Factors associated with glycaemic outcome of childhood diabetes care in Denmark.

AIMS: To study how structure and process of care is associated with outcome assessed by HbA(1c). METHODS: Data for this cross-sectional study originated from the nationwide Danish Registry for Childhood Diabetes and two questionnaires. One questionnaire was sent to all children under 16 years of age with Type 1 diabetes in the year 2000 (N = 1087, response rate 80%). Another questionnaire was sent to the 19 centres in Denmark treating these children (response rate 100%). Simultaneously the children were asked to take a blood sample for central HbA(1c) analysis. Linear mixed models were used for analysis of associations between structure and process indicators and HbA(1c). Age, diabetes duration, sex, ethnicity, family structure and parents' occupational status were included as patient factors possibly affecting HbA(1c). RESULTS: More visits to the outpatient clinic and higher insulin dosage were significantly associated with higher HbA(1c) (P = 0.002 and P = 0.0001, respectively). Increased frequency of blood glucose monitoring (BGM/week) and completed nephropathy screening were significantly associated with lower HbA(1c) value (estimates -0.008 and -0.49, P = 0.02, respectively). The structure indicators were not associated with HbA(1c), but telephone hot-line was positively associated with the process indicator BGM (estimate 4.02, P = 0.04). Children without Danish parents performed BGM significantly less frequently (-7.11, P = 0.0005) and had higher HbA(1c) (0.41, P = 0.06). CONCLUSIONS: Most process indicators were significantly associated with HbA(1c), indicating relevant action of staff on glucose regulation. The structure indicators were not associated with outcome, necessitating more detailed studies on the influence of staffing resources, treatment strategies and targets in childhood diabetes management.     

A one-item workability measure mediates work demands, individual resources and health in the prediction of sickness absence

Objectives

The study tested the hypothesis that a one-item workability measure represented an assessment of the fit between resources (the individuals’ physical and mental health and functioning) and workplace demands and that this resource/demand fit was a mediator in the prediction of sickness absence. We also estimated the relative importance of health and work environment for workability and sickness absence.

Methods

Baseline data were collected within a Danish work and health survey (3,214 men and 3,529 women) and followed up in a register of sickness absence. Probit regression analysis with workability as mediator was performed for a binary outcome of sickness absence. The predictors in the analysis were as follows: age, social class, physical health, mental health, number of diagnoses, ergonomic exposures, occupational noise, exposure to risks, social support from supervisor, job control and quantitative demands.

Results

High age, poor health and ergonomic exposures were associated with low workability and mediated by workability to sickness absence for both genders. Low social class and low quantitative demands were associated with low workability and mediated to sickness absence among men. The mediated part was from 11 to 63 % of the total effect for the significant predictors.

Conclusion

Workability mediated health, age, social class and ergonomic exposures in the prediction of sickness absence. The health predictors had the highest association with both workability and sickness absence; physical work environment was higher associated with the outcomes than psychosocial work environment. However, the explanatory value of the predictors for the variance in the model was low.     

Quality of diabetes management in children and adolescents in Denmark.

AIM: To describe the management of children and adolescents with Type 1 diabetes mellitus in Denmark. METHODS: Quality indicators with standards of childhood diabetes management were chosen based on international and national guidelines. Data originated from the nation-wide Danish Registry for Childhood Diabetes and two questionnaires: one questionnaire was sent to all children with diabetes (response rate 78%, n=1335) and the other was sent to the 19 centres in Denmark treating these children (response rate 100%). Simultaneously, the children were asked to take a blood sample for central HbA1c-analysis (normal range 4.3-5.8, mean 5.1%). RESULTS: Most children were managed at centres which complied with the standards for the process indicators for good diabetes management, but not with the standards for most structure and outcome indicators. Only one third of the children reached the treatment target for HbA1c. Their mean HbA1c-level increased gradually from ages 4-14 without significant difference between genders. The youngest children had the lowest HbA1c (mean 8.2%) and the lowest rate of severe hypoglycaemic events (4.6 events per 100 patient years). The subgroup of children without any hypoglycaemic events had the significantly lowest mean HbA1c-level (8.6%, P=0.028). CONCLUSIONS: The Danish Registry for Childhood Diabetes provided useful data for quality improvement, but had to be supplemented with data from questionnaires on the structure and process indicators. Outcome of paediatric diabetes management in Denmark was unsatisfactory. Centres need feedback on ways to improve care to lower the children's risk of developing severe diabetes complications.     

Incorporation of the TLR4 Agonist Monophosphoryl Lipid A Into the Bilayer of DDA/TDB Liposomes: Physico-Chemical Characterization and Induction of CD8<Superscript>+</Superscript> T-Cell Responses <Emphasis Type="Italic">In Vivo</Emphasis>

Purpose  

The combination of delivery systems like cationic liposomes and immunopotentiators such as Toll-like receptor (TLR) ligands is a promising approach for rational vaccine adjuvant design. The purpose of this study was to investigate how the incorporation of the poorly soluble TLR4 agonist monophosphoryl lipid A (MPL) into cationic liposomes based on dimethyldioctadecylammonium (DDA) and trehalose 6,6′-dibehenate (TDB) influenced the physicochemical and immunological properties of the liposomes.     

Development and validation of a prediction model for long-term sickness absence based on occupational health survey variables

Purpose: The purpose of this study is to develop and validate a prediction model for identifying employees at increased risk of long-term sickness absence (LTSA), by using variables commonly measured in occupational health surveys.

Materials and methods: Based on the literature, 15 predictor variables were retrieved from the DAnish National working Environment Survey (DANES) and included in a model predicting incident LTSA (≥4 consecutive weeks) during 1-year follow-up in a sample of 4000 DANES participants. The 15-predictor model was reduced by backward stepwise statistical techniques and then validated in a sample of 2524 DANES participants, not included in the development sample. Identification of employees at increased LTSA risk was investigated by receiver operating characteristic (ROC) analysis; the area-under-the-ROC-curve (AUC) reflected discrimination between employees with and without LTSA during follow-up.

Results: The 15-predictor model was reduced to a 9-predictor model including age, gender, education, self-rated health, mental health, prior LTSA, work ability, emotional job demands, and recognition by the management. Discrimination by the 9-predictor model was significant (AUC = 0.68; 95% CI 0.61–0.76), but not practically useful.

Conclusions: A prediction model based on occupational health survey variables identified employees with an increased LTSA risk, but should be further developed into a practically useful tool to predict the risk of LTSA in the general working population.

• Implications for rehabilitation

• Long-term sickness absence risk predictions would enable healthcare providers to refer high-risk employees to rehabilitation programs aimed at preventing or reducing work disability.

• A prediction model based on health survey variables discriminates between employees at high and low risk of long-term sickness absence, but discrimination was not practically useful.

• Health survey variables provide insufficient information to determine long-term sickness absence risk profiles.

• There is a need for new variables, based on the knowledge and experience of rehabilitation professionals, to improve long-term sickness absence risk profiles.

     

Quality of life and symptoms in patients with malignant diseases admitted to a comprehensive cancer centre

Purpose

Quality of life and symptomatology in patients with malignancies admitted to comprehensive cancer centres are rarely investigated. Thus, this study aimed to investigate symptomatology and health-related quality of life of inpatients with cancer.

Methods

A prospective, cross-sectional study was carried out on two occasions 5 weeks apart in haematology and oncology departments at a comprehensive cancer centre. Assessment included demographic data, WHO performance status (PS), EORTC QLQ-C30 and pain scales of brief pain inventory. Comparisons were analysed using Wilcoxon two-sample test, rank tests and Fisher’s exact test.

Results

One hundred twenty-four patients were analysed, mean age?=?59 years (SD?=?13.7), 42 % admitted to haematological department; lung cancer was the most frequent diagnosis (15 %). Low health-related quality of life and severe symptom burden, especially fatigue and appetite loss, were observed among the inpatients. In addition, role and social functions appeared to be more impaired in haematology patients than in those admitted to oncology (P?=?0.0372 and 0.0167, respectively). On the other hand, pain and constipation were more severely affected in oncology patients (P?=?0.0194 and 0.0064, respectively).

Conclusions

Patients in the wards of haematology and oncology had pronounced symptomatology and low quality of life. A more systematic focus on the amelioration of problems with functioning and symptoms among inpatients with malignant diseases is warranted.     

Transplantation of Glial Progenitors That Overexpress Glutamate Transporter GLT1 Preserves Diaphragm Function Following Cervical SCI

Approximately half of traumatic spinal cord injury (SCI) cases affect cervical regions, resulting in chronic respiratory compromise. The majority of these injuries affect midcervical levels, the location of phrenic motor neurons (PMNs) that innervate the diaphragm. A valuable opportunity exists following SCI for preventing PMN loss that occurs during secondary degeneration. One of the primary causes of secondary injury is excitotoxicity due to dysregulation of extracellular glutamate homeostasis. Astrocytes express glutamate transporter 1 (GLT1), which is responsible for the majority of CNS glutamate clearance. Given our observations of GLT1 dysfunction post-SCI, we evaluated intraspinal transplantation of Glial-Restricted Precursors (GRPs)—a class of lineage-restricted astrocyte progenitors—into ventral horn following cervical hemicontusion as a novel strategy for reconstituting GLT1 function, preventing excitotoxicity and protecting PMNs in the acutely injured spinal cord. We find that unmodified transplants express low levels of GLT1 in the injured spinal cord. To enhance their therapeutic properties, we engineered GRPs with AAV8 to overexpress GLT1 only in astrocytes using the GFA2 promoter, resulting in significantly increased GLT1 protein expression and functional glutamate uptake following astrocyte differentiation in vitro and after transplantation into C4 hemicontusion. Compared to medium-only control and unmodified GRPs, GLT1-overexpressing transplants reduced lesion size, diaphragm denervation and diaphragm dysfunction. Our findings demonstrate transplantation-based replacement of astrocyte GLT1 is a promising approach for SCI.     

Improved metabolic outcome in a Danish diabetic paediatric population aged 0–18 yr: results from a nationwide continuous Registration

The objective of the present study was to describe the changes in glycaemic control based on data from the nationwide Danish Registry of Childhood Diabetes with valid haemoglobin A1c (HbA1c) readings centrally analysed between 1996 and 2006. The glycaemic control was assessed using generalized linear mixed models. Centre, age, diabetes duration, ethnicity, sex, self-monitoring of blood glucose, insulin regimens and hypoglycaemia was tested as explanatory variables. There were 9291 HbA1c recordings from 2705 children with T1D during the 10-yr period. The unadjusted mean HbA1c value in 1997 was 9.05% (95% CI ± 0.82) and in 2006 was 8.20% (95% CI ± 0.06). Mean HbA1c was significantly reduced over the years with a linear decrease of 0.08% per year (95% CI ±0.011) (p < 0.0001). The decrease was unaffected by adjusting for number of injections, insulin/kg and use of insulin analogous. During the period, an increased frequency of self-monitored blood glucose was observed that was associated with a reduction in HbA1c (p < 0.0001). The percentage of children with severe hypoglycaemia decreased from 12.2 to 7.8% in those with HbA1c between 6 and 8%. Metabolic control in diabetic children has improved on a nationwide basis from the establishment of the national registry in 1996. The reduction in HbA1c was related to an increased number of self-monitoring of blood glucose values and a decrease in the number of hypoglycaemic events in those with the best metabolic control, whereas there were no association with the use of new analogous or insulin regimens.     

Access to primary care from the perspective of Aboriginal patients at an urban emergency department

In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.