Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda

BACKGROUND

Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done.

RESULTS

The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences.

CONCLUSIONS

In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Multidisciplinary healthcare teams' challenges and strategies in supporting people with type 1 diabetes to recover from disordered eating

AIM

To examine the challenges healthcare teams face when treating people with type 1 diabetes and disordered eating and the strategies these teams have developed to facilitate effective treatment.

METHODS

Four semi-structured focus groups were conducted including two tertiary diabetes specialist teams and three tertiary eating disorders specialist teams between July and December 2018. Thematic analysis of the transcripts followed a six-phase process.

RESULTS

Twenty-nine experienced healthcare professionals (16 diabetes and 13 eating disorder specialists, 16±12 years' professional experience) were interviewed. The challenges identified in treating people with type 1 diabetes and disordered eating included subthemes the 'challenges specific to the healthcare professional' (feeling not competent enough and perceived emotional burden), 'challenges pertaining to patient factors' (e.g. difficulties with engaging in therapy) and 'challenges created by the healthcare system' (time pressure and staff shortage). Healthcare professionals expressed the need for a consensus on diagnosis and the definition of disordered eating in type 1 diabetes, as well as the need for training and educational resources specific to type 1 diabetes and disordered eating. Healthcare professionals gave practical examples of strategies of communication for better patient engagement and felt that multidisciplinary working in joint clinics with the other specialty were facilitators for recovery from disordered eating.

CONCLUSIONS

Healthcare professionals require multidisciplinary team support when treating people with type 1 diabetes and to improve their own competencies. The development of effective screening and assessment tools, educational resources and training for healthcare professionals, and developing multidisciplinary treatment pathways will be key to improving outcomes for their service users with type 1 diabetes and disordered eating.

A pilot study of an integrated mental health, social and medical model for diabetes care in an inner-city setting: Three Dimensions for Diabetes (3DFD)

AIMS

We examined the effectiveness of a service innovation, Three Dimensions for Diabetes (3DFD), that consisted of a referral to an integrated mental health, social care and diabetes treatment model, compared with usual care in improving biomedical and health economic outcomes.

METHODS

Using a non-randomized control design, the 3DFD model was offered in two inner-city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA_1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA_1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA_1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes.

RESULTS

3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [-14 mmol/mol (-1.3%) vs. -6 mmol/mol (-0.6%) respectively, P < 0.001], adjusted for confounding. Total follow-up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost-effectiveness ratio was £398 per mmol/mol unit decrease in HbA_1c , indicating the 3DFD intervention was more effective and costed more than usual care.

CONCLUSIONS

A biomedical, psychological and social criteria-based referral system for identifying and managing high-cost and high-risk individuals with poor glycaemic control can lead to improved health in all three dimensions.

Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in children and adults with type 1 diabetes

AIM

We conducted a systematic review aggregate and network meta-analysis of psychological interventions for people with type 1 diabetes to assess their effectiveness in improving glycaemic levels.

METHODS

We searched the following databases from 1 January 2003 to 1 July 2018: MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Controlled Trials, Web of Science, clinicaltrials.gov, Dissertation Abstract International. We included randomized controlled trials (RCT) of psychological interventions for children and adults with type 1 diabetes reported in any language. We extracted data on publications, participant characteristics at baseline, intervention and control group, and data for the primary outcome, change in glycaemic control [HbA_1c (mmol/mol/%)]. Study authors were contacted for missing data. The review was registered with international prospective register of systematic reviews registration (PROSPERO) CRD42016033619.

RESULTS

Twenty-four adult RCTs and 23 of children with type 1 diabetes were included in the systematic review. In aggregate meta-analysis there was no overall effect of psychological intervention compared with control on HbA_1c [adults, nine RCTs, n = 1102, pooled mean difference -0.12, 95% confidence intervals (CI) -0.27 to 0.03, I² = 29.0%, P = 0.19; children, 20 RCTs, n = 2567, -0.09, 95% CI -0.22 to 0.04, I² =54.0% P=0.002]. Network meta-analysis suggested that probability and rank-ordering of effectiveness is highest for attention control groups (b = -0.47, 95% CI -0.80 to -0.12) followed by cognitive behavioural therapy (CBT) (-0.26, 95% CI -0.45 to -0.06) compared with usual care for adults.

CONCLUSIONS

Overall psychological interventions for children and adults with type 1 diabetes do not improve glycaemic control. For adults, CBT-based interventions have the potential to be effective.

Is there an increased risk of perinatal mental disorder in women with gestational diabetes? A systematic review and meta-analysis

AIM

Gestational diabetes (GDM) and mental disorder are common perinatal morbidities and are associated with adverse maternal and child outcomes. While there is a relationship between type 2 diabetes and mental disorder, the relationship between GDM and mental disorder has been less studied. We conducted a systematic review and meta-analysis of the prevalence of mental disorders in women with GDM and their risk for mental disorders compared with women without GDM.

METHODS

Published, peer-reviewed literature measuring prevalence and/or odds of GDM and perinatal mental disorders was reviewed systematically. Risk of bias was assessed using a checklist. Two independent reviewers were involved. Analyses were grouped by stage of peripartum, i.e. antepartum at the time of GDM diagnosis and after diagnosis, and in the postpartum.

RESULTS

Sixty-two studies were included. There was an increased risk of depressive symptoms in the antenatal period around the time of diagnosis of GDM [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.42, 3.05] and in the postnatal period (OR 1.59; 95% CI 1.26, 2.00).

CONCLUSIONS

Given the potential relationship between GDM and perinatal mental disorders, integration of physical and mental healthcare in women experiencing GDM and mental disorders could improve short- and long-term outcomes for women and their children.

25 Years of psychological research investigating disordered eating in people with diabetes: what have we learnt?

Disordered eating is a serious and under-recognized problem in people with diabetes. This narrative review summarizes the research contributions made by psychological science over the past 25 years to the study of disordered eating in people with type 1 or type 2 diabetes, and identifies gaps and future directions relevant to both healthcare professionals and researchers. Key focus areas of psychological research investigating disordered eating in people with diabetes have been: (1) defining and classifying types of disordered eating; (2) identifying demographic, diabetes-specific and psychosocial correlates of disordered eating, and developing theoretical models of disordered eating in people with type 1 diabetes; (3) identifying the physical and psychosocial consequences of disordered eating; and (4) developing screening measures to identify disordered eating in people with type 1 diabetes. Psychological science has made significant contributions over the past 25 years to our understanding of the nature of this problem and the multiple factors which may interrelate with disordered eating in people with diabetes. Key areas for further attention include: (1) a better definition of disordered eating subtypes in people with type 1 diabetes; (2) characterizing disordered eating in people with type 2 diabetes; and (3) developing multidisciplinary, evidence-based prevention and treatment interventions for comorbid disordered eating and diabetes.

Assessment of the aggregation and adsorption behavior of newly synthesized tetradecylpyridinium-based metallosurfactants and their interaction with bovine serum albumin

Tetradecylpyridinium (TP) based metallosurfactants, TP₂[MCl₄] (M = Mn, Co, Ni, Cu, Zn): synthesis, aggregation behavior and interaction with bovine serum albumin.

Transforming mental well-being for people with diabetes: research recommendations from Diabetes UK's 2019 Diabetes and Mental Well-Being Workshop

AIMS

To identify key gaps in the research evidence base that could help to improve the mental well-being of people with diabetes, and to provide recommendations to researchers and research funders on how best to address them.

METHODS

A 2-day international research workshop was conducted, bringing together research experts in diabetes and in mental health, people living with diabetes and healthcare professionals.

RESULTS

The following key areas needing increased financial investment in research were identified: understanding the mechanisms underlying depression; understanding the multifactorial impact of social stigma; improving the language used by healthcare professionals; supporting people who find it difficult to engage with their diabetes; supporting significant others; supporting people with diabetes and eating disorders; improving models of care by learning from best practice; the potential benefits of screening and managing diabetes distress in routine diabetes care pathways; primary prevention of mental health issues at the time of diagnosis of diabetes; establishing the effectiveness of diabetes therapies on mood and other mental health issues; and understanding the impact of current diabetes technologies on mental health. Research recommendations as to how to address each of these priority areas were also developed.

CONCLUSIONS

This inaugural position statement outlines recommendations to address the urgent unmet need related to the mental well-being of people living with diabetes, and calls on the research community and funders to develop research programmes and strategies to reduce this need.

Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention

Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.

Depression and change in occupational functioning in type 2 diabetes

BACKGROUND

The effect of depression on both employment and productivity in type 2 diabetes (T2D) is poorly understood.

AIMS

We tested whether depressive symptoms at diagnosis of T2D are associated with change in employment status and productivity over 2-year follow-up.

METHODS

In a prospective analysis of working-age (18-63 years) people with newly diagnosed T2D recruited from primary care, we tested the association between depressive symptoms at diagnosis of T2D (baseline) and employment rates over 2 years. Using the Patient Health Questionnaire-9, depressive symptoms were measured categorically (depression caseness score ≥10) and continuously. In those employed, we measured changes in presenteeism and absenteeism using the World Health Organization (WHO) Health and Work Performance Questionnaire in univariate and multivariate models, respectively, including and excluding part-time workers.

RESULTS

Of 1202 people aged 18-63 at baseline, 982 (82%) provided employment information; the mean age was 50.3 (SD 8.1) years, 44% were female, 59% of non-white ethnicity and 16% had depression. After adjustment for age, sex, ethnicity, socio-economic status, diabetes control and depression treatment, depression caseness was associated with worsening unemployment over 2 years only in full-time workers (odds ratio 0.43 (95% CI 0.20, 0.96), P < 0.05). In those employed full-time or part-time, total depressive symptoms were associated with worsening presenteeism over 2 years after full adjustment (β = -2.63 (95% CI -4.81, -0.45), P < 0.05), despite no association with worsening absenteeism.

CONCLUSIONS

In newly diagnosed T2D, depressive symptoms demonstrate an association with worsening employment rate and decline in work productivity over 2-year follow-up.

Learning about Type 1 diabetes and learning to live with it when diagnosed in adulthood: two distinct but inter-related psychological processes of adaptation A qualitative longitudinal study

AIM

To explore the experiences of adults with newly diagnosed Type 1 diabetes in order to understand the adaptive processes that occur in the early phase of the condition.

METHODS

We conducted longitudinal semi-structured interviews with 30 adults newly diagnosed with Type 1 diabetes (age range 20-67 years; 16 men; median diabetes duration 23.5 months), recruited from hospitals in Denmark and the UK. The data were analysed using a narrative approach.

RESULTS

The narratives could be grouped into three thematic areas: the diagnosis; learning about diabetes; and learning to live with diabetes. Diabetes was characterized as a major disruptor to the established and future life plans of participants, causing significant emotional distress. The narratives showed how early experiences triggered the development of ongoing psychological problems (fear of complications or hypoglycaemia) and diabetes distress, and that navigating different social scenarios (relationships and employment) could be challenging, leading to suboptimal self-management behaviours. The narratives also showed that health professionals often did not attend effectively to participants' emotional needs after diagnosis, and that the language used frequently triggered negative feelings, such as fear or a sense of failure.

CONCLUSIONS

Many of the common psychosocial problems associated with Type 1 diabetes seem to gestate in the early phase of life with the condition. There appear to be opportunities to enhance the support provided in this phase to minimize these problems.

A qualitative study exploring women's health behaviours after a pregnancy with gestational diabetes to inform the development of a diabetes prevention strategy

AIM

To inform targeted interventions for women with gestational diabetes mellitus (GDM) by exploring the factors that influence their health behaviours and their preferences for lifestyle support.

METHODS

Participants were women with previous GDM taken from a diverse inner-city UK population. Data collection involved focus groups (n = 35 women in six groups) and semi-structured interviews (n = 15 women). The transcribed data were analysed using framework analysis.

RESULTS

Eight themes relating to factors influencing health behaviour were identified: psychological legacy of pregnancy, relationships with healthcare professionals, physical impacts of pregnancy, social support and cultural norms, life-scheduling, understanding and risk perception, appetite regulation, and prioritization of the baby. The women's recommendations for intervention components included addressing the emotional stress of pregnancy; conveying personalized risk in a motivational way, adopting a family-centered approach, focusing on women's health rather than just the infant's, and developing flexible interventions. These recommendations were used to construct a model integrating the behaviour-regulating factors with a suggested framework for intervention.

CONCLUSIONS

This study identified some common drivers that may regulate the health behaviours of women following GDM, and recognized some ways to improve care to impact on this. Interventions for diabetes prevention in this population need to address factors at both the individual and systemic levels.

'Diabulima' through the lens of social media: a qualitative review and analysis of online blogs by people with Type 1 diabetes mellitus and eating disorders

AIMS

To perform a qualitative review of online blogs authored by people self-identifying as having Type 1 diabetes and an eating disorder or 'diabulimia', a term used by people with Type 1 diabetes to describe an eating disorder that is characterized by deliberate restriction of insulin to control weight.

METHODS

We conducted a structured qualitative review of online blogs published between 2012 and 2017 authored by people who report having Type 1 diabetes and an eating disorder or diabulimia. The subsequent thematic analysis followed a six-phase process and was conducted by two independent researchers.

RESULTS

From 147 000 search results, 11 blogs (304 posts) matched criteria for further analyses. Three key themes and 18 subthemes emerged: 1) different aspects of bloggers' relationship with insulin, including motives for omitting insulin, secrecy of insulin omission and perception of control; 2) bloggers' experiences of diabetes complications, and diabetes ketoacidosis in particular, as well as their worries about future complications; 3) strategies for recovery and triggers for relapse, which involved diabetes self-management and setting up a support system.

CONCLUSIONS

Qualitative analyses of blogs authored by people with Type 1 diabetes and an eating disorder or diabulimia have identified high levels of diabetes distress and provided insight into different motives for insulin omission and strategies for recovery. Considering the limited evidence for effective interventions, these findings may help the development of complex interventions to improve biomedical and psychological outcomes in this group.

Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Care guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes.

Healthcare professionals' views of group structured education for people with newly diagnosed Type 2 diabetes

AIM

To determine healthcare professionals' (HCP) views of group structured education for people with newly diagnosed Type 2 diabetes.

METHODS

This was a qualitative study using semi-structured interviews to ascertain primary care HCPs' views and experiences of education for people with newly diagnosed Type 2 diabetes. A thematic framework method was applied to analyse the data. Participants were HCPs (N = 22) from 15 general practices in three south London boroughs.

RESULTS

All but one HCP viewed diabetes education favourably and all identified that low attendance was a problem. Three key themes emerged from the qualitative data: (1) benefits of diabetes education, including the group mode of delivery, improved patient interactions, saving HCPs' time and improved patient outcomes; (2) factors limiting uptake of education, including patient-level problems such as access and the appropriateness of the programme for certain groups, and difficulties communicating the benefits to patients and integration of education management plans into ongoing diabetes care; and (3) suggestions for improvement, including strategies to improve attendance at education with more localized and targeted marketing and enhanced programme content including follow-up sessions and support for people with pre-existing psychological issues.

CONCLUSIONS

Most HCPs valued diabetes education and all highlighted the lack of provision for people with different levels of health literacy. Because there was wide variation in terms of the level of knowledge regarding the education on offer, future studies may want to focus on how to help HCPs encourage their patients to attend.

Eating disorders in people with Type 1 diabetes: experiential perspectives of both clients and healthcare professionals

AIMS

To explore the experiential perspective of people with Type 1 diabetes mellitus and eating disorders and that of the healthcare professionals treating them, and to understand the experience of both sides to inform future development of healthcare services.

METHODS

Participants were recruited from Diabetics with Eating Disorders (a national UK charity), and through professional networks. Nine partially/fully recovered individuals with Type 1 diabetes and eating disorders and eight healthcare professionals participated in semi-structured interviews carried out by medically trained researchers. Data were transcribed and coded using a six-stage framework of thematic analysis.

RESULTS

Four superordinate themes and several subordinate themes emerged from the Type 1 diabetes and eating disorders dataset: (1) perceptions surrounding service provision; (2) reflections on the recovery process; (3) the experiential perspective of living with Type 1 diabetes and an eating disorder; and (4) support mechanisms. Healthcare professional data elicited three superordinate themes and several subordinate themes: (1) service provision; (2) personal insight and reflection of professional role; and (3) challenges of working with dual diagnoses.

CONCLUSION

People with Type 1 diabetes and eating disorders and their healthcare professionals provided insight into healthcare services from the patient and care delivery perspectives. There was general agreement from both groups that a multidisciplinary, collaborative (family inclusive), clinical approach to treatment is important, as well as adequate training opportunities for service providers. These findings may help to inform development strategies for multidisciplinary care approaches to Type 1 diabetes complicated by eating disorders.

Systematic review and meta-analysis of the efficacy of interventions for people with Type 1 diabetes mellitus and disordered eating

AIM

To examine the types of interventions currently available for people with Type 1 diabetes mellitus and their effectiveness.

BACKGROUND

The prevalence of disordered eating in people with Type 1 diabetes mellitus is twice that in their counterparts without diabetes, and is associated with worse biomedical outcomes and greater mortality.

METHODS

Medline, Embase, PsycINFO, the Cochrane Library, PubMed and OpenGrey databases were searched up to August 2016 to identify studies on interventions in people with Type 1 diabetes-associated disordered eating. For the systematic review, intervention components were identified and their effectiveness was examined. For the meta-analysis, the pooled effect sizes of glycaemic control (HbA_1c ) between pre- and post-treatment in treatment and comparison groups were calculated using a random effects model.

RESULTS

Of 91 abstracts reviewed, six studies met the inclusion criteria, of which three had appropriate data for the meta-analysis (n = 118). The pooled effect size was -0.21 95% CI (-0.58 to 0.16; where negative values represent an improvement in HbA_1c levels), indicating no statistically significant improvement in the treatment group compared with comparison group. Inpatient therapy appeared to be the most effective treatment, and this had multiple components including cognitive behavioural therapy, psychoeducation and family therapy.

CONCLUSION

Limited or no improvement in glycaemic control and disordered eating symptoms was observed in people with Type 1 diabetes-associated disordered eating who were receiving currently available interventions. The present review suggests that developing an intensive intervention with a joint focus on both disordered eating and diabetes management is needed for this complex patient group.

The effect of temperature, composition and alcohols on the microstructures of catanionic mixtures of sodium dodecylsulfate and cetyltrimethylammonium bromide in water

The influence of mixing protocol, composition, temperature, ageing and added alcohols on the characteristics of the microstructures of sodium dodecylsulfate (SDS) + cetyltrimethylammonium bromide (CTAB) mixtures has been investigated in this paper. In this catanionic mixture (1 weight% total surfactant content) temperature induced microstructural transition occurs, which is (i) a micelle-to-vesicle transition (MVT) if α_SDS (mole fraction of SDS) = 0.7, 0.8 or 0.9 and (ii) a vesicle-to-micelle transition (VMT) if α_SDS = 0.1, 0.2 or 0.3. In the mixture of α_SDS = 0.7, specific conductivity and dynamic light scattering measurements also support the occurrence of MVT. Transition electron microscopy and small angle neutron scattering measurements were also made to assess the characteristics of the microstructures. Alcohols added to the mixture of α_SDS = 0.7 reduced the size of the vesicle, while only monohydric alcohols suppressed the temperature induced transition indicating that the number and location of -OH groups of the alcohols have a dramatic modulating influence on the structural transition occurring in catanionic mixtures. The influence of the alcohols is explained in terms of changes produced in the dielectric constant and hydrophobicity of the medium.

Investigating incretin-based therapies as a novel treatment for depression in type 2 diabetes: Findings from the South London Diabetes (SOUL-D) Study

We aimed to investigate the association between incretin-based therapies and 1-year change in depressive symptoms in a cohort of 1735 patients with newly diagnosed type 2 diabetes. The incretin group experienced significant reduction in depressive symptoms compared to controls. This was independent of HbA1c and may be mediated by an anti-inflammatory mechanism.

A cardiac arrest following the administration of succinylcholine

A twenty-three year old woman, admitted to the intensive care unit (ICU) with a diagnosis of menin- gitis and associated lower limb ischemia suffered a car- diac arrest, due to extreme hyperkalemia, following the administration of succinylcholine in order to replace an endo-tracheal tube. After prolonged cardiopulmonary resuscitation (CPR) lasting 45 minutes, during which 8 mg of epinephrine was administered, cardiac output was restored. Four weeks later the patient left intensive care, having made a full recovery with no neurological deficit. The following case highlights the risks of succinylcholine in the septic patient and that prolonged resuscitation can have a succesfiil outcome.

Aggregation and surface behavior of aqueous solutions of cis-bis(1,3-diaminopropane)bis(dodecylamine)cobalt(iii) nitrate. A double-chained metallosurfactant

Metallosurfactants or amphiphilic metal complexes are emerging as a new class of material with a range of properties inherent to both metal complexes and surfactants.

Developing a theoretical maintenance model for disordered eating in Type 1 diabetes

BACKGROUND

According to the literature, eating disorders are an increasing problem for more than a quarter of people with Type 1 diabetes and they are associated with accentuated diabetic complications. The clinical outcomes in this group when given standard eating disorder treatments are disappointing. The Medical Research Council guidelines for developing complex interventions suggest that the first step is to develop a theoretical model.

AIM

To review existing literature to build a theoretical maintenance model for disordered eating in people with Type 1 diabetes.

METHOD

The literature in diabetes relating to models of eating disorder (Fairburn's transdiagnostic model and the dual pathway model) and food addiction was examined and assimilated.

RESULTS

The elements common to all eating disorder models include weight/shape concern and problems with mood regulation. The predisposing traits of perfectionism, low self-esteem and low body esteem and the interpersonal difficulties from the transdiagnostic model are also relevant to diabetes. The differences include the use of insulin mismanagement to compensate for breaking eating rules and the consequential wide variations in plasma glucose that may predispose to 'food addiction'. Eating disorder symptoms elicit emotionally driven reactions and behaviours from others close to the individual affected and these are accentuated in the context of diabetes.

CONCLUSION

The next stage is to test the assumptions within the maintenance model with experimental medicine studies to facilitate the development of new technologies aimed at increasing inhibitory processes and moderating environmental triggers.

DNA methylation and gene expression patterns in adipose tissue differ significantly within young adult monozygotic BMI-discordant twin pairs

BACKGROUND

Little is known about epigenetic alterations associated with subcutaneous adipose tissue (SAT) in obesity. Our aim was to study genome-wide DNA methylation and gene expression differences in SAT in monozygotic (MZ) twin pairs who are discordant for body mass index (BMI). This design completely matches lean and obese groups for genetic background, age, gender and shared environment.

METHODS

14We analyzed DNA methylome and gene expression from SAT, together with body composition (magnetic resonance imaging/spectroscopy) and glucose tolerance test, lipids and C-reactive protein from 26 rare BMI-discordant (intrapair difference in BMI ⩾3 kg m(-2)) MZ twin pairs identified from 10 birth cohorts of young adult Finnish twins.

RESULTS

We found 17 novel obesity-associated genes that were differentially methylated across the genome between heavy and lean co-twins. Nine of them were also differentially expressed. Pathway analyses indicated that dysregulation of SAT in obesity includes a paradoxical downregulation of lipo/adipogenesis and upregulation of inflammation and extracellular matrix remodeling. Furthermore, CpG sites whose methylation correlated with metabolically harmful fat depots (intra-abdominal and liver fat) also correlated with measures of insulin resistance, dyslipidemia and low-grade inflammation, thus suggesting that epigenetic alterations in SAT are associated with the development of unhealthy obesity.

CONCLUSION

This is the first study in BMI-discordant MZ twin pairs reporting genome-wide DNA methylation and expression profiles in SAT. We found a number of novel genes and pathways whose methylation and expression patterns differ within the twin pairs, suggesting that the pathological adaptation of SAT to obesity is, at least in part, epigenetically regulated.

Cardiovascular risk factors and metabolic syndrome in people with established psychotic illnesses: baseline data from the IMPaCT RCT study--Corrigendum

The author regrets to announce that affiliation 8, in the above article (Gardner-Sood et al. 2015), contained an error in the author affiliation address and author surname, which were published in the approved article. The correct surname and affiliation address are given below. J. Eberhard, Clinical Psychiatric Research Center, Lund University, Skåne, Sweden

Cardiovascular risk factors and metabolic syndrome in people with established psychotic illnesses: baseline data from the IMPaCT randomized controlled trial

BACKGROUND

The aims of the study were to determine the prevalence of cardiometabolic risk factors and establish the proportion of people with psychosis meeting criteria for the metabolic syndrome (MetS). The study also aimed to identify the key lifestyle behaviours associated with increased risk of the MetS and to investigate whether the MetS is associated with illness severity and degree of functional impairment.

METHOD

Baseline data were collected as part of a large randomized controlled trial (IMPaCT RCT). The study took place within community mental health teams in five Mental Health NHS Trusts in urban and rural locations across England. A total of 450 randomly selected out-patients, aged 18-65 years, with an established psychotic illness were recruited. We ascertained the prevalence rates of cardiometabolic risk factors, illness severity and functional impairment and calculated rates of the MetS, using International Diabetes Federation (IDF) and National Cholesterol Education Program Third Adult Treatment Panel criteria.

RESULTS

High rates of cardiometabolic risk factors were found. Nearly all women and most men had waist circumference exceeding the IDF threshold for central obesity. Half the sample was obese (body mass index ≥ 30 kg/m2) and a fifth met the criteria for type 2 diabetes mellitus. Females were more likely to be obese than males (61% v. 42%, p < 0.001). Of the 308 patients with complete laboratory measures, 57% (n = 175) met the IDF criteria for the MetS.

CONCLUSIONS

In the UK, the prevalence of cardiometabolic risk factors in individuals with psychotic illnesses is much higher than that observed in national general population studies as well as in most international studies of patients with psychosis.

Effect of sodium salicylate and sodium deoxycholate on fibrillation of bovine serum albumin: comparison of fluorescence, SANS and DLS techniques

Adsorbed sodium salicylate (NaSal) and sodium deoxycholate (NaDC) retard the thermal denaturation of bovine serum albumin.

Controlling the aggregation of sodium dodecylsulphate in aqueous poly(ethylene glycol) solutions

The role of PEG's of different molecular weights on the self-assembly of SDS and the role of added NaCl has been addressed opening new scopes for further studies.

Influence of hydrotropic coions on the shape transitions of sodium dioctylsulfosuccinate aggregates in an aqueous medium

The slope change of the CH plot is a manifestation of the shape change of the ionic micelles. However, binding of the salicylate coion to ionic micelles is an exception to this inference.

Patient explanations for non-attendance at structured diabetes education sessions for newly diagnosed Type 2 diabetes: a qualitative study

AIM

To determine the reasons for non-attendance at structured education sessions among people with a recent diagnosis of Type 2 diabetes.

METHODS

This was a qualitative study using semi-structured interviews to elicit the main themes explaining non-attendance. A thematic framework method was applied to analyse the data. People who had not attended structured education were recruited from a population cohort of newly diagnosed Type 2 diabetes from South London (the South London Diabetes cohort study), UK.

RESULTS

A sample of 30 people was interviewed. Three main themes emerged from the qualitative data explaining non-attendance at structured education: (1) lack of information/perceived benefit of the programme (e.g. not being informed about the course by their health professional); (2) unmet personal preferences (e.g. parking, timing); and (3) shame and stigma of diabetes (e.g. not wishing to tell others of diabetes diagnosis).

CONCLUSION

This is the first time that reasons for non-attendance have been explored in depth among people who have newly diagnosed Type 2 diabetes. Novel reasons identified included non-attendance because of shame and stigma of diabetes. To improve uptake at structured education we need to: consider how health professionals in primary care communicate with their patients on the subject of structured diabetes education; offer alternatives to the traditional group education format; and understand that diabetes is associated with health-related stigma, which may affect participation.

Reasons for cannabis use in first-episode psychosis: does strength of endorsement change over 12 months?

BACKGROUND

Why patients with psychosis use cannabis remains debated. The self-medication hypothesis has received some support but other evidence points towards an alleviation of dysphoria model. This study investigated the reasons for cannabis use in first-episode psychosis (FEP) and whether strength in their endorsement changed over time.

METHODS

FEP inpatients and outpatients at the South London and Maudsley, Oxleas and Sussex NHS Trusts UK, who used cannabis, rated their motives at baseline (n=69), 3 months (n=29) and 12 months (n=36). A random intercept model was used to test the change in strength of endorsement over the 12 months. Paired-sample t-tests assessed the differences in mean scores between the five subscales on the Reasons for Use Scale (enhancement, social motive, coping with unpleasant affect, conformity and acceptance and relief of positive symptoms and side effects), at each time-point.

RESULTS

Time had a significant effect on scores when controlling for reason; average scores on each subscale were higher at baseline than at 3 months and 12 months. At each time-point, patients endorsed 'enhancement' followed by 'coping with unpleasant affect' and 'social motive' more highly for their cannabis use than any other reason. 'Conformity and acceptance' followed closely. 'Relief of positive symptoms and side effects' was the least endorsed motive.

CONCLUSIONS

Patients endorsed their reasons for use at 3 months and 12 months less strongly than at baseline. Little support for the self-medication or alleviation of dysphoria models was found. Rather, patients rated 'enhancement' most highly for their cannabis use.