Effectiveness of self-management interventions in young adults with type 1 and 2 diabetes: a systematic review and meta-analysis.

AIM: Diabetes in young adulthood has been associated with poor outcomes. Self-management is fundamental to good diabetes care, and self-management interventions have been found to improve outcomes in older adults. We performed a systematic review and meta-analysis to assess the effectiveness of self-management interventions in young adults (aged 15-39 years) with type 1 or type 2 diabetes. METHODS: We searched five databases and two clinical trial registries from 2003 to February 2019, without language restrictions. We included randomized controlled trials (RCTs) comparing the effectiveness of self-management interventions with usual care or enhanced usual care in young adults. Outcomes of interest included clinical outcomes, psychological health, self-care behaviours, diabetes knowledge and self-efficacy. Pairwise meta-analysis was conducted using a random effects model and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. We followed Cochrane gold standard systematic review methodology and reported this systematic review according to PRISMA guidelines. The protocol was registered with PROSEPRO (CRD42018110868). RESULTS: In total, 13 studies (1002 participants) were included. Meta-analysis showed no difference between self-management interventions and controls in post-intervention HbA1c levels, BMI, depression, diabetes-related distress, overall self-care, diabetes knowledge and self-efficacy. Quality of evidence ranged from very low to moderate due to study limitations, inconsistency and imprecision. CONCLUSIONS: Current self-management interventions did not improve outcomes in young adults with diabetes. Our findings, which contrast with those from systematic reviews in older adults, highlight the need for the development of more effective interventions for young adults with diabetes.

The combined diabetes and renal control trial (C-DIRECT) - a feasibility randomised controlled trial to evaluate outcomes in multi-morbid patients with diabetes and on dialysis using a mixed methods approach.

BACKGROUND: This cluster randomised controlled trial set out to investigate the feasibility and acceptability of the "Combined Diabetes and Renal Control Trial" (C-DIRECT) intervention, a nurse-led intervention based on motivational interviewing and self-management in patients with coexisting end stage renal diseases and diabetes mellitus (DM ESRD). Its efficacy to improve glycaemic control, as well as psychosocial and self-care outcomes were also evaluated as secondary outcomes. METHODS: An assessor-blinded, clustered randomised-controlled trial was conducted with 44 haemodialysis patients with DM ESRD and ≥ 8% glycated haemoglobin (HbA1c), in dialysis centres across Singapore. Patients were randomised according to dialysis shifts. 20 patients were assigned to intervention and 24 were in usual care. The C-DIRECT intervention consisted of three weekly chair-side sessions delivered by diabetes specialist nurses. Data on recruitment, randomisation, and retention, and secondary outcomes such as clinical endpoints, emotional distress, adherence, and self-management skills measures were obtained at baseline and at 12 weeks follow-up. A qualitative evaluation using interviews was conducted at the end of the trial. RESULTS: Of the 44 recruited at baseline, 42 patients were evaluated at follow-up. One patient died, and one discontinued the study due to deteriorating health. Recruitment, retention, and acceptability rates of C-DIRECT were generally satisfactory HbA1c levels decreased in both groups, but C-DIRECT had more participants with HbA1c < 8% at follow up compared to usual care. Significant improvements in role limitations due to physical health were noted for C-DIRECT whereas levels remained stable in usual care. No statistically significant differences between groups were observed for other clinical markers and other patient-reported outcomes. There were no adverse effects. CONCLUSIONS: The trial demonstrated satisfactory feasibility. A brief intervention delivered on bedside as part of routine dialysis care showed some benefits in glycaemic control and on QOL domain compared with usual care, although no effect was observed in other secondary outcomes. Further research is needed to design and assess interventions to promote diabetes self-management in socially vulnerable patients. TRIAL REGISTRATION NUMBER: Trial registered with the International Standard Randomised Controlled Trial (ISRCTN10546597). Registered 12 September 2016 (Retrospectively registered).

Health-Related Quality of Life in Patients Treated with Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis in Singapore.

OBJECTIVE: This study aimed to compare the health-related quality of life (HRQOL) in patients with end-stage renal disease (ESRD) treated with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) in Singapore. METHODS: The data used in this study were from two cross-sectional surveys of ESRD patients. HRQOL was assessed using the Kidney Disease Quality of Life (KDQOL) instrument. Socio-demographic characteristics and clinical data were collected. The physical component summary (PCS) and mental component summary (MCS) scores, kidney disease component summary (KDCS) score and its three scales (symptoms, effects, burden), and one health utility score [EuroQol 5-dimension (EQ-5D)] were calculated and compared between CAPD and APD using multivariate linear regression. RESULTS: In total, 266 patients were included, with 145 on CAPD (mean age 60.8 years) and 121 on APD (mean age 57.4 years). After adjustment for all variables collected, APD patients had significant higher scores in PCS and KDQOL symptoms than CAPD patients, suggesting that APD was associated with better physical health and milder dialysis-related symptoms. CONCLUSION: The HRQOL of CAPD and APD patients was largely equivalent in Singapore, but APD patients seemed to experience better physical health and be less bothered by dialysis-related symptoms.

The burden of filial piety: A qualitative study on caregiving motivations amongst family caregivers of patients with cancer in Singapore.

OBJECTIVE: This study explores (1) the motivations and challenges facing family caregiving for cancer in Singapore and (2) suggests a possible framework to guide culturally sensitive future work on caregivers. DESIGN: Twenty caregivers of patients being treated for cancer at a public hospital in Singapore were interviewed. A semi-structured interview format and inductive thematic analysis were used to analyse the data. Caregivers were asked about their motivations for caregiving and the challenges they faced. RESULTS: Caregivers' motivations grouped into three categories: personal value and fulfilment, giving care because of societal expectations such as filial piety, and practical need. Challenges were grouped into interpersonal challenges, disclosure and finding balance. Caregivers with different primary motivations varied in their responses to these challenges. More autonomous caregivers cited learning points and reprioritised more effectively than less autonomous caregivers, who reported more internal conflict and less control over their situation. CONCLUSIONS: In Singapore and Asia, sociocultural values of family caregiving are not uniformly experienced as positive, and may be burdensome for caregivers who give care primarily for extrinsic motivations. As family caregiving needs increase, targeted psychosocial support for caregivers with less autonomous behavioural orientations may pre-empt caregiver burnout and burden.

Quality of life and emotional distress in patients and burden in caregivers: a comparison between assisted peritoneal dialysis and self-care peritoneal dialysis.

PURPOSE: Assisted peritoneal dialysis (PD) involving caregivers allows more patients to get started on home-based dialysis with good clinical outcomes, but evidence on patient-reported and caregiver-reported outcomes is lacking. This study aimed to compare assisted PD versus self-care PD on quality of life (QoL) and psychosocial outcomes for patients and caregivers. The effect of PD modality [automated PD (APD); continuous ambulatory PD (CAPD)] in relation to self-care or assisted care was also examined. METHODS: A cross-sectional sample of 231 PD patients [142 self-care (57 APD/85 CAPD) and 89 assisted care PD (45 APD/44 CAPD)], 72 caregivers of assisted PD patients and 39 family members of self-care PD patients completed the Kidney Disease Quality of Life Short Form (KDQOL-SF), World Health Organisation Quality of Life Instrument-brief and the Hospital Anxiety and Depression Scale. Caregivers and family members completed the Lay Care-Giving for Adults Receiving Dialysis questionnaire and Zarit Burden Interview. RESULTS: Case-mix-adjusted comparisons indicated comparable QoL in all dimensions with the exception of physical SF-12 (p = .001) and the KDQOL effects of kidney disease in favour of self-care PD. Levels of anxiety (9.72 ± 4.90; 8.25 ± 5.22) and depression (8.63 ± 3.80; 6.35 ± 4.76) were equivalent in assisted PD and self-care PD, respectively. Assisted PD caregivers reported more task-orientated duties (p = .007), yet levels of perceived burden were equal to those reported by family members of self-care PD. CONCLUSION: Our findings of mostly comparable patient and caregiver outcomes in assisted PD and self-care PD suggest that caregiver burden and QoL should not be a barrier to using assisted PD.

Health-related quality of life of Asian patients with end-stage renal disease (ESRD) in Singapore.

BACKGROUND: This study aimed to identify factors associated with the health-related quality of life (HRQOL) of multiethnic Asian end-stage renal disease (ESRD) patients treated with dialysis. The role of dialysis modality was also explored. METHODS: Data used in this study were from two cross-sectional surveys of Singaporean ESRD patients on haemodialysis (HD) or peritoneal dialysis (PD). In both surveys, participants were assessed using the kidney disease quality of life (KDQOL) instrument and questions assessing socio-demographic characteristics. Clinical data including co-morbidity (measured by Charlson comorbidity index [CCI]), albumin level, haemoglobin level, and dialysis-related variables (e.g. dialysis vintage and dialysis adequacy) were retrieved from medical records. The 36-item KDQOL (KDQOL-36) was used to generate three summary scores (physical component summary [PCS], mental component summary [MCS] and kidney disease component summary [KDCS]) and two health utility scores (Short Form 6-dimension [SF-6D] and EuroQol 5-dimension [EQ-5D]). Linear regression analysis was performed to examine the association of factors with each of the HRQOL scale scores. RESULTS: Five hundred and two patients were included in the study (mean age 57.1 years; male 52.4 %; HD 236, PD 266). Mean [standard deviation (SD)] PCS, MCS and KDCS scores were 37.9 (9.7), 46.4 (10.8) and 57.6 (18.1), respectively. Mean (SD) health utility score was 0.66 (0.12) for SF-6D and 0.60 (0.21) for EQ-5D. In multivariate regression analysis, factors found to be significantly associated with better HRQOL included: young (<45 years) or old age (>60 years), low CCI (<5), high albumin (≥37 g/l) and high haemoglobin (≥11 g/dl) with PCS; long dialysis vintage (≥3.5 years) with MCS; old age, Malay ethnicity and PD modality with KDCS; low CCI, high albumin and high haemoglobin with EQ-5D and high albumin with SF-6D. CONCLUSIONS: Clinical characteristics are better predictors of HRQOL in ESRD patients than socio-demographics in Singapore. Dialysis modality has no impact on the health utility of those patients.

Sensitivity of three widely used questionnaires for measuring psychological distress among patients with type 2 diabetes mellitus.

BACKGROUND: Although a range of generic and diabetes-specific instruments are available to assess emotional distress, no studies have evaluated sensitivity in relation to sample size requirement. The present study sets out to compare the sensitivity among the Diabetes Health Profile Psychological Distress scale (DHP-PD), Problem Areas in Diabetes (PAID) and Kessler-10 Psychological Distress scale (K10). We hypothesized that the diabetes-specific measures (DHP-PD and PAID) would require smaller sample sizes than the generic measure (K10), yet remain specific. RESEARCH DESIGN: A total of 208 patients with type 2 diabetes mellitus (mean age 45.2 (12.4) years; 63.1 % males, 45.8 % Chinese, 11.3 % Malay and 26.6 % Indian), recruited from a Singapore tertiary hospital diabetes clinic, completed the English DHP-PD, PAID and K10. Clinical information derived from medical records and HbA1c was recorded. Effect sizes (ES), ratio of ES and sample size requirement relative to the most sensitive questionnaire were computed. RESULTS: A comparison of patients with good versus poor glycaemic control (HbA1c ≥ 7.0) revealed that using K10 will require 4 times the sample size of a study using the PAID in order to detect the same level of psychological distress. The DHP-PD and PAID had similar sensitivity when comparing between patients with good versus poor glycaemic control. CONCLUSIONS: As hypothesized, sample size requirement is largest for K10 and remarkably similar for PAID and DHP-PD. This information is useful for designing clinical trials and studies.

Quality of life and emotional distress between patients on peritoneal dialysis versus community-based hemodialysis.

PURPOSE: Patient-reported outcomes are important endpoints to evaluate new models of renal delivery. This is the first study to compare Quality of Life (QOL) and emotional adjustment outcomes between patients on community-based hemodialysis (HD) and those on peritoneal dialysis (PD). METHODS: Data were collected between 2009 and 2011 from a cross-sectional sample of 232 HD patients and 201 PD patients recruited through community dialysis centers and outpatient PD clinics in Singapore. Participants completed the Hospital Anxiety and Depression Scale, World Health Organization Quality of Life Brief and the Short form for the Kidney Disease Quality of Life. Measures of ESRD severity, comorbidity and biochemistry were also collected. RESULTS: Physical and emotional QOL impairments were noted for both dialysis groups. Case-mix-adjusted comparisons indicated higher symptoms of depression (p = 0.027), and poorer physical health yet higher satisfaction with care (p = 0.001) in PD relative to community-based HD. CONCLUSIONS: Peritoneal dialysis regimes offer flexibility and autonomy under the support of PD teams. Although outcomes for most QOL domains measured were equivalent, PD patients are more satisfied with care but are at risk for emotional distress and provide poor ratings of physical health. Further research is needed to explore the expansion of standards of care to address psychosocial needs in PD populations.

Managing treatment for end-stage renal disease--a qualitative study exploring cultural perspectives on facilitators and barriers to treatment adherence.

Although adherence to hemodialysis (HD) regimes is important to maximise good clinical outcomes, it remains suboptimal and not well understood, particularly for those in non-Western settings and patients from Asian cultures. This qualitative study sought to explore cultural perspectives on facilitators and barriers to treatment adherence in HD patients. A descriptive exploratory design was used for the study, incorporating individual semi-structured interviews (n = 17) and three focus groups (n = 20). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted by two coders using an iterative process. Study participants identified personal and social/contextual factors as major barriers or facilitators of treatment adherence. Barriers include time consumption, forgetfulness, concerns about safety, poor knowledge/understanding, poor communication and lack of control/social pressure. Participants also identified facilitators, both internal (self-initiated) and external (initiated by family, health care professional and peers) to ensure treatment adherence. These included support from family members and social obligation towards others, risk perception, establishment of routines and peer support. Internal and external factors can hinder or facilitate adherence to diet, fluid and medications in the context of dialysis. Several of these barriers/facilitators can be effectively addressed in the context of interventions and psycho-educational programmes.

The Transplant Effects Questionnaire (TxEQ): The development of a questionnaire for assessing the multidimensional outcome of organ transplantation - example of end stage renal disease (ESRD).

OBJECTIVES: To develop a questionnaire to assess the responses of transplant recipients to the receipt of an organ, including their self-care behaviour. DESIGN: Following a literature review, open-ended interviews and a focus group, a transplant questionnaire was developed. Two studies (Study 1: N = 231, Study 2: N = 105) were conducted to evaluate its psychometric properties. METHODS: A pool of 51 items was derived from themes identified in published studies and from interviews and a focus group discussion with renal transplant recipients. These were constructed into a questionnaire and were then administered to two renal transplant out-patients populations. Item responses of study sample 1 were subjected to principal components analysis (PCA) using varimax rotation to examine the structure of responses. In order to investigate the stability of the factor structure found in Study 1, item responses of the second sample were subjected to confirmatory factor analysis (CFA) using structural equation modelling. RESULTS: PCA indicated six factors that accounted for 64.2% of the variance. With extraneous items omitted, the final questionnaire derived from Study 1 has 24 items clustered around five conceptual coherent factors: worry about transplant (22.1%), guilt regarding donor (11.9%), disclosure (9.58%), medication adherence (8.73%), and responsibility (6.63%). CFA on the final 24-item version of the TxEQ revealed that the resulting model was a good fit for the Study 2 data (RMSEA = 0.08, pclose =.005). CONCLUSIONS: The TxEQ has potential application as a measure in the area of transplantation research. CFA demonstrated that the factor structure of the TxEQ is consistent across different renal transplant out-patients populations. Further research is currently in progress to assess other groups of transplant recipients and to examine its relationship to other measures.

[Causes of death in Bulgaria, 1975-1985]. / Smartnost po prichini v Balgariya prez perioda 1975-1985 g..

PIP: Mortality by cause of death in Bulgaria is examined for the period 1975-1985. Consideration is given to sex differentials and to excess mortality among men. Diseases with the greatest increase in mortality rate are endocrine and intestinal disorders, cancer, and circulatory diseases. (SUMMARY IN ENG AND RUS)^ieng

[The life potential of the population of the People's Republic of Bulgaria in 1956-1957 and 1974-1976]. / Zhiznen potentsial na naselenieto v NRB prez periodite 1956-1957 g. i 1974-1976 g.

PIP: Some theoretical concepts concerning the demography of longevity are reviewed, and several alternative methods of calculating life expectancy are considered. Changes in life expectancy by sex in Bulgaria from 1956-1957 to 1974-1976 are then analyzed. The reasons for recent unfavorable trends in male life expectancy are discussed. (summary in ENG, RUS)^ieng

[A comparative estimate of some demographic processes using the methods of potential and traditional demography]. / Sravnitelna otsenka na nyakoi demografski protsesi chrez metodite na potentsialnata i traditsionnata demografiya

PIP: The use of potential and traditional indexes to estimate demographic change is discussed. Potential indexes are defined as those that treat demographic phenomena as able to change not only population size but also its future life potential. The advantages of measuring birth and death rates using potential indexes are described. (summary in ENG, RUS)^ieng

[The development of the death rate in Bulgaria and in some other European countries in the years 1955-1980]. / Razvitie na smartnostta v Balgariya i v nyakoi drugi strani na Evropa prez 1955-1980 g.

PIP: Recent changes in the death rate in Europe are analyzed, with special emphasis on Bulgaria. Age- and sex-specific rates for 16 countries are examined by cause of death, and possible reasons for differences are considered. (summary in ENG, RUS)^ieng