Obstructive Sleep Apnea Among Obese Patients With Type 2 Diabetes

OBJECTIVE

To assess the risk factors for the presence and severity of obstructive sleep apnea (OSA) among obese patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Unattended polysomnography was performed in 306 participants.

RESULTS

Over 86% of participants had OSA with an apnea-hypopnea index (AHI) ≥5 events/h. The mean AHI was 20.5 ± 16.8 events/h. A total of 30.5% of the participants had moderate OSA (15 ≤ AHI <30), and 22.6% had severe OSA (AHI ≥30). Waist circumference (odds ratio 1.1; 95% CI 1.0–1.1; P = 0.03) was significantly related to the presence of OSA. Severe OSA was most likely in individuals with a higher BMI (odds ratio 1.1; 95% CI 1.0–1.2; P = 0.03).

CONCLUSIONS

Physicians should be particularly cognizant of the likelihood of OSA in obese patients with type 2 diabetes, especially among individuals with higher waist circumference and BMI.We report the prevalence of obstructive sleep apnea (OSA) and the factors that increase the risk and severity of OSA among 306 obese patients with type 2 diabetes enrolled in Sleep AHEAD, a four-site ancillary study of the Look AHEAD Trial (Action for Health in Diabetes).     

Lipid-lowering drugs as primary prevention in general practice: Do patients reach guideline goals and continue treatment? ADDITION Denmark

Objective

To describe lipid-lowering treatment in a primary care setting and how well target levels are reached. Furthermore, the aim is to describe long-term adherence to treatment.

Design

Population-based cross-sectional study with follow-up.

Setting

A total of 139 general practices from three of five Danish regions, taking part in the ADDITION study from 2001 to 2006.

Subjects

The study population comprises 1468 patients who started lipid-lowering drugs and were followed for a minimum of one year after starting treatment. Median time of follow-up after starting drug therapy was 936 days (range: 366–2068).

Results

Of 1468 patients starting treatment, a total of 781 (53%) reached the treatment goal of total cholesterol <5.0 and low-density lipoprotein <3 mmol/l within one year after drug therapy start. The percentage increased throughout the study period from 27% of patients initiating treatment in 2001 to 66% of patients initiating treatment in 2005. Age over 50, repeated cholesterol measurements within three months after treatment start, larger initial dose, and calendar year of treatment start were associated with reaching the goal within the first year, and most recent total cholesterol measurement before start of treatment >7 mmol/L was associated with not reaching the goal in the first year. Among patients followed for a minimum of three years after drug therapy started (n = 536), adherence was 77%, 72%, 75% in the first, second, and third year respectively.

Conclusion

Initial doses and the percentage reaching their goal increased substantially throughout the study period. Adherence to lipid-lowering treatment is relatively high in a primary care setting. However, current practice shows room for improvement if treatment recommendations are to be met.Key Words: Adherence, cardiovascular risk factors, dyslipidemia, family practice, preventionManagement of dyslipidemia in general practiceis progressing towards better adherence to guidelines.

• The initial doses prescribed and the percentage reaching the guideline goal within one year after treatment initiation increased considerably from 2001 to 2005.
• Well above 70% were adherent to treatment over a three-year period.
• However, current practice shows room for improvement if treatment recommendations are to be met.

     

The course of mental health problems in children presenting with abdominal pain in general practice

Objective

To investigate the course of mental health problems in children presenting to general practice with abdominal pain and to evaluate the extent to which abdominal pain characteristics during follow-up predict the presence of mental health problems at 12 months’ follow-up.

Design

A prospective cohort study with one-year follow-up.

Setting

53 general practices in the Netherlands, between May 2004 and March 2006.

Subjects

281 children aged 4–17 years.

Main outcome measures

The presence of a depressive problem, an anxiety problem, and multiple non-specific somatic symptoms at follow-up and odds ratios of duration, frequency, and severity of abdominal pain with these mental health problems at follow-up.

Results

A depressive problem persisted in 24/74 children (32.9%; 95% CI 22.3–44.9%), an anxiety problem in 13/43 (30.2%; 95% CI 17.2–46.1%) and the presence of multiple non-specific somatic symptoms in 75/170 children (44.1%; 95% CI 36.7–51.6%). None of the abdominal pain characteristics predicted a depressive or an anxiety problem at 12 months’ follow-up. More moments of moderate to severe abdominal pain predicted the presence of multiple non-specific somatic symptoms at follow-up.

Conclusions

In one-third of the children presenting to general practice for abdominal pain, anxiety and depressive problems persist during one year of follow-up. Characteristics of the abdominal pain during the follow-up period do not predict anxiety or depressive problems after one-year follow-up. We recommend following over time children seen in primary care with abdominal pain.Key Words: Abdominal pain, adolescent, child, cohort study, family practice, mental disorders, prognosisChildren with abdominal pain often have mental health problems; however, the prognosis of these problems is unknown. This follow-up study showed that:

• in one-third of the children depressive and anxiety problems persist over one year;
• characteristics of the abdominal pain during follow-up do not predict the presence of depressive and anxiety problems at 12 months’ follow-up;
• in children with persisting moderate to severe abdominal pain other non-specific somatic symptoms also persist.

     

Nursing home residents' self-perceived resources for good sleep

Objective

To explore the nursing home residents’ self-perceived resources for good sleep.

Design

A qualitative research design. Episodic interviews were conducted, and analysis was done using thematic coding.

Setting

Five German nursing homes from different providers.

Subjects

Thirty nursing home residents who were at least 64 years old and oriented to place and person.

Results

The nursing home residents’ self-perceived resources for good sleep can be classified into three general patterns: calmness, daily activity, and environmental factors. The residents see calmness as a psychological state and a prerequisite for good sleep. Rumination was reported as the main reason for disruption of calmness. Daily activity is also seen by residents to foster sleep, but most residents do not know how to be physically active. Environmental factors such as fresh air, silence, or the type of bed contribute individually to good sleep; however, nursing home residents usually lack strategies to foster these resources by themselves.

Conclusion

The nursing home residents’ self-perceived resources for good sleep – calmness, daily activity, and environmental factors – can be starting points for non-pharmacological treatment of sleep disorders. The residents’ primary care physicians should explore these individual resources during consultation and attempt to foster them.Key Words: Nursing homes, physical activity, psychological needs, qualitative research, resources, sleep disordersSleep disorders among nursing home residents are a relevant problem for residents and primary care physicians and are difficult to treat. The residents’ perspective on the problem has not yet been researched.

• Most residents regard calmness as the most important resource for good sleep. Physicians should thus consider psychological factors when treating sleep problems.
• Other resources for good sleep include physical activity and environmental factors.
• Because nursing home residents typically lack strategies to foster these resources, physicians should empower residents to make use of their resources.

     

Assessment of cardiovascular risk in primary health care

Objective

This study aimed at investigating whether cardiovascular risk factors and their impact on total risk estimation differ between men and women.

Design

Cross-sectional cohort study.

Subjects

Finnish cardiovascular risk subjects (n = 904) without established cardiovascular disease, renal disease, or known diabetes.

Main outcome measures

Ankle-brachial index (ABI), estimated glomerular filtration rate (eGFR), oral glucose tolerance test, and total cardiovascular risk using SCORE risk charts.

Results

According to the SCORE risk charts, 27.0% (95% CI 23.1–31.2) of the women and 63.1% (95% CI 58.3–67.7) of the men (p < 0.001) were classified as high-risk subjects. Of the women classified as low-risk subjects according to SCORE, 25% had either subclinical peripheral arterial disease or renal insufficiency.

Conclusions

The SCORE system does not take into account cardiovascular risk factors typical in women, and thus underestimates their total cardiovascular risk. Measurement of ABI and eGFR in primary care might improve cardiovascular risk assessment. especially in women.Key Words: Ankle-brachial index, cardiovascular risk estimation, gender difference, glucose disorders, renal functionMore women than men die from cardiovascular disease in Europe, but the non-conventional risk factors in women may remain undiagnosed or ignored.

• In a cohort of middle-aged cardiovascular risk subjects in primary care, 27% of the women and 63% of the men (p < 0.001) were classified as high-risk subjects according to the SCORE risk charts.
• Of the women classified as low-risk subjects according to SCORE, 25% had either subclinical peripheral arterial disease or renal insufficiency.
• Measurement of ABI and eGFR in primary care might improve cardiovascular risk assessment, especially in women.

     

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective

To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups.

Design

Observational study.

Setting and subjects

Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study.

Main outcome measures

Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug–drug interactions; changes during stay.

Results

The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug–drug interactions were scarce both on admission and discharge (0.7%).

Conclusions

Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.Key Words: Acute illness, drug–drug interactions, elderly, general practice, hospital, intermediate care unit, NORGEP screening tool, Norway, potentially inappropriate medicationsOlder people are at increased risk of adverse drug events. Screening tools may identify potentially inappropriate medications. Treatment in intermediate care units may possibly provide an opportunity for reducing inappropriate prescribing.

• Inappropriate prescribing was prevalent among community-dwelling older people on emergency admittance to hospitals in Bergen, Norway.
• Concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly during stay.
• Serious drug–drug interactions were scarce on admission and discharge.

     

Personal continuity of care in Norwegian general practice: A national cross-sectional study

Objective

Personal continuity is regarded as a core value in general practice. The aim of this study was to determine the level of personal continuity in Norwegian general practice. An investigation was made of the associations between high levels of personal continuity and patient, general practitioner (GP), and list characteristics.

Design

Cross-sectional register-based study

Setting

Norwegian general practice in 2009.

Subjects

3220 GPs and 3 725 998 patients on the GP lists.

Main outcome measures

The Usual Provider Continuity Index (UPC), which measures the proportion of consultations made by the usual GP, was estimated for patients and aggregated to the GP list level. GPs were grouped into quartiles based on the UPC. Being a GP with a UPC in the two highest quartiles (UPC ≥ 0.80) was the outcome in the statistical analyses.

Statistics

Poisson regression models were used to estimate relative risks (RR).

Results

The overall UPC was 0.78, increasing gradually from 0.68 in patients < 15 years of age to 0.86 for patients ≥ 60 years of age, and from 0.75 to 0.83 for patients with < 3 annual consultations compared with patients with > 10 consultations. A UPC > 0.80 was associated with longer patient lists and high GP consultation rates. Working in municipalities with < 10 000 residents was negatively associated with a high UPC. The UPC level for GPs was associated with total utilization of GP consultations in the list populations.

Conclusion

Overall, the Norwegian goal of a personal GP has been achieved; however, there are substantial variations between GPs and lower UPCs among young patients and in smaller municipalities.Key Words: Clinical practice variation, continuity of care, cross-sectional analysis, general practice, health service research, NorwayPersonal continuity in the relationship between a patient and a GP is regarded as a core value in general practice and is a motivation for the Norwegian patient list system.

• In 2009, 78% of consultations in Norwegian general practice were with the usual or chosen GP of the patient.
• The level of personal continuity was highest among the elderly and patients who see their GP most frequently and was lowest among young patients and in municipalities with less than 10 000 residents.
• A high level of personal continuity in a GP list was associated with a high GP consultation rate, but inversely associated with the GP rates of multidisciplinary meetings.

     

Prevalence, awareness, treatment, and control of hypertension: rule of thirds in the Skaraborg project

Objective

To describe the prevalence, awareness, and control of hypertension in a Swedish population during the early 2000s to address implications for care and prevention.

Design

A cross-sectional population survey.

Setting

Primary health care in Skaraborg, a rural part of western Sweden.

Subjects

Participants (n =2816) in a population survey of a random sample of men and women between 30 and 75 years of age in the municipalities of Vara (81% participation rate) and Skövde (70%), in western Sweden during 2001–2005.

Main outcome measures

Anthropometric measures, blood pressure, leisure-time physical activity, current smoking, fasting glucose, and cholesterol. Hypertension was defined as ongoing treatment for hypertension, or three consecutive blood pressure readings ≥140 systolic and/or ≥90 mmHg diastolic. Hypertension was considered controlled when the blood pressure was <140/90 mm Hg (both).

Results

The prevalence of hypertension was 20% in both men and women with a steep increase by age. Among hypertensive subjects, 33% were unaware, 36% aware but uncontrolled, and 31% aware and controlled, with no statistically significant differences between men and women. Patients with diabetes had a higher awareness (87% vs. 64%, p <0.001), but the same control rate (56% vs. 44%, p =0.133), when compared with those without diabetes.

Conclusion

A large proportion of subjects with hypertension are still unaware of their condition, or aware but not controlled. It is important to emphasize population-based prevention to reduce the prevalence of hypertension, to perform screening to increase awareness, and to improve implementation of expert guidelines in clinical practice to improve control.Key Words: Awareness, control, hypertension, population survey, prevention

• Using strict measures of blood pressure we found the prevalence of hypertension in the ages 30–75 years in Sweden to be 20%.
• A rule of thirds evolved as 1/3 was not previously known, 1/3 was treated but not controlled, and only 1/3 was treated and controlled.
• It is important to emphasize population-based prevention to reduce the prevalence of hypertension, to perform screening to increase awareness, and to improve implementation of expert guidelines in clinical practice to improve control.

     

Primary aldosteronism among newly diagnosed and untreated hypertensive patients in a Swedish primary care area

Objective

To evaluate the prevalence of primary aldosteronism (PA) in newly diagnosed and untreated hypertensive patients in primary care using the aldosterone/renin ratio (ARR), and to assess clinical and biochemical characteristics in patients with high and normal ARR.

Design

Patient survey study.

Setting and subjects

A total of 200 consecutive patients with newly diagnosed and untreated hypertension from six primary health care centres in Sweden were included.

Main outcome measures

ARR was calculated from serum aldosterone and plasma renin concentrations. The cut-off level for ARR was 65. Patients with an increased ARR were considered for confirmatory testing with the fludrocortisone suppression test (FST), followed by adrenal computed tomographic radiology (CT) and adrenal venous sampling (AVS).

Results

Of 200 patients, 36 patients had an ARR > 65. Of these 36 patients, 11 patients had an incomplete aldosterone inhibition during FST. Three patients were diagnosed with an aldosterone producing adenoma (APA) and eight with bilateral adrenal hyperplasia (BHA). Except for moderately lower level of P-K in patients with an ARR > 65 and in patients with PA, there were no biochemical or clinical differences found among hypertensive patients with PA compared with patients without PA.

Conclusion

Eleven of 200 evaluated patients (5.5%) were considered to have PA. The diagnosis of PA should therefore be considered in newly diagnosed hypertensive subjects and screening for the diagnosis is warranted.Key Words: Aldosterone, aldosterone to renin ratio, family practice, hypertension, primary aldosteronism, reninPrimary aldosteronism (PA) is common in patients diagnosed with “essential hypertension” in specialized centres; however, reports on prevalence in primary care are few.

• Screening with the aldosterone to renin ratio followed by confirmatory testing showed that 5.5% of newly diagnosed and untreated hypertensive patients had PA.
• No particular clinical features could distinguish these patients from patients with essential hypertension.
• Screening for PA should always be performed in younger patients with newly diagnosed hypertension and in patients with resistant hypertension irrespective of potassium concentrations.

Hypertension affects up to 25% of the adult population in Sweden [1,2]. Primary aldosteronism (PA) is a common form of secondary hypertension, characterized by excessive aldosterone secretion and renin suppression, followed by hypertension, alkalosis and hypokalemia [3–6]. The latter is, however, not necessarily an integral element [3–6]. Resistant hypertension requiring more than three antihypertensive drugs, hypertension diagnosed at a young age, or family history of stroke at a young age are factors that suggest the possibility of PA [7]. PA arises from one or both adrenal glands. The two major subtypes are aldosterone producing adenoma (APA; 1/3 of the cases) and bilateral adrenal hyperplasia (BAH; 2/3 of the cases). APA is preferably treated by surgery while BHA is treated with aldosterone antagonists. The diagnosis thus enables tailored medical therapy or surgical intervention with possible cure [8].PA has been considered a rare cause of hypertension [9] but recent studies suggest a prevalence of 5–10% [3,4,10–17]. Frequencies vary in different study populations and are increased in severe hypertension, especially at referral centres treating resistant hypertension [12]. Despite the fact that a number of studies have been carried out, the prevalence among primary care patients still remains uncertain. In a previous study [13] we confirmed an 8.5% prevalence of PA among 200 screened hypertensive patients in primary care. However, these patients had all been treated with antihypertensive medication for several years, which might have affected the attendance for screening, since only approximately 50% of invited subjects participated. Furthermore, it is known that a number of antihypertensive drugs alter the aldosterone to renin ratio (ARR); therefore withdrawal of medication is strongly suggested before screening [18].The aim of this study was to clarify the prevalence of PA by screening newly diagnosed and medically untreated hypertensive patients in primary care. Patients with a high ARR were referred for confirmatory testing. In addition, the study compared clinical and biochemical characteristics in patients with high or normal ARR.     

Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care: exploratory study

Background

Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown.

Objectives

To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI.

Design

Exploratory, observational study.

Setting

Four general practices in South Wales.

Subjects

A total of 99 sequential attendees with acute illness aged less than five years.

Main outcome measure

UTI defined by >10⁵ organisms/ml on laboratory culture of urine.

Results

Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections.

Conclusion

Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.Key Words: Children, diagnosis, prevalence, primary care, urinary tract infectionDiagnosis of UTI in young children is difficult as symptoms are non-specific and urine samples often hard to obtain. The presentation of 99 unwell children in general practice is described.

• Urine samples were obtained in over 75% of cases; 4% of these met microbiological criteria for a UTI.
• Although more robust epidemiological studies are required, GPs should maintain a high index of suspicion of the possibility of UTI and have a low threshold for urine sampling.

Symptoms of UTI in young children tend to be non-specific [1]. If UTI is not suspected or there is difficulty obtaining a sample, the diagnosis will be missed. This is particularly the case in primary care where children frequently consult with non-specific symptoms and where appropriate paediatric equipment is not always available [2].Urine is infrequently sampled from children in primary care [3]. In 2007, the UK National Institute for Clinical Excellence (NICE) issued a guideline concerning UTI in children [4]. This promotes increased urine sampling, particularly from primary care. It advises against urine sampling if an alternative site of infection is identified.A recent review found that prevalences of UTI in children ranged from 2% to 20% [5]. Most of the included studies were from the US and included only febrile infants (temp >38°C; age <12 months). No studies have systematically sampled from consecutive acutely ill children in primary care, without selecting on the basis of presenting features.We do not know how often UTI is the cause of illness in young children presenting in general practice-based primary care and which children should be targeted for urine sampling. We conducted an exploratory study of the prevalence of UTI describing presenting symptoms and the proportion found to have a UTI when urine samples were systematically requested from all eligible children.     

Measuring body mass index (BMI) in nursing home residents: the usefulness of measurement of arm span

Objective

To study whether arm span can be used as substitute for measurement of height in nursing home patients for calculating body mass index (BMI).

Design

Explanatory observational study.

Setting

Assessment of 35 nursing home residents admitted to long-term stay in a nursing home.

Main outcome measures

Correlation between measured height and arm span and of BMI based on both measures.

Results

Measured height and arm span, and BMI calculated from either measure were significantly correlated, r_s=0.75, p <0.001 and r_s=0.89, p <0.001, respectively. The ratios of measured height and arm span and between BMIs based on height or arm span are close to 1, but the dispersion is rather large.

Conclusion

Arm span is a reliable substitute for measurement of height in nursing home patients. In persons with severe height reduction, arm-span-based BMI is probably more accurate than conventional height-based BMI.     

Violence towards personnel in out-of-hours primary care: a cross-sectional study

Objective

To investigate (1) the prevalence of occupational violence in out-of-hours (OOH) primary care, (2) the perceived cause of violence, and (3) the associations between occupation, gender, age, years of work, and occupational violence.

Design

A cross-sectional study using a self-administered postal questionnaire.

Setting

Twenty Norwegian OOH primary care centres.

Subjects

Physicians, nurses, and others with patient contact at OOH primary care centres, 536 responders (75% response rate).

Main outcome measures

Verbal abuse, threats, physical abuse, sexual harassment.

Results

In total, 78% had been verbally abused, 44% had been exposed to threats, 13% physically abused, and 9% sexually harassed during the last 12 months. Significantly more nurses were associated with verbal abuse (OR 3.85, 95% confidence interval 2.17–6.67) after adjusting for gender, age, and years in OOH primary care. Males had a higher risk for physical abuse (OR 2.36, CI 1.11–5.05) and higher age was associated with lower risk for sexual harassment (OR 0.28, CI 0.14–0.59), when adjusted for background variables. Drug influence and mental illness were the most frequently perceived causes for the last occurring episode of physical abuse, threats, and verbal abuse.

Conclusion

This first study on occupational violence in Norwegian OOH primary care found that a substantial number of health care workers experience occupational violence from patients or visitors. The employer should take action to prevent occupational violence in OOH primary care.Key Words: Cross-sectional studies, general practice, nurses, out-of-hours, physicians, prevalence, violenceThis study describes the prevalence of occupational violence among health workers in Norwegian out-of-hours primary care.

• One in three has been exposed to physical abuse during their working career in out-of-hours primary care.
• Nurses experience more verbal abuse than the other occupational groups.
• The perceived main causes of occupational violence are drug influence and mental illness.

     

Portable recording for detecting sleep disorder breathing in patients under the care of a heart failure clinic

Background

Sleep disordered breathing (SDB) has important clinical implications in patients with congestive heart failure (CHF). We performed portable recording in unselected CHF patients on contemporary therapy. Data on the interactions of SDB in patients supervised at heart failure clinics are rare and we illustrate diversities of obstructive sleep apnoea (OSA) and central sleep apnoea (CSA).

Methods

We studied 176 consecutive subjects on contemporary medical therapy with a median left ventricular ejection fraction of 25.0 % (range 7–35 %) and median NT-pro BNP levels of 3,413.0 pg/ml (range 305.1–35,000.0 pg/ml). Participants underwent prospective overnight portable recording.

Results

50 % presented with an at least moderate form of nocturnal breathing disorder [apnoea–hypopnoea index (AHI) ≥15/h]. Only 15 patients (17.1 %) with AHI ≥15/h reported excessive daytime sleepiness. Irrespective of left ventricular ejection fraction, patients with CSA had higher levels of NT-pro BNP compared to patients with OSA (differences in medians = 2,639.0 pg/ml, p = 0.016), and compared to patients with an AHI <15/h (differences in medians = 2,710.0 pg/ml, p < 0.001). OSA affected 26 patients (14.8 %).

Conclusions

Patients with severe stable CHF on contemporary therapy have a prevalence of 50.0 % of moderate to severe SDB. The natural cascade of the failing heart is initially characterised by absent SDB or OSA, whereas end-stage CHF is associated with CSA.     

General practitioners' experiences using cognitive behavioural therapy in general practice: a qualitative study

Objective

To explore GPs’ experiences using cognitive behavioural therapy (CBT), with a focus on factors that promote or limit the use of CBT in general practice.

Design

Qualitative study using data from written evaluation reports and focus-group interviews.

Setting

Norwegian general practice.

Subjects

GPs who participated in a longitudinal CBT course in the continuous medical education (CME) programme for GPs in Norway, of whom 19 filled in evaluation forms and 15 participated in focus-group interviews.

Main outcome measures

Experiences with the use of CBT in general practice.

Results

GPs used CBT mainly in the treatment of patients with anxiety disorders and depression. Factors that promoted the use of CBT in general practice were structured supervision and group counselling, receiving feedback on individual video-recorded consultations, and experiencing that one mastered the therapeutic techniques. Limiting factors were that it took some time before one mastered the techniques, lack of eligible patients, constraints related to attending group supervision during office hours, and the lack of financial incentives to use CBT in general practice.

Conclusion

Tailored training programmes in CBT for GPs may contribute to more frequent use of CBT in general practice. A formal recognition of CBT in the reimbursement scheme for GPs might counter limiting factors to an increased use of CBT in general practice.Key Words: Anxiety disorders, cognitive therapy, depressive disorder, family practice, physiciansCognitive behavioural therapy (CBT) is effective for treatment of anxiety disorders and moderate depression in general practice, but the use of CBT in general practice is limited.

• GPs experienced increased confidence in using CBT after completing a longitudinal course in CBT, involving seminars and group meetings with individual case supervision.
• A formal recognition of CBT in the reimbursement scheme for GPs might facilitate more frequent use of CBT in general practice.

The lifetime prevalence of mental disorders in the Norwegian population is 50% [1]. The majority of patients with mental disorders who seek health care are managed in primary care, and psychiatric illness represents about 9–10% of contacts in regular GPs’ daytime practices [2]. Four out of 10 Norwegian GPs suggest that improvement of GPs’ skills and knowledge would be helpful to improve treatment of mental disorders [3]. The methods GPs use for treating mental disorders, apart from medication, are often self-taught, not based on a specific approach, and often referred to as “talking therapy” or “supportive therapy” [4].Cognitive behavioural therapy (CBT) is a time-limited, structured psychological intervention aimed at treating patients with various mental disorders. CBT consultations usually last for 30–60 minutes, and a treatment series usually consists of 10–20 consultations. CBT aims at helping patients change how they think and what they do, and CBT focuses on problems and difficulties at present, rather than issues from the past. The patient works collaboratively with the therapist. CBT aims at helping the patient to develop skills to identify, to counteract, and to cope with problematic thoughts, beliefs, and interpretations, and to learn how these affect symptoms, feelings, and problems. CBT is effective for treatment of anxiety disorders and moderate depression in primary care [5,6], but only a minority of GPs use CBT systematically. Lack of time and confidence, and practice distractions have been identified as barriers to GPs using CBT in their clinical practice [7]. In Norway, CBT has usually been taught to GPs in the format of one- to three-day courses, mainly based on lectures. Recently, a new course has been introduced in the Norwegian continuous medical education (CME) programme for GPs, involving seminars and group meetings with individual case supervision.As medical doctors with an interest in management of psychiatric conditions in general practice, we wanted to understand more about the factors that influence the use of CBT in general practice, and what challenges and advantages GPs experience when they start using CBT in their own practice. The purpose of this study was to explore GPs’ experiences with using cognitive behavioural therapy (CBT), with a focus on factors that promote or limit the use of CBT in general practice.     

Sleep architecture and glucose and insulin homeostasis in obese adolescents

OBJECTIVE

Sleep deprivation is associated with increased risk of adult type 2 diabetes mellitus (T2DM). It is uncertain whether sleep deprivation and/or altered sleep architecture affects glycemic regulation or insulin sensitivity or secretion. We hypothesized that in obese adolescents, sleep disturbances would associate with altered glucose and insulin homeostasis.

RESEARCH DESIGN AND METHODS

This cross-sectional observational study of 62 obese adolescents took place at the Clinical and Translational Research Center and Sleep Laboratory in a tertiary care children’s hospital. Subjects underwent oral glucose tolerance test (OGTT), anthropometric measurements, overnight polysomnography, and frequently sampled intravenous glucose tolerance test (FSIGT). Hemoglobin A_1c (HbA_1c) and serial insulin and glucose levels were obtained, indices of insulin sensitivity and secretion were calculated, and sleep architecture was assessed. Correlation and regression analyses were performed to assess the association of total sleep and sleep stages with measures of insulin and glucose homeostasis, adjusted for confounding variables.

RESULTS

We found significant U-shaped (quadratic) associations between sleep duration and both HbA_1c and serial glucose levels on OGTT and positive associations between slow-wave sleep (N3) duration and insulin secretory measures, independent of degree of obesity, pubertal stage, sex, and obstructive sleep apnea measures.

CONCLUSIONS

Insufficient and excessive sleep was associated with short-term and long-term hyperglycemia in our obese adolescents. Decreased N3 was associated with decreased insulin secretion. These effects may be related, with reduced insulin secretory capacity leading to hyperglycemia. We speculate that optimizing sleep may stave off the development of T2DM in obese adolescents.Sleep deprivation is endemic; 9.3% of U.S. adults sleep <6 h per night (1), and 75% of high-school seniors report getting insufficient sleep (2). This cumulative societal sleep curtailment is significant, as sleep deprivation is associated with a number of metabolic consequences: increased predisposition to obesity (3) and insulin resistance (IR) (4) in both adults and children, increased risk of type 2 diabetes mellitus (T2DM) in adults (5), and higher fasting glucose in young adults with preexisting diabetes (6). The metabolic consequences of insufficient sleep may be the result of a lack of total sleep or insufficiency of a certain sleep component. The American Academy of Sleep Medicine recognizes four different sleep stages indicated as follows: stage 1 (N1), a brief transition between wake and sleep; stage 2 (N2); stage 3 (N3), “slow-wave” or “deep” sleep; and rapid eye movement (REM) (dream) sleep. In adult studies, cerebral glucose utilization declines (7) and plasma glucose rises (8) in N3 sleep. One pediatric study found a negative association between REM sleep duration and obesity (9), but there is little pediatric data on sleep architecture and glucose and insulin homeostasis. A potential confounding factor is obstructive sleep apnea (OSA), a syndrome more common in obesity in which upper airway obstruction leads to sleep fragmentation and desaturation (10). OSA has been associated with T2DM risk in adults (10) and with IR in children (11,12). We hypothesized that in obese adolescents (who are at risk for T2DM), altered sleep architecture is associated with abnormalities of insulin secretion and sensitivity and of glucose homeostasis independently of confounding factors (e.g., degree of obesity, presence of OSA, sex, and pubertal stage). Therefore, the aim of our study was to investigate the relationship between sleep architecture and insulin secretion and sensitivity and overall glycemia in this population.     

Young male daily smokers are nicotine dependent and experience several unsuccessful quit attempts

Objective

Previous studies on smoking cessation have generally been conducted with adolescents or adults. Very little is known about the cessation attempts, their success, and/or use of pharmacological aids in young adult smokers who want to quit. The present study aimed to investigate quitting attempts in a group of both young male daily and occasional smokers.

Design and subjects

614 male smokers aged 18–26 years completed a standardized questionnaire about their smoking habits, quit attempts, and aids used in smoking cessation.

Results

Nearly all daily smokers (95.3%, 95% CI 93.1–96.8) were nicotine addicted to some extend according to the standardized questionnaire, and the more addicted they were, the more often they had tried to quit (p = 0.025). Of the daily smokers, 55.6% (95% CI 51.3–59.9) had made quit attempts and 36.2% (95% CI 32.1–40.4) had used nicotine replacement therapy (NRT). In all, 34.1% (95% CI 25.2–44.3) of all occasional smokers reported having intended to quit but they had seldom made more than one attempt whereas 20.2% of daily smokers had made at least three attempts. The stronger the nicotine dependence in daily smokers was, the more likely the subject was to have attempted to use NRT (quite dependent 23.8% vs. totally dependent 48.9%) (p < 0.001).

Conclusions

A high proportion of young male daily smokers were nicotine addicted. Young smokers make many unsuccessful attempts to stop smoking using nicotine replacement therapy (NRT) on their own. A better availability of professional cessation services directed to young adult smokers is needed.Key Words: Finland, general practice, male smoking cessation, nicotine dependence, pharmacological aid, quit attempt, young adults

• Nearly all young male daily smokers concede that they suffer from nicotine addiction, whereas most occasional smokers consider the question of nicotine addiction irrelevant.
• Both daily and occasional young male smokers make unsuccessful attempts to stop smoking without nicotine replacement therapy (NRT) and/or use NRT on their own without supervision.
• Young male quitters seem to be unfamiliar with free national web-based counselling services or they lack plans for quitting beforehand.