Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in Type 2 diabetes care in Norway.

AIMS: To assess population, general practitioner (GP) and practice characteristics associated with the performance of microvascular screening procedures and to propose strategies to improve Type 2 diabetes care. METHODS: A cross-sectional survey in Norway (281 GPs from 77 practices) identified 8246 people with a Type 2 diabetes duration of 1 year or more. We used multilevel regression models with either the recording of at least two of three recommended screening procedures (albuminuria, monofilament, eye examination) or each procedure separately as dependent variable (yes/no), and characteristics related to the person with diabetes, GP or practice as independent variables. RESULTS: The performance of recommended screening procedures was recorded in the following percentages: albuminuria 31.5%, monofilament 27.5% and eye examination 60.0%. There was substantial heterogeneity between practices, and between GPs within practices for all procedures. Compared with people aged 60-69 years, those aged < 50 years were less likely to have an albuminuria test performed [odds ratio (OR) 0.75, 95% CI 0.61 to 0.93] and eye examination (OR 0.79, 95% CI 0.66 to 0.95). People with macrovascular disease had fewer screening procedures recorded (OR 0.68, 95% CI 0.59 to 0.78). Use of an electronic diabetes form was associated with improved screening  (OR 2.65, 95% CI 1.86 to 3.78). GPs with high workload recorded fewer procedures (OR 0.59, 95% CI 0.39 to 0.90). CONCLUSIONS: Performance of screening procedures was suboptimal overall, and in people who should be prioritized. Performance varied substantially between GPs and practices. The use of a structured diabetes form should be mandatory.

Thought-Action Fusion in Individuals with a History of Recurrent Depression and Suicidal Depression: Findings from a Community Sample.

Although suicidal ideation is one of the most consistent symptoms across recurrent episodes of depression, the mechanisms underpinning its maintenance are poorly understood. In order to develop effective treatments for suicidally depressed patients, understanding what maintains suicidal distress is critical. We hypothesised that Thought-Action Fusion (TAF), i.e., to assume that having a thought has real world consequences, originally described in Obsessive-Compulsive Disorder, might be a bias in recurrently suicidally depressed people. To assess this, we revised the original TAF scale, and assessed TAF in three samples: healthy controls, recurrently depressed individuals with no history of suicidality (D-NS) and individuals with a history of recurrent suicidal depression (D-S). Exploratory and confirmatory factor analyses indicated a three-factor solution of TAF: (1) TAF for uncontrollable events, (2) self-suicidal TAF for suicidal acts related to oneself, and (3) TAF for positive controllable events. Compared to healthy controls, the D-NS group reported significantly higher total TAF, TAF uncontrollable, and TAF self-suicidal subscales, whilst positive controllable TAF was lower compared to healthy controls. Both D-S and D-NS samples reported higher TAF for suicidal thought compared to healthy controls, i.e., believing that having suicidal thoughts means they will act on them, however in the context of low mood this became more pronounced for the D-S group. These findings suggest that targeting TAF both in suicidal and non-suicidal depression has merit.

Subjective health complaints predict functional outcome six months after stroke.

OBJECTIVES: Cerebrovascular stroke is a main cause of lasting disability in older age, and initial stroke severity has been established as a main determinant for the degree of functional loss. In this study, we searched for other predictors of functional outcome in a cohort of stroke patients participating in an early supported discharge randomised controlled trial. METHODS: Thirty candidate variables related either to premorbid history or to the acute stroke were examined by ordered logistic regression in 229 stroke patients. Dependent variables were modified Rankin Scale (mRS) at 6 months and mRS change from baseline to 6 months. RESULTS: For mRS at 6 months, Barthel Index at stable baseline post-stroke was the main predictor, with sex, age, previous cerebrovascular disease, previous peripheral artery disease and the necessity for tube feeding in the acute phase also contributing to the final model. For mRS change, only age and previous cerebrovascular disease were significant predictors. Prestroke subjective health complaints added significantly to all final models concurrently with sex losing its predictive power. CONCLUSIONS: Initial stroke severity was the main predictor of functional outcome. Subjective health complaints score was a potent predictor for both outcome and improvement from baseline to 6 months and at the same time ameliorated the predictive impact of sex. The poorer functional prognosis for women after stroke may therefore be related to their higher load of subjective health complaints rather than to their sex itself. Treating these complaints may possibly improve the functional prognosis.

Fatigue in multiple sclerosis: associations with health-related quality of life and physical performance.

BACKGROUND AND PURPOSE: fatigue is a common, but still one of the least understood symptoms in multiple sclerosis (MS). We aimed to investigate whether fatigue was associated with demographic-, clinical-, health-related quality of life (HRQoL)- and physical performance variables, and whether change in fatigue after treatment was associated with changes in HRQoL and physical performance. METHODS: sixty patients were included for inpatient physiotherapy. Fifty-six patients completed the study and were available for analysis. Fatigue (Fatigue Severity Scale; FSS), HRQoL (Multiple Sclerosis Impact Scale; MSIS-29) and physical performance (walking ability and balance) were assessed at screening, baseline, after treatment and at follow-up after 3 and 6 months. We analysed possible associations between fatigue and other variables at baseline by regression models, and between change in fatigue versus changes in both HRQoL and physical performance variables after physiotherapy by correlation analysis. RESULTS: fatigue at baseline was associated with HRQoL (explained 21.9% of variance), but not with the physical performance tests. Change in fatigue was correlated with change in HRQoL, but not with changes in physical performance. All measures were improved after treatment (P ≤ 0.001). While improvements in fatigue and HRQoL were lost at follow-up, improvements in physical performance tests were maintained for at least 6 months (P ≤ 0.05). CONCLUSIONS: fatigue was associated with HRQoL at baseline. Improvement in fatigue seemed to be related to other factors than improvement in physical performance. A broader strategy including both physical and psychological dimensions seems to be needed to improve fatigue over the long-term.

The influence of warm versus cold climate on the effect of physiotherapy in multiple sclerosis.

OBJECTIVE: To compare the effect of inpatient physiotherapy in a warm versus cold climate in short- and long-term perspectives. METHODS: Sixty multiple sclerosis (MS) patients with gait problems, without heat intolerance, were included in a randomized cross-over study of 4-week inpatient physiotherapy in warm (Spain) and cold (Norway) climate. The primary outcome, 6-min walk test (6MWT), and secondary physical performance and self-reported measures were scored at screening, baseline, after treatment and at 3 and 6 months of follow-up. Treatment effects were analysed by mixed models. RESULTS: After treatment, the mean walking distance had increased by 70 m in Spain and 49 m in Norway (P = 0.060). Improvement in favour of warm climate was demonstrated at 6 months of follow-up, 43 m (Spain) compared to 20 m (Norway) (P = 0.048). The patients reported less exertion after walking (6MWT) in favour of treatment in Spain at all time points (P < 0.05). No significant differences in change were detected for the other physical performance measures. Most self-reported measures showed more improvement after treatment in Spain, but these improvements were not sustained at follow-up. CONCLUSION: The results indicate that MS patients without heat intolerance have additional benefits from physiotherapy in a warm climate.

[Botulinum toxin A--effect on spasticity]. / Botulinumtoksin A--effekt på spastisitet.

BACKGROUND: Severe spasticity may lead to problems of movement and function, pain and hygiene, and may be difficult to treat. A team of neurologists and physiotherapists evaluated the effect of botulinum toxin A (BTX-A) on spasticity. MATERIAL AND METHODS: Ten patients with central nervous disorders were included in this study. Function, pain and personal hygiene were assessed before and after injections with BTX-A. RESULTS: Nine patients experienced improvement of function and/or pain relief. One patient had improved perception in his hand, and one patient needed only two injections to stop a vicious circle. The effect varied from patient to patient. It seemed that patients with some preserved motor control in the spastic limb could use it to learn more appropriate movement strategies. INTERPRETATION: We recommend that doctors and physiotherapists work together to identify muscle groups that need to be targeted for injection and evaluate consequences of the treatment. Injections with BTX-A should be combined with physiotherapy.

[Pharmacological prevention of cardiovascular diseases in general practice]. / Medikamentell forebygging av hjerte- og karsykdommer i allmennpraksis.

BACKGROUND: In this paper the Norwegian College of General Practitioners, Working Group on Hypertension report recommendations for primary preventive drug treatment of elevated cardiovascular risk. MATERIAL AND METHODS: Updated metaanalyses and randomised controlled trials are the main basis for the recommendations. The purpose of treating hypertension is prevention of cardiovascular diseases. Drug treatment with documented effect on morbidity and mortality is therefore recommended. We have also evaluated the cost effectiveness of drug treatment. RESULTS: An estimate of the total risk of future cardiovascular disease is a necessary basis for treatment decisions. This paper presents tools for estimating total cardiovascular risk. Drug treatment is recommended if ten-year risk exceeds 20% or blood pressure equals or exceeds 170/100 mmHg. Drug treatments include antihypertensive, antithrombotic, antidiabetic and lipid-lowering drugs with documented effect on hard endpoints. Aspirin, thiazides, betablockers, metformin, calcium blockers, ACE inhibitors and statins are all drugs with documented effects on significant endpoints, but the costs of these treatments differ substantially. INTERPRETATION: Drug treatment to prevent cardiovascular disease should be recommended for patients at significant risk of cardiovascular disease. Drugs with documented effect on morbidity and mortality should be used. Considerations of costs are important in treatment decisions.

[Life style advice provided by primary health care to prevent cardiovascular diseases]. / Forebyggende livsstilsråd mot hjerte- og karsykdommer i primaerhelsetjenesten.

BACKGROUND: The Working Group on Hypertension of the Norwegian College of General Practitioners reports in this paper on the documentation on behavioural advice in the prevention of cardiovascular disease. Emphasis is given to hypertension. MATERIAL AND METHODS: The recommendations are mainly based on updated metaanalyses and randomised controlled trials. Hypertension is treated to prevent cardiovascular disease; that is why we put emphasis on documentation with significant end points. The validity of the documentation for general practice is assessed. We have also assessed whether certain methods or theories for behavioural change could be helpful to the general practitioner. RESULTS: The value of advice against smoking, dietary advice (increased intake of grain products, vegetables, fruit, poultry and fish), and advice about exercise are well documented and applicable in general practice. Respect for the patient's autonomy and interest in the patients and their health-related habits seem to be important factors for improving doctor's chances of influencing patient behaviour. INTERPRETATION: The value of life-style advice is well documented and should play an important role in clinical strategies to prevent cardiovascular disease in high-risk patients.