Time preferences, diabetes self-management behaviours and outcomes: a systematic review

AIM

Time preferences, i.e. individuals' degree of patience/impatience in intertemporal choice, have been found to be associated with suboptimal health behaviours and health outcomes such as smoking, physical inactivity, unhealthy food intake and obesity. In this systematic review, we aimed to synthesise reported associations between time preferences, diabetes self-management behaviours, including use of diabetes technology, and outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit and all databases in the Web of Science Core Collection. Peer-reviewed studies of people with diabetes that included at least one diabetes-related behaviour or outcome and a measure of time preferences were included. Non-English language studies were excluded.

RESULTS

A total of 961 records were identified, of which 12 articles were included. Three studies analysed both time-consistent and time-inconsistent preferences, three studies solely analysed time-inconsistent preferences and six studies did not explicitly define a time preference model. Measured outcomes across studies included self-care activities, such as medication-taking, exercising and eating a healthy diet, and biomedical outcomes, such as HbA_1c and diabetes-related complications. There were 10 cross-sectional studies and two panel-data studies. No studies explicitly analysed the relationship between time preferences and diabetes technology use.

CONCLUSIONS

Associations between measures of time preferences, diabetes self-management behaviours and clinical outcomes exist. Higher discount rates determined by both time-consistent and time-inconsistent models predict less diabetes-related self-care and worse outcomes. These findings may add to explanations of the observed variation in diabetes-related health and provide new insights for tailoring interventions and policies aimed at improving diabetes self-management.

Integrating psychosocial support into routine diabetes care: perspectives from participants at the Self-Management Alliance meeting 2016

AIMS

To identify challenges and solutions to integrating psychosocial support into routine diabetes care from the perspective of stakeholders with expertise in diabetes self-management education and support.

METHODS

Ninety-four people attended the annual international Diabetes Self-Management Alliance meeting in 2016, which included plenary sessions and workshops on self-management education, support and prevention. One workshop focused on how to integrate psychosocial support into routine diabetes care; this was run four times consecutively, allowing all conference participants to attend the workshops in groups of 20-25 people.

RESULTS

Challenges and solutions associated with integrating psychosocial support into routine diabetes care concern the patient-provider relationship, the healthcare system and the community. Challenges identified were: lack of time, skills and resources to deal with psychological well-being; a culture of patient blame and care expectations; the complexity of person-centred assessment of psychological issues; and the substantial healthcare system focus on productivity and biomedical indicators. Lack of involvement of local communities and of inclusion of social determinants of health were also highlighted as challenging. Solutions identified were more patient-provider dialogue; more training and better skills among care providers; system incentives for psychosocial outcomes; and targeting social determinants of health and involvement of family and peers.

CONCLUSIONS

From the perspective of international stakeholders with an expertise in diabetes self-management and support attending the conference in Denmark, substantial new incentives and systematic cultural changes are needed in healthcare systems to integrate psychosocial support into routine diabetes care, as recommended in international guidelines.

Lyman-α source for laser cooling antihydrogen

We present a Lyman-α laser developed for cooling trapped antihydrogen. The system is based on a pulsed Ti:sapphire laser operating at 729 nm that is frequency doubled using an LBO crystal and then frequency tripled in a Kr/Ar gas cell. After frequency conversion, this system produces up to 5.7 μW of average power at the Lyman-α wavelength. This laser is part of the ATRAP experiment at the antiproton decelerator in CERN.

Abstract P2-02-14: Circulating tumor DNA predicts clinical outcome in early stage triple negative breast cancer

Background- Triple negative breast cancer (TNBC) is the most aggressive subtype of breast cancer as these patients have the highest risk of recurrence and death. Only 35% of TNBC patients achieve a pathologic complete response (pCR) following neoadjuvant chemotherapy. Patients who do not achieve pCR have a 27% risk of distant recurrence and ultimate death at 3 years compared to 9% for pCR. Unidentified micrometastases are responsible for ultimate overt progression and death. Developing strategies to identify patients with minimal residual disease following curative treatment is an unmet need. Circulating tumor DNA (ctDNA) can characterize and monitor advanced cancers. In this study, we sought to assess if ctDNA can predict clinical outcome in TNBC.

Methods-Biospecimens were obtained from patients with stages II and III TNBC enrolled on a neoadjuvant trial (NCT02124902). Patients have a research biopsy and plasma for ctDNA collected at baseline, cycle 1 day 3, definitive surgery for those with residual disease, and at recurrence for those who relapse. Plasma for ctDNA is also collected every 6 months for 5 years after treatment. Patients receive docetaxel and carboplatin every 3 weeks X 6 cycles. Surgery is 3-5 weeks after chemotherapy. Six patients' serial tumor samples and germline DNA were studied by whole exome sequencing. The median sequencing depth was 90.13x. Sequencing was performed on samples with high cellularity (≥50%). All 6 patients also had serial ctDNA analyzed using Swift Biosciences Accel-Amplicon™ 56G Oncology Panel v2. After identifying somatic mutations in each breast tumor series, we determined the subset of mutations that intersected with the regions targeted by the Swift 56 gene panel. We then evaluated whether corresponding mutations could be detected in ctDNA, and if ctDNA predicted clinical outcome.

Results-Four of the 6 patients were non-pCR with residual disease following chemotherapy. We identified 627 somatic variants by exome analysis that were called by at least two somatic variant callers and passed additional quality filtering steps. Of these, 10 variants overlapped with the Swift panel. TP53 variants were identified in all 6 patients' tumor tissue samples. At least one TP53 variant was identified in 4 patients' baseline pre-chemotherapy ctDNA samples. Both pCR patients had either no detectable ctDNA TP53 mutations (NTN007-ref. in baseline tumor tissue was 19.58% variant allele frequency [VAF]); or clearance of ctDNA following chemotherapy from 4.45% VAF at baseline to 0.06% following chemotherapy (NTN004-ref. in baseline tumor tissue 37.34% VAF). Three non-PCR patients had persistent TP53 mutations in ctDNA during the treatment course. One non-pCR patient did not have detectable mutations in ctDNA. The only patient with recurrent disease whose ctDNA TP53 mutation persisted during the treatment course (baseline VAF-1.65%, cycle 1 day 3-0.78%, definitive surgery-0.09%), was found to have a higher ctDNA VAF at recurrence (29.55%).

Conclusion-In this pilot study, mutation tracking by ctDNA is sensitive and distinguishes pCR from non-pCR in TNBC patients receiving neoadjuvant chemotherapy. ctDNA also identifies recurrence following curative therapy. Evaluating ctDNA as a biomarker of outcome in TNBC is warranted.

Citation Format: Ademuyiwa F, Feng Y-Y, Skidmore Z, Kunisaki J, Walker J, Fulton R, Krysiak K, Skinner T, Weilbaecher K, Ma C, Griffith O, Griffith M. Circulating tumor DNA predicts clinical outcome in early stage triple negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-02-14.

Characteristics associated with non-disclosure of Type 2 diabetes at work

AIM

To explore factors associated with non-disclosure of Type 2 diabetes to employers among Danish workers with Type 2 diabetes.

METHODS

A total of 705 workers with Type 2 diabetes completed a Danish cross-sectional survey. Logistic regression models were used to estimate the associations between background characteristics and probability of non-disclosure of diabetes to the employer. The models were mutually adjusted for background characteristics, socioeconomic-, diabetes- and work-related factors.

RESULTS

Among the participants, 23% had not disclosed their Type 2 diabetes to their current employer. Non-disclosure was associated with more sickness absence, more years with diabetes, greater use of diabetic medication, higher educational level and a perception of not being respected by superior. Personal traits such as gender, age and well-being were not associated with disclosure.

CONCLUSIONS

Among the feasible targets for interventions, good psychosocial work environment was associated with disclosure.

Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis

Post-partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post-partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post-partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self-monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home- or centre-based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta-analysis (1,892 women, age 24-36 years). Studies with self-monitoring had significantly greater weight lost than those without (-4.61 kg [-7.08, -2.15] vs. -1.34 kg [-1.66, -1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (-3.24 kg [-4.59, -1.90] vs. -1.63 kg [-2.16, -1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self-monitoring and take a combined diet-and-exercise approach have significantly greater weight loss in post-partum women.

The management of Type 2 diabetes: a survey of Australian general practitioners

OBJECTIVE

To explore how clinical and demographic variables impact on the management of diabetes mellitus in general practice.

DESIGN

A structured vignette survey was conducted in Australia. This included nine vignettes chosen at random from 128 developed around seven clinical variables. Respondents were asked to recommend a change in treatment and make specific recommendations. A random sample of general practitioners (GPs) were recruited. Two diabetologists involved in the development of national guidelines also participated.

RESULTS

125 (13.8%) GPs participated. Statistical analyses were used to generate outcome measures. GPs recommended a change in treatment for most (81.1%) cases; were less likely to prescribe a statin (68.5% GPs vs. 76.3% diabetologists), less likely to treat hypertension (66.7% vs.89%) and less likely to refer for lifestyle modification (82.3% vs. 96.5%). Significant disagreement occurred around prescribing or changing oral hypoglycaemics. No GP characteristics showed significant impact. The proportion of GPs who agreed with diabetiologists on dose and choice of drugs was 35.7% for statins, 49.6% for antihypertensives and 39.6% for oral hypoglycaemics.

CONCLUSIONS

There were significant differences between diabetologists and GPs on the management of diabetes. The survey suggests significant under-dosing by GPs. These findings warrant further investigation.

Perceptions of Caribbean type 2 diabetes patients on self-monitoring of blood glucose

CONTEXT

The views of type 2 diabetes (T2DM) patients have not been considered in the debate on the role of self-monitoring of blood glucose (SMBG) in the management of T2DM.

OBJECTIVE

To assess the views of T2DM patients on SMBG.

METHODS

Two previously trained research assistants used a structured pre-tested questionnaire to interview 416 T2DM patients practising SMBG in out-patient clinics in the privacy of the patients after they have consented to be interviewed.

RESULTS

79% of patients were unemployed with mean duration of diabetes of 11.8 ± 0.5 year. 94% of patients did not have health insurance policies while 86% did not belong to any diabetes support group. Although 70% of the patients identified SMBG as expensive, 94% believed it assists glycaemic control, while 89% thought it was worth the expense.

CONCLUSION

Caribbean T2DM patients believe SMBG was beneficial for the management of their diabetes and empowering them may reduce diabetes complications.

The use of thromboembolic deterrent stockings and a sequential compression device to prevent spinal hypotension during caesarean section

Hypotension is a common side effect of spinal anaesthesia for caesarean section. We have performed a randomised, controlled study to determine the efficacy of a sequential compression device (SCD) (Kendall) in combination with thromboembolic deterrent (TED) stockings (Kendall) to reduce the incidence of hypotension in this setting. Within 20 min of spinal injection, there was no statistically significant difference in the incidence of hypotension (defined as less than 100 mmHg and less than 80% of baseline blood pressure) (TED/SCD group 65%, control 80%, P = 0.12). However, there was a trend for those receiving TED/SCD prophylaxis to require less ephedrine to maintain normotension than the control group (median TED/SCD 3 mg, control 6 mg, P = 0.08). The administration of ephedrine deviated from protocol on a total of 46 occasions (2.3% of recordings). To try to reduce the influence of this, we reinspected our data using time to first episode of hypotension with a Kaplan-Meier survival analysis. This showed that the instantaneous risk (hazard) of developing hypotension was 1.8 (95% CI: 1.1-2.9) times higher in controls than those receiving TED/SCD prophylaxis (P = 0.02). Despite demonstrating some benefit of TED/SCD prophylaxis to prevent hypotension, we do not consider that the magnitude of this benefit warrants their routine use.

Computerized medical record in a private neurotology practice

OBJECTIVE

To develop a computerized medical record for a private neurotology practice using a relational database with templates.

BACKGROUND

Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given.

METHODS

Using a commercially available, record-keeping software in a local area computer network. templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record.

RESULTS

A fully computerized medical record has been developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer.

CONCLUSION

Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.

Porcine lung surfactant protein D: complementary DNA cloning, chromosomal localization, and tissue distribution

Porcine organs and lung surfactant have medically important applications in both xenotransplantation and therapy. We have started to characterize porcine lung surfactant by cloning the cDNA of porcine surfactant protein D (SP-D). SP-D and SP-A are important mediators in innate immune defense for the lung and possibly other mucosal surfaces. Porcine SP-D will also be an important reagent for use in existing porcine animal models for human lung infections. The complete cDNA sequence of porcine SP-D, including the 5' and 3' untranslated regions, was determined from two overlapping bacteriophage clones and by PCR cloning. Three unique features were revealed from the porcine sequence in comparison to SP-D from other previously characterized species, making porcine SP-D an intriguing species addition to the SP-D/collectin family. The collagen region contains an extra cysteine residue, which may have important structural consequences. The other two differences, a potential glycosylation site and an insertion of three amino acids, lie in the loop regions of the carbohydrate recognition domain, close to the carbohydrate binding region and thus may have functional implications. These variations were ruled out as polymorphisms or mutations by confirming the sequence at the genomic level in four different pig breeds. Porcine SP-D was shown to localize primarily to the lung and with less abundance to the duodenum, jejunum, and ileum. The genes for SP-D and SP-A were also shown to colocalize to a region of porcine chromosome 14 that is syntenic with the human and murine collectin loci.

The adenovirus E3 region 14.7 kDa protein, heat and sodium arsenite inhibit the TNF-induced release of arachidonic acid

In this report we show that the adenovirus E3 region 14.7 kDa protein, heat and sodium arsenite, which have been defined previously as inhibitors of cytolysis, inhibit the tumor necrosis factor-alpha (TNF)-induced release of 3H-arachidonic acid from cycloheximide-sensitized C3HA fibroblasts. Since the A23187-induced release of 3H-a.a. was unaffected, our results suggest that these inhibitors provide resistance to lysis by selectively interfering with the lytic response pathway. Our results also show that heat and sodium arsenite can themselves induce the release of 3H-arachidonic acid. These results raise the possibility that stressor-induced resistance to TNF results from the selective desensitization of phospholipase A2.

Disparate serum thioridazine concentrations: liquid chromatography versus radioreceptor assay

A radioreceptor and a liquid chromatographic assay quantitating serum thioridazine and its active metabolites yield widely disparate results. The difference between the results of the two assays was relatively random. Contrary to earlier suggestions the radioreceptor assay may not be suitable for the measurement of all neuroleptics particularly when a common reference, such as chlorpromazine, is used.

Clomipramine and doxepin in depressive neurosis. Plasma levels and therapeutic response

The therapeutic efficacy, plasma levels, and psychomotor effects of tryptophan (L-tryptophan), clomipramine hydrochloride, and doxepin were investigate in "neurotically" depressed outpatients. The tricyclic antidepressants were significantly more efficacious than tryptophan in inducing remission. The alleviation of depression was preceded by an improvement of the initially slow information-processing rates in the depressed patients. The plasma levels of the tricyclics that were associated with a therapeutic response were significantly lower than those reported in "endogenously" depressed inpatients.

Diazepam and N-desmethyldiazepam redistribution after heparin

The effects of heparin, 1,000 U intravenously, on the blood, plasma, and free concentrations of diazepam and its metabolite, N-desmethyldiazepam, have been investigated 3 hr after oral administration of 10 mg diazepam to 5 normal subjects. The percent free diazepam and N-desmethyldiazepam increased 15 min after heparin from 1.66 +/- 0.35 to 3.99 +/- 1.88 (mean +/- SD; p less than 0.05) in the case of diazepam anolite. The actual free concentration of diazepam rose from 3.6 +/- 1.04 to 6.9 +/- 1.33 ng/ml (p less than 0.05) 15 min after heparin while total blood concentration was unchanged (144 +/- 54 vs 130 +/- 57 ng/ml). Free concentrations of N-desmethyldiazepam rose from 0.62 +/- 0.17 to 1.01 +/- 0.34 but the effect, though consistent, was not statistically significant. Blood concentrations did not change (15 +/- 3.2 vs 14 +/- 3.9 ng/ml). That free drug level rose without a change in blood or total plasma levels suggests that factors other than simple plasma binding displacement are involved in this drug interaction.