Association between mediterranean diet and metal(loid) exposure in 4-5-year-old children living in Spain

Even relatively low levels of metals exposure may impact health, particularly among vulnerable populations such as infants and young children. However, little is known about the interplay between simultaneous metal exposures, common in real-life scenarios, and their association with specific dietary patterns. In this study, we have evaluated the association between adherence to Mediterranean diet (MD) and urinary metal concentrations individually and as an exposure mixture in 713 children aged 4-5-years from the INMA cohort study. We used a validated food frequency questionnaire to calculate two MD indexes scores: aMED and rMED. These indexes gather information on various food groups within the MD and score differently. To measure urinary concentrations of cobalt, copper, zinc, molybdenum, selenium, lead, and cadmium as exposure biomarkers, we used inductively coupled plasma mass spectrometry (ICP-MS), coupled with an ion chromatography (IC) equipment for arsenic speciation analysis. We applied linear regression and quantile g-computation, adjusted for confounders, to analyse the association between MD adherence and exposure to the metal mixture. High adherence to MD such as the quintile (Q) 5 MD was associated with higher urinary arsenobetaine (AsB) levels than Q1, with β values of 0.55 (confidence interval - CI 95% 0.01; 1.09) for aMED and 0.73 (CI 95% 0.13; 1.33) for rMED. Consumption of fish was associated with increased urinary AsB but reduced inorganic arsenic concentrations. In contrast, the aMED vegetables consumption increased urinary inorganic arsenic content. A moderate level of adherence to MD (Q2 and Q3) was associated with lower copper urinary concentrations than Q1, with β values of -0.42 (CI 95% -0.72; -0.11) for Q2 and -0.33 (CI 95% -0.63; -0.02) for Q3, but only with aMED. Our study, conducted in Spain, revealed that adhering to the MD reduces exposure to certain metals while increasing exposure to others. Specifically, we observed increase in exposure to non-toxic AsB, highlighting the significance of consuming fish/seafood. However, it is crucial to emphasize the necessity for additional efforts in reducing early-life exposure to toxic metals, even when adhering to certain food components of the MD.

Determining patient knowledge of direct oral anticoagulants: a questionnaire study

Introduction

There has been a significant increase in the number of patients prescribed Direct Oral Anticoagulants (DOACs) (1). One of the advantages of DOACs is reduced need for monitoring compared to warfarin, however less frequent contact with healthcare professionals (HCPs) may contribute to poor patient knowledge leading to negative health consequences.

Aim

To determine patients’ knowledge on DOACs in the hospital and community pharmacy setting.

Methods

Participants were recruited from a university hospital and from a convenience sample of community pharmacies. Potential participants were identified by the pharmacist in that setting using the following criteria: age ≥18 years, adequate cognition, DOAC use ≥3 months. Following consent, the participant completed a questionnaire which consisted of participant demographics and questions from the KODOA (The Knowledge of Direct Oral Anticoagulants) questionnaire. Depending on participant preference, they either self-completed the questionnaire or provided oral answers which the researcher documented. Based on previous research (2), a target sample of 40 participants was set. Descriptive statistics were performed.

Results

40 participants were recruited; the mean (SD) age was 70.2 years (10.1), with 70% of participants reporting male gender. 62.5% of participants had an indication of atrial fibrillation. Mean (SD) duration of DOAC use was 5.6 years (3.6). Most patients rated their knowledge of their DOAC as moderate (50%) or good (27.5%). The results of the KODOA are presented in the table. The average score achieved by participant was 11.55/15 (± 1.88 SD). Participants scored high in areas such as DOAC indication, frequency of dosing, side-effects, drug interactions and when to seek further help. Areas of knowledge deficits included what to do when patients have forgotten a dose or have taken too much DOAC.

Conclusion

One limitation of the questionnaire is that the questions are presented in a multiple-choice format and it is possible that participants may have selected the correct answer due to chance. However, overall, participants demonstrated good levels of knowledge of their DOAC therapy. This study has identified areas of knowledge deficits which could be included in patient education when HCPs are counselling patients, when starting their DOAC and continually throughout treatment.

References

(1) Barry, Michael. Medicines Management Programme: Oral anticoagulants for stroke prevention in non-valvular atrial fibrillation [Internet]. 2019 [cited 2021 Jul 24]. Available from: https://www.hse.ie/eng/about/who/cspd/ncps/medicines-management/oral-anticoagulants/oral-anticoagulants-for-stroke-prevention-in-non-valvular-atrial-fibrillation-march-2019.pdf

(2) Metaxas C, Albert V, Stahl M, Hersberger KE, Arnet I. Development and validation of a questionnaire to self-assess patient knowledge of direct oral anticoagulants (KODOA-test). Drug Healthc Patient Saf. 2018 Jul 20;10:69–77.

Clinical Characteristics and Outcomes in Patients with COVID-19 and Cancer: a Systematic Review and Meta-analysis

Much of routine cancer care has been disrupted due to the perceived susceptibility to SARS-CoV-2 infection in cancer patients. Here, we systematically review the current evidence base pertaining to the prevalence, presentation and outcome of COVID-19 in cancer patients, in order to inform policy and practice going forwards. A keyword-structured systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 in cancer patients. Studies were critically appraised using the NIH National Heart, Lung and Blood Institute's quality assessment tool set. The pooled prevalence of cancer as a co-morbidity in patients with COVID-19 and pooled in-hospital mortality risk of COVID-19 in cancer patients were derived by random-effects meta-analyses. In total, 110 studies from 10 countries were included. The pooled prevalence of cancer as a co-morbidity in hospitalised patients with COVID-19 was 2.6% (95% confidence interval 1.8%, 3.5%, I2: 92.0%). Specifically, 1.7% (95% confidence interval 1.3%, 2.3%, I2: 57.6.%) in China and 5.6% (95% confidence interval 4.5%, 6.7%, I2: 82.3%) in Western countries. Patients most commonly presented with non-specific symptoms of fever, dyspnoea and chest tightness in addition to decreased arterial oxygen saturation, ground glass opacities on computer tomography and non-specific changes in inflammatory markers. The pooled in-hospital mortality risk among patients with COVID-19 and cancer was 14.1% (95% confidence interval 9.1%, 19.8%, I2: 52.3%). We identified impeding questions that need to be answered to provide the foundation for an iterative review of the developing evidence base, and inform policy and practice going forwards. Analyses of the available data corroborate an unfavourable outcome of hospitalised patients with COVID-19 and cancer. Our findings encourage future studies to report detailed social, demographic and clinical characteristics of cancer patients, including performance status, primary cancer type and stage, as well as a history of anti-cancer therapeutic interventions.

"There's always something else": Patient perspectives on improving the implementation of obesity guidelines in general practice

OBJECTIVES

The prevalence of obesity in Australia is rising. National guidelines for the management of overweight and obesity exist but our previous work demonstrates poor implementation of key elements in general practice. The aim of this study was to describe patient perspectives on the implementation of obesity guidelines in general practice.

METHODS

Qualitative study of 40 people living with obesity (PwO) who were recruited through general practices in Melbourne, Australia. PwO had a recorded BMI in the overweight range or above (>25), had attended a consultation in the last 6 months and had a diagnosis of at least one of the following: diabetes, kidney disease, hyperlipidemia, hypertension, or cardiovascular disease. Semi-structured telephone interviews were conducted with patients. Interviews were audio-recorded, transcribed verbatim and analysed thematically.

RESULTS

While a strong general practitioner (GP)-patient relationship enabled conversation to occur about weight management there was uncertainty as to whether patients or GPs should broach the topic of weight. Patients described complacency regarding their weight and often being unprepared to take up GP advice. Other health issues were felt to take precedence, and patients described inconsistent provision of information and resources to assist them in tackling their weight problems.

CONCLUSIONS

It is imperative to take into account patient perspectives on obesity management in general practice in order to improve health outcomes. This study provides valuable insights into how PwO can be better managed. Interventions should also include strategies to help patients maintain motivation in making lifestyle changes to support healthy weight loss.

Reducing the cadmium, inorganic arsenic and dimethylarsinic acid content of rice through food-safe chemical cooking pre-treatment

Cadmium, inorganic arsenic and, potentially, dimethyl arsenic acid are carcinogens widely elevated in rice. Here it was identified that the food-safe and common cadmium chelator citric acid efficiently removed cadmium from intact grain via pre-soaking procedure, while also reducing arsenic species. A twostep pre-soaking stage was developed whereby rice was first incubated, at ambient temperature, in 1 M citric acid for 12 h, and then in 1 M calcium carbonate for another 12 h, the latter step to neutralize pH, followed by cooking. When 10 different individual types of rice were processed in such a way this resulted in removal rates of 79% for cadmium, 81% for inorganic arsenic and a 66% for DMA. The technology is particularly suitable for bulk food processing and could be deployed in the most cadmium and arsenic impacted regions where rice is a staple.

Feed-derived iodine overrides environmental contribution to cow milk

Diets worldwide are deficient in iodine, leading to a range of undesirable health effects at the population level. Dairy products are a primary source of iodine in diets for those populations in which iodized salt is not systematically used or available. However, the flows of iodine through dairy agroecosystems are not well understood. The aim of this research was to investigate iodine flows though the dairy agroecosystem, including the influence of atmospheric depositional inputs, environmental variables, season, husbandry, and diet. Three farm-based sampling campaigns were carried out in this investigation, with milk, soil, silage, grass, and feed iodine determined by inductively coupled plasma mass spectroscopy, and nonparametric statistical analysis tests were conducted on data sets obtained. Natural iodine inputs into the environment are dominated by atmospheric deposition, which mainly from sea spray, and thus the location of farms relative to the coast and prevailing wind direction. Herbage and silage produced from grass-based systems strongly correlated with soil iodine, yet there was a strong disconnect between soil, forage, and feed and the milk that results. This was due to the levels of iodine in supplemental feeds being approximately 10-fold higher than those in forage-derived feeds. The practice of feed supplementation, accentuated by summer housing of cows, led to elevated milk iodine.

A control hardware based on a field programmable gate array for experiments in atomic physics

Experiments in Atomic, Molecular, and Optical (AMO) physics require precise and accurate control of digital, analog, and radio frequency (RF) signals. We present control hardware based on a field programmable gate array core that drives various modules via a simple interface bus. The system supports an operating frequency of 10 MHz and a memory depth of 8 M (2²³) instructions, both easily scalable. Successive experimental sequences can be stacked with no dead time and synchronized with external events at any instructions. Two or more units can be cascaded and synchronized to a common clock, a feature useful to operate large experimental setups in a modular way.

Exploring organizational support for the provision of structured self-management education for people with Type 2 diabetes: findings from a qualitative study

AIM

To explore the organizational context in which Type 2 diabetes structured group education is provided.

METHODS

Four Clinical Commissioning Groups in England providing Type 2 diabetes structured self-management education participated in a qualitative study exploring the context for provision of that education. Using UK National Diabetes Audit returns, two Clinical Commissioning Groups were selected that had non-attendance rates of ≤25%, and two that had non-attendance rates of ≥50%. Between May 2016 and August 2017, 20 interviews were conducted with Clinical Commissioning Group staff including: commissioners, healthcare professionals, managers, general practitioners and diabetes educators. Data gathering was prolonged as it proved challenging to engage with healthcare staff as a result of frequent local restructuring and service disruption.

RESULTS

Local audits revealed discrepancies in basic data such as referral and attendance numbers compared with national audit data. There was a commonality in the themes identified from interviews: diabetes education was rarely embedded in service structure; where education uptake was poor, a lack of central support to delivery teams was noticeable; and where education uptake was positive, delivery teams were actively engaged, sometimes relying on enthusiastic individuals. Both situations put the local sustainability of diabetes education at risk.

CONCLUSIONS

There appears to be a link between attendance rates and organizational issues, therefore, when considering how to increase attendance rates, the state of the diabetes education infrastructure should be reviewed. Good uptake of diabetes education can be too reliant on the enthusiastic commitment of small teams or individuals delivering the education.

"90% of the time, it's not just weight": General practitioner and practice staff perspectives regarding the barriers and enablers to obesity guideline implementation

OBJECTIVE

To identify the views of GPs and general practice staff regarding barriers and enablers to implementation of obesity guideline recommendations in general practice.

METHODS

Twenty general practitioners (GPs) and 18 practice staff from inner-eastern Melbourne, Australia, participated in semi-structured telephone interviews. The interview schedule was informed by the Theoretical Domains Framework (TDF). Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis.

RESULTS

Participants lacked familiarity with and knowledge of the NHMRC obesity guidelines. Barriers and enablers were predominantly related to five theoretical domains: (1) environmental context and resources, (2) knowledge, (3) emotion, (4) beliefs about consequences, and (5) motivation and goals. Time pressures in consultations, costs for the patient, reluctance to add to patient burden particularly in those with comorbidities such as mental health issues, lack of awareness about services to refer patients to and GPs' fear of embarrassing patients and losing them were significant barriers. Enablers included having a strong doctor-patient relationship and a sense of responsibility to the patient to address weight.

CONCLUSIONS

Obesity guidelines and policy makers need to better engage with issues of multimorbidity, socioeconomic disadvantage and workforce issues if recommendations are to be widely adopted in general practice. Tasksharing, teamwork and technology are potential solutions to some of the barriers. Patient perspectives and approaches to being able to overcome stigma and legitimise obesity management in primary care consultations could also assist.

Experiences with rotavirus vaccines: can we improve rotavirus vaccine impact in developing countries?

Rotavirus vaccines have been introduced into over 95 countries globally and demonstrate substantial impact in reducing diarrheal mortality and diarrheal hospitalizations in young children. The vaccines are also considered by WHO as “very cost effective” interventions for young children, particularly in countries with high diarrheal disease burden. Yet the full potential impact of rotavirus immunization is yet to be realized. Large countries with big birth cohorts and where disease burden is high in Africa and Asia have not yet implemented rotavirus vaccines at all or at scale. Significant advances have been made demonstrating the impact of the vaccines in low- and lower-middle income countries, yet the modest effectiveness of the vaccines in these settings is challenging. Current research highlights these challenges and considers alternative strategies to overcome them, including alternative immunization schedules and host factors that may inform us of new opportunities.

A national study of the unmet needs of support persons of haematological cancer survivors in rural and urban areas of Australia

Purpose

This study aimed to compare support persons of haematological cancer survivors living in rural and urban areas in regard to the type, prevalence and factors associated with reporting unmet needs.

Methods

One thousand and four (792 urban and 193 rural) support persons of adults diagnosed with haematological cancer were recruited from five Australian state population-based cancer registries. Participants completed the Support Person Unmet Needs Survey (SPUNS) that assessed the level of unmet needs experienced over the past month across six domains.

Results

Overall, 66% of support persons had at least one ‘moderate, high or very high’ unmet need and 24% (n = 182) reported having multiple (i.e. 6 or more) ‘high/very high’ unmet needs in the past month. There were no significant differences between rural and urban support persons in the prevalence of multiple unmet needs or mean total unmet needs scores. There were however significant differences in the types of ‘high/very high’ unmet needs with support persons living in rural areas more likely to report finance-related unmet needs. Support persons who indicated they had difficulty paying bills had significantly higher odds of reporting multiple ‘high/very high’ unmet needs.

Conclusions

This is the first large, population-based study to compare the unmet needs of support persons of haematological cancer survivors living in rural and urban areas. Findings confirm previous evidence that supporting a person diagnosed with haematological cancer correlates with a high level of unmet needs and highlight the importance of developing systemic strategies for assisting support persons, especially in regard to making financial assistance and travel subsidies known and readily accessible to those living in rural areas.

Pilot feasibility study examining a structured self-management diabetes education programme, DESMOND-ID, targeting HbA1c in adults with intellectual disabilities

AIM

To report on the outcomes of a pilot feasibility study of a structured self-management diabetes education programme targeting HbA_1c .

METHODS

We conducted a two-arm, individually randomized, pilot superiority trial for adults with intellectual disability and Type 2 diabetes mellitus. A total of 66 adults with disabilities across the UK met the eligibility criteria. Of these, 39 agreed to participate and were randomly assigned to either the DESMOND-ID programme (n = 19) or a control group (n = 20). The programme consisted of seven weekly educational sessions. The primary outcome was HbA_1c level, and secondary outcomes included BMI, diabetes illness perceptions, severity of diabetes, quality of life, and attendance rates.

RESULTS

This study found that the DESMOND-ID programme was feasible to deliver. With reasonable adjustments, the participants could be recruited successfully, and could provide consent, complete the outcome measures, be randomized to the groups and attend most of the sessions, with minimal loss to follow-up. The fixed-effects model, the interaction between occasion (time) and condition, showed statistically significant results (0.05 level) for HbA_1c ; however, the CI was large.

CONCLUSION

This is the first published study to adapt and pilot a national structured self-management diabetes education programme for adults with intellectual disability. This study shows it is possible to identify, recruit, consent and randomize adults with intellectual disabilities to an intervention or control group. Internationally, the results of this pilot are promising, demonstrating that a multi-session education programme is acceptable and feasible to deliver. Its effectiveness should be further tested in an adequately powered trial.

Deficiencies in postgraduate training for healthcare professionals who provide diabetes education and support: results from the Diabetes Attitudes, Wishes and Needs (DAWN2) study

AIMS

To consider the global provision of self-management diabetes education and training for healthcare professionals using data from the second Diabetes Attitudes, Wishes and Needs (DAWN2) study.

METHODS

A total of 4785 healthcare professionals caring for people with diabetes were surveyed in 17 countries to assess diabetes healthcare provision, self-management support and training.

RESULTS

Of the healthcare professionals surveyed, 33.5% received formal postgraduate training in self-management (19.3-51.4% across countries) and 62.9% received training for medical management of diabetes (47.6-70.6% variation). Training in psychological management was low (19.1%), ranging from 3.6 to 36.5%, while 20.4% (a range of 3.6-36.4% across countries) had received no postgraduate training. Overall, the greatest training need was in the management of psychological aspects of diabetes (59.5%). For some, training in a domain was positively associated with a perceived need for further training. Communication skills, for example, listening (76.9%) and encouraging questions (76.1%), were the skills most widely used. Discussion of emotional issues was limited; 31-60% of healthcare professionals across the different countries reported that this only occurred if initiated by patients. Approximately two-thirds of participants reported a need for major improvements in emotional/psychological support, but few had received training in this area, with consistent findings across professional affiliations.

CONCLUSIONS

The present study shows that healthcare professionals report being insufficiently equipped to provide diabetes self-management education, including emotional and psychological aspects of diabetes, and many are not receiving postgraduate training in any part (including medical care) of the management of diabetes. It is paramount that those responsible for the continuing professional development of healthcare professionals address this skills gap.

Improving diabetes care for people with intellectual disabilities: a qualitative study exploring the perceptions and experiences of professionals in diabetes and intellectual disability services

BACKGROUND

Globally, diabetes is increasing with concerns about the impact on outcomes, including premature death and the costs associated with managing the condition. Research indicates that adults with intellectual disabilities (ID) are two to three times more likely to develop diabetes; however, there has been limited focus on diabetes service utilisation in this population. The aim of this study is to explore the perceptions and experiences of diabetes and ID practitioners.

METHODS

A series of 1:1 semi-structured interviews were undertaken in one Scottish health service area. In total, 29 qualitative interviews were conducted: 10 with diabetes practitioners from primary and secondary care, 14 from ID services and 5 from community care services regarding diabetes service provision for this population. Thematic content analysis was undertaken to identify the themes and subthemes.

RESULTS

Three main themes were identified: (1) enabling access to services to meet diabetes-related care needs of people with ID; (2) communication and service improvements between staff, patients and across services; and (3) providing person-centred diabetes care and developing adapted resources to increase patient self-care.

CONCLUSIONS

The findings of this study have important international implications in how diabetes practitioners plan and deliver services for people with ID and other vulnerable groups with limited cognitive ability and communication skills and difficulties in self-management. The findings highlight that access to diabetes education and adapted resources is needed, and if 'reasonable adjustments' are made to service provision and practice, people with ID can benefit from improved healthcare. Developing joint clinics to share knowledge and resources between diabetes and ID practitioners may improve service delivery and continuity of care, and thereby diminish the costs of not providing quality care.

MP2: PATHOPHYSIOLOGY AND METABOLIC PHENOTYPE OF LOW BODY MASS INDEX DIABETES

Purpose of Study

Millions of individuals with low body mass index (BMI) globally have diabetes of unclear etiology. These include patients with Fibrocalculous Pancreatic Diabetes (FCPD) and Lean Diabetes (LD), defined by the presence or absence of pancreatic calcifications on ultrasound. We present the first studies using gold-standard methodologies to assess their metabolic phenotype.

Methods Used

Stepped euglycemic-hyperinsulinemic (∼30 and 80 mU/m2/min) clamp studies were performed in n=8 Indian males with LD (age 38±3 y, BMI 18.4±0.1 kg/m2, HbA1c 11.0±0.8%) and n=22 with FCPD (age 30±1 y, BMI 19.7±0.6 kg/m2, HbA1c 10.2±0.6%), compared with n=12 type 2 diabetes subjects (T2DM, BMI 25.7±0.3 kg/m2, HbA1c 9.7±0.6%) and n=12 age and BMI matched non-diabetic (ND) subjects and n=16 with type 1 diabetes (T1DM, HbA1c 9.1±0.3%). Therapeutic regimens were intensified for two weeks to correct glucose toxicity in all groups. Lean body mass was determined for all subjects from percentage of total body fat as assessed by DXA.

Summary of Results

Peripheral insulin sensitivity (Rd, mg/kg lean body weight/min), was markedly impaired in T2DM (2.3±0.6; p<0.01) compared to LD (9.2±1.6) and FCPD (5.8±0.7). Rd did not differ between T1DM (5.8±0.7), LD and FCPD groups (figure 1).

Conclusions

Thus, these comprehensive studies suggest patients with LD and FCPD are only mildly insulin resistant once hyperglycemia is corrected. This promotes a paradigm shift in our understanding of low body mass index diabetes and could have profound therapeutic implications for millions of people.

Abstract MP2 Figure 1

13: LOW BODY MASS INDEX DIABETES IS CHARACTERIZED BY IMPAIRED INSULIN SECRETION

Purpose of Study

Fibrocalculous Pancreatic Diabetes (FCPD) and Lean Diabetes (LD) are unique forms of diabetes affecting millions of people in developing countries, characterized by the presence or absence of pancreatic calcifications on ultrasound and insulin-requiring but ketosis-resistant diabetes. To optimize therapeutic strategies for FCPD and lean diabetes patients, it is imperative to conclusively assess their insulin secretion using gold-standard methodologies.

Methods Used

Comprehensive tests were undertaken in n=22 Indian males with FCPD (age 30±2 y, BMI 19.7±0.6 kg/m2, HbA1c 9.0±0.3%) and n=6 with LD (age 36±4 y, BMI 18.3±0.1 kg/m2, HbA1c 11.6±1.3%), and compared with n=12 age, BMI matched ND, n=16 T1D (HbA1c 9.1±0.3%) and n=12 T2D subjects (age 36±2 y, BMI 26.0±0.3 kg/m2, HbA1c 9.7±0.6%). Following correction of hyperglycemia for over two weeks, mixed-meal tolerance tests (MMTT) and C-peptide deconvolution analysis was performed to assess beta-cell function.

Summary of Results

Glucose and C-peptide responses to MMTT suggest subjects with FCPD (14.5±2.2 pmol/kg/min) and LD (15.0±2.9 pmol/kg/min) have markedly impaired insulin secretion relative to both ND and T2D (p<0.001), and not statistically different from T1D (figure 1).

Conclusions

Thus, we report the first studies showing that patients with low BMI diabetes have impaired insulin secretion despite correction of hyperglycemia, consistent with nutritional effects on beta cell development or function.

Abstract 13 Figure 1

Self-monitoring of blood glucose versus self-monitoring of urine glucose in adults with newly diagnosed Type 2 diabetes receiving structured education: a cluster randomized controlled trial

AIMS

To compare the effectiveness and acceptability of self-monitoring of blood glucose with self-monitoring of urine glucose in adults with newly diagnosed Type 2 diabetes.

METHODS

We conducted a multi-site cluster randomized controlled trial with practice-level randomization. Participants attended a structured group education programme, which included a module on self-monitoring using blood glucose or urine glucose monitoring. HbA1c and other biomedical measures as well as psychosocial data were collected at 6, 12 and 18 months. A total of 292 participants with Type 2 diabetes were recruited from 75 practices.

RESULTS

HbA1c levels were significantly lower at 18 months than at baseline in both the blood monitoring group [mean (se) -12 (2) mmol/mol; -1.1 (0.2) %] and the urine monitoring group [mean (se) -13 (2) mmol/mol; -1.2 (0.2)%], with no difference between groups [mean difference adjusted for cluster effect and baseline value = -1 mmol/mol (95% CI -3, 2); -0.1% (95% CI -0.3, 0.2)]. Similar improvements were observed for the other biomedical outcomes, with no differences between groups. Both groups showed improvements in total treatment satisfaction, generic well-being, and diabetes-specific well-being, and had a less threatening view of diabetes, with no differences between groups at 18 months. Approximately one in five participants in the urine monitoring arm switched to blood monitoring, while those in the blood monitoring arm rarely switched (18 vs 1% at 18 months; P < 0.001).

CONCLUSIONS

Participants with newly diagnosed Type 2 diabetes who attended structured education showed similar improvements in HbA1c levels at 18 months, regardless of whether they were assigned to blood or urine self-monitoring.

Increasing capacity to deliver diabetes self-management education: results of the DESMOND lay educator non-randomized controlled equivalence trial

AIM

To develop and test a format of delivery of diabetes self-management education by paired professional and lay educators.

METHODS

We conducted an equivalence trial with non-randomized participant allocation to a Diabetes Education and Self Management for Ongoing and Newly Diagnosed Type 2 diabetes (DESMOND) course, delivered in the standard format by two trained healthcare professional educators (to the control group) or by one trained lay educator and one professional educator (to the intervention group). A total of 260 people with Type 2 diabetes diagnosed within the previous 12 months were referred for self-management education as part of routine care and attended either a control or intervention format DESMOND course. The primary outcome measure was change in illness coherence score (derived from the Diabetes Illness Perception Questionnaire-Revised) between baseline and 4 months after attending education sessions. Secondary outcome measures included change in HbA1c level. The trial was conducted in four primary care organizations across England and Scotland.

RESULTS

The 95% CI for the between-group difference in positive change in coherence scores was within the pre-set limits of equivalence (difference = 0.22, 95% CI 1.07 to 1.52). Equivalent changes related to secondary outcome measures were also observed, including equivalent reductions in HbA1c levels.

CONCLUSION

Diabetes education delivered jointly by a trained lay person and a healthcare professional educator with the same educator role can provide equivalent patient benefits. This could provide a method that increases capacity, maintains quality and is cost-effective, while increasing access to self-management education.

Stability and predictive utility, over 3 years, of the illness beliefs of individuals recently diagnosed with Type 2 diabetes mellitus

AIM

To determine the stability of beliefs of patients with Type 2 diabetes about their diabetes over 3 years, following diagnosis.

METHODS

Data were collected as part of a multicentre cluster randomized controlled trial of a 6-h self-management programme, across 207 general practices in the UK. Participants in the original trial were eligible for follow-up with biomedical data (HbA1c levels, blood pressure, weight, blood lipid levels) collected at the practice, and questionnaire data collected by postal distribution and return. Psychological outcome measures were depression (Hospital Anxiety and Depression Scale) and diabetes distress (Problem Areas in Diabetes scale). Illness beliefs were assessed using the Illness Perceptions Questionnaire-Revised and the Diabetes Illness Representations Questionnaire scales.

RESULTS

At 3-year follow-up, all post-intervention differences in illness beliefs between the intervention and the control group remained significant, with perceptions of the duration of diabetes, seriousness of diabetes and perceived impact of diabetes unchanged over the course of the 3-year follow-up. The control group reported a greater understanding of diabetes during the follow-up, and the intervention group reported decreased responsibility for diabetes outcomes during the follow-up. After controlling for 4-month levels of distress and depression, the perceived impact of diabetes at 4 months remained a significant predictor of distress and depression at 3-year follow-up.

CONCLUSIONS

Peoples' beliefs about diabetes are formed quickly after diagnosis, and thereafter seem to be relatively stable over extended follow-up. These early illness beliefs are predictive of later psychological distress, and emphasize the importance of initial context and provision of diabetes care in shaping participants' future well-being.

Diabetes self-management education: acceptability of using trained lay educators

BACKGROUND

The use of lay people to deliver education programmes for people with chronic conditions is a potential method of addressing healthcare staff capacity and increasing the cost efficiency of delivering education. This qualitative substudy is embedded within an equivalence trial (2008-2011 including development stage).

OBJECTIVES

In the qualitative substudy, we aimed to elicit the views of key stakeholders (patients, educators) about using lay people to deliver education to people recently diagnosed with type 2 diabetes, alongside a healthcare professional educator with an equal role. In this way, we sought to explore perceptions about acceptability and also contribute to understanding the reasons underlying positive or negative quantitative findings from main trial.

METHODS

We conducted 27 telephone interviews with a purposive sample of patients, lay educators and healthcare professional educators involved in the main trial. Thematic analysis of transcribed data was underpinned by the constant comparative approach and structured using Framework methodology.

RESULTS

Overall, the data suggested that the use of lay educators was acceptable to educators and patients. Perceived difference in knowledge levels between lay and healthcare professional educators did not appear to have an impact on perceived acceptability or the effectiveness of the education received. Additional themes explored were related to peer status of educators and feasibility. Some concerns were raised about lay educators with diabetes, transferring personal issues and about the impact of healthcare professional time taken up by mentoring and supporting lay educators.

CONCLUSIONS

Positive perceptions about the use of lay educators support the positive quantitative findings from the main trial. Acceptability is an important consideration in relation to implementation of the model of delivery studied. Concerns raised within the interviews should be considered in the design of training for lay educators.

TRIAL REGISTRATION NUMBER

ISRCTN 99350009.

Pubovaginal or Vicryl Mesh Rectus Fascia Sling in Intrinsic Sphincter Deficiency

The aim of this study was to compare the pubovaginal sling with a new Vicryl mesh rectus fascia (VMRF) sling in the surgical treatment of low urethral pressure genuine stress incontinence. Fifty-one consecutive women who had a VMRF (n = 27) or a pubovaginal sling (n = 24) procedure between March 1995 and December 1997 were evaluated. The patient-determined subjective success rate of the VMRF sling (85%) was significantly higher than that of the pubovaginal sling (58%) in women with low urethral pressure stress incontinence (P=0.03). The objective success rates following the VMRF and the pubovaginal sling were 52% and 50%, respectively. The prevalence of postoperative symptomatic voiding dysfunction and de novo detrusor instability was 7% after the VMRF sling and 25% following the pubovaginal sling (P = 0.08). The VMRF sling had a higher patient-determined success rate and a lower complication rate than the pubovaginal sling, and should be considered in the surgical management of women with low urethral pressure stress incontinence.

Pause for thought? Syncope and sinus arrest as the presenting feature of temporal lobe epilepsy

Some forms of focal epilepsy, including temporal lobe epilepsy, are rarely associated with ictal bradycardia and sinus node arrest. We report a case of a previously healthy man presenting with syncope in whom telemetry revealed sinus arrest. Initial treatment was with permanent pacemaker implantation and it was only following a subsequent grand mal seizure that other symptoms suggestive of temporal lobe epilepsy were documented. Anti-epileptic medication was subsequently commenced with resolution of all symptoms. There are few previously reported cases of syncope and documented sinus node arrest as the presenting feature of temporal lobe epilepsy.

Roles of cholesterol and bile salts in the pathogenesis of gallbladder hypomotility and inflammation: cholecystitis is not caused by cystic duct obstruction

A large number of human and animal studies have challenged the hypothesis that cystic duct obstruction by gallstones causes cholecystitis. These studies suggest that lithogenic bile that can deliver high cholesterol concentrations to the gallbladder wall causes hypomotility and creates a permissive environment that allows normal concentrations of hydrophobic bile salts to inflame the mucosa and impair muscle function inhibiting gallbladder emptying. High concentrations of cholesterol increase its diffusion rates through the gallbladder wall where they are incorporated into the sarcolemmae of muscle cells by caveolin proteins. High caveolar cholesterol levels inhibit tyrosine-induced phosphorylation of caveolin proteins required to transfer receptor-G protein complexes into recycling endosomes. The sequestration of these receptor-G protein complexes in the caveolae results in fewer receptors recycling to the sarcolemmae to be available for agonist binding. Lower internalization and recycling of CCK-1 and other receptors involved in muscle contraction explain gallbladder hypomotility. PGE2 receptors involved in cytoprotection are similarly affected. Cells with a defective cytoprotection failed to inactivate free radicals induced by normal concentrations of hydrophobic bile salts resulting in chronic inflammation that may lead to acute inflammation. Ursodeoxycholic acid salts (URSO) block these bile salts effects thereby preventing the generation of free radicals in muscle cells in vitro and development of cholecystitis in the ligated common bile duct in guinea pigs in vivo. Treatment with URSO improves muscle contraction and reduces the oxidative stress in patients with symptomatic cholesterol gallstones by lowering cholesterol concentrations and blocking the effects of hydrophobic bile salts on gallbladder tissues.

Measuring psychosocial outcomes: is the consumer or the professional the best judge?

In this review, we explore professionally-driven and consumer-driven paradigms in measuring psychosocial outcomes for cancer care. Early measures of psychosocial well-being focussed on clinically-derived concepts of dysfunction. Recent literature reflects a paradigm shift toward a consumer-driven approach to the conceptualisation and measurement of psychosocial well-being. The key distinction between the two approaches rests on whether the professional or consumer retains judgement authority and raises the question of whether it is necessary to include both perspectives in research and practice. Research is proposed to clarify our interpretation of these approaches with a view to devising novel interventions to benefit patient well-being.

Can residents be effective trauma team leaders in a major trauma centre?

OBJECTIVE

The overall objective of this study was to compare senior Emergency Department (ED) trainees (residents) with consultant trauma team leaders, assessing their influence on trauma team performance and patient outcomes. We aimed to identify the effect of seniority of leader on time-based performance measures and clinical outcomes.

METHODS

This retrospective study of prospectively collected data was conducted in an urban Major Trauma Centre which has a well-established trauma team. For the period covered by this study the trauma team was led by either an ED consultant or specialist registrar having completed a local trauma team leader development programme. Data from all adult trauma team activations for seriously injured trauma patients (ISS - Injury Severity Score >15) presenting between 1st January 2008 and 31st October 2009 were included. Performance measures included time to FAST, time to CT scan and time to haemorrhage control. Patient outcomes were mortality, critical care and hospital length of stay.

RESULTS

There were 579 patients seriously injured in the study period. Trainees led 126 (22%) of the trauma teams. Significant differences in times to diagnostics or haemorrhage control between trainees and consultants were only seen in patients presenting with shock. Compared with trainees, consultant team leaders were significantly more likely to achieve targets for diagnostic imaging (FAST <15 min: consultants 97% vs. 33% trainees, p<0.01; CT scan <60 min: 76% vs. 50%, p<0.01) and haemorrhage control (surgery or angiography <60 min: 82% vs. 54%, p<0.001). There was no significant difference in overall mortality between consultants and trainees (consultants 25% vs. trainees 27%, p 1.00). Critical care length of stay was also the same for both (consultants median 5 days vs. trainees median 5 days).

CONCLUSIONS

Consultant team leaders improve team performance, resulting in shorter times to diagnostic imaging, and faster transfer to haemorrhage control. The greatest benefit seems to be for bleeding patients. Clinical outcomes were similar for trainees and consultants in our major trauma centre.

A survey of the prevalence of persistent pain after vaginal delivery: a pilot study

INTRODUCTION

Pain that has lasted for 2 months is considered to be persistent, as defined by The International Association for the Study of Pain (IASP). To date, there is no data on the incidence of persistent pain after vaginal delivery available for Ireland. The aim of this pilot study is to determine the incidence of persistent pain in women post-vaginal delivery at 8 weeks postpartum in the Coombe Women's & Infants University Hospital, Dublin (CWIUH).

METHODS

50 women post-vaginal delivery at the CWIUH were recruited over a 2-month period. At 8 weeks after delivery, the patients were contacted by telephone interview to assess the presence of pain, if any, using a modified painDETECT Questionnaire.

RESULTS

The incidence of persistent pain at 8 weeks from our pilot study is 28%.

Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey

Waiting times can raise significant concern for cancer patients. This study examined cancer patients' concern levels at each phase of waiting. Demographic, disease and psychosocial characteristics associated with concern at each phase were also assessed. 146 consenting outpatients (n= 146) were recruited from two hospitals in Sydney, Australia. Each completed a touch-screen computer survey, asking them to recall concern experienced regarding waiting times at each treatment phase. Approximately half (52%) reported experiencing concern during at least one treatment phase, while 8.9% reported experiencing concern at every phase. Higher proportions of patients reported concern about waiting times from: deciding to have radiotherapy to commencement of radiotherapy (31%); the first specialist appointment to receiving a cancer diagnosis (28%); and deciding to have chemotherapy to commencement of chemotherapy (28%). Patient groups more likely to report concern were those of lower socio-economic status, born outside Australia, or of younger age. Although a small proportion of patients reported very high levels of concern regarding waiting times, the experience of some concern was prevalent. Opportunities for reducing this concern are discussed. Vulnerable groups, such as younger and socio-economically disadvantaged patients, should be the focus of efforts to reduce waiting times and patient concern levels.

Do cancer patients' psychosocial outcomes and perceptions of quality of care vary across radiation oncology treatment centres?

This study aimed to explore whether rates of depression, and anxiety and patient views about quality of patient-centred care varied across four metropolitan radiation therapy treatment centres in Sydney, Australia. Participants were radiation therapy outpatients, aged 18 or older and English-speaking. Participants completed a brief survey by touch screen computer while waiting for their radiation therapy treatment appointment. For eight indicators of patient-centred care, participants were asked to indicate whether their well-being would have been improved by better care related to the indicator. Participants also completed the Hospital Anxiety and Depression Scale. No differences between treatment centres were found for rates of anxiety and depression, or for the mean number of domains of care endorsed as needing improvement (indicated by agreeing or strongly agreeing that their well-being would have been improved by better care). The lack of variance in these outcomes may reflect that variation in treatment centre characteristics does not influence psychosocial outcomes and patient views of their care. Alternatively, it may suggest that the characteristics of the four treatment centres which participated in the present study were too similar for differences in patient outcomes to be observed.

Financial and social impact of supporting a haematological cancer survivor

Support persons of haematological cancer survivors may be faced with unique challenges due to the course of these diseases and the treatments required. This study aimed to examine the social and financial impacts associated with their role. Eight hundred adult survivors of haematological cancer within 3 years of diagnosis were invited via an Australian state population-based cancer registry to complete a survey. Survivors were mailed two questionnaire packages, one for themselves and one for their primary support person. Non-respondents were mailed reminders via the survivor after 3 weeks. One hundred and eighty-two support persons completed the questionnaire (85% response rate). Of these, 67 (46%) support persons reported having at least one personal expense and 91 (52%) experienced at least one financial impact. Male support persons and support persons of survivors in active treatment reported experiencing more personal expenses than other support persons. Older participants reported fewer financial consequences. A greater number of social impacts were reported by those born outside Australia, those who had to relocate for treatment and support persons of survivors in active treatment. Future research should focus on practical solutions to reducing these impacts on support persons.

Epidural analgesia for labour: maternal knowledge, preferences and informed consent

Epidural analgesia has become increasingly popular as a form of labour analgesia in Ireland. However obtaining true inform consent has always been difficult. Our study recruited 100 parturients who had undergone epidural analgesia for labour, aimed to determine the information they received prior to regional analgesia, and to ascertain their preferences regarding informed consent. Only 65 (65%) of patients planned to have an epidural. Knowledge of potential complications was variable and inaccurate, with less than 30 (30%) of women aware of the most common complications. Most women 79 (79%) believed that discomfort during labour affected their ability to provide informed consent, and believe consent should be taken prior to onset of labour (96, 96%). The results of this study helps define the standards of consent Irish patients expect for epidural analgesia during labour.

Multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: the Microalbuminuria Education and Medication Optimisation (MEMO) study

AIMS

To determine whether tighter cardiovascular risk factor control with structured education in individuals with type 2 diabetes (T2DM) and microalbuminuria benefits cardiovascular risk factors.

METHODS

Participants from a multiethnic population, recruited from primary care and specialist clinics were randomised to intensive intervention with structured patient (DESMOND model) education (n=94) or usual care by own health professional (n=95).

PRIMARY OUTCOME

change in HbA1c at 18months.

SECONDARY OUTCOMES

changes in blood pressure (BP), cholesterol, albuminuria, proportion reaching risk factor targets, modelled cardiovascular risk scores.

RESULTS

Mean (SD) age and diabetes duration of participants were 61.5 (10.5) and 11.5 (9.3) years, respectively. At 18months, intensive intervention showed significant improvements in HbA1c (7.1(1.0) vs. 7.8(1.4)%, p<0.0001), systolic BP (129(16) vs. 139(17) mmHg, p<0.0001), diastolic BP (70(11) vs. 76(12) mmHg, p<0.001), total cholesterol (3.7(0.8) vs. 4.1(0.9) mmol/l, p=0.001). Moderate and severe hypoglycaemia was 11.2 vs. 29.0%; p=0.001 and 0 vs. 6.3%; p=0.07, respectively. More intensive participants achieved ≥3 risk factor targets with greater reductions in cardiovascular risk scores.

CONCLUSIONS

Intensive intervention showed greater improvements in metabolic control and cardiovascular risk profile with lower rates of moderate and severe hypoglycaemia. Intensive glycaemic interventions should be underpinned by structured education promoting self-management in T2DM.

Assessment of physical fitness for esophageal surgery, and targeting interventions to optimize outcomes

This review examines how higher levels of physiological reserve and fitness can help the patient endure the demands of esophageal surgery. Lung function, body composition, cardiac function, inflammatory mediators and exercise performance are all determinants of fitness. Physical fitness, both as an independent risk factor and through its effect on other risk factors, has been found to be significantly associated with the risk of developing postoperative pulmonary complications (PPCs) in patients following esophagectomy. Respiratory dysfunction preoperatively poses the dominant risk of developing complications, and PPCs are the most common causes of morbidity and mortality. The incidence of PPCs is between 15 and 40% with an associated 4.5-fold increase in operative mortality leading to approximately 45% of all deaths post-esophagectomy. Cardiac complications are the other principal postoperative complications, and pulmonary and cardiac complications are reported to account for up to 70% of postoperative deaths after esophagectomy. Risk reduction in patients planned for surgery is key in attaining optimal outcomes. The goal of this review was to discuss the risk factors associated with the development of postoperative pulmonary complications and how these may be modified prior to surgery with a specific focus on the pulmonary complications associated with esophageal resection. There are few studies that have examined the effect of modifying physical fitness pre-esophageal surgery. The data to date would indicate a need to develop targeted interventions preoperatively to increase physical function with the aim of decreasing postoperative complications.

Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis

OBJECTIVES

To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes.

DESIGN

We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current "real world" costs of delivering the intervention estimated for a hypothetical primary care trust.

SETTING

Primary care trusts in the United Kingdom.

PARTICIPANTS

Patients with newly diagnosed type 2 diabetes.

INTERVENTION

A six hour structured group education programme delivered in the community by two professional healthcare educators.

MAIN OUTCOME MEASURES

Incremental costs and quality adjusted life years (QALYs) gained.

RESULTS

On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is pound209 (95% confidence interval - pound704 to pound1137; euro251, -euro844 to euro1363; $326, -$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (-0.0813 to 0.1786), and the mean incremental cost per QALY is pound5387. Using "real world" intervention costs, the lifetime incremental cost of the DESMOND intervention is pound82 (- pound831 to pound1010) and the mean incremental cost per QALY gained is pound2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of pound20 000 per QALY is 66% using trial based intervention costs and 70% using "real world" costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year.

CONCLUSION

Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Depressive symptoms in the first year from diagnosis of Type 2 diabetes: results from the DESMOND trial

AIMS

To describe the course of depressive symptoms during the first year after diagnosis of Type 2 diabetes.

METHODS

Post hoc analysis of data from a randomized controlled trial of self-management education for 824 individuals newly diagnosed with Type 2 diabetes. Participants completed the Depression scale of the Hospital Anxiety and Depression Scale after diagnosis and at 4, 8 and 12 months follow-up. Participants also completed the Problem Areas in Diabetes scale at 8 and 12 months follow-up. We present descriptive statistics on prevalence and persistence of depressive symptoms. Logistic regression is used to predict possible depression cases, and multiple regression to predict depressive symptomatology.

RESULTS

The prevalence of depressive symptoms in individuals recently diagnosed with diabetes (18-22% over the year) was not significantly different from normative data for the general population (12%) in the UK. Over 20% of participants indicated some degrees of depressive symptoms over the first year of living with Type 2 diabetes; these were mostly transient episodes, with 5% (1% severe) reporting having depressive symptoms throughout the year. At 12 months post diagnosis, after controlling for baseline depressive symptoms, diabetes-specific emotional distress was predictive of depressive symptomatology.

CONCLUSIONS

The increased prevalence of depressive symptoms in diabetes is not manifest until at least 1 year post diagnosis in this cohort. However, there are a significant number of people with persistent depressive symptoms in the early stages of diabetes, and diabetes-specific distress may be contributing to subsequent development of depressive symptoms in people with Type 2 diabetes.

Rapid domain wall motion in permalloy nanowires excited by a spin-polarized current applied perpendicular to the nanowire

We study domain wall dynamics in Permalloy nanowires excited by alternating spin-polarized current applied perpendicular to the nanowire. Spin torque ferromagnetic resonance measurements reveal that domain wall oscillations at a pinning site in the nanowire can be excited with velocities as high as 800 m/s at current densities below 10{7} A/cm{2}.

How can structured self-management patient education improve outcomes in people with type 2 diabetes?

Type 2 diabetes (T2DM) is a long-term chronic condition that is complex to manage, with the majority of management being done by the person with diabetes outside of the clinical setting. Because of its complexities, effective self-management requires skills, confidence and the ability to make decisions and choices about treatments and lifestyle on a day-to-day basis. Equipping a person with these self-management skills is in itself challenging and it is now widely accepted that structured education is an integral part of the management of T2DM. This paper explores whether structured self-management education can improve outcomes in people with diabetes. The authors explore what self-management education is, why it is needed and then go on to examine the recent evidence from clinical trials from 2006 onwards.

Vaginal repair with mesh versus colporrhaphy for prolapse: a randomised controlled trial

OBJECTIVE

To compare vaginal repair augmented by mesh with traditional colporrhaphy for the treatment of pelvic organ prolapse.

DESIGN

Prospective randomised controlled trial.

SETTING

Tertiary teaching hospital.

POPULATION

One hundred and thirty-nine women with stage >or=2 prolapse according to the pelvic organ prolapse quantification (POP-Q) system requiring both anterior and posterior compartment repair.

METHODS

Subjects were randomised to anterior and posterior vaginal repair with mesh augmentation (mesh group, n = 69) or traditional anterior and posterior colporrhaphy (no mesh group, n = 70).

MAIN OUTCOME MEASURES

The primary outcome was the absence of POP-Q stage >or=2 prolapse at 12 months. Secondary outcomes were symptoms, quality-of-life outcomes and satisfaction with surgery. Complications were also reported.

RESULTS

For subjects attending the 12-month review, success in the mesh group was 81.0% (51 of 63 subjects) compared with 65.6% (40/61) in the no mesh group and was not significantly different (P-value = 0.07). A high level of satisfaction with surgery and improvements in symptoms and quality-of-life data were observed at 12 months compared to baseline in both groups, but there was no significant difference in these outcomes between the two groups. Vaginal mesh exposure occurred in four women in the mesh group (5.6%). De novo dyspareunia was reported by five of 30 (16.7%) sexually active women in the mesh group and five of 33 (15.2%) in the no mesh group at 12 months.

CONCLUSION

In this study, vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy 12 months following surgery.