Attitudes and Barriers to Exercise in Adults with Type 1 Diabetes (T1DM) and How Best to Address Them: A Qualitative Study

Background

Regular physical activity has recognised health benefits for people with T1DM. However a significant proportion of them do not undertake the recommended levels of activity. Whilst questionnaire-based studies have examined barriers to exercise in people with T1DM, a formal qualitative analysis of these barriers has not been undertaken. Our aims were to explore attitudes, barriers and facilitators to exercise in patients with T1DM.

Methodology

A purposeful sample of long standing T1DM patients were invited to participate in this qualitative study. Twenty-six adults were interviewed using a semi-structured interview schedule to determine their level of exercise and barriers to initiation and maintenance of an exercise programme.

Principal findings

Six main barriers to exercise were identified: lack of time and work related factors; access to facilities; lack of motivation; embarrassment and body image; weather; and diabetes specific barriers (low levels of knowledge about managing diabetes and its complications around exercise). Four motivators to exercise were identified: physical benefits from exercise; improvements in body image; enjoyment and the social interaction of exercising at gym or in groups. Three facilitators to exercise were identified: free or reduced admission to gyms and pools, help with time management, and advice and encouragement around managing diabetes for exercise.

Significance

Many of the barriers to exercise in people with T1DM are shared with the non-diabetic population. The primary difference is the requirement for education about the effect of exercise on diabetes control and its complications. There was a preference for support to be given on a one to one basis rather than in a group environment. This suggests that with the addition of the above educational requirements, one to one techniques that have been successful in increasing activity in patients with other chronic disease and the general public should be successful in increasing activity in patients with T1DM.     

Death after Taking Medicaments

A register of reported adverse reactions, recently made available to major hospitals and medical schools gives an indication of prescribing habits under the N.H.S. in England and Wales. An analysis is made here of the chief medicaments allegedly leading to death. Such data are incomplete because of lack of knowledge of the total use of each drug in the United Kingdom and because reporting of adverse reactions is very incomplete. Nevertheless, data about various groups of drugs do draw attention to some hazards and should encourage more widespread reporting of reactions to drugs and other medicaments.     

Medical simulation: the new tool for training and skill assessment

Medical simulation is a new method to facilitate skill training and assessment. Simulation has achieved a high degree of sophistication in aviation and other fields. However, the complexity of health care, the numerous stakeholders, and the lack of central control of medical education have been barriers to the development and broad implementation of medical simulation. Acceptance by the medical community is growing, with the publication of scientific validation studies, the development of economic models and funding, and the integration of simulation into existing curricula and training programs. The major forces for implementing simulation will most likely come from the medical device industry and from institutions with mandates to improve the quality of health care and enhance patient safety. Certification boards are expected to increase their utilization of simulation technology to objectively assess proficiency of skills relevant to physicians and the health care system. Medical simulation has made the transition from an experimental technology to the clinical world, and the next five to 10 years may be viewed as the golden age of medical simulation.     

Classifying medical devices according to their maintenance sensitivity: a practical, risk-based approach to PM program management

Many medical equipment items need periodic attention to ensure that they continue to operate properly and safely; and most inspecting agencies require healthcare facilities to have a competent equipment maintenance program that is focused on the most critical of those devices. There is however a long-standing lack of consensus on how best to determine which devices should be included in this critical device category, and which can reasonably be excluded. A new methodology is proposed for establishing a logical, fact-based framework for determining which devices should be included. It is based in part on a new FDA-sanctioned definition of what an appropriate regimen of planned maintenance activities for a medical device should include. This new definition addresses the medical device users' concerns about periodic performance verification and safety testing as well as detecting and correcting the wear or progressive deterioration of any non-durable parts, which is the primary focus of the conventional preventive maintenance programs found in less critical industries. The analytical approach proposed utilizes technical information that is either already available or which can be easily developed. It characterizes each different device by means of a 3-letter maintenance sensitivity profile that can be used to analyze the effectiveness of the maintenance procedures as well as quantify the device's sensitivity to planned maintenance. A collaborative effort to assemble and organize this data would provide the industry with a sound, logical platform for narrowing the scope of most PM programs and allow us to redirect a significant amount of scarce technical manpower into more productive activities such as device user training.     

The immunologic significance of variation within malaria circumsporozoite protein sequences

We have previously suggested that variation within the circumsporozoite protein of the malaria parasite Plasmodium falciparum was the result of selection by immune T cells. Our hypothesis has been supported by experiments documenting a lack of cross-reactivity between variant peptides from the C-terminal region for murine T cells primed by 7G8-specific sequences. Now, by using a murine model we have found that peptides representing variant regions (amino acid residues 326-343 and 361-380) of two other parasite clones (Wel and LE5) are also immunodominant for murine T cells. However, there were distinct changes in response profiles. For example, whereas lymph node cells from H-2d and H mice immunized with peptides from the 326-343 region of all three variants proliferated in vitro after homologous challenge, only lymph node cells from H-2b mice immunized with LE5 peptide proliferate after homologous challenge. In contrast, only LE5 did not induce lymphoproliferation against homologous challenge in the H-2s background. These data suggest that the naturally occurring substitutions affect agretopic (i.e., Ia). Peptides from all variants representing the 361-380 domain were recognized only by T cells from H-2k mice. Also, in nearly all cases, T cells primed by one sequence did not recognize variant sequences. The immunodominance of these domains from three different clones and the lack of significant cross-reactivity further supports the hypothesis that variation is the result of T cell immune pressure.     

Copper chaperones: personal escorts for metal ions

Copper serves as the essential cofactor for a number of enzymes involved in redox chemistry and virtually all organisms must accumulate trace levels of copper in order to survive. However, this metal can also be toxic and a number of effective methods for sequestering and detoxifying copper prevent the metal from freely circulating inside a cell. Copper metalloenzymes are therefore faced with the challenge of acquiring their precious metal cofactor in the absence of available copper. To overcome this dilemma, all eukaryotic organisms have evolved with a family of intracellular copper binding proteins that help reserve a bioavailable pool of copper for the metalloenzymes, escort the metal to appropriate targets, and directly transfer the copper ion. These proteins have been collectively called copper chaperones. The identification of such molecules has been made possible through molecular genetic studies in the bakers' yeast Saccharomyces cerevisiae. In this review, we highlight the findings that led to a new paradigm of intracellular trafficking of copper involving the action of copper chaperones. In particular, emphasis will be placed on the ATX1 and CCS copper chaperones that act to deliver copper to the secretory pathway and to Cu/Zn superoxide dismutase in the cytosol, respectively.     

Scottish MDs benefit from database model developed in Saskatchewan.

A data-tracking system developed in Saskatchewan has helped health authorities in Scotland identify some deficiencies in the way certain drugs are prescribed and used. A researcher who published survey results in a local medical journal said the findings have helped doctors improve prescribing practices and identified a need to educate patients about the way antidepressant drugs work.     

Case of pregnancy and labor dispite an intrauterine device]

A case of normal pregnancy and labor with an IUD in place is described. No abnormalities occurred during the course of the pregnancy besides some slight spotting during the 4th month. But the knowledge that the device was in place was the cause of a poor psychological condition in the patient. The device, which was inserted during the 3rd month of pregnancy was of the Copper T Cu 200 L type. This device caused no adverse effects on the development of the fetus or on the course of labor.     

Actinomyces in cervical smears of women using intrauterine contraceptive devices

Cervical smears from 1,784 women who attended the family planning clinics of the Institute for Research in Reproduction were examined for the presence of Actinomyces-like organisms. Among 815 intrauterine contraceptive device (IUD) users, the repeat smears from 57 women were positive for Actinomyces-like organisms, giving a prevalence rate of 6.99%. Immunofluorescent staining using specific antisera confirmed the presence of A. israelii in all 57 women. Forty IUD users whose smears were positive for Actinomyces-like organisms underwent bacteriologic culture studies; A. israelii was isolated in 23 of these cases. The clinical findings at the time of smear collection in the 57 IUD users were within normal limits. The initial cervical smears of all IUD users and both the initial and repeat smears of all nonusers were negative for Actinomyces-like organisms. The data indicate that prolonged use (greater than 2 years) of an inert or copper intrauterine device promotes the overgrowth of Actinomyces in the vagina and that this can be detected by routine cervical cytology.     

Pain relief in medical patients: does clinical judgment and prescribing knowledge suffice?

The aim of this study was to evaluate the quality of pain management in hospitalised patients. A cross-sectional study design that included all medical patients experiencing pain was used. Out of 167 patients hospitalized at the Department of Medicine at the University Hospital Zagreb, 41 patients were experiencing pain and 40 out of them received analgesics. Twenty-two out of 38 patients were treated for malignant pain, 16 for non-malignant pain, and 2 patients could not be classified. Adequate pain relief was reported in less than 25% of patients in both groups. Our study revealed under-prescribing of combination therapy, low utilization rates of strong opioids and prevailing "as needed" prescribing practice. In conclusion, unsatisfactory pain management in medical patients is often present if left solely to the clinical judgement and knowledge of the prescribing physician. Regular pain assessment, evidence-based guidelines, education and regular audits of implementation of these measures are a prerequisite for effective pain treatment, and should all be employed in patients experiencing pain.     

Continuous intrauterine copper contraception for 3 years: comparison of replacement at 2 years with continuation of use.

A total of 1245 women had a copper 7 intrauterine contraceptive device (IUD) inserted in 1971-3 were followed up for three years (22 761-5 women months of use). After 24 months 483 women elected to continue with the same copper 7 (continuation group), and 183 had their copper 7 replaced with a new one (replacement group). The subsequent pregnancy and expulsion rates were both significantly lower in the replacement group. The higher pregnancy rate among the women who continued to use their copper 7 device for a third year suggests that although the copper is still there, it is not available for contraceptive action. Replacing the device at 24 months did not seem to cause again the problems that usually occur in the first six months of IUD use.     

Misunderstandings in prescribing decisions in general practice: qualitative study

ObjectivesTo identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.DesignQualitative study.Setting20 general practices in the West Midlands and south east England.Participants20 general practitioners and 35 consulting patients.Results14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor''s decision, and relationship factors. All the misunderstandings were associated with lack of patients'' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors'' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients'' ideas about medicines for successful prescribing.ConclusionsPatients'' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.     

Self-poisoning with Drugs: A Worsening Situation

The incidence of self-poisoning with drugs has doubled in Sheffield in the past 10 years. It now causes almost 1 in 10 of all medical admissions and one in five of all medical emergencies; it is the second most common reason for emergency admission to medical beds.The average age of the patients has fallen; one in five has previously been admitted to hospital with self-poisoning. The drugs used are normally prescribed by a doctor and the types employed reflect national prescribing trends. It is estimated that over 70,000 self-poisoning cases may be admitted to hospitals in the United Kingdom each year.     

Intrauterine Contraception with the Copper 7: Evaluation after Two Years

From 1,156 insertions of the copper 7 contraceptive device with 15,044 women-months of use we conclude that it offers advantages in intrauterine contraception. Continuity is improved for all users. It is a useful method for those who have not been pregnant and as an exchange device for patients having problems with other intrauterine devices or contraceptive methods. These advantages must be set against the necessity of replacing the copper 7 after a limited life span. In no cases in our series did cervical cytological examination show anything abnormal, and a 98·1% follow-up was achieved.     

Comparing Accuracy in an Unpaired Post‐market Device Study with Incomplete Disease Assessment

The sensitivity and specificity of a new medical device are often compared relative to that of an existing device by calculating ratios of sensitivities and specificities. Although it would be ideal for all study subjects to receive the gold standard so true disease status was known for all subjects, it is often not feasible or ethical to obtain disease status for everyone. This paper proposes two unpaired designs where each subject is only administered one of the devices and device results dictate which subjects are to receive disease verification. Estimators of the ratio of accuracy and corresponding confidence intervals are proposed for these designs as well as sample size formulae. Simulation studies are performed to investigate the small sample bias of the estimators and the performance of the variance estimators and sample size formulae. The sample size formulae are applied to the design of a cervical cancer study to compare the accuracy of a new device with the conventional Pap smear.