Real-life dosage and clinical efficacy of biphasic insulin preparations in patients with type 2 diabetes.

INTRODUCTION: This retrospective study used data from a primary care database to compare two insulin products in routine clinical practice for the treatment of type 2 diabetes in the UK. PATIENTS AND METHODS: Records were analyzed for patients with type 2 diabetes who had been initiated on biphasic insulin aspart 30 (BIAsp30) (n=632) or biphasic isophane human insulin 30 (BHI30) (n=762) and who had a glycated hemoglobin (HbA1(c)) measurement at baseline (up to 6 months before the index date) and end of study (6-12 months after index date). Regression analyses were used to test for a statistically significant interaction between reduction in HbA1(c) from baseline to end of study and the log-transformed average daily dose (logADD) of insulin. RESULTS: With BIAsp30 a significantly lower dose of insulin (47.74 insulin units [IU]/day vs. 66.63 IU/day, P<0.0001) was required to obtain a similar HbA1(c) reduction (1.71%-point vs. 1.55%-point, P=0.24). To achieve an additional reduction of 0.1 percentage points in HbA1(c) (eg, reduction from 9% to 7.9% HbA1(c) instead of from 9% to 8%), the dose of BIAsp30 would need to be increased by a factor of 1.15. For BHI30, a greater increase in dose would be needed to achieve the same additional HbA1(c) reduction (dose increase by a factor of 1.74). CONCLUSION: Clinically meaningful reductions in HbA1(c) can be achieved at lower insulin doses with BIAsp30 treatment than with BHI30. Lower insulin doses may have important implications for medication costs.

A meta-analysis of placebo-controlled clinical trials assessing the efficacy and safety of incretin-based medications in patients with type 2 diabetes.

AIMS: A systematic review of the literature, in combination with a meta-analysis of randomized controlled trials comparing treatments with placebo, was conducted to provide an update on the clinical efficacy and safety of incretin-based medications in adult patients with type 2 diabetes. METHODS: A literature search (2000-2009) identified 38 placebo-controlled trials (phase II or later - parallel design) comparing exenatide (n = 8), liraglutide (n = 7), vildagliptin (n = 11) and sitagliptin (n = 12) with placebo. Outcomes were change from baseline in HbA(1c) and in weight, and the number of patient-reported hypoglycemic episodes. HbA(1c) and weight outcomes were analyzed as weighted mean differences (WMD), and the number of hypoglycemic episodes as relative risks (RR). RESULTS: Patients receiving liraglutide showed greater reduction in HbA(1c) in comparison to placebo (WMD = -1.03, 95% confidence interval, CI = -1.16 to -0.90, p < 0.001) than those on sitagliptin (WMD = -0.79, 95% CI = -0.93 to -0.65, p < 0.001), exenatide (WMD = -0.75, 95% CI = -0.83 to -0.67, p < 0.001) or vildagliptin (WMD = -0.67, 95% CI = -0.83 to -0.52, p < 0.001). Weight was statistically significantly negatively associated with exenatide (WMD = -1.10, 95% CI = -1.32 to -0.87, p < 0.001) and positively associated with sitagliptin (WMD = 0.60, 95% CI = 0.33-0.87, p < 0.001) and vildagliptin (WMD = 0.56, 95% CI = 0.27-0.84, p < 0.001). The number of patient-reported hypoglycemic episodes was statistically significantly associated with the use of sitagliptin (RR = 2.56, 95% CI = 1.23-5.33, p = 0.01) and exenatide (RR = 2.40, 95% CI = 1.30-4.11, p = 0.002). CONCLUSION: Incretin-based therapies are effective in glycemic control and also offer other advantages such as weight loss (exenatide and liraglutide). This may have an important impact on patient adherence to medication.

Functional incapacity and physical and psychological symptoms: how they interconnect in chronic fatigue syndrome.

BACKGROUND: It has been argued that perceived functional incapacity might be a primary characteristic of chronic fatigue syndrome (CFS) and could be explained by physical symptoms. If so, it could be expected to be closely associated with physical, but not psychological symptoms. The study tests this hypothesis. SAMPLING AND METHODS: The sample consisted of 73 patients, with a diagnosis of CFS according to the Oxford criteria, randomly selected from clinics in the Departments of Immunology and Psychiatry at St. Bartholomew's Hospital, London. The degree of fatigue experienced by patients was assessed using the Chalder Fatigue Questionnaire and a visual analogue scale. Self-rated instruments were used to measure physical and social functioning, quality of life, and physical and psychological symptoms. RESULTS: Principal-component analysis of all scale scores revealed 2 distinct components, explaining 53% of the total variance. One component was characterized by psychological symptoms and generic quality of life indicators, whilst the other component was made up of physical symptoms, social and physical functioning and indicators of fatigue. CONCLUSIONS: The findings suggest that perceived functional incapacity is a primary characteristic of CFS, which is manifested and/or explained by physical symptoms.

Be good to your patient: how the therapeutic relationship in the treatment of patients admitted to assertive outreach affects rehospitalization.

We investigated whether the quality of the therapeutic relationship (TR) between patient and clinician predicts rehospitalization in patients in assertive outreach treatment. Analyses were conducted on 332 "established" (equal to in care for > or =3 months) and 150 "new" (equal to in care for <3 months) patients with severe mental illness sampled from 24 assertive outreach teams in London, England. TR was assessed at baseline using the clinician version of the Helping Alliance Scale. Rehospitalization was assessed over a 9-month follow-up period. Controlling for other predictors, a more positive TR was found to predict fewer hospitalizations in new patients but not in established ones.

Goals of new long-stay patients in supported housing: a UK study.

AIM: This study assessed the goals 'new' long-stay clients aim to achieve by being in supported housing (SH), compared the goals stated by clients and staff, and tested whether subgroups of clients can be identified on the basis of their goals, quality of life and psychopathology. METHOD: Interviews were conducted with 41 clients and 39 staff of supported houses in London and Essex, UK. Descriptive, content and cluster analyses were used to analyse the results. RESULTS: Clients' most frequently reported goal was moving to independent housing, followed by staying healthy, and increasing living skills. A comparison of goals reported by clients and staff showed poor or no agreement between them. Cluster analyses identified two clusters of clients. Cluster A (n = 23) contained those with no stated goals (or with the aim of staying healthy), lower quality of life, and more psychopathology; cluster B (n = 18) included those with an aim to move to independent housing, better quality of life, and less psychopathology. CONCLUSION: In the UK, more staff training may be needed to identify and achieve the goals of the 'new' long-stay clients. For a subgroup of these clients, SH may still be a long-term care setting; while for another subgroup, new forms of rehabilitation in SH and better opportunities to leave SH may have to be developed. More conceptual and practical efforts are needed to manage the transformation of many settings from homes for life to transitional places where residents receive specific interventions.

Morale and job perception of community mental health professionals in Berlin and London.

INTRODUCTION: Morale and job perception of staff in community mental health care may influence feasibility and quality of care, and some research has suggested particularly high burnout of staff in the community. The aims of this study were to: a) assess morale, i. e. team identity, job satisfaction and burnout, in psychiatrists, community psychiatric nurses and social workers in community mental health care in Berlin and London; b) compare findings between the groups and test whether personal characteristics, place of working and professional group predict morale; and c) explore what tasks, obstacles, skills, enjoyable and stressful aspects interviewees perceived as important in their jobs. METHODS: In all, 189 mental health professionals (a minimum of 30 in each of the six groups) responded to a postal survey and reported activities per week using pre-formed categories. Perception of professional role was assessed on the Team Identity Scale, job satisfaction on the Minnesota Job Satisfaction Scale, and burnout on the Maslach Burnout Inventory. Seven simple open questions were used to elicit the main tasks, skills that staff did and did not feel competent in, aspects that they did and did not enjoy in their job, and obstacles and factors that caused pressure. Answers were subjected to content analysis using a posteriori formed categories. RESULTS: Weekly activities and morale varied between sites and professional groups. Some mean scores for groups in London exceeded the threshold for a burnout syndrome, and are particularly less favourable for social workers. Working in London predicted higher burnout, lower job satisfaction and lower team identity. Being a psychiatrist predicted higher team identity, whilst being a social worker was associated with higher burnout and lower job satisfaction. Male gender predicted lower burnout and higher team identity. However, professional group and site interacted in predicting burnout and job satisfaction. Psychiatrists in London had much more favourable scores than the other two groups, whilst this did not hold true in Berlin. Answers to open questions revealed universal aspects, such as enjoying direct patient contact and disliking bureaucracy, but also various views that were specific to a site or professional group or both. CONCLUSIONS: Burnout remains a problem for some, but not all, professional groups in community mental health care, and social workers in London appear to be a group with particularly low morale. Differences between professional groups depend on the location, and it remains unclear to what extent job-related and general factors impact on the morale of mental health professionals. Answers to open questions reveal general as well as specific aspects of the job perception of the professional groups, some of which may be relevant for service development, training and supervision. More conceptual and methodological work and more extensive studies are required to develop a better understanding of how community mental health professionals perceive their job and how morale may be improved.

Subjective quality of life and posttraumatic stress disorder.

Subjective quality of life (SQOL) and its predictors were assessed in 117 patients with posttraumatic stress disorder (PTSD) in a specialized clinic. Scores were compared with other samples. PTSD patients had lower SQOL than the comparison groups. Higher levels of depression and anxiety, fewer PTSD avoidance symptoms, being older, and being from an ethnic minority were all independent predictors of lower SQOL. The high dissatisfaction with several social domains of life should be considered in treatment, and depressive and anxiety symptoms might be targeted to improve SQOL.

Research in supported housing.

BACKGROUND: De-institutionalization has led to the provision of various forms of housing with or without support for people with mental illness in the community. In this paper, we review the conceptual issues related to the provision of supported housing schemes, the characteristics of residents, research methods and outcomes, and the factors influencing the quality of care provided. METHODS: A Medline and hand search of published literature was complemented by information derived from contacting expert researchers in the field. FINDINGS: There is considerable diversity of models of supported housing and inconsistent use of terminology to describe them. This makes it difficult to compare schemes, processes, and outcomes. Patients in supported housing are characterized by deficits in self-care and general functioning, whilst behavioral problems such as violence, drug abuse and extreme antisocial habits predict exclusion from supported housing. Most evaluative studies are merely descriptive. In terms of outcomes, it seems that functioning can improve, social integration can be facilitated, and residents are generally more satisfied in supported housing compared with conventional hospital care. Further evidence suggests that most patients prefer regimes with low restrictiveness and more independent living arrangements, although loneliness and isolation have occasionally been reported to be a problem. Little information is available on the factors that mediate outcomes and on skills required by staff. CONCLUSION: Research in supported housing for psychiatric patients has so far been neglected. Large scale surveys on structure, process, and outcomes across a variety of housing schemes may be useful in the future to identify some of the key variables influencing outcomes. The use of direct observation methods in conjunction with other more conventional, standardized instruments may also highlight areas for improvement. In conducting research, structure and process, as well as outcomes, need to be considered. Thus, we need to know not just what to provide, but how to provide it in such a way that it will maximize beneficial outcomes. This represents a considerable research agenda.

Subjective evaluation: is there more than one criterion?

Previous cross-sectional investigations have shown that subjective evaluation criteria (criteria that are used in psychiatric research for evaluating care based on patients' statements) do overlap and that there exists a single general factor underlying all these criteria. In this study, we tested longitudinally and in two different samples of schizophrenia patients the distinctness and covariation at baseline and at followup of three common subjective evaluation criteria (subjective quality of life, self-rated needs, and self-reported symptoms). Scores were intercorrelated at both baseline and followup and showed some intercorrelations over time, suggesting temporal covariation. One stable subjective appraisal factor was identified at both baseline and followup, summarizing a negative subjective quality of life and more symptoms and needs. This factor explained 50 percent to 69 percent of the variance. It was found to be strongly associated with observer-rated mood and was mainly predicted by reporting dark thoughts and being dissatisfied with life as a whole. In subjective evaluation, there appears to be a need to distinguish between a general appraisal factor and specific aspects of different criteria. Therefore, future research needs to focus on how the general factor can be assessed more directly and to identify how the specific variance of different criteria independent of that factor can be maximized.