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Continuous glucose monitors (CGMs) improve glycemic outcomes and quality of life for many people with diabetes. Research and clinical practice efforts have focused on CGM initiation and uptake. There is limited understanding of how to sustain CGM use to realize these benefits and limited consideration for different reasons/goals for CGM use. Therefore, we apply the Information-Motivation-Behavioral Skills (IMB) model as an organizing framework to advance understanding of CGM use as a complex, ongoing self-management behavior. We present a person-centered, dynamic perspective with the central thesis that IMB predictors of optimal CGM use vary based on the CGM use goal of the person with diabetes. This reframe emphasizes the importance of identifying and articulating each person's goal for CGM use to inform education and support.
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AIMS: Continuous glucose monitoring (CGM) systems are standard of care for youth with type 1 diabetes with the goal of spending >70% time in range (TIR; 70-180 mg/dL, 3.9-10 mmol/L). We aimed to understand paediatric CGM user experiences with TIR metrics considering recent discussion of shifting to time in tight range (TITR; >50% time between 70 and 140 mg/dL, 3.9 and 7.8 mmol/L). METHODS: Semi-structured interviews and focus groups with adolescents with type 1 diabetes and parents of youth with type 1 diabetes focused on experiences with TIR goals and reactions to TITR. Groups and interviews were audio-recorded, transcribed and analysed using content analysis. RESULTS: Thirty participants (N = 19 parents: age 43.6 ± 5.3 years, 79% female, 47% non-Hispanic White, 20 ± 5 months since child's diagnosis; N = 11 adolescents: age 15.3 ± 2 years, 55% female, 55% non-Hispanic White, 16 ± 3 months since diagnosis) attended. Participants had varying levels of understanding of TIR. Some developed personally preferred glucose ranges. Parents often aimed to surpass 70% TIR. Many described feelings of stress and disappointment when they did not meet a TIR goal. Concerns about TITR included increased stress and burden; risk of hypoglycaemia; and family conflict. Some participants said TITR would not change their daily lives; others said it would improve their diabetes management. Families requested care team support and a clear scientific rationale for TITR. CONCLUSIONS: The wealth of CGM data creates frequent opportunities for assessing diabetes management and carries implications for management burden. Input from people with type 1 diabetes and their families will be critical in considering a shift in glycaemic goals and targets.
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Diabetes is unique among chronic diseases because clinical outcomes are intimately tied to how the person living with diabetes reacts to and implements treatment recommendations. It is further characterised by widespread social stigma, judgement and paternalism. This physical, social and psychological burden collectively influences self-management behaviours. It is widely recognised that the individual's perspective about the impact of trying to manage the disease and the burden that self-management confers must be addressed to achieve optimal health outcomes. Standardised, rigorous assessment of mental and behavioural health status, in interaction with physical health outcomes is crucial to aid understanding of person-reported outcomes (PROs). Whilst tempting to conceptualise PROs as an issue of perceived quality of life (QoL), in fact health-related QoL is multi-dimensional and covers indicators of physical or functional health status, psychological and social well-being. This complexity is illuminated by the large number of person reported outcome measures (PROMs) that have been developed across multiple psychosocial domains. Often measures are used inappropriately or because they have been used in the scientific literature rather than based on methodological or outcome assessment rigour. Given the broad nature of psychosocial functioning/mental health, it is important to broadly define PROs that are evaluated in the context of therapeutic interventions, real-life and observational studies. This report summarises the central themes and lessons derived in the assessment and use of PROMs amongst adults with diabetes. Effective assessment of PROMs routinely in clinical research is crucial to understanding the true impact of any intervention. Selecting appropriate measures, relevant to the specific factors of PROs important in the research study will provide valuable data alongside physical health data.
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Diabetes Mellitus , Medición de Resultados Informados por el Paciente , Calidad de Vida , Humanos , Diabetes Mellitus/terapia , Diabetes Mellitus/psicología , Adulto , Consenso , Estado de SaludRESUMEN
AIMS: To describe the development of a novel, conceptually sound instrument with contemporary content for assessing diabetes distress (DD) among adults with type 1 diabetes. METHODS: Qualitative interviews with 15 adults and 7 clinicians were used to develop Core (intensity of DD emotional burden) and primary Source (key DD contributors) items. These were administered to a national sample recruited from the TCOYD Research Registry, T1D Exchange and our previous studies. Exploratory and confirmatory factor analyses were undertaken, along with reliability and construct validity studies, and cut-point analyses to determine elevated DD. RESULTS: Analyses based on 650 respondents yielded an 8-item Core DD scale (α = 0.95) and 10 2- or 3-item DD Source Scales (α range = 0.53-0.88): Financial Worries, Interpersonal Challenges, Management Difficulties, Shame, Hypoglycemia Concerns, Healthcare Quality, Lack of Diabetes Resources, Technology Challenges, Burden to Others and Worries about Complications. Core and Source scores were significantly associated with criterion variables: Higher DD scores were significantly linked with higher HbA1C, more frequent episodes of severe hypoglycaemia, missed boluses, and poorer quality of life (p > 0.001). A ≥2.0 scale cut-point to define elevated DD is suggested. CONCLUSIONS: The new T1-Diabetes Distress Assessment System demonstrated good reliability and validity, and with measures of both Core emotional burden and Sources of DD, it provides a contemporary, flexible and practical approach to assessing DD that can be used seamlessly to inform intervention for clinicians and researchers.
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Diabetes Mellitus Tipo 1 , Distrés Psicológico , Humanos , Diabetes Mellitus Tipo 1/psicología , Masculino , Femenino , Adulto , Persona de Mediana Edad , Reproducibilidad de los Resultados , Calidad de Vida , Estrés Psicológico/diagnóstico , Emociones , Psicometría , Encuestas y Cuestionarios , Investigación Cualitativa , Anciano , Hipoglucemia/psicología , Adulto JovenRESUMEN
AIM: To better understand the prevalence of self-reported psychosocial burdens and the unmet needs identified by people with diabetes in relation to routine diabetes visits. METHODS: An English language, online survey was distributed via social media, key stakeholder networks, charity and advocacy groups to adults with type 1 diabetes or type 2 diabetes. Survey items were designed by members of the FDA RESCUE Collaborative Community Governing Committee prior to pilot testing with potential participants. Descriptive statistical analyses were conducted, as well as thematic analyses on free-text responses using NVivo v14. RESULTS: Four hundred and seventy-eight participants completed the survey: 373 (78%) had type 1 diabetes, 346 (73%) identified as a woman and 433 (91%) were white. Most participants had experienced self-reported (rather than diagnosed) anxiety and depression (n = 323 and n = 313, respectively), as well as fear of low blood sugars (n = 294), low mood (n = 290) and diabetes-related distress (n = 257). Sixty-eight percent reported that diabetes had negatively affected self-esteem, 62% reported the feelings of loneliness, but 93% reported that friends/family/work colleagues were supportive when needed. Two hundred and seventy-two percent (57%) reported that their diabetes team had never raised the topic of mental health. The overwhelming majority stated that the best thing their diabetes team could do to help was to simply ask about mental well-being, listen with empathy and without judgement, and practice skills to understand psychosocial issues in diabetes. CONCLUSION: Integrating psychosocial discussions and support within routine healthcare visits is crucial to improve outcomes for people with diabetes. Such a biopsychosocial model of healthcare has long been advocated by regulatory bodies.
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Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Adulto , Femenino , Humanos , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 1/psicología , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Emociones , Ansiedad/epidemiologíaRESUMEN
People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.
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Diabetes Mellitus , Estigma Social , Adulto , Humanos , Prejuicio , Atención a la Salud , Encuestas y Cuestionarios , Diabetes Mellitus/terapiaRESUMEN
Fundamento: El carcinoma basocelular es infrecuente en la piel cabelluda. Es un tumor de invasión local y crecimiento lento, puede ser agresivo, destruir tejidos vecinos, causar ulceración e invadir en profundidad cartílago y hueso. Objetivo: Evaluar los resultados de la aplicación del HeberFERON y el seguimiento con ecografía cutánea en pacientes con carcinoma basocelular en la piel cabelluda. Metodología: Se realizó un estudio observacional, descriptivo y longitudinal en una serie de casos con diagnóstico de carcinoma basocelular de la piel cabelluda en el Policlínico Centro de la ciudad Sancti Spíritus, durante el período de 10 de julio del 2018 a 29 de julio del 2022. Se incluyeron 6 casos. Las variables estudiadas fueron la respuesta al tratamiento mediante la clínica, la ecografía cutánea e histopatología y presencia de eventos adversos. Resultados: Predominó el sexo masculino, subtipo histológico sólido, subtipo clínico nódulo ulcerativo, tamaño del tumor mayor de 30 mm y tiempo de evolución de más de 12 meses; la respuesta al tratamiento en la mayoría de los casos fue parcial. Los eventos adversos fueron dolor y ardor en el sitio de inyección, fiebre, edema y eritema perilesional. Conclusiones: El HeberFERON resultó de utilidad en los pacientes con carcinoma basocelular del cuero cabelludo ya que redujo el tumor en unos casos y en otros lo eliminó. La ecografía permitió la evaluación en tiempo real de la neoplasia; los eventos adversos más frecuentes fueron la fiebre y el dolor en el sitio de inyección, a pesar de ello ningún paciente abandonó el tratamiento.
Background: Basal cell carcinoma is uncommon in the scalp. It is a slow-growing locally invasive tumor, it can be aggressive in destroying neighboring tissues, cause ulceration and invade deep into the cartilage and bone. Objective: To evaluate the results of HeberFERON application and follow-up with cutaneous echographical in patients with scalp basal cell carcinoma. Methodology: An observational, descriptive and longitudinal study was conducted in a series of cases diagnosed with scalp basal cell carcinoma at the Center Polyclinic in Sancti Spíritus city during the period from July 10, 2018 to July 29, 2022. Six clinical cases were included. The studied variables were the answer to the treatment by clinical, cutaneous echographical and histopathology and the presence of adverse events. Results: Male sex predominated, solid histologic subtype, clinical subtype ulcerative nodule, tumor size greater than 30 mm and evolution time of over 12 months; the treatment response in most cases was partial; adverse events were pain and burning at the injection site, fever, edema and perilesional erythema. Conclusion: It was observed that in patients with scalp basal cell carcinoma, the HeberFERON treatment reduced in some cases and eliminated the tumor in others. Echography allowed real-time evaluation of the neoplasm, fever and pain at the injection site were the most frequent adverse events. In spite of this, none of the patients abandoned the therapy.
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Acceptance of the COVID-19 vaccination becomes more critical as new variants continue to evolve and the United States (US) attempts to move from pandemic response to management and control. COVID-19 stands out in the unique way it has polarized patients and generated sustained vaccine hesitancy over time. We sought to understand differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant patients, with the goal of informing communication and implementation strategies to increase uptake of COVID-19 vaccines in Veteran and non-Veteran communities. This qualitative study used interview data from focus groups conducted by the Department of Veterans Affairs (VA) and the University of Utah; all focus groups were conducted using the same script March-July 2021. Groups included forty-six United States Veterans receiving care at 28 VA facilities across the country and 166 non-Veterans across Utah for a total of 36 one-hour focus groups. We identified perceptions and attitudes toward COVID-19 vaccination through qualitative analysis of focus group participant remarks, grouping connections with identified themes within domains developed based on the questions asked in the focus group guide. Responses suggest participant attitudes toward the COVID-19 vaccine were shaped primarily by vaccine attitude changes over time, impacted by perceived vaccine benefits, risks, differing sources of vaccine information and political ideology. Veterans appeared more polarized, being either largely non-hesitant, or hesitant, whereas non-Veterans had a wider range of hesitancy, with more participants identifying minor doubts and concerns about receiving the vaccine, or simply being altogether unsure about receiving it. Development of COVID-19 vaccine communication strategies in Veteran and non-Veteran communities should anticipate incongruous sources of information and explicitly target community differences in perceptions of risks and benefits associated with the vaccine to generate candid discussions and repair individuals' trust. We believe this could accelerate vaccine acceptance over time.
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COVID-19 , Vacunas , Humanos , Vacunas contra la COVID-19 , COVID-19/prevención & control , Vacunación , Transporte BiológicoRESUMEN
AIM: Youth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES. METHODS: We analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status. RESULTS: For youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = -0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = -0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027). CONCLUSION: PGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.
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Diabetes Mellitus Tipo 1 , Humanos , Adolescente , Femenino , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/epidemiología , Encuestas y Cuestionarios , Clase Social , Glucemia , Medición de Resultados Informados por el PacienteRESUMEN
Objective: Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background: Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods: Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. Results: A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. Conclusions: The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.
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Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Tomografía de Coherencia Óptica , Arterias , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: DiabetesWise is an unbranded, data-driven online resource that tailors device recommendations based on preferences and priorities of people with insulin-requiring diabetes. The objective of this study is to examine whether DiabetesWise increases uptake of diabetes devices, which are empirically supported to improve glycemic and psychosocial outcomes. METHODS: The sample included 458 participants (Mage = 37.1, SD = 9.73; 66% female; 81% type 1 diabetes) with insulin-requiring diabetes and minimal diabetes device use at enrollment. Participants used DiabetesWise and completed online surveys. Chi-square and t tests evaluated requests for a device prescription, receiving a prescription, and starting a new device at 1 and 3 months post use. Baseline predictors of these variables and past use of continuous glucose monitors (CGMs) and changes in diabetes distress post use were also examined. RESULTS: Within the first month of interacting with DiabetesWise 19% of participants asked for a prescription for a diabetes device. This rate rose to 31% in the first 3 months. These requests resulted in 16% of the sample starting a new device within the first 3 months. Whereas several factors were associated with prior CGM use, receiving a prescription, and starting a new device, more diabetes distress (t(343) = -3.13, p = .002) was the only factor associated with asking for a prescription. Diabetes distress decreased after interacting with DiabetesWise within 1 month (t(193) = 3.51, p < .001) and 3 months (t(180) = 5.23, p < .001). CONCLUSIONS: Within 3 months of interacting with DiabetesWise, one in three participants had requested a prescription for a new diabetes device and average distress levels were reduced, indicating benefit from this low-intensity online platform.
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Diabetes Mellitus Tipo 1 , Humanos , Femenino , Adulto , Masculino , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Glucemia , Insulina/uso terapéutico , Automonitorización de la Glucosa Sanguínea , Sistemas de Infusión de Insulina/psicología , Hipoglucemiantes/uso terapéuticoRESUMEN
OBJECTIVE: People with diabetes have an increased risk of depression, intentional self-injury and self-harm (ISI), and suicide compared with the general population. This study aimed to explore experiences and awareness of health care professionals (HCPs) regarding depression, ISI, and suicide, and understand resource use and needs among HCPs who care for persons with diabetes (PWD). METHODS: Health care professionals who see children and/or adults with type 1 diabetes or type 2 diabetes anonymously completed an online survey about their experiences, opinions, barriers, and needs surrounding identification and care of PWD with depression, ISI, and suicide. RESULTS: One hundred twenty-nine HCPs participated. The majority were medical doctors (MDs) or advanced practice providers (APPs). Only a quarter of MDs and APPs felt very comfortable asking about ISI or suicidal ideation (SI), whereas 20% felt they had received appropriate training to support those with ISI or SI. The primary needs reported include more training on how to ask, respond, and support those expressing ISI and SI. Health care professionals reported wanting better access to resources for PWD. DISCUSSION: The HCPs tend to underestimate SI in the diabetes population and rates of training were low. Areas to address include providing education and training to HCPs to improve identification and management of ISI and suicide risk. These data can inform the development of mechanisms to improve discussions of depression and suicide and of resources to help HCPs support PWD.
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BACKGROUND: Previous literature has explored parent/caregiver perspectives and satisfaction with the health care transition (HCT) process for their adolescents and young adults with special health care needs (AYASHCN). Limited research has explored the opinion of health care providers and researchers on parent/caregiver outcomes associated with a successful HCT for AYASHCN. METHODS: A web-based survey was distributed through the international and interdisciplinary Health Care Transition Research Consortium listserv, which at the time of the survey was composed of 148 providers dedicated to optimizing the HCT of AYAHSCN. Participants responded to the open-ended question, 'What parent/caregiver-related outcome(s) would represent a successful healthcare transition?' Respondents included 109 providers (52 health care professionals, 38 social service professionals and 19 other). Responses were coded for emergent themes, and research suggestions were identified. RESULTS: Qualitative analyses identified two major themes: emotion- and behaviour-based outcomes. Emotion-based subthemes included relinquishing control of child's health management (n = 50, 45.9%) as well as parental satisfaction and confidence in their child's care and HCT (n = 42, 38.5%). Respondents also noted that parents/caregivers should experience an improved sense of well-being and decreased stress (n = 9, 8.2%) due to a successful HCT. Behaviour-based outcomes included early preparation and planning for HCT (n = 12, 11.0%) and parental instruction on the knowledge and skills necessary for their adolescent to independently manage their health (n = 10, 9.1%). CONCLUSIONS: Health care providers can assist parents/caregivers in learning strategies for instructing their AYASHCN about condition-related knowledge and skills as well as provide support for 'letting go' of the caregiver role during the HCT to adult-focused health services and adulthood. Communication between the AYASCH, their parents/caregivers and paediatric- and adult-focused providers needs to be consistent and comprehensive to ensure continuity of care and a successful HCT. We also offered strategies to address the outcomes suggested by the participants of this study.
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Transición a la Atención de Adultos , Humanos , Adolescente , Niño , Adulto Joven , Cuidadores , Transferencia de Pacientes , Atención a la Salud , PadresRESUMEN
AIMS: This study examined the psychosocial impact of Loop, an open-source automated insulin dosing system that has emerged from the diabetes technology "Do-It-Yourself" (DIY) movement. METHODS: Subsamples of 239 adults, 115 children, and 243 parents completed data collection at the time of Loop initiation and 3 and 6 months later. Surveys collected demographic and clinical information, percent time-in-range, HbA1c, and validated psychosocial measures. Analyses included paired t tests and McNemar's tests to compare psychosocial functioning at 3 and 6 months and regression models to assess baseline predictors of psychosocial outcomes at 6 months. RESULTS: Adults reported significant improvements in diabetes distress (t = -7.20 P < .001; t = -8.01, P < .001), sleep quality (t = 6.81, P < .001; t = 2.98, P = .003), fear of hypoglycemia (t = -4.42, P < .001; t = -4.97, P < .001), and hypoglycemia confidence (t = 8.68, P < .001; t = 7.96 P < .001) from baseline to 3 months and 6 months, respectively. Significant improvements in parents' and children's sleep quality and parents' fear of hypoglycemia were also observed. Several baseline characteristics were associated with psychosocial outcomes at 6 months. CONCLUSIONS: The current findings support the broad and sustained benefits of Loop across multiple aspects of psychosocial well-being. Advancement and dissemination of such technologies has the potential to improve mental and physiological health among people living with type 1 diabetes.
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Diabetes Mellitus Tipo 1 , Hipoglucemia , Adulto , Niño , Humanos , Insulina , Glucemia/análisis , Sistemas de Infusión de Insulina/psicología , Hipoglucemia/inducido químicamente , Hipoglucemia/prevención & control , Hipoglucemia/psicología , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/psicología , Insulina Regular Humana/uso terapéutico , HipoglucemiantesRESUMEN
Acute hypercapnic ventilatory failure is becoming more frequent in critically ill patients. Hypercapnia is the elevation in the partial pressure of carbon dioxide (PaCO2) above 45 mmHg in the bloodstream. The pathophysiological mechanisms of hypercapnia include the decrease in minute volume, an increase in dead space, or an increase in carbon dioxide (CO2) production per sec. They generate a compromise at the cardiovascular, cerebral, metabolic, and respiratory levels with a high burden of morbidity and mortality. It is essential to know the triggers to provide therapy directed at the primary cause and avoid possible complications.
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Dióxido de Carbono , Hipercapnia , Dióxido de Carbono/metabolismo , Enfermedad Crítica/terapia , Humanos , Hipercapnia/terapiaRESUMEN
Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.