Management of type 2 diabetes mellitus in people with severe mental illness: an online cross-sectional survey of healthcare professionals

Objectives To establish healthcare professionals’ (HCPs) views about clinical roles, and the barriers and enablers to delivery of diabetes care for people with severe mental illness (SMI). Design Cross-sectional, postal and online survey. Setting Trusts within the National Health Service (NHS), mental health and diabetes charities and professional bodies. Participants HCPs who care for people with type 2 diabetes mellitus (T2DM) and/or SMI in the UK. Primary and secondary outcome measures The barriers, enablers and experiences of delivering T2DM care for people with SMI, informed by the Theoretical Domains Framework (TDF). Results Responders were 273 HCPs, primarily mental health nurses (33.7%) and psychiatrists (32.2%). Only 25% of respondents had received training in managing T2DM in people with SMI. Mental health professionals felt responsible for significantly fewer recommended diabetes care standards than physical health professionals (p<0.001). For those seeing diabetes care as part of their role, the significant barriers to its delivery in the regression analyses were a lack of knowledge (p=0.003); a need for training in communication and negotiation skills (p=0.04); a lack of optimism about the health of their clients (p=0.04) and their ability to manage T2DM in people with SMI (p=0.003); the threat of being disciplined (p=0.02); fear of working with people with a mental health condition (p=0.01); a lack of service user engagement(p=0.006) and a need for incentives (p=0.04). The significant enablers were an understanding of the need to tailor treatments (p=0.04) and goals (p=0.02) for people with SMI. Conclusions This survey indicates that despite current guidelines, diabetes care in mental health settings remains peripheral. Even when diabetes care is perceived as part of a HCP’s role, various individual and organisational barriers to delivering recommended T2DM care standards to people with SMI are experienced

Erratum to: ’Effectiveness and cost-effectiveness of a patient-initiated botulinum toxin treatment model for blepharospasm and hemifacial spasm compared to standard care: study protocol for a randomised controlled trial’.

Blepharospasm and hemifacial spasm are debilitating conditions that significantly impact on patient quality of life. Cyclical treatment with botulinum toxin injections offers temporary relief, but the duration of treatment efficacy is variable. The standard model of patient care defines routine fixed-time based scheduled treatment cycles which may lead to unnecessarily frequent treatment for some patients and experience of distressing symptoms in others, if symptoms return before the scheduled follow-up period

Diabetes self-management in people with severe mental illness

Diabetes is a common and a serious global health problem, currently affecting an estimated 8.3% of adults - 382 million people worldwide, and taking up 11% of international health expenditure (International Diabetes Federation, 2013). Type 2 diabetes is the commonest type of diabetes and accounts for around 90% of cases. This condition typically develops during adulthood, usually in people over the age of 40 years, but younger onset is becoming increasingly more common. The disease is characterised by poorly regulated blood glucose levels, which may arise from defects in insulin secretion (insulin deficiency), or in its action (insulin resistance), or both. Therefore, the aim of treatment is to manage blood glucose levels to alleviate short-term symptoms and prevent or delay the development of long-term complications. Raised glucose in the blood, known as hyperglycaemia can initially be controlled by lifestyle management such as changes to diet and exercise, but given the progressive nature of type 2 diabetes it is likely that most individuals will ultimately require pharmacological intervention as well. This may initially be with oral hypoglycaemic drugs to increase the production or uptake of insulin and, if the disease remains uncontrolled, insulin therap

Vision-related quality of life and Appearance concerns are associated with anxiety and depression after eye enucleation: A cross-sectional study

© 2015 Ye et al. Aims: To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation. Methods: This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression. Results: The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression. Conclusions: Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocialrather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed. Copyright

Does strabismus surgery improve quality and mood, and what factors influence this?

Aims To establish the impact of adult strabismus surgery on clinical and psychosocial well-being and determine who experiences the greatest benefit from surgery and how one could intervene to improve quality of life post-surgery. Methods A longitudinal study, with measurements taken pre-surgery and at 3 and 6 months post-surgery. All participants completed the AS-20 a disease specific quality of life scale, along with measures of mood, strabismus and appearance-related beliefs and cognitions and perceived social support. Participants also underwent a full orthoptic assessment at their preoperative visit and again 3 months postoperatively. Clinical outcomes of surgery were classified as success, partial success or failure, using the largest angle of deviation, diplopia and requirement for further therapy. Results 210 participants took part in the study. Strabismus surgery led to statistically significant improvements in psychosocial and functional quality of life. Those whose surgery was deemed a partial success did however experience a deterioration in quality of life. A combination of clinical variables, high expectations, and negative beliefs about the illness and appearance pre-surgery were significant predictors of change in quality of life from pre- to post-surgery. Conclusions Strabismus surgery leads to significant improvements in quality of life up to 6 months postoperatively. There are however a group of patients who do not experience these benefits. A series of clinical and psychosocial factors have now been identified, which will enable clinicians to identify patients who may be vulnerable to poorer outcomes post-surgery and allow for the development of interventions to improve quality of life after surgery

Questionnaire study to gain an insight into the manufacturing and fitting process of artificial eyes in children: an ocularist perspective

Purpose To gain an insight into the manufacturing and fitting of artificial eyes in children and potential improvements to the process. Method An online qualitative survey was distributed to 39 ocularists/prosthetists in Europe and Canada. Participants were recruited through purposive sampling, specifically maximum variation sampling from the researcher’s contacts and an online search. Results The findings highlighted the current impression technique as being the most difficult yet most important part of the current process for both the ocularist and child patient. Negatively affecting obtaining a good impression, the child patients distress can be reduced by their parents by providing encouragement, reassurance, practicing the insertion and removal of the artificial eye and being matter of fact. Whilst improvements to the current process provided mixed views, the incorporation of current technology was perceived as not being able to meet the requirements to produce aesthetically pleasing artificial eyes. Conclusion The current artificial eye process can be seen as an interaction with its success being dependent on the child patient’s acceptance and adjustment which is dependent on the factors associated to the process. Investigation into the needs of the patient and whether technology can improve the process are the next steps in its advancement

Self management interventions for type 2 diabetes in adult people with severe mental illness

Background: People with severe mental illness are twice as likely to develop type 2 diabetes asthose without severe mental illness. Treatment guidelines for type 2 diabetes recommend that structured education should be integrated into routine care and should be offered to all.However, for people with severe mental illness, physical health may be a low priority, and motivation to change may be limited. These additional challenges mean that the findings reported in previous systematic reviews of diabetes self management interventions may not be generalised to those with severe mental illness, and that tailored approaches to effective diabetes education may be required for this population. Objectives: To assess the effects of diabetes self management interventions specifically tailored for people with type 2 diabetes and severe mental illness. Search methods: We searched the Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature(CINAHL), the International Clinical Trials Registry Platform (ICTRP) Search Portal, ClinicalTrials.gov and grey literature. The date of the last search of all databases was 07 March 2016. Selection criteria Randomised controlled trials of diabetes self management interventions for people with type 2 diabetes and severe mental illness. Data collection and analysis: Two review authors independently screened abstracts and full-text articles, extracted data and conducted the risk of bias assessment. We used a taxonomy of behaviour change techniques and the framework for behaviour change theory to describe the theoretical basis of the interventions and active ingredients. We used the GRADE method (Grades of Recommendation, Assessment, Development and Evaluation Working Group) to assess trials for overall quality of evidence. Main results: We included one randomised controlled trial involving 64 participants with schizophrenia or schizoaffective disorder. The average age of participants was 54 years; participants had been living with type 2 diabetes for on average nine years, and with their psychiatric diagnosis since they were on average 28 years of age. Investigators evaluated the 24-week Diabetes Awareness and Rehabilitation Training(DART) programme in comparison with usual care plus information (UCI). Follow-up after trial completion was six months. Risk of bias was mostly unclear but was high for selective reporting. Trial authors did not report on diabetes-related complications, all-cause mortality, adverse events, health-related quality of life nor socioeconomic effects. Twelve months of data on self care behaviours as measured by total energy expenditure showed a mean of 2148 kcal for DART and 1496 kcal for UCI (52 participants; very low-quality evidence), indicating no substantial improvement. The intervention did not have a substantial effect on glycosylated haemoglobin A1c (HbA1c) at 6 or 12 months of follow-up (12-month HbA1c data 7.9% for DART vs 6.9% for UCI; 52 participants; very low-quality evidence). Researchers noted small improvements in body mass index immediately after the intervention was provided and at six months, along with improved weight post intervention. Diabetes knowledge and self efficacy improved immediately following receipt of the intervention, and knowledge also at six months. The intervention did not improve blood pressure. Authors? conclusions: Evidence is insufficient to show whether type 2 diabetes self management interventions for people with severe mental illness are effective in improving outcomes. Researchers must conduct additional trials to establish efficacy, and to identify the active ingredients in these interventions and the people most likely to benefit from them

Autoantistoffer ved cøliaki: Klinisk betydning og mulige mekanismer for dannelse

The principles of basic immunology have shown to play an important role in medicine as immunology reaches into a variety of medical fields. Through a better understanding of the pathogenesis on a molecule level, treatments in forms of immunotherapy can be established. Writing this thesis, it was therefore logical for me to present a platform of immunological theory before starting to dissect dysregulation that can take place and create autoimmunity. Coeliac disease is in a unique position with a well-established understanding of the genetic predisposition and with the driver for the disease identified, namely gluten. Thus, I will use this disease as a model to illustrate possible mechanisms underlying production of autoantibodies. With help of basic concepts, the aim is to illuminate possible mechanisms and see if they have clinical value in diagnostics. Literature were collected from a search in PubMed, and supplemented with references from the supervisor and references cited in what was my primary literature. The HLA-DQ molecules HLA-DQ2.2, HLA-DQ2.5 and HLA-DQ8 have a chief role in coeliac disease. These HLA molecules preferentially bind deamidated gluten peptides and present them to CD4+ T cells which then become activated. The gluten peptides become deamidated by the enzyme transglutaminase 2 (TG2). This enzyme can also cross-link gluten peptides including to the enzyme itself so that complexes of TG2-gluten are formed. Such TG2-gliadin complexes are the basis of a so-called hapten-carrier model which outlines that gluten specific CD4+ T cells can give help to TG2 specific B cells thereby facilitating formation of the anti-TG2 autoantibodies. This model I will discuss at length. In the first guidelines for paediatric coeliac disease was considered a food intolerance. The diagnostic scheme was based on intestinal biopsies showing alterations on elimination-provocation diets. In 2012, new guidelines were launched. In these guidelines, IgA anti-TG2 antibodies are central. As I will describe, many patients now effectively get their diagnosis on the basis of having auto-antibodies. Thus, coeliac disease has made a journey from being perceived a food intolerance disorder to being perceived an autoimmune disease. This fact illustrates very well how diagnostic approaches and medical wisdom rapidly can change

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study.

To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation.This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression.The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression.Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed