Experiences of hypoglycaemia unawareness amongst people with Type 1 diabetes: A qualitative investigation.

OBJECTIVES: To explore the experiences of people who have hypoglycaemia unawareness and its impact on their everyday lives. METHODS: In-depth interviews with 38 people with Type 1 diabetes who have hypoglycaemia unawareness. Data analysis used an inductive, thematic approach. RESULTS: Participants reported imposed and self-imposed changes to their lives following onset of hypoglycaemia unawareness including: leaving employment, curtailing pastimes and spending more time at home or being supervised by others. However, some reported getting on with life by downplaying the significance and impact of their condition, which could put their health and safety at risk. Many relied on frequent self-monitoring of blood glucose and/or prompting from others to detect hypoglycaemia. Some expressed concerns about becoming a burden on family and/or responding in irrational and aggressive ways to others' suggestions to test for and treat hypoglycaemia. Participants reported responding best to composed and directive prompts from family. Health professionals mainly advised on clinical aspects, and did not enquire about the emotional and psychosocial impact of hypoglycaemia unawareness. DISCUSSION: Hypoglycaemia unawareness can have a profound impact on people's confidence, careers and personal relationships. Healthcare professionals should pay more attention during consultations to the emotional and social aspects of living with hypoglycaemia unawareness.

The impact of anxiety and depression on patients within a large type 1 diabetes insulin pump population. An observational study.

BACKGROUND: Continuous subcutaneous insulin infusion (CSII) is generally successful for patients with type 1 diabetes in improving glycaemic control, alleviating the burden of hypoglycaemia and improving the quality of life. There is however, a cohort of patients who fail to thrive on pump therapy and psychological factors or "brittleness" have been posited as a cause for this. We aimed to assess the extent and spectrum of psychological illness in a population of pump patients. METHODS: We analysed the patient data and records of 350 patients with type 1 diabetes who formed the insulin pump patient population from a large teaching hospital and compared them with an age and sex matched reference population of patients with type 1 diabetes. We quantified the prevalence of anxiety and depression before and after the initiation of pump therapy and looked to see whether this had implications for changes in glycaemic control and hypoglycaemia reduction. RESULTS: Mental health problems amongst patients selected for CSII occur significantly more frequently than in a matched population with type 1 diabetes (51% vs 40%, P<0.05). Depression and anxiety were more prevalent in the CSII group. Of those with mental health problems, there is a tendency to do less well in terms of improvements in glycaemic control as indicated by changes in HbA(1c) and hypoglycaemia reduction--the latter most notable in patients with co-existent depression. CONCLUSIONS: The incidence and prevalence of mental health problems in individuals with diabetes is greater than that of the general population. In patients who are selected to go onto insulin pump therapy, the incidence is again greater. We have shown that in those with psychological illness, they tend to do less well in terms of improving their overall diabetes control. These results suggest that CSII may not be a suitable route of therapy alone for all of those who would fulfill the traditional criteria and suggest that psychological assessment, therapy and intervention may be an altogether more appropriate or alternative or adjunctive course of action in supporting their diabetes self management. The wider implication is that all the patients with diabetes should be regularly assessed for psychological problems and that there needs to be greater psychology/psychiatric support available to intensive diabetes clinics, especially as part of a pre-pump pathway.

Success of cricopharyngeal myotomy for specific and non-specific cervical dysphagia.

OBJECTIVE: The present study aimed to compare outcomes of cricopharyngeal myotomy (CPM) in patients with documented cricopharyngeal dysfunction (CPD) and those in whom the diagnosis is complex or in doubt. MATERIALS AND METHODS: Retrospective comparative study of all patients undergoing CPM between 2001 and 2010 at a single UK centre. Patients were classified as having either CPD (n = 15) or non-specific cervical dysphagia (NSCD) (n = 12) based on contrast swallow results. They completed a 10-point visual analogue scale (VAS) questionnaire regarding their ability to swallow solids preoperatively and 6 months postoperatively. Scores were compared between groups, and symptom recurrence at 12 months postoperatively was also noted. RESULTS: The median VAS for all patients in both groups preoperatively was 5.5 and improved postoperatively to 8.0 (p < 0.001), and median preoperative ratings between groups were similar (CPD = 6.0 vs. NSCD = 5.5; p > 0.05). The CPD group scored better postoperatively compared to their NSCD counterparts (CPD = 9.0 vs. NSCD = 7.5; p < 0.001). Recurrence rate at 12 months was lower in CPD (12.5%) compared to NSCD (60%) patients. CONCLUSION: After CPM, patients with CPD showed significant improvement in swallowing solids, as did patients with NSCD, although to a lesser extent. CPD patients experienced better outcomes compared to their NSCD counterparts, including lower complication and recurrence rates. Larger studies are required before CPM can be advocated as the standard of care for NSCD patients.