Problem Solving and Adjustment in Families of Children With Diabetes

Communication and problem-solving skills in families of children with diabetes (n'= 20) and families of healthy children (n = 20) were compared. Families completed paper-pencil measures and engaged in simulated problem-solving situations while being videotaped. In terms of raw behavior frequencies, diabetes families talked less than comparison families and used less of some problem solving skills. When overall verbosity was controlled for, however, fewer differences emerged in terms of problem-solving and communication skills. For diabetes families, significant relationships were found among behavior, adjustment, and illness variables. The importance of understanding the specific influence of diabetes-related stress on family functioning is discussed.     

Problem Solving and Adjustment in Families of Children With Diabetes

Communication and problem-solving skills in families of children with diabetes (n'= 20) and families of healthy children (n = 20) were compared. Families completed paper-pencil measures and engaged in simulated problem-solving situations while being videotaped. In terms of raw behavior frequencies, diabetes families talked less than comparison families and used less of some problem solving skills. When overall verbosity was controlled for, however, fewer differences emerged in terms of problem-solving and communication skills. For diabetes families, significant relationships were found among behavior, adjustment, and illness variables. The importance of understanding the specific influence of diabetes-related stress on family functioning is discussed.     

银川市社区2型糖尿病患者自我管理现状调查

目的：探讨银川社区2型糖尿病患者自我现状及其与患者血糖、文化、病程问的关系。方法：采用2型糖尿病患者自我管理量表对社区糖尿病患者进行问卷调查。结果（1）患者自我管理的平均得分指标为66．93％，整体情况较差，以足部护理得分指标最低51．79％。（2）得分较高的患者其血糖控制也较理想。（3）随着患者文化水平的提高其得分也在增加。（4）随着患者病程的增加其得分也在增加。结论：2型糖尿病患者自我管理能力整体较差，尤其是足部管理有待改善。而患者自我管理能力又受文化水平、病程的影响。因此，应对不同个体，不同病程的患者进行不同形式、不同内容的健康教育。     

Experience of hypoglycaemia and strategies used for its management by community-dwelling adults with diabetes mellitus: a systematic review

Aim To synthesise the evidence on how community-dwelling adults with type 1 and type 2 diabetes mellitus experience hypoglycaemia and the strategies they use to control it. Methods Using a three-step search strategy, all published and unpublished qualitative studies in English from January 2000 to August 2010 were retrieved. Participants diagnosed with type 1 or type 2 diabetes mellitus, experienced in self-managing their hypoglycaemia, and who lived independently in the community and attended primary care or outpatient clinics were included. An initial limited search was conducted in MEDLINE and CINAHL to identify keywords and index terms, which were then used in a second search across the CINAHL, PUBMED, SCOPUS, PsycINFO, PsycARTICLES, Web of Science, JSTOR, EMBASE and MEDNAR databases. Additionally, the reference lists of all retrieved papers were hand-searched for additional studies. Retrieved studies were assessed for methodological validity using the standardised Joanna Briggs Institute-Qualitative Assessment and Review Instrument (JBI-QARI). Data, in terms of research findings, were extracted from included studies using the standardised JBI-QARI data extraction tool. Five studies (six papers) were included in the review. Results The 20 findings from the six papers were grouped into three categories, which were then synthesised into one overall finding - that is 'People with diabetes mellitus can self-manage their diabetes and thus prevent hypoglycaemic episodes more effectively when health professionals provide psychological, physiological and spiritual support, and an individually targeted education programme'. Conclusions Within the constraints of this review, it appears that the patient-identified priority is to maintain normality in blood glucose self-management. There is also evidence that some people lack the knowledge to identify and self-manage hypoglycaemia. Implications for practice To enable community-dwelling adults with diabetes mellitus to self-manage hypoglycaemia, healthcare professionals should provide individualised information and emotional support and regularly discuss and assess the person's level of knowledge, awareness of hypoglycaemia and their ability to self-manage.     

An initial evaluation of learning units to facilitate problem solving and self-directed study (portable patient problem pack)

This paper describes the initial evaluation of the portable patient problem pack, a learning unit designed to facilitate the development of problem-solving skills and stimulate self study.
A cross-over design using two neurological patient problems, each presented in two formats (simulated patient and P4), was used with a sample of twenty-nine volunteer nursing and medical students.
The results indicate that the P4 appears to be feasible and effective in stimulating problem solving and self-directed study. The suggested concurrent validity, low cost of production, and implementation make it a potentially potent tool for evaluation.     

The importance of relationship processes for lowering BMI over time in women with type 2 diabetes in a randomized controlled trial

ObjectiveWeight change may be affected by dyadic processes within couple relationships. The aim of this secondary data analysis was to explore trends in BMI across time, and assess whether relationship processes (i.e., relationship satisfaction, positive problem-solving), predict BMI trajectories in men and women.MethodsData are from 268 participants in the Diabetes Support Project, a randomized trial of behavioral intervention for individuals with type 2 diabetes (T2D) in poor glycemic control. For secondary analyses, BMI was measured at pre-treatment (baseline), 4 months (post-treatment), 8 months, and 12 months. Multiple relationship variables were measured at all time points and were modeled as predictors and correlates of change in BMI across time.ResultsIn general, BMI trajectories had higher starting values (intercepts) for females than for males in the sample (b = −2.51, p < .05), and slopes trended downward from pre-treatment to 12 months (b = −.09, p < .05). Downward trajectories of BMI were more pronounced for women with higher relationship satisfaction (b = .05, p < .05) and higher positive problem solving skills (b = .06, p < .05) at baseline. Change in relationship processes were not correlated with change in BMI across time.ConclusionFor women with T2D in this behavioral intervention study, relationship process scores at the beginning of treatment predicted changes in BMI over time, with better problem solving and higher relationship satisfaction at baseline related to steeper decreases in BMI across treatment. Additional research is needed to understand how improving relationship interaction prior to diabetes treatment may positively influence weight loss during treatment.     

Relationships and their potential for change developed in difficult type 1 diabetes

Few researchers have explored how relationships between patients and providers might change problem solving in clinical practice. The authors used grounded theory to study dyads of 11 people with diabetes and poor glycemic control, and 8 nurses interacting in diabetes teams. Relational Potential for Change was identified as a core category that involved three types of relationships. Professionals mostly shifted between less effective relationships characterized by I-you-distant provider dominance and I-you-blurred sympathy. Although rarely seen, a third relationship, I-you-sorted mutuality proved more effective than the others in exploiting the Relational Potential for Change. The three types of relationship differed in (a) scope of problem solving, (b) the roles assigned to the patient and the professionals, (c) use of difficult feelings and different points of view, and (d) quality of knowledge achieved as the basis for problem solving and decision making. The authors discuss implications for practice and further research.     

A method to predict the metabolic effects of changes in insulin treatment in subgroups of a large population based patient cohort

This case-control study was designed to analyse predictors of the effects on HbA1c levels in 4001 type 1 and type 2 diabetic patients after changing their insulin treatment. Patients from 15 outpatient diabetic clinics were treated with basal insulin and multiple injections of short-acting insulin. The effects on HbA1c of changing from NPH insulin to insulin glargine as basal insulin were studied, compared to patients continuing with NPH insulin. The following possible predictors were examined with multiple regression analysis: age, sex, type and duration of diabetes, smoking, metformin use, insulin requirement, number of basal doses per day, BMI and HbA1c at baseline. The difference between the two regression functions yielded the effect of switching treatment to insulin glargine compared to continuing with NPH insulin. Male gender, low BMI and high baseline HbA1c levels were significant predictors for a greater decrease in HbA1c when changing to insulin glargine. For example, for men with a BMI of 25 and an HbA1c of 8.0%, there was a calculated mean benefit in HbA1c of 0.26 percentage points by changing to insulin glargine, whereas women with a BMI 30 had no benefit of such a change. Thus, changing to insulin glargine had best effect in male patients with low BMI. This is one of the first studies designed to find responders to insulin treatment. Analyses of predictors may prove useful in order to tailor insulin treatment in diabetic patients in clinical practice. The clinical effects need to be confirmed in other studies and randomised controlled trials.     

REPORTS

Clinical (diagnostic) reasoning is inherently a problem-solving activity in which the practitioner's efficiency and effectiveness are strongly dependent on an ability to access and manipulate a vast knowledge base. In real patient interactions, students must gather, analyse and synthesize information; generate hypotheses; and make decisions (e.g. diagnosis and treatment). To develop skills in problem solving it is argued that students need to be provided with more tools rather than more answers.¹     

Research charting a course for evidence‐based clinical dietetic practice in diabetes

Nutrition and lifestyle interventions have been a critical component in three of the four largest clinical trials that focused on diabetes in the past two decades. Evidence of the effectiveness of nutrition and lifestyle interventions with resepect to achieving diabetes‐related outcomes for diabetes prevention and a reduction in diabetes complications for people with diabetes is clearly mounting. The Diabetes Control and Complications Trial (1983–1993), the Diabetes Prevention Program (1996–2001) and the Look AHEAD (Action for Health in Diabetes) Trial (2001–2012) have been providing key evidence for the dietitian’s role in delivering effective nutrition and lifestyle interventions for people with prediabetes, type 1 and type 2 diabetes. The dietitians in these multicentre efficacy trials contributed to this evidence base by expanding their roles beyond implementing the protocol defined goal‐based nutrition and lifestyle interventions to conducting ancillary research and using problem‐solving strategies that tailor counselling approaches toward participants’ barriers to goal achievement. As lifestyle coaches and case managers, dietitians had the opportunity to work with the same group of study participants over extended periods of time and use their clinical and research expertise to uncover important insights and strategies that helped achieve clinical goals related to glycaemia control, weight loss and activity. The present review will ‘chart the course’ of how the evidence base for nutrition and lifestyle interventions emanated from these trials and discuss the implications for clinical dietetic practice. Dietitians can use insights gleaned from these experiences with the research process to expand their roles and guide cutting edge evidence‐based clinical dietetic practice in diabetes.     

Repaglinide, potentially a therapeutic improvement for diabetes mellitus type 2

In about 25% of type 2 diabetes patients, good diabetes control is not attainable with oral blood-glucose lowering drugs. Furthermore, in many people with diabetes the disease deteriorates, despite the use of blood-glucose lowering medication, due to the decline of the pancreatic beta cells. The development of new drugs, such as repaglinide, is therefore important. Repaglinide is an insulin secretion enhancer with a different mechanism of action to the sulphonylureas, which means it does not continuously stimulate insulin secretion. The tablets should be taken with each meal. After oral ingestion repaglinide is resorbed quickly, with a half-life of between 30 minutes to an hour. In clinical trials repaglinide has been found to be equally effective as glibenclamide. Repaglinide has been found to be particularly effective in sulphonylurea-na?ve patients. Skipping the meal plus tablet combination results in less frequent hypoglycaemic symptoms compared to glibenclamide. Repaglinide results in greater reductions in postprandial glucose levels than glibenclamide. It does not affect insulin resistance. Long-term data are lacking, both with regard to efficacy and side effects. Repaglinide deserves a place in the diabetes treatment of newly-diagnosed type 2 diabetes patients who are well-informed about their disease, as well as in patients with renal failure. It should also be considered for patients whose diabetes is poorly controlled on metformin monotherapy.     

Training for skills

The World Federation for Medical Education Summit in Edinburgh in 1993 called for bold, clear, attractive and feasible strategies to equip doctors with the skills for the future of health care. There was special emphasis on skills for problem-solving, ethical and evidence-based medicine, effective communication, health promotion and illness prevention, and to educate and be educated. There were also skills for the shaping of the future of health services to form partnerships with other professionals and communities, to promote primary health care and to respond to culture and context. Strategies for effective training for skills include linking them to knowledge and attitude, selection of students of aptitude and motivation, training through practice with feedback, training teachers and assessors, and the reinforcement of skills after graduation. This presentation describes practical examples of these strategies in action to address each of the identified skills, all of them based on experience in the real world in Australia and Nigeria.     

Learning decision-making in clinical medicine: a card game dealing with acute emergencies for undergraduate use

A card game concerning the assessment and management of patients involved in medical emergencies was constructed for use by medical students who were beginning Year 3 of a 5-year curriculum. Particular emphasis was placed on the identification by the student of priorities for action and the justification for decisions made on the basis of underlying mechanisms. Our aim was to help the student sharpen his problem-solving skills in situations where decisions may have to be made and interventions undertaken before information gathering is complete. The game is simple in construct and may be played by individuals or groups. It has a major advantage over other forms of problem presentation in that the student can select and document his own decision-making pathway with minimal cueing and he may compare his pathway with that of the experts at the end of the game. Students and tutors found this approach enjoyable and realistic and considered the game a useful tool in our problem solving curriculum.     

Preliminary testing of a program to prevent type 2 diabetes among high-risk youth

Type 2 diabetes is increasing among youth, with minority youth at highest risk. This preliminary study tested the feasibility of a school-based program to prevent type 2 diabetes in youth at risk. Forty-one participants (age 12.6 +/- 1.1 years; 63% female, 51% African American, 44% Hispanic, and 5% Caucasian) were randomly assigned to one of two groups. Both the experimental and control groups received nutrition education and exercise training. The experimental group also received coping skills training. Data collected included body mass index (BMI), insulin resistance, dietary intake (24-Hour Food Recall), self-efficacy (Health Behavior Questionnaire), activity (Revised Godin-Shepard Activity Survey), and parents' health promoting behaviors (Health Promoting Lifestyle Profile III). At baseline BMI ranged from 27 to 53 (M = 36.2 +/- 6.0), and 95% (n = 39) demonstrated insulin resistance or pre-diabetes on an oral glucose tolerance test. After 12 months, the experimental group showed trends in improved usual food choices (p = .1) and increased dietary knowledge (p = .3). They also demonstrated lower glucose (p = .07) and insulin levels (p = .2). Experimental group parents demonstrated improved health responsibility (p = .03), healthier nutrition choices (p = .05), improved stress management skills (p = .05), increased activity (p = .2), and increased spirituality (p = .2). Data suggest a school-based program tailored to multiethnic youth may prove successful in helping these youth increase activity, improve nutrition status, and stabilize glucose and insulin metabolism, and also may be effective in changing parent health behavior.     

城市社区糖尿病患者治疗和控制现状研究

目的了解我国城市社区糖尿病患者治疗和控制现状。方法对在4个城市社区居住并确诊1a以上的糖尿病患者进行问卷调查和体检。结果共调查1047名糖尿病患者,其中50.9%的糖尿病患者伴有高血压,32.7%的患者伴有高血脂。被调查者中,70.8%的患者单纯口服降糖药,9.8%的患者不采用任何药物治疗,10.2%的患者单纯使用胰岛素,6.3%的患者既口服降糖药,又使用胰岛素,糖尿病患者注射胰岛素的比例仅有16.5%。各项治疗措施实施的比例分别为：药物治疗81.2%,饮食控制69.4%,运动80.6%,糖尿病教育咨询69.8%,血糖监测66.9%。规范化实施5项综合治疗措施的比例为34.9%。空腹血糖、血压达不到控制标准的患者分别占63.0%和50.0%。结论当前我国城市社区糖尿病患者糖尿病治疗不规范、患者规范化治疗比例低,血糖、血压控制效果欠佳。     

Supporting gifted students' acquisition of relevant knowledge for solving math problems

Studies conducted in cognitive laboratories as well as in other settings suggest ways to facilitate people's abilities to use relevant knowledge in problem-solving and decision making. Such activities help students understand the nature of the problems that various concepts and procedures were designed to solve, and hence enable them to understand the functional significance of new information. This study presented gifted 4th grade students with “real life” problem-solving content, via videodisc technology, and then asked them to make valid suggestions about how to solve problems posed. Results illustrated that when children are instructed in problem-solving strategies and then presented story information, they are more successful in solving posed problems than children who did not receive training.     

Clinical Competence: General Ability or Case-specific?

Background

Before the 1970s, research into the development of clinical competence was mainly focused on general problem-solving abilities. The scope of research changed when Elstein and colleagues discovered that individual ability to solve clinical problems varies considerably across cases. It was concluded that problem solving abilities are highly dependent on domain-specific knowledge rather than on general problem solving skills. Elstein called this phenomenon “case specificity.”

Purpose

The finding of content specificity will be contrasted with the existence of a general clinical problem solving ability, and the relationship between preclinical knowledge and a problem solving ability will be investigated.

Methods

A correlation matrix was calculated with clerkship final scores from 10 disciplines to examine the magnitude of the interrelations. A confirmatory factor analysis was applied to the corresponding covariances using structural equation modeling to investigate whether scores on finals shared any common variance across clerkships. Finally, two additional models were tested to examine the nature of the relationship between preclinical knowledge and problem solving.

Results

Low to moderate correlations across clerkship disciplines were found, supporting the original findings of content specificity. Further investigation showed that in addition to specific knowledge, a general, content-independent ability is needed to perform on these examinations.

Conclusions

Clinical competence, as measured in this study, is based on a combination of specific preclinical knowledge and a problem-solving ability. Case specificity fits perfectly well in this interactional perspective on clinical problem solving but does not explain it. The phenomenon “case specificity” is therefore not solely a result of content knowledge, but of level of experience and level of case difficulty.

     

An evaluation of the clinical problem-solving process using a simulation technique

Currently, research does not agree as to the extent to which medical content and problem-solving processes underlie clinical problem-solving. The results of research in this area fall into two categories: (1) clinical problem-solving is primarily dependent upon medical content specific within the case, and (2) clinical problem-solving is a skill, or series of skills, which can be applied to all clinical problems. In the study reported in this paper, seventy-one second-year medical students who had completed a 2-year, body-systems oriented curriculum were given an examination designed to measure clinical problem-solving. The results indicated that gathering data on patient history and hypotheses generation were specific skills common to clinical problem-solving, while hypotheses refinement, identification of relevant physical examinations, ordering laboratory investigations and making a diagnosis were case-related.     

基于网络及移动客户端优化基础胰岛素使用的应用研究

目的评价基于网络及移动客户端优化基础胰岛素使用的实施效果。方法基础胰岛素临床规范化使用优化管理项目是针对初始基础胰岛素治疗的糖尿病患者开展3个月随访管理。首先,统一开发系统的糖尿病管理软件平台。在糖尿病管理软件平台的支持下,医生引导已确诊需要进行基础胰岛素治疗的患者接受规范化首日教育,首日教育后护士将患者资料录入管理软件,系统通过短信系统定期管理患者血糖水平和胰岛素用量。护士及时对数据进行评估,并嫁接医生、患者沟通桥梁,及时沟通患者治疗方案。同时在第1、2、4、8、12周对患者进行电话随访,邀请患者参加患教课堂及名医热线。干预结束3个月后通过短信或者系统复测患者的血糖水平及胰岛素使用依从性。结果基于网络及移动客户端的胰岛素优化管理后糖尿病患者胰岛素注射治疗依从性为100%,干预结束后3个月复测,依从性降至74.55%(χ~2=65.309,P0.001)。基于网络及移动客户端的胰岛素优化管理后糖尿病患者血糖控制达标率为66.07%,干预结束3个月后复测,结果显示血糖控制达标率降至42.41%(χ~2=37.239,P0.001)。结论基于网络及移动客户端优化基础胰岛素临床规范化使用项目实施后,患者胰岛素注射治疗的依从性较高,血糖控制达标率较高。     

Enhancing health literacy and behavioural change within a tele‐care education and support intervention for people with type 2 diabetes

Background Behavioural change interventions for persons with chronic illness draw on a variety of theoretical approaches including motivational interviewing and shared decision making. Health literacy provides an additional, potentially powerful explanatory framework to guide research and practice. Objective To examine the changes in the depth and detail of diabetes‐related knowledge and confidence for persons with type 2 diabetes. Design Two‐year, prospective, observational study, using questionnaire data at two time points (baseline and 2 years later) and in‐depth interviews with a theoretically selected subsample. Setting and participants A total of 319 patients initially recruited from a deprived urban area in north‐west England Intervention Dedicated tele‐carer education and support, tailored to the individual circumstances of the patient. Main outcome measures Perceptions of confidence, levels of empowerment, learning for self‐care and most helpful aspects of the intervention. Results Over 90% expressed confidence in keeping their blood sugar controlled, and high levels of perceived empowerment (mean = 4.25; 95% CI, 4.17–4.33) were found. Changes in the depth and detail of diabetes‐related knowledge and confidence, from the specific to the more general, were observed and enhanced competence in translating knowledge into practice. Discussion and conclusions The intervention, built within a developed working partnership between tele‐carer and patient, operated at two levels: health literacy, enhancing knowledge, developing personal skills and enabling self‐control; and socio‐psychological behavioural change, tailored to individuals within their socio‐economic environments, enabling increased motivation and supportive problem‐solving. Both approaches find reflection in the findings and provide powerful explanatory lenses to interrogate the data.