A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus.

BACKGROUND: Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS: Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION: Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS: This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Building capacity in the rural physiotherapy workforce: a paediatric training partnership.

CONTEXT: Building capacity in the rural physiotherapy workforce: a paediatric training partnership' provided 6 months postgraduate paediatric clinical and academic training for two physiotherapists in rural Australia. It is described as a model for improving services and workforce retention. The need for 'an appropriate, skilled and well-supported health workforce' is the third goal in Australia's National Strategic Framework for Rural and Remote Health 2011. The World Health Organization recently published its first global policy for improving the retention of rural and remote health workers. Education is its first recommendation and aims to 'design continuing education and professional development programmes that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention …'. Additionally, '… to be successful, continuing education needs to be linked to career paths, as well as with other education interventions'. ISSUES: The problem is a lack of paediatric physiotherapy expertise in rural areas due to an absence of postgraduate clinical training opportunities in the rural workforce. The result is fragmented local services for families who are forced to travel to metropolitan services, costly in terms of both time and money. The aims were to improve local paediatric physiotherapy clinical services, provide physiotherapists additional access to professional development and subsequently provide a career path to retain these health professionals. Evaluation of the project used purpose-built questionnaires as there are no specific indicators to monitor the performance of systems and services that are available to children and families in Australia. LESSONS LEARNED: The paediatric physiotherapy training program was enabled through initial funding for a 12-month pilot project. Further government funding built on that success for this reported 6-month project. Funding to employ the postgraduate physiotherapists was essential to the success of the clinical training program, and lack of future funding is a barrier to its sustainability. The program included the consolidation of the initial management and education committees and the expert reference group. Weekly tutorials, case studies and presentations formed an important part of clinical rotation between hospital outpatients, specialist school and the disability sector. This increased the provision of skilled paediatric physiotherapy services close to home in a timely fashion not previously available. Concurrently, the training increased the clinicians' paediatric knowledge and confidence, promoting workforce retention by providing a career pathway. The senior clinicians who provided clinical supervision reported that it enabled succession planning through introduction of appropriately skilled younger peers to their clinical practice. Project recommendations are that funding and stakeholder partnerships are necessary to enable health professionals to undertake postgraduate clinical training in paediatrics in rural areas. The partnership should include education providers (university), rural health service providers (hospital) and community or disability services (government and non-government) with financial recognition of expertise in the rural workforce for clinical supervision. The training experience was reported as a very positive experience from trainees, families, clinical supervisors, managers, academics and paediatricians. Lack of continued funding to educate skilled postgraduate paediatric physiotherapy clinicians means that rural children with physical disabilities will continue to be disadvantaged.

Pilot study of a community pharmacist led program to treat hepatitis C virus among people who inject drugs.

Background: People who inject drugs (PWID) are a key population for treatment with direct-acting antiviral medications (DAAs) to eliminate hepatitis C virus (HCV). We developed a Pharmacist, Physician, and Patient Navigator Collaborative Care Model (PPP-CCM) for delivery of HCV treatment; this study describes clinical outcomes related to HCV treatment (initial evaluation, treatment initiation, completion, and cure), as well as patient satisfaction. Methods: We conducted a single-arm prospective pilot study of adult PWID living with HCV. Participants completed baseline and six-month follow-up surveys, and treatment and outcomes were abstracted from electronic health records. Primary outcome was linkage to pharmacist for HCV evaluation; secondary outcomes included DAA initiation, completion, and cure, as well as patient-reported satisfaction. Results: Of the 40 PWID enrolled, mean age was 43.6 years, 12 (30 %) were female, 20 (50 %) were non-white, and 15 (38 %) were unhoused. Thirty-eight (95 %) were successfully linked to the pharmacist for initial evaluation. Of those, 21/38 (55 %) initiated DAAs, and 16/21 (76 %) completed treatment. Among those completing treatment who had viral load data to document whether they achieved "sustained virologic response", i.e. cure, 10/11 (91 %) were found to be cured. There was high satisfaction with 100 % responding "agree or strongly agree" that they had a positive experience with the pharmacist. Conclusion: Nearly all participants in this pilot were successfully linked to the pharmacist for evaluation, and more than half were started on DAAs; results provide preliminary evidence of feasibility of pharmacist-led models of HCV treatment for PWID. Clinicaltrialsgov registration number: NCT04698629.

Use of a chaperone during breast examination: the attitude and practice of consultant breast surgeons in the United Kingdom.

BACKGROUND: Professional guidelines and clinical practice regarding use of chaperones vary substantially in different health care settings. Although there are several studies in primary care practice, no such studies are available in a breast care setting. We have undertaken a questionnaire survey of practicing consultant breast surgeons in the U.K. regarding the use of a chaperone during breast examination. METHOD: A self-completion questionnaire, with 18 items was developed, piloted, modified and mailed to 400 consultant breast surgeons across the U.K. RESULT: 302/400 questionnaires were returned (76%). Sixty-five per cent had a policy on the use of chaperone. Although 73% always offer a chaperone, the majority never documented the offer (74%) or identity (73%). Overall use of chaperone was significantly higher among male (82%), compared to female surgeons (38%, p < 0.001). The majority said that patient embarrassment (54%) and the availability of a nurse (57%) strongly influence chaperone use unlike patient's age, marital status, ethnicity, anxiety, instinct. Seventy per cent of respondents believed that the presence of a chaperone was important for medico-legal protection of doctor and patient (55%). CONCLUSION: Our study shows that the majority of consultant breast surgeons in the UK use a chaperone. The overall use of a chaperone in secondary breast care setting is higher compared to previous studies in primary care. Documentation of the offer and identity of the chaperone is very poor.

Agreement between self-reported asthma symptoms and exhaled nitric oxide levels: impact on inhaled corticosteroid prescribing in general practice. An observational study.

BACKGROUND: The National Review of Asthma Deaths UK highlighted that 46% of deaths could be avoided and recommended that all sufferers receive a structured asthma annual review which assess asthma control. In primary care this is commonly achieved using symptom-based questionnaires such as the Asthma Control Test (ACT). A newer method of assessing asthma control is Fractional Exhaled Nitric Oxide (FeNO) testing, which is currently recommended for the diagnosis of asthma, but not for monitoring of asthma control. The study aim was to assess the correlation between self-reported symptoms as measured by the ACT and FeNO testing and the subsequent impact of FeNO testing on prescribing of asthma medication. METHODS: A retrospective review of 65 patients who had received both ACT and FeNO testing as part of their asthma annual review. A spearman correlation was used to estimate the correlation between ACT scores and FENO levels. A χ2 test was used to compare prompting frequency of the measures and Kendalls τ statistic was made to estimate their concordance and influence on subsequent ICS medication prescription. RESULTS: The mean age of the participants was 41 years (4-93 years). There was no statistically significant correlation between ACT and FeNO (ρ = 0.195, p = 0.120). The median FeNO was 26 ppb (range 8-279 ppb), and the ACT score 20 (range 5 to 25 points). Furthermore, FeNO more frequently prompts a change in medication than ACT, 66% versus 42% (p = 0.005). A low concordance between the measures was found (Kendall's τ statistic - 0.321). CONCLUSION: FeNO should be considered for monitoring of control in asthma. To balance the cost of implementing this technology into primary care a risk stratified approach could be applied to testing.

Potential role of NovoSeven in the prevention of rebleeding following aneurysmal subarachnoid haemorrhage.

Rebleeding following aneurysmal subarachnoid haemorrhage is a major factor contributing to unfavourable outcome. Antifibrinolytic agents reduce the rate of rebleeding but increase the risk of cerebral ischaemia and infarction and hence provide no overall benefit. To address the theoretical concern that recombinant activated factor VII (NovoSeven, Novo Nordisk A/S, Bagsvaerd, Denmark) might increase the risk of cerebral ischaemia while stabilizing the clot at the site of aneurysmal rupture, an open-label, dose-escalation safety study has been developed in collaboration with the UK Spontaneous Intracranial Haemorrhage Group. The trial design includes the recruitment of 15 patients (aged 18 years or over) in good grade with subarachnoid haemorrhage verified by computerized tomography scan or lumbar puncture. Safety evaluation includes clinical observation, monitoring of laboratory variables, positron emission tomography (PET) scanning (rCBF, rOEF, rCMRO2) and transcranial Doppler ultrasound. To date, ten patients have been recruited [NovoSeven 80 microg/kg single bolus (n = 2), NovoSeven 80 microg/kg single bolus followed by continuous infusion at 3.5 microg/kg per h (n = 2) or 7 microg/kg per h (n = 1), or control (n = 5)]. Clinical observation, transcranial Doppler ultrasound and PET studies revealed no evidence of cerebral ischaemia in the first nine patients treated with NovoSeven. The last patient developed middle cerebral artery branch thrombosis contralateral to the aneurysm. The study is currently suspended pending further investigation.

Use of nursing and social services by elderly patients discharged from hospital.

As part of a study to determine reasons for early unplanned readmission of elderly patients to hospital, the provision of nursing and social services before and after admission was assessed for two groups of patients aged 65 years and over. A random sample of 133 patients who had been readmitted in an emergency and 133 matched controls who had not been readmitted were interviewed. Prior to the first admission the readmitted patients had received more services than the control patients. A substantial number of patients had had some services organized for them before leaving hospital. There was a net increase in the provision of district nursing services for both groups. The readmitted group had significantly more nursing and social services both before and after discharge than the non-readmitted group. The level of district nursing, home help and social work all increased significantly with age. Problems were experienced with services after discharge from hospital. These included: no arrangements, delay in starting services and inadequate services to meet the patient's needs. Guidelines for the provision of nursing and social services after discharge of patients from hospital are suggested.

Residents of private nursing homes and their care.

A study was undertaken to examine the characteristics of residents in private nursing homes, to measure residents' dependency levels, to determine the adequacy of procedures for admitting new residents and to explore general practitioners' work with residents. Details were obtained of 61 nursing homes registered by Nottingham district health authority and of a selection of residents. Information about residents provided by the nurses in charge included aspects of self care, orientation and social integration, these items contributing to a dependency score for each resident. General practitioners completed postal questionnaires. Information was sought on the numbers of residents on the general practitioners' lists, visiting patterns, and opinions on their work with residents. It was found that almost half of the reports accompanying residents on admission were considered inadequate by the nurses in charge. The 357 residents varied widely in dependency level, need for nursing care and medication; 31% had low dependency scores. Most of the residents (57%), had been admitted from hospital, 26% from their own home and 15% from other nursing or residential homes. Higher overall dependency levels, problems with mobility and continence and need for care of wounds, catheters or colostomies were more frequent in residents admitted from hospital or nursing or residential homes than in those admitted from their own home. The 70 responding general practitioners varied widely in the numbers of residents on their lists and in their visiting patterns. The 16 general practitioners providing medical care for entire nursing homes were significantly more likely than the other general practitioners to visit routinely.(ABSTRACT TRUNCATED AT 250 WORDS)

Stereotype or reality: another look at alcohol and drug use among African American children.

The Center for Substance Abuse Prevention's Division of Communications Programs launched its Urban Youth Public Education Campaign in late 1990 to target African American youth in 14 cities with prevention messages about alcohol and other drugs. During the market research phase of the campaign, the Center sought to determine the extent inner city African American children are impacted by alcohol and other drugs and how widespread the use of these substances is among younger children. Is it rampant and universal, as some press accounts have it, or are the images portrayed by the news media, by popular movies, and by other communication outlets fueling harmful stereotypes? The campaign's market research consisted of in-depth reviews of the literature, of personal communications, conference proceedings, grant and contract reports, monographs, newspaper and magazine articles, and of national survey results, and the analysis of findings from focus groups conducted with 143 African American children living in several urban environments. Although information and conclusions gleaned from the market research revealed a longstanding trend of comparatively lower rates of alcohol and drug use by African American youth, also disclosed was a need for an expanded framework to address the problems of substance abuse within the African American community. An expanded framework acknowledges the dimension of substance use and abuse but also addresses three other dimensions--involvement, exposure, and victimization--that unfold as having major significance for this population of youth who live in urban, high-risk environments.

Medical clearance of psychiatric patients.

Patients with primarily psychiatric complaints commonly present to emergency departments. The challenges to emergency medicine physicians are to distinguish functional from organic disease and to address any underlying medical comorbidities. The key elements of this medical "clearance" evaluation of psychiatric patients are discussed. The tremendous importance of the history and physical examination are highlighted, as is judicious use of laboratory and radiographic testing. Toxicology testing is specifically addressed.

Pressure exerted by head bandages used in otological surgery.

The pressure exerted by head bandages at the operation site following ear surgery was measured using a balloon catheter and pressure transducer. The initial pressures achieved, their diminution with time and the relationship of pressure to the induction of headache in the patient were studied. The principal findings were that the standard otological head bandage is rarely tight enough to prevent haematoma formation, bandages have lost their efficacy after the first hour and headaches are associated with a significantly higher initial bandage pressure.

The family with AIDS: multiple challenges for caregivers.

Acquired Immune Deficiency Syndrome (AIDS) continues to increase in the United States, especially among minority groups. The disease is impacting not only individuals, but entire families through multiple infections of family members. This results in simultaneous illness and multiple loss within the family system. Delivery and management of quality care for the family is often made difficult by the lack of resources experienced by families with limited income and the multiplicity of problems associated with poverty in the US. This presents numerous challenges to health care providers. Utilizing a case study, this article presents a model demonstrating the coordination of services among several providers as a means of meeting a variety of family needs and providing quality, cost-effective care.

Profile of young people's advice clinic in reproductive health, 1988-93.

For an unprepared sexually active teenager the 1990s present a minefield of potential problems in addition to the most obvious problems of unplanned pregnancy and sexually transmitted disease. Promoting the importance of a healthy sexual and reproductive life to young people requires openness, better sex education, realistic discussion of related issues, and provision of contraception, as well as support if things go wrong. The Woodhouse Park Clinic in south Manchester opened in October 1988 with the aim of providing weekly advice sessions to young people up to the age of 18. Advice is given on topics such as substance misuse and smoking as well as on family planning. Attendance has steadily increased over the years; from April to June 1993 the average number of attenders per session was 39, one third of whom were young men.

PIP: Opened in October 1988, Woodhouse Park Clinic serves Wythenshawe, a large council housing estate in south Manchester. The district has a total population of 48,072, with an average conception rate over the period 1989-91 of 17.1/1000 among girls aged 11-15. The clinic was opened with the goal of providing weekly advice sessions to young people up to the age of 18 years, along with advice on topics such as substance misuse, smoking, and family planning. The authors describe how in 1986 family planning managers, school nurses, and the local midwife and parentcraft tutor planned the weekly clinic intended to lower the rates of teenage pregnancy in the area. One two-hour clinic session was held from 3:30 P.M. to 5:30 P.M. each Thursday in a multipurpose community health center, staffed by two female school nurses, the female midwife and parentcraft tutor, and one female family planning doctor. Program launching, facilities, consultation, pregnancy tests, clinic management, and attendances are described. Attendance increased steadily over the years, with an average of 39 attendees per session over the period April-June 1993; young men comprised one-third of those who attended.

Construction of an automated health problem inventory.

An Automated Health Problem Inventory was designed to monitor resident exposure, provide access to subgroups of the patient population, allow for study of patient care patterns over time, and aid in health-care evaluation studies. Major design steps such as choosing data and codes are discussed. Data collection documents and data reports are described. Data were collected over a 12-month period in two clinical settings - a model clinic in a residency program and a private practice clinics. These data are displayed by categories of problems and frequency of individual problems. The authors comment on the human and procedural support needed to make a data system useful.