problem for an increasing epidemic

A comprehensive understanding of the social and psychological impact of diabetes mellitus is important for informing policy and practice. One potentially significant, yet under-researched, issue is the social stigma surrounding diabetes. This narrative review draws on literature about health-related stigma in diabetes and other chronic conditions in order to develop a framework for understanding diabetes-related stigma. Our review of the literature found that people who do not have diabetes assume that diabetes is not a stigmatized condition. In contrast, people with diabetes report that stigma is a significant concern to them, experienced across many life domains, e.g., in the workplace, in relationships. The experience of diabetes-related stigma has a significant negative impact on many aspects of psychological well-being and may also result in sub-optimal clinical outcomes for people with diabetes. We propose a framework that highlights the causes (attitudes of blame, feelings of fear and disgust, and the felt need to enforce social norms and avoid disease), experiences (being judged, rejected, and discriminated against), and consequences (e.g., distress, poorer psychological well-being, and sub-optimal self-care) of diabetes-related stigma and also identifies potential mitigating strategies to reduce diabetes-related stigma and/or enhance coping and resilience amongst people with diabetes. The systematic investigation of the experiences, causes, and consequences of diabetes-related stigma is an urgent research priority.

Challenging evidence and assumptions: is there a role for self-monitoring of blood glucose in people with type 2 diabetes not using insulin?

BACKGROUND

There is debate in the literature about the effectiveness of self-monitoring of blood glucose (SMBG) for people with type 2 diabetes (T2DM) who do not use insulin. Several recent systematic reviews and meta-analyses conclude that SMBG does not have any clinical benefit for this group.

OBJECTIVE

We critically appraise the available evidence, and argue whether SMBG is warranted for people with non-insulin-treated T2DM.

RESULTS

Considerable heterogeneity exists amongst the literature, and aspects of the methodology of some of these studies confound interpretation of results. Recent evidence demonstrates that when SMBG is 'structured', incorporated as part of a complex intervention, and embedded within education and collaborative care, improvements in average blood glucose levels result. In contrast, studies that do not apply SMBG systematically, or that assess a low frequency SMBG regimen that precludes identification and interpretation of SMBG patterns, are not clinically effective. Psychosocial outcomes, such as self-efficacy and diabetes-related distress, and other clinical outcomes, such as hypoglycaemia detection, should also be considered as important clinical endpoints.

LIMITATIONS

This is not a systematic literature review. The literature is limited by a lack of studies evaluating a 'structured' approach to SMBG.

CONCLUSIONS

It is the quality, not quantity, of SMBG that makes a difference to outcomes for people with non-insulin-treated T2DM. The benefits of 'structured' SMBG should be considered as part of a complex intervention when making decisions about policy and practice, and assumptions about the benefits of SMBG for people with non-insulin-treated T2DM should be challenged.

Assessing the impact of diabetes on the quality of life of older adults living in a care home: validation of the ADDQoL Senior

AIMS

Around a quarter of UK care-home residents have diabetes. Diabetes is known to impact quality of life but existing diabetes-specific quality of life measures are unsuitable for elderly care-home residents. We aimed to develop and evaluate a new measure for use with older adults, to be particularly suitable for use with care-home residents: the Audit of Diabetes-Dependent Quality of Life (ADDQoL) Senior*.

METHODS

Content and format changes were made to the 19-domain ADDQoL, informed by related measures for people with visual impairments (12 domain-specific items were retained, four items were revised/added and three items were removed). This revision was modified further following cognitive debriefing interviews with three older adults living in a care home. Psychometric evaluation of the newly developed 17-domain ADDQoL Senior was conducted using data from 90 care-home residents with diabetes who took part in a broader intervention study.

RESULTS

The life domains most impacted by diabetes were 'independence' and 'freedom to eat as I wish'. The ADDQoL Senior demonstrated good factor structure and internal consistency (Cronbach's alpha = 0.924). Domain scores were, as expected, significantly intercorrelated.

CONCLUSIONS

The ADDQoL Senior measures the perceived impact of diabetes on quality of life in older adults, and has been found to be suitable for those living in care homes if administered by interview. The scale has demonstrated acceptability and excellent psychometric properties. It is anticipated that the number of items may be reduced in the future if our current findings can be replicated.

Diabetes MILES--The Netherlands: rationale, design and sample characteristics of a national survey examining the psychosocial aspects of living with diabetes in Dutch adults

BACKGROUND

As the number of people with diabetes is increasing rapidly worldwide, a more thorough understanding of the psychosocial aspects of living with this condition has become an important health care priority. While our knowledge has grown substantially over the past two decades with respect to the physical, emotional and social difficulties that people with diabetes may encounter, many important issues remain to be elucidated. Under the umbrella of the Diabetes MILES (Management and Impact for Long-term Empowerment and Success) Study International Collaborative, Diabetes MILES--The Netherlands aims to examine how Dutch adults with diabetes manage their condition and how it affects their lives. Topics of special interest in Diabetes MILES--The Netherlands include subtypes of depression, Type D personality, mindfulness, sleep and sexual functioning.

METHODS/DESIGN

Diabetes MILES--The Netherlands was designed as a national online observational study among adults with diabetes. In addition to a main set of self-report measures, the survey consisted of five complementary modules to which participants were allocated randomly. From September to October 2011, a total of 3,960 individuals with diabetes (40% type 1, 53% type 2) completed the battery of questionnaires covering a broad range of topics, including general health, self-management, emotional well-being and contact with health care providers. People with self-reported type 1 diabetes (specifically those on insulin pump therapy) were over-represented, as were those using insulin among respondents with self-reported type 2 diabetes. People from ethnic minorities were under-represented. The sex distribution was fairly equal in the total sample, participants spanned a broad age range (19-90 years), and diabetes duration ranged from recent diagnosis to living with the condition for over fifty years.

DISCUSSION

The Diabetes MILES Study enables detailed investigation of the psychosocial aspects of living with diabetes and an opportunity to put these findings in an international context. With several papers planned resulting from a pooled Australian-Dutch dataset and data collections planned in other countries, the Diabetes MILES Study International Collaborative will contribute substantially to identifying potentially unmet needs of those living with diabetes and to inform clinical research and care across the globe.

Diabetes MILES--Australia (management and impact for long-term empowerment and success): methods and sample characteristics of a national survey of the psychological aspects of living with type 1 or type 2 diabetes in Australian adults

Background

Successful management of diabetes requires attention to the behavioural, psychological and social aspects of this progressive condition. The Diabetes MILES (Management and Impact for Long-term Empowerment and Success) Study is an international collaborative. Diabetes MILES--Australia, the first Diabetes MILES initiative to be undertaken, was a national survey of adults living with type 1 or type 2 diabetes in Australia. The aim of this study was to gather data that will provide insights into how Australians manage their diabetes, the support they receive and the impact of diabetes on their lives, as well as to use the data to validate new diabetes outcome measures.

Methods/design

The survey was designed to include a core set of self-report measures, as well as modules specific to diabetes type or management regimens. Other measures or items were included in only half of the surveys. Cognitive debriefing interviews with 20 participants ensured the survey content was relevant and easily understood. In July 2011, the survey was posted to 15,000 adults (aged 18-70 years) with type 1 or type 2 diabetes selected randomly from the National Diabetes Services Scheme (NDSS) database. An online version of the survey was advertised nationally. A total of 3,338 eligible Australians took part; most (70.4%) completed the postal survey. Respondents of both diabetes types and genders, and of all ages, were adequately represented in both the postal and online survey sub-samples. More people with type 2 diabetes than type 1 diabetes took part in Diabetes MILES--Australia (58.8% versus 41.2%). Most respondents spoke English as their main language, were married/in a de facto relationship, had at least a high school education, were occupied in paid work, had an annual household income > $AUS40,000, and lived in metropolitan areas.

Discussion

A potential limitation of the study is the under-representation of respondents from culturally and linguistically diverse backgrounds (including Aboriginal and Torres Strait Islander origin). Diabetes MILES--Australia represents a major achievement in the study of diabetes in Australia, where for the first time, the focus is on psychosocial and behavioural aspects of this condition at a national level.

Chronic stress impairs oxidative metabolism and hepatic excretion of model xenobiotic substrates in the rat

Traumatic injury to both hard and soft tissue has been associated with a decrease in the rate of hepatic drug metabolism. The mechanism(s) underlying this phenomenon have yet to be determined, but may involve substances released from damaged tissues or activation of the adrenocortical axis secondary to stress. To determine whether a generalized stress response is involved in the trauma-induced perturbations of xenobiotic metabolism, rats were exposed to atraumatic stress for a period of 21 days prior to determining the disposition of antipyrine (an in vivo marker for the hepatic mixed-function oxidase system) and indocyanine green (a tricarbocyanine dye often used as an in vivo marker of active hepatic uptake). Exposure to stress resulted in a significant decrease in the systemic clearance of antipyrine, suggesting a stress-induced inhibition of hepatic oxidation. In addition, the stressed animals evidenced a decreased rate of uptake of indocyanine green by the liver, an apparent decrease in the storage of the dye within the liver, and a decreased hepatic clearance of indocyanine green (presumably due to a decrease in the KM for biliary transport). These observations suggest that atraumatic stress affects several processes involved in the hepatobiliary disposition of xenobiotics.

Bayesian forecasting of serum lithium concentrations. Comparison with traditional methods

Twelve pharmacokinetic methods of estimating lithium maintenance dosage requirements were compared in 21 patients with bipolar illness. Methods which were compared included the single- and multiple-point methods of Perry, 4 non-linear regression and 6 Bayesian methods. The REVOL algorithm was employed for converging on to estimates of clearance and apparent volume of distribution for the non-linear regression and Bayesian methods. Data analysis was based on an evaluation of prediction error as a measure of bias, and absolute prediction error as a measure of precision. In a direct comparison, there were no statistically significant differences in bias or precision between any of the methods.

A comparison of pharmacokinetic versus empirical lithium dosing techniques

Three methods for estimating maintenance dosage requirements of lithium carbonate were retrospectively evaluated in 20 inpatients who met criteria of the Diagnostic and Statistical Manual, Third Edition, for "bipolar disorder, manic phase." Dosing methods evaluated included a pharmacokinetic method, the single-point method of Perry et al.; a population-based nomogram approach, the Zetin et al. method; and a physician-based empirical dosing procedure. The ability of each dosing procedure to produce dosing recommendations that resulted in a targeted steady-state serum lithium concentration was evaluated. The empirical dosing procedure demonstrated a significant tendency (bias) to underestimate the dose necessary to produce a desired steady-state serum lithium concentration. Comparison of the predictive accuracy of the various dosing methods failed to demonstrate any statistically significant differences among the dosing procedures. There was a strong trend, however, for the Perry method to produce predictions of steady-state lithium levels that were more frequently within 0.2 mEq/L of actual levels.

Comparison of pharmacokinetic procedures for dosing lithium based on analysis of prediction error

Five pharmacokinetic methods for estimating maintenance dosage requirements of lithium carbonate were compared retrospectively in 20 inpatients with acute bipolar illness. Specific pharmacokinetic methods tested included the method of Cooper, the multiple-point method of Perry, the single-point method of Perry, the method of Zetin, and the method of Pepin. Data analysis was based on evaluation of prediction error or the difference between the predicted steady-state lithium concentration and the measured steady-state lithium concentration at equivalent daily doses. Each dosing method was assessed in regard to accuracy and bias of predicted steady-state serum lithium concentrations. Bias was assessed by comparison of the median value of the prediction error with zero. The dosing recommendation based on the Cooper nomogram resulted in a significant positive bias (p less than or equal to 0.05). Intermethod accuracy was assessed by comparison of the absolute prediction errors of each dosing method. Significant differences in accuracy were observed between the method of Pepin when compared with the single-point method of Perry (p less than or equal to 0.05, k-sample sign test). All other comparisons were nonsignificant.

A review of alprazolam withdrawal

A cumulative review of case reports in the literature describing withdrawal reactions secondary to alprazolam is presented. In four of eight reports, the primary withdrawal manifestations were grand mal seizures. One case was characterized by painful myoclonus. In the remaining three cases, the major complications consisted of rebound anxiety with psychotic features. Despite tapering of the daily dosage according to manufacturer guidelines, a withdrawal syndrome was precipitated in three of the cases. As a result of alprazolam's atypical pharmacodynamic profile, the issue is raised as to whether alprazolam is pharmacologically cross-tolerant with other benzodiazepines.

Effects of smoking on nortriptyline plasma concentrations in depressed patients

The pharmacokinetic parameters of half-life, volume of distribution, and steady-state nortriptyline plasma concentration normalized to a 100-mg/day maintenance dose were calculated in nine smokers and 15 nonsmokers. The mean normalized total nortriptyline concentration for the smokers of 118 +/- 33 ng/ml was significantly lower than the nonsmokers' mean value of 158 +/- 35 ng/ml. The mean normalized free plasma concentrations for the smokers of 11.4 +/- 3.5 ng/ml was not different from the nonsmokers' mean concentrations of 11.5 +/- 2.6 ng/ml. The smokers had a slightly higher percentage free drug values of 10.2 +/- 4.0% (p = 0.08) as contrasted to 7.4 +/- 1.5% free nortriptyline for the nonsmokers. The nortriptyline half-life figures for both the free and total drug concentrations did not differ. Multiple linear regression analysis utilizing age, smoking status, sex, liver function, and the presence or absence of enzyme-inducing or -inhibiting drugs as the potential independent variables and percentage free nortriptyline or total nortriptyline concentration as the dependent variable, found that smoking status explained 21% of the variation in the percentage free nortriptyline in the patients and 26% of the variation in the total nortriptyline concentrations. These preliminary data suggest that smokers ideally should be dosed at the lower end of the nortriptyline therapeutic range, whereas nonsmokers should be dosed at the upper end to maximize the antidepressant effect and minimize adverse effects.

Exacerbation of tardive dyskinesia by Joseph disease

A 76-year-old patient is described in whom a severe, life-threatening tardive dyskinesia developed after oral administration of approximately 2 mg of haloperidol per day for 4 weeks. The patient's strong genetic predisposition for Joseph disease may have potentiated both the development and the severity of the tardive dyskinesia. Withdrawal of neuroleptic agents accompanied by aggressive treatment with reserpine resulted in a complete recovery over 5 weeks. The clinical and pathologic characteristics of Joseph disease and tardive dyskinesia are compared.