Therapeutic alliance and glycaemic control in type 1 diabetes: a pilot study.

AIM: Effective diabetes care requires integrating physicians' clinical expertise with patients' concerns and resources. This prospective study examined whether or not two measures of therapeutic alliance could predict glycaemic control after 1 year of follow-up in patients with type 1 diabetes. METHODS: Consecutive type 1 diabetic outpatients were recruited, and their age, gender, level of education, marital status and age at the time of diabetes diagnosis were self-reported. The presence of diabetes complications was ascertained by the patients' physicians. Both patients and physicians completed the revised Helping Alliance Questionnaire (HAQ-R) and the 12-item Working Alliance Inventory (WAI-12) to assess therapeutic alliance. Patients also completed the Center for Epidemiological Studies Depression scale to assess depressive mood. HbA(1c) was measured at baseline and 1 year later. RESULTS: Sixty-four type 1 diabetic outpatients (32 men, 32 women; mean age±standard deviation [S.D.]: 38.2±8.0 years) were included. HbA(1c) level at follow-up (mean±S.D.: 7.56±1.18%) was positively correlated with the HbA(1c) level at baseline (r=0.698, P<0.001), and associated with presence of retinopathy at baseline (8.18±1.24% versus 7.41±1.13%, P=0.036). In addition, the HbA(1c) level at follow-up was negatively correlated with therapeutic alliance, as assessed at baseline by the physicians using either the HAQ-R (r=-0.431, P<0.001) or the WAI-12 (r=-0.365, P=0.003), even after controlling for the HbA(1c) at baseline. CONCLUSION: Although the observational nature of the present study prevents causal conclusions to be drawn, these preliminary results suggest that promoting therapeutic alliance can improve glycaemic control in type 1 diabetes.

[Primary Human Immunodeficiency Virus infection revealed by psychiatric symptoms]. / Primo-infection par le VIH révélée par une symptomatologie psychiatrique.

INTRODUCTION: Any atypical psychiatric disorder, especially if associated with somatic manifestations and when any psychiatric antecedents are missing, should lead to search for an organic pathology, and notably a Human Immunodeficiency Virus (HIV) infection. In the case of Primary Human Immunodeficiency Virus Infection (PHI), which is often symptomatic, the diagnosis is seldom made, probably because of atypical or non specific manifestations. Therefore, it is essential to consider such a diagnosis, because it may have important clinical and public health consequences (stopping the contamination chain). CASE-REPORT: We present the case of a 38 year-old homosexual man from West Indies, in whom the diagnosis of PHI had been made on the basis of psychiatric symptoms evoking a Major Depressive Episode with a doubt on the presence of psychotic symptoms. To our knowledge, this is the first report of psychiatric PHI found in scientific literature. Clinical presentation was atypical: the patient had no psychiatric history (except probably a schizotypical personality, according to his family), symptoms were atypical (sudden onset and fast improvement) associated with somatic symptoms (fever, headache, sound intolerance), the latter possibly due to a meningo-encephalitis, which had been underestimated and attributed to dehydration in a period when France was faced with an important and unexpected heatwave. Blood samples were performed on admission and revealed a thrombopenia and presence of HIV P24 antigen, testifying a contamination by HIV 2 to 4 weeks earlier, this possibility having been confirmed by the patient. Further analyses found a Western-Blot partially positive test and an HIV viral load of 315 711 Eq copies/mL. DISCUSSION: The main question about this report is the primary or secondary nature of psychiatric symptoms towards HIV infection, given that in this patient mood alteration could have possibly occurred, before HIV contamination, due to particularities of his personal and professional life. We can also question whether the neurological manifestations of PHI might be changed by a schizotypical personality. Further reports are required to answer these questions.