Psychological interventions for women with non-metastatic breast cancer.

BACKGROUND: Breast cancer is the most common cancer affecting women worldwide. It is a distressing diagnosis and, as a result, considerable research has examined the psychological sequelae of being diagnosed and treated for breast cancer. Breast cancer is associated with increased rates of depression and anxiety and reduced quality of life. As a consequence, multiple studies have explored the impact of psychological interventions on the psychological distress experienced after a diagnosis of breast cancer. This review is an update of a Cochrane Review first published in 2015. OBJECTIVES: To assess the effect of psychological interventions on psychological morbidities and quality of life among women with non-metastatic breast cancer.  SEARCH METHODS: We searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov up to 16 March 2021. We also scanned the reference lists of relevant articles. SELECTION CRITERIA: Randomised controlled trials that assessed the effectiveness of psychological interventions for women with non-metastatic breast cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently appraised, extracted data from eligible trials, and assessed risk of bias and certainty of the evidence using the GRADE approach. Any disagreement was resolved by discussion. Extracted data included information about participants, methods, the intervention and outcomes. MAIN RESULTS: We included 60 randomised controlled trials comprising 7998 participants. The most frequent reasons for exclusion were non-randomised trials and the inclusion of women with metastatic disease. The updated review included 7998 randomised women; the original review included 3940 women. A wide range of interventions was evaluated. Most interventions were cognitive- or mindfulness-based, supportive-expressive, and educational. The interventions were mainly delivered face-to-face (56 studies) and in groups (50 studies) rather than individually (10 studies). Most intervention sessions were delivered on a weekly basis with an average duration of 14 hours. Follow-up time ranged from two weeks to 24 months.  Pooled standardised mean differences (SMD) from baseline indicated that the intervention may reduce depression (SMD -0.27, 95% confidence interval (CI) -0.52 to -0.02; P = 0.04; 27 studies, 3321 participants, I2 = 91%, low-certainty evidence); anxiety (SMD -0.43, 95% CI -0.68 to -0.17; P = 0.0009; 22 studies, 2702 participants, I2 = 89%, low-certainty evidence); mood disturbance in the intervention group (SMD -0.18, 95% CI -0.31 to -0.04; P = 0.009; 13 studies, 2276 participants, I2 = 56%, low-certainty evidence); and stress (SMD -0.34, 95% (CI) -0.55 to -0.12; P = 0.002; 8 studies, 564 participants, I2 = 31%, low-certainty evidence). The intervention is likely to improve quality of life in the intervention group (SMD 0.78, 95% (CI) 0.32 to 1.24; P = 0.0008; 20 studies, 1747 participants, I2 = 95%, low-certainty evidence). Adverse events were not reported in any of the included studies. AUTHORS' CONCLUSIONS: Based on the available evidence, psychological intervention may have produced favourable effects on psychological outcomes, in particular depression, anxiety, mood disturbance and stress. There was also an improvement in quality of life in the psychological intervention group compared to control group. Overall, there was substantial variation across the studies in the range of psychological interventions used, control conditions, measures of the same outcome and timing of follow-up.

Prepared to practice? Perception of career preparation and guidance of recent medical graduates at two campuses of a transnational medical school: a cross-sectional study.

BACKGROUND: Graduating medical students enter the workforce with substantial medical knowledge and experience, yet little is known about how well they are prepared for the transition to medical practice in diverse settings. We set out to compare perceptions of medical school graduates' career guidance with their perceptions of preparedness to practice as interns. We also set out to compare perceptions of preparedness for hospital practice between graduates from two transnational medical schools. METHODS: This was a cross-sectional study. A Preparedness for Hospital Practice (PHPQ) survey and career guidance questionnaire was sent to recent medical graduates, incorporating additional free text responses on career preparation. Data was analyzed using descriptive statistics and tests of association including Chi-square, Mann-Whitney U and Kruskal-Wallis H tests. RESULTS: Forty three percent (240/555) of graduates responded to the survey: 39 % of respondents were domestic (Dublin, Ireland or Manama, Kingdom of Bahrain) and interning locally; 15 % were overseas students interning locally; 42 % were overseas students interning internationally and 4 % had not started internship. Two variables explained 13 % of the variation in preparedness for hospital practice score: having planned postgraduate education prior to entering medical school and having helpful career guidance in medical school. Overseas graduates interning internationally were more likely to have planned their postgraduate career path prior to entering medical school. Dublin graduates found their career guidance more helpful than Bahrain counterparts. The most cited shortcomings were lack of structured career advice and lack of advice on the Irish and Bahraini postgraduate systems. CONCLUSIONS: This study has demonstrated that early consideration of postgraduate career preparation and helpful medical school career guidance has a strong association with perceptions of preparedness of medical graduates for hospital practice. In an era of increasing globalization of medical education, these findings can direct ongoing efforts to ensure all medical students receive career guidance and preparation for internship appropriate to their destination.

Psychological interventions for women with non-metastatic breast cancer.

BACKGROUND: Breast cancer is the most common cancer affecting women worldwide. It is a distressing diagnosis and, as a result, considerable research has examined the psychological sequelae of being diagnosed and treated for breast cancer. Breast cancer is associated with increased rates of depression and anxiety and reduced quality of life. As a consequence, multiple studies have explored the impact of psychological interventions on the psychological distress experienced after a diagnosis of breast cancer. OBJECTIVES: To assess the effects of psychological interventions on psychological morbidities, quality of life and survival among women with non-metastatic breast cancer. SEARCH METHODS: We searched the following databases up to 16 May 2013: the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO; and reference lists of articles. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) search portal and ClinicalTrials.gov for ongoing trials in addition to handsearching. SELECTION CRITERIA: Randomised controlled trials that assessed the effectiveness of psychological interventions for non-metastatic breast cancer in women. DATA COLLECTION AND ANALYSIS: Two review authors independently appraised and extracted data from eligible trials. Any disagreement was resolved by discussion. Extracted data included information about participants, methods, the intervention and outcome. MAIN RESULTS: Twenty-eight randomised controlled trials comprising 3940 participants were included. The most frequent reasons for exclusion were non-randomised trials and the inclusion of women with metastatic disease. A wide range of interventions were evaluated, with 24 trials investigating a cognitive behavioural therapy and four trials investigating psychotherapy compared to control. Pooled standardised mean differences (SMD) from baseline indicated less depression (SMD -1.01, 95% confidence interval (CI) -1.83 to -0.18; P = 0.02; 7 studies, 637 participants, I(2) = 95%, low quality evidence), anxiety (SMD -0.48, 95% CI -0.76 to -0.21; P = 0.0006; 8 studies, 776 participants, I(2) = 64%, low quality evidence) and mood disturbance (SMD -0.28, 95% CI -0.43 to -0.13; P = 0.0003; 8 studies, 1536 participants, I(2) = 47%, moderate quality evidence) for the cognitive behavioural therapy group than the control group. For quality of life, only an individually-delivered cognitive behavioural intervention showed significantly better quality of life than the control with an SMD of 0.65 (95% CI 0.07 to 1.23; P = 0.03; 3 studies, 141 participants, I(2) = 41%, very low quality evidence). Pooled data from two group-delivered studies showed a non-significant overall survival benefit favouring cognitive behavioural therapy compared to control (pooled hazard ratio (HR) 0.76, 95% CI 0.25 to 2.32; P = 0.63; 530 participants, I(2) = 84%, low quality evidence). Four studies compared psychotherapy to control with one to two studies reporting on each outcome. The four studies were assessed as high risk of bias and provided limited evidence of the efficacy of psychotherapy. Adverse events were not reported in any of the included studies. AUTHORS' CONCLUSIONS: A psychological intervention, namely cognitive behavioural therapy, produced favourable effects on some psychological outcomes, in particular anxiety, depression and mood disturbance. However, the evidence for survival improvement is still lacking. These findings are open to criticism because of the notable heterogeneity across the included studies and the shortcomings of the included studies.

Cultural sensitivity or professional acculturation in early clinical experience?

AIM: This study aimed to explore the early clinical experience of medical students following the adaptation of an Early Patient Contact curriculum from a European culture in Ireland to an Arab culture in Bahrain. METHODS: Medical students in Bahrain took part in an Early Patient Contact module modelled on a similar module from a partner medical school in Ireland. We used a qualitative approach employing thematic analysis of 54 student reflective logbooks. Particular attention was placed on reflections of cultural influences of experience in the course. RESULTS: Medical students undergoing this module received reported documented benefits of early clinical experience. However, students in Bahrain were exposed to cultural norms of the local Arab society including gender values, visiting the homes of strangers, language barriers and generous hospitality that led to additional challenges and learning for the medical students in acculturating to norms of the medical profession. CONCLUSION: Modules intended for curriculum adaptation between two cultures would be best served by a group of "core" learning outcomes with "secondary" outcomes culturally appropriate to each site. Within the context of the Arab culture, early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.

Quality of life of Bahraini women with breast cancer: a cross sectional study.

BACKGROUND: Breast cancer can impact survivors in many aspects of their life. Scarce information is currently available on the quality of life of cancer survivors in Bahrain. The objective of this study is to describe the quality of life of Bahraini women with breast cancer and its association with their sociodemographic and clinical data. METHODS: This is a cross sectional study in which the European Organization for Research and Treatment of Cancer Quality of Life Cancer Specific version translated into Arabic was administered to a random sample of 337 Bahraini women with breast cancer. Relevant descriptive statistics were computed for all items. The equality of means across the categories of each categorical independent variable was tested using parametric tests (ANOVA and independent t-test) or non-parametric tests (Kruskal Wallis and Mann Whitney tests) of association where appropriate. RESULTS: Of the total sample, 239 consented to participation. The mean and median age of participants were 50.2 (SD ± 11.1) and 48.0 respectively. Participants had a mean score for global health of 63.9 (95% CI 61.21-66.66). Among functional scales, social functioning scored the highest (Mean 77.5 [95% CI 73.65-81.38]) whereas emotional functioning scored the lowest (63.4 [95% CI 59.12-67.71]). The most distressing symptom on the symptom scales was fatigability (Mean 35.2 [95% CI 31.38-39.18]). Using the disease specific tool it was found that sexual functioning scored the lowest (Mean 25.9 [95% CI 70.23-77.90]). On the symptom scale, upset due to hair loss scored the highest (Mean 46.3 [95% CI 37.82-54.84]). Significant mean differences were noted for many functional and symptom scales. CONCLUSION: Bahraini breast cancer survivors reported favorable overall global quality of life. Factors associated with a major reduction in all domains of quality of life included the presence of metastases, having had a mastectomy as opposed to a lumpectomy and a shorter time elapsed since diagnosis. Poorest functioning was noted in the emotional and sexual domains. The most bothersome symptoms were fatigability, upset due to hair loss and arm symptoms. This study identifies the categories of women at risk of poorer quality of life after breast cancer and the issues that most need to be addressed in this Middle East society.

Beliefs and perceptions toward quitting waterpipe smoking among cafe waterpipe tobacco smokers in Bahrain.

INTRODUCTION: There is a rising prevalence of waterpipe smoking worldwide, but still a paucity of information on perceptions toward quitting waterpipe use. We set out to establish the beliefs and perceptions of café waterpipe smokers toward quitting waterpipe smoking in the Kingdom of Bahrain. METHODS: A cross-sectional study. A random sample of 20 of 91 cafés serving waterpipe tobacco in Bahrain was taken. A questionnaire was administered in each café to 20 participants aged 18 and above. RESULTS: Three hundred eighty participants completed questionnaires from waterpipe smokers. Eighty-four percent of participants were Bahraini and 71% had a university degree. Mean age was 28.9 years. Average age of waterpipe smoking initiation was 20.3 years. The majority of waterpipe users chose flavored tobacco. Sixty-one percent smoked waterpipe tobacco daily with a mean smoking time of 2.6hr/day. Seventy-two percent considered waterpipe tobacco as harmful as or more harmful than cigarettes, but 67% considered cigarettes as more addictive. Eighty-two percent stated that they could quit waterpipe at any time, but only 40% were interested in quitting. Interest in quitting smoking was related to 4 variables: a physician mentioning the need to quit smoking, being non-Bahraini, having a family with a hostile attitude toward waterpipe smoking, and not considering oneself "hooked" on waterpipe tobacco. CONCLUSIONS: Waterpipe smokers in Bahrain cafés are frequent and high users. Health professionals must consider waterpipe smoking in all consultations and health promotion messages. A partnership between health professionals and disapproving members of families may be an effective strategy in encouraging waterpipe smokers to quit.

Cross-border contextualisation of family medicine curriculum: an examination of the process.

Objectives: This study explores a method of transferring a post graduate medical education curriculum internationally and contextualising it to the local environment. This paper also explores the experiences of those local medical educationalists involved in the process. Methods: Several methods were implemented. Firstly, a modified Delphi process for the contextualisation of learning outcomes was implemented with a purposefully sampled expert group of Malaysian Family Medicine Specialists. Secondly a small group review for supporting materials was undertaken. Finally, qualitative data in relation to the family medicine specialists' experiences of the processes was collected via online questionnaire and analysed via template analysis. Descriptive statistics were used. Results: Learning outcomes were reviewed over three rounds; 95.9% (1691/1763) of the learning outcomes were accepted without modification, with the remainder requiring additions, modifications, or deletions. Supporting materials were extensively altered by the expert group. Template analysis showed that Family Medicine Specialists related positively to their involvement in the process, commenting on the amount of similarity in the medical curriculum whilst recognising differences in disease profiles and cultural approaches. Conclusions: Learning outcomes and associated material were transferable between "home" and "host" institution. Where differences were discovered this novel approach places "host" practitioners' experiences and knowledge central to the adaptation process, thereby rendering a fit for purpose curriculum. Host satisfaction with the outcome of the processes, as well as ancillary benefits were clearly identified.

From prevention to nursing home care: a comprehensive national audit of stroke care.

BACKGROUND: Many countries are developing national audits of stroke care. However, these typically focus on stroke care from acute event to hospital discharge rather than the full spectrum from prevention to long-term care. We report on a comprehensive national audit of stroke care in the community and hospitals in the Republic of Ireland. The findings provide insights into the wider needs of people with stroke and their families, a basis for developing stroke-appropriate health strategies, and a global model for the evaluation of stroke services. METHODS: Six national surveys were completed: general practitioners (prevention and primary care), hospital organisational and clinical audit of 2,570 consecutive stroke admissions (acute and hospital care), allied health professionals and public health nurses (discharge to community care), nursing homes (needs of patients discharged to long-term care), and patient and carers (post-hospital phase of rehabilitation and ongoing care). RESULTS: The audit identified substantial deficits in a number of areas including primary prevention, emergency assessment/investigation and treatment in hospital, discharge planning, rehabilitation and ongoing secondary prevention, and communication with patients and families. There was a lack of coordination and communication between the acute and community services, with a dearth of therapy services in both home and nursing home settings. CONCLUSION: This multi-faceted national stroke audit facilitated multiple perspectives on the continuum of stroke prevention and care. An overall synthesis of surveys supports the development of a multidisciplinary perspective in planning the development of comprehensive stroke services at the national level, and may assist in regional and global development of stroke strategies.

A multidisciplinary primary care team consultation in a socio-economically deprived community: an exploratory randomised controlled trial.

BACKGROUND: Psychosocial problems in socioeconomically deprived communities are not always amenable to traditional medical approaches. Mothers living in these areas are a particularly vulnerable group. The objective of this study was to evaluate the effectiveness of a lengthened multi-disciplinary team consultation in primary care in reducing anxiety and depression in mothers. METHODS: This was a prospective randomised controlled trial of a multidisciplinary team consultation against normal care. 94 mothers were recruited from three general practices from an area of extreme socio-economic deprivation. Mothers randomised into the intervention group attended a multidisciplinary consultation with up to four case-specific health care professionals. Consultations addressed medical, psychological and social problems and lasted up to one hour. Conventional primary care continued to be available to the intervention families. Control group families received normal primary care services. The outcomes measured were anxiety and depression as using the Hospital Anxiety and Depression Scale (HADS), health status using SF36v2, and quality of life using the abbreviated Schedule for the Evaluation of Individual Quality of Life (SEIQoL-DW) at baseline, 6 months and 12 months. RESULTS: Ordered logistic regression was used to analyse the data. There was no significant difference found between intervention and control groups after 6 months and 12 months in all of the measured outcomes. CONCLUSIONS: The new lengthened multi-disciplinary team consultation did not have any impact on the mental health, general health, and quality of life of mothers after 6 and 12 months. Other methods of primary health care delivery in socio-economically deprived communities need to be evaluated.

The use of complementary and alternative medicine by patients with diabetes mellitus in Bahrain: a cross-sectional study.

BACKGROUND: CAM use is widespread, especially among patients with diabetes. The Gulf States have a high prevalence of diabetes, alongside a long tradition of CAM use. The aim of this study is to establish the prevalence of CAM use among patients with diabetes mellitus in Bahrain and to examine the characteristics of the CAM users. METHODS: A questionnaire was developed and administered to a convenience sample of patients with diabetes (n = 402) above the age of 20 attending two hospital diabetes clinics. Data were analysed using descriptive statistics and non-parametric tests of association. RESULTS: 63% of responders utilized CAM within the previous 12 months. CAM users were more likely to be female, to have had diabetes for longer and to have complications of their diabetes. 64% of CAM users stated that they had used CAM for managing their diabetic condition, with 46% of these having used it solely for their diabetes. Respondents using CAM to manage their diabetes were more likely to be male, to be using CAM on a daily basis and to have informed their physician of their CAM use. CONCLUSIONS: There is a high rate of CAM use in patients with diabetes attending two hospital diabetes clinics in Bahrain. There is also a high rate of non-disclosure of CAM use to physicians. There is a continuing need for health professionals to be more aware and better trained in order to inform their decision making and communication related to CAM use.

Reducing health risk in family members of patients with type 2 diabetes: views of first degree relatives.

BACKGROUND: Patients with type 2 diabetes can have an important role in discussing health risk within families. This study aimed to establish the acceptability to first degree relatives towards their relative with type 2 diabetes intervening as health promoters in their own families, using the Health Belief Model as a theoretical framework for evaluation. METHODS: Cross-sectional questionnaire design. Survey questionnaire for first degree relative (sibling or child) mailed to a random sample of patients with type 2 diabetes registered with an urban hospital diabetes clinic (n = 607 eligible patients). Patients were asked to pass on questionnaires to one to two first degree relatives. RESULTS: Questionnaires were returned from 257 families (42% response rate) with two responses provided by 107 families (a total of 364 questionnaires). The majority (94%) of first degree relatives of patients with type 2 diabetes would like to be informed about reducing their risk. Half (48%) of respondents reported being spoken to by a relative with type 2 diabetes about their risk of diabetes. Those spoken to were more likely to see themselves at risk of diabetes, to worry about developing diabetes and to view diabetes as a serious condition. CONCLUSIONS: A role for patients with type 2 diabetes in discussing health risk in their family appears to be acceptable to many relatives. Discussion of risk and interventions to reduce health risk with their relatives should be encouraged in patients with type 2 diabetes.

Is primary care a neglected piece of the jigsaw in ensuring optimal stroke care? Results of a national study.

BACKGROUND: Stroke is a major cause of mortality and morbidity with potential for improved care and prevention through general practice. A national survey was undertaken to determine current resources and needs for optimal stroke prevention and care. METHODS: Postal survey of random sample of general practitioners undertaken (N = 204; 46% response). Topics included practice organisation, primary prevention, acute management, secondary prevention, long-term care and rehabilitation. RESULTS: Service organisation for both primary and secondary prevention was poor. Home management of acute stroke patients was used at some stage by 50% of responders, accounting for 7.3% of all stroke patients. Being in a structured cardiovascular management scheme, a training practice, a larger practice, or a practice employing a practice nurse were associated with structures and processes likely to support stroke prevention and care. CONCLUSION: General practices were not fulfilling their potential to provide stroke prevention and long-term management. Systems of structured stroke management in general practice are essential to comprehensive national programmes of stroke care.

Telephone survey of private patients' views on continuity of care and registration with general practice in Ireland.

BACKGROUND: The desire of patients for personal continuity of care with a General Practitioner (GP) has been well documented, but not within non-registered private patients in Ireland. This study set out to examine the attitudes and reported behaviours of private fee-paying patients towards continuity of GP care and universal registration for patients. METHODS: Cross-sectional telephone survey of 400 randomly chosen fee-paying patients living within County Dublin. There is no formal system of registration with a GP for these patients. Main outcomes were attendance of respondents at primary health care facilities and their attitudes towards continuity of care and registration with a GP. Data was analysed using descriptive statistics and using parametric and non-parametric tests of association. Pearson correlation was used to quantify the association between the described variables and attitudes towards continuity and registration with a GP. Variables showing significance at the 5% level were entered into multiple linear regression models. RESULTS: 97% of respondents had seen a GP in the previous 5 years. The mean number of visits to the GP for respondents was 2.3 per annum. 89% of respondents had a regular GP and the mean length of time with their GP was 15.6 years. 96% preferred their personal medical care to be provided within one general practice. 16% of respondents had consulted a GP outside of their own practice in the previous year. They were more likely to be female, commute a longer distance to work or have poorer health status. 81% considered it important to be officially registered with a GP practice of their choice. CONCLUSION: Both personal and longitudinal continuity of care with a GP are important to private patients. Respondents who chose to visit GPs other than their regular GP were not easily characterised in this study and individual circumstances may lead to this behaviour. There is strong support for a system of universal patient registration within general practice.

A randomised controlled trial of a lengthened and multi-disciplinary consultation model in a socially deprived community: a study protocol.

BACKGROUND: There has been little development of the general practice consultation over the years, and many aspects of the present consultation do not serve communities with multiple health and social problems well. Many of the problems presenting to general practitioners in socio-economically disadvantaged areas are not amenable to a purely medical solution, and would particularly benefit from a multidisciplinary approach. Socio-economic deprivation is also associated with those very factors (more psychosocial problems, greater need for health promotion, more chronic diseases, more need for patient enablement) that longer consultations have been shown to address. This paper describes our study protocol, which aims to evaluate whether a lengthened multidisciplinary primary care team consultation with families in a socially deprived area can improve the psychological health of mothers in the families. METHODS/DESIGN: In a randomised controlled trial, families with a history of social problems, substance misuse or depression are randomly allocated to an intervention or control group. The study is based in three general practices in a highly deprived area of North Dublin. Primary health care teams will be trained in conducting a multidisciplinary lengthened consultation. Families in the intervention group will participate in the new style multidisciplinary consultation. Outcomes of families receiving the intervention will be compared to the control group who will receive only usual general practitioner care. The primary outcome is the psychological health of mothers of the families and secondary outcomes include general health status, quality of life measures and health service usage. DISCUSSION: The main aim of this study is to evaluate the effectiveness of a lengthened multidisciplinary team consultation in primary care. The embedded nature of this study in general practices in a highly deprived area ensures generalisability to other deprived communities, but more particularly it promises relevance to primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN70578736.

Peer support in type 2 diabetes: a randomised controlled trial in primary care with parallel economic and qualitative analyses: pilot study and protocol.

BACKGROUND: Diabetes is a chronic illness, which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self-management training for diabetes has been delivered in a didactic manner. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. This paper describes the pilot study and protocol for a study that aims to evaluate the effectiveness of a peer support intervention for people with type 2 diabetes in a primary care setting. METHODS/DESIGN: A pilot study was conducted to access the feasibility of a randomized controlled trial of a peer support intervention. We used the MRC Framework for the evaluation of complex interventions. Elements of the intervention were defined and the study protocol was finalized. In this cluster randomised controlled trial twenty general practices are assigned to control and intervention groups. Each practice compiles a diabetes register and randomly selects 21 patients. All practices implement a standardised diabetes care system. In the intervention group all practices recruit three peer supporters. The peer supporters are trained to conduct nine group meetings in their general practice over a period of two years. Each meeting has a structured component. The primary outcomes are blood pressure, total cholesterol, HBA1c and the Diabetes Well-being score. In addition to biophysical, psychosocial, economic and health service utilization data peer supporter activity and qualitative data are collected. DISCUSSION: Peer support is a complex intervention and evaluating such an intervention presents challenges to researchers. This study will evaluate whether a peer support programme for patients with type 2 diabetes improves biophysical and psychosocial outcomes and whether it is an acceptable, cost effective intervention in the primary care setting. TRIAL REGISTRATION: Current Controlled Trials ISRCTN42541690.

Does Sickle Cell Disease Protect Against Diabetes Mellitus?: Cross-sectional study.

Objectives: The co-existence of diabetes mellitus (DM) and sickle cell disease (SCD) is rare. This study aimed to explore whether SCD patients have the same DM prevalence as the general population in a country with a high prevalence of DM. Methods: This cross-sectional study included all SCD adult patients admitted to Salmaniya Medical Complex, Bahrain, between 2003 and 2010 (n = 2,204). A random sample (n = 520) was taken to establish the prevalence of DM. Laboratory records were examined to determine the presence of DM. Results: There were 376 SCD patients with complete records; of these, 24 (6.4%) had DM. The age- and sex-standardised prevalence of DM was 8.3%. Conclusion: While the prevalence of DM in SCD patients in Bahrain was high, it was lower than expected in this population. SCD may have a protective effect towards DM development. However, the impact of these two conditions on vascular diseases suggest a need for screening and aggressive treatment in this population.

Stroke in Bahrain: rising incidence, multiple risk factors, and suboptimal care.

The incidence of stroke in Bahrain is rising in the Bahraini population and has nearly doubled over the last 16 years, while the incidence in the non-Bahraini population has not changed. Incidence of stroke in the Bahraini population (110/100,000) is now much greater than in the non-Bahraini population (27/100,000). The Bahraini stroke population is 10 years younger than Western comparators with a much higher prevalence of many of the risk factors for stroke, including diabetes (54%), hypertension (75%) and hyperlipidemia (34%). The combination of an ageing Bahraini population alongside a high prevalence of risk factors suggests a 'ticking time bomb' that is likely to see a continuing rise in the incidence of stroke. The quality of risk factor prevention and hospital-based stroke care is therefore crucial in Bahrain. While 88% of patients were scanned within 24 h and 86% with non-haemorrhagic strokes were commenced on aspirin within 48 h, none of the patients received thrombolysis or were admitted to a stroke unit. Improvement of stroke outcomes in Bahrain could be achieved through implementation of evidence-based measures, including improved risk factor management in primary care and stroke units and thrombolysis in secondary care.

Influences on the variation in prevalence of type 2 diabetes between general practices: practice, patient or socioeconomic factors?

BACKGROUND: The prevalence of type 2 diabetes is known to vary between countries, districts and general practices. The influence of early detection and screening on the variation of prevalence between general practices has not previously been investigated. AIM: To test the hypothesis that the prevalence of type 2 diabetes is associated with awareness of and screening for diabetes within general practices and to explore other factors that may explain the variation in prevalence between practices. DESIGN OF STUDY: Cross-sectional study of general practices. SETTING: Forty-two general practices in Newcastle and North Tyneside; 20% random sample of patients with type 2 diabetes (n = 1056). METHOD: Factors thought to be associated with the variation of type 2 diabetes prevalence were collected from general practices through practice managers, medical records, and patient questionnaire. Pearson's correlation coefficient was used to quantify the association, and variables significant at the 5% level were entered into a multiple linear regression model. RESULTS: There was a wide inter-practice variation in age/sex standardised type 2 diabetes prevalence (range = 0.69% to 2.73%; P < 0.001). There was no significant association between the prevalence of type 2 diabetes and the proportion of patients detected outside primary care or the proportion of patients detected through screening, accounting for only 2% and 3% of the variation in type 2 prevalence between practices, respectively. The mean Townsend deprivation score accounted for 42% of the variation in type 2 diabetes prevalence between practices, with more deprived practices having a higher prevalence. CONCLUSION: This study suggests that socieconomic deprivation, rather than detection through screening or awareness of diabetes, accounts for much of the variation in prevalence of type 2 diabetes between practices.

Understanding the experiences and quality of life issues of Bahraini women with breast cancer.

We explored the experiences of Bahraini women who have survived breast cancer and their perception of quality of life after diagnosis. We conducted in depth, semi-structured face-to-face interviews with twelve women diagnosed with breast cancer. A qualitative method using semi-structured interviews on a purposive sample of 12 Bahraini women with breast cancer was conducted. Similarities and differences in women's experience were identified through thematic analysis of interview transcripts using a constant comparative approach. The themes identified were meaning of cancer and quality of life, spirituality and beliefs about causes of breast cancer, coping mechanisms, impact of illness and change in relationships. Quality of life was framed in terms of the ability to perform daily duties with emphasis on the physical component of quality of life. Themes that differed from previous western studies included a heavy emphasis on spiritual practices for comfort; the use of traditional clothing (hijab and abaya) to hide hair and body changes; the important role played by the family and husband in treatment decisions and concerns regarding satisfying the sexual needs of the husband, which were related to a fear of losing the husband to a second wife. Evil eye, stress and God's punishment were believed to be fundamental causes of the disease. The emotional shock of the initial diagnosis, concerns about whether to reveal the diagnosis and a desire to live a normal life were consistent with previous studies. However, cultural and religious issues such as role of the husband and impact of prayers were also important here. These themes are important to healthcare professionals for ensuring an individualized approach to the treatment of women with breast cancer.

Impact of clinical inertia on cardiovascular risk factors in patients with diabetes.

AIMS: To determine whether clinical inertia is associated with simpler interventions occurring more often than complex changes and the association between clinical inertia and outcomes. METHODS: Prevalence of clinical inertia over a 30 month period for hyperglycaemia, hypertension and dyslipidaemia was calculated in a random sample (n=334) of patients attending a diabetes clinic. Comparisons between prevalence of clinical inertia and outcomes for each condition were examined using parametric tests of association. RESULTS: There was less clinical inertia in hyperglycaemia (29% of consultations) compared with LDL (80% of consultations) and systolic BP (68% of consultations). Consultations where therapy was intensified had a greater reduction in risk factor levels than when no change was made. No association was found between treatment intensity scores and changes in HbA1c, LDL or blood pressure over 30 months. CONCLUSIONS: Physicians are no more likely to intervene in conditions where simple therapeutic changes are necessary as opposed to complex changes. Greater clinical inertia leads to poorer outcomes. There continues to be substantial clinical inertia in routine clinical practice. Physicians should adopt a holistic approach to cardiovascular risk reduction in patients with diabetes, adhere more closely to established management guidelines and emphasize personal individualized target setting.