Children's and young People's diabetes services: What works well and what doesn't?

Objectives: The first year of care, post diagnosis, is pivotal for children and young people diagnosed with type 1 diabetes. This study evaluated a paediatric type 1 diabetes intervention, the 'First Year of Care', designed to maximise the care that newly diagnosed children and young people received. Study design: An observational mixed methods approach, underpinned by the Influencer Framework. Methods: A purposeful, non-probability sample of children and young people with type 1 diabetes and their families, and healthcare professionals were invited to take part. Data were collected through medical records of thirty-two newly diagnosed children and young people, plus thirty seven semi-structured interviews and exposure to six concurrent sources of influence through a questionnaire. Results: For many participants, HbA1c levels were within the optimal range by the time of their first clinic visit post-diagnosis and continued to stay within this range throughout the first year of care. Healthcare professionals prioritised the 'First Year of Care' intervention. Positive practices included: a cohesive and collaborative approach; patient-centred care; latest health technology and embedded structured education. Unusually, different multidisciplinary team members were located in one place.Data indicated statistically significant differences in total sources of influence score (t [35] = 2.331, p = 0.026); healthcare professionals' scores were higher compared to children. This suggests that children and young people have less social capital to self-manage their diabetes effectively. Greater encouragement and assistance from healthcare professionals and social networks may be needed. Conclusions: This paper identifies contemporary issues in practice and highlights the strengths and challenges for a paediatric diabetes intervention. The findings confirm the potential of layered approaches to behaviour change in managing type 1 diabetes across multiple domains of influence. Our study strongly suggests enhancing social motivation among children, young people and families to support successful long-term engagement in a paediatric diabetes intervention. Findings demonstrate healthcare professionals are key in delivering the intervention, along with opportunities to improve patient care, experience and outcomes.

How prepared are healthcare professionals for delivering physical activity guidance to those with diabetes? A formative evaluation.

BACKGROUND: Physical activity is recognised as important for diabetes management and improved overall health of individuals with diabetes, yet many adults with diabetes are inactive. Healthcare professionals have been identified as key to promoting physical activity, including individuals with diabetes, but are ill-prepared to deliver this. Our paper evaluates the barriers/facilitators of healthcare professionals' delivery of physical activity guidance to adults with diabetes and aims to inform efforts to investigate and enhance their preparedness to promote physical activity. METHODS: A sequential mixed method, two-phase design was adopted involving a purposeful sample of healthcare professionals. Phase one was an online pilot survey designed to test assumptions around healthcare professionals' knowledge, training and preparedness to deliver physical activity guidance. Phase two comprised eighteen semi-structured interviews, thematically analysed to provide an in-depth exploration of healthcare professionals' experiences of delivering physical activity guidance to adults with diabetes. RESULTS: Healthcare professionals are committed to promoting physical activity to adults with diabetes and are reasonably confident in giving basic, generic guidance. Yet, significant challenges prevent them from achieving this in their practice, including: lack of education and training around physical activity, diabetes and health; ignorance of recommended physical activity and diabetes guidelines; lack of awareness of referral options; limited time and accessibility to appropriate resources. Nevertheless, healthcare professionals believed discussions around physical activity needed to be an integral part of consultations, incorporating improved communication strategies for conveying key physical activity messages. CONCLUSIONS: HCPs have a key role in the promotion of physical activity to people with long-term conditions such as diabetes and they are identified within both the strategic policy context and national interventions for physical activity. Yet, this study indicated that HCPs face multiple and at times complex barriers to physical activity promotion generally and with diabetes patients. Conversely HCPs also reported what works, why and how, when promoting physical activity. Rich information derived from the day-to-day, working healthcare professional is integral to shaping future practices going forward. The bottom up, iterative design adopted in this study provides an approach to tap into this information.

Physical activity and exercise in adults with type 1 diabetes: understanding their needs using a person-centered approach.

Physical activity is a key component in the management of diabetes, but most people do not engage in recommended levels of physical activity. A recent consensus statement on exercise management in type 1 diabetes (T1D) fails to mention behavioral change and the specific determinants impacting on exercise management. The aim of this study is to investigate the needs of adults with T1D around physical activity and the challenges they face. Using a person-centered approach, focus groups and individual semi-structured interviews recorded the perspectives of 67 adults aged ≥18 with diabetes. Four global themes were identified: (i) it's a balancing act, (ii) winging it, (iii) engagement and (iv) encouraging uptake. These findings suggest that adults with T1D find it difficult to manage their diabetes and physical activity and decision-making is based on trial and error with minimal input from healthcare professionals. Participants want more information to enable them to manage their diabetes and physical activity effectively. Adults with T1D face unique challenges in relation to physical activity. Participants reported key determinants for being active. Research is needed to understand how physical activity promotion is best developed for those with T1D and the preparedness of healthcare professionals for delivering guidance to adults with T1D.

Intrinsic circuitry in the deep layers of the cat superior colliculus.

The mammalian superior colliculus is involved in the transformation of sensory signals into orienting behaviors. Sensory and motor signals are integrated in the colliculus to produce movements of the eyes, head, and neck. While there is a considerable amount of information available on the afferent and efferent connections of the colliculus, almost nothing is known about its intrinsic circuitry, particularly that of its deepest layers. It is likely that intrinsic connections in these deeper layers of the colliculus participate in the sensory-motor transformations leading to orienting movements. In this study, we used the neuroanatomical tracer biocytin to label small groups of neurons in the deeper layers of the cat superior colliculus and examine the distribution of their axons and terminals. We found a broadly distributed network of intrinsic projections throughout the deep layers of the superior colliculus. While the majority of terminals were found in a 1-2 mm radius around the injection site, labeled terminals were found throughout the deep layers of the colliculus up to 5 mm from the injection site. In addition, these injections sometimes labeled terminals in the superficial tectum. Extensive projections were demonstrated by the more superficial injections, but few terminals were found when injections were confined to the deepest layers of the colliculus. There was no evidence of anisotropy in the distribution of terminals from injections made at different rostrocaudal or mediolateral locations; neurons located in any one region in the colliculus could potentially influence any other region. This network of intrinsic connections in the cat superior colliculus could provide a means for deeper-layer efferent neurons to associate, and to modulate or coordinate their output. Interneurons could also provide a substrate for mutual inhibition between neurons at the rostral pole of the colliculus that are active during fixation, and more caudally located neurons whose activity is associated with saccadic eye movements.

Spatial distribution of tectotectal connections in the cat.

In mammals, the paired superior colliculi of the midbrain play a significant role in the generation and guidance of eye movements that enable an animal to orient to novel visual stimuli. In several species including monkey, cat and hamster, the paired colliculi are connected by a commissure. In the cat, many commissural axons arise from tectotectal neurons located in the deep layers in the rostral two-thirds of the colliculus. The role of these tectotectal neurons is unclear, but it is likely that they play some role in eye movement control. In this study, the neuroanatomical tracer Biocytin was used to make small, localized injections into the deep layers of the cat superior colliculus at a variety of different locations in nine animals. The distribution of tectotectal synaptic terminals in the opposite colliculus was then plotted. Regardless of which layers were included the injection site, labelled boutons were most dense in the deep layers in the contralateral colliculus. There was a striking point-to-point organization in the tectotectal projection such that terminals were concentrated at an almost mirror-symmetrical region to the injection site in the rostrocaudal plane. In the majority of cases, however, the focus of terminal boutons was shifted medially by 1-2 mm. These results suggest that tectotectal connections may influence select populations of neurons in the contralateral colliculus. By coupling specific groups of neurons in the two colliculi, their effectiveness in sensory motor processing could be enhanced. At this time it is not clear whether specific commissural terminals contain excitatory or inhibitory neurotransmitters, and our ongoing studies are addressing this question.

Postnatal development of substance-P immunoreactivity in the rat superior colliculus.

Immunocytochemical techniques have been used to examine the distribution of substance-P (SP)-labeled neurons in the superior colliculus of rats from birth to adulthood. At birth, there are almost no SP-immunopositive neurons in the tectum. A small number of SP neurons appear over the next several days. However, the vast majority of SP neurons appear between P9 and P10, and by P12 have attained adult-like numbers and distribution. Neurons are confined to the superficial layers of the colliculus, specifically the upper two-thirds of the stratum griseum superficiale (SGS). There is no indication of a differential developmental sequence along rostrocaudal or mediolateral axes. Neuronal types can be distinguished as early as P6 and include horizontal, vertical, and multipolar cells. Substance-P-immunoreactive axons and boutons are also present in the superior colliculus at birth, and are for the most part confined to the deep layers. Boutons are generally of the en-passant type. The density of labeled axons and boutons increases progressively, and by P10 there is an almost adult-like lamination and patchiness. In the adult, labeled axons and boutons are most dense in the stratum opticum and stratum griseum intermedium. Bridges of dorsoventrally oriented labeled axons span the relatively label-poor stratum album intermedium. SP label in the stratum griseum profundum is dense and patchy, and there is also dense label in the stratum album profundum bordering the periaqueductal grey. The role of substance-P-labeled neurons in the superior colliculus is still a matter of speculation. The findings of this study indicate that SP neurons may play a role in intrinsic collicular circuitry.

Transit of a meal through the stomach, small intestine, and colon in normal subjects and its role in the pathogenesis of diarrhea.

A method for measuring the transit time of a meal, containing sausages, mashed potato, baked beans, and a pineapple custard dessert, through the gastrointestinal tract was evaluated in 14 healthy volunteers. Gastric emptying was determined by incorporating a radioactive marker in the meal and counting over the surface of the stomach using a crystal scintillation detector. Small intestinal transit time was determined by measuring breath hydrogen excretion and by estimating the radioactivity over the cecum. Finally, whole gut transit time was measured by incorporating radiopaque plastic markers or carmine red in the meal and estimating the appearance of these markers in the stool. Our results showed that measurements of small intestinal transit time were reproducible and in the majority of subjects the increase in hydrogen excretion occurred at the same time as the increase in radioactive counts over the surface of the cecum. The passage of the first marker in the stool coincided with the appearance of carmine red. There were no significant correlations between small intestinal transit time and whole gut transit time or the half time for gastric emptying. Incorporation of 10, 25, and 40 g lactulose into our standard meal in place of sucrose increased the rate of transit through the small intestine but did not significantly alter the rate of gastric emptying or the whole gut transit time. Total stool weight for 48 hr after ingestion of the meal was inversely related to whole gut transit time but not to small intestinal transit time suggesting that the tendency to develop diarrhea in response to a meal containing unabsorbable carbohydrate depends more on the lack of colonic accommodation than on the rate of small intestinal transit. Finally, there was no significant correlation between the measurements of small intestinal transit time after a drink of lactulose and the transit time of a meal in the same subjects.