Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

Background

The risk of depression is increased in people with long term conditions (LTCs) and is associated with poorer patient outcomes for both the depressive illness and the LTC, but often remains undetected and poorly managed. The aim of this study was to identify and explore barriers to detecting and managing depression in primary care in people with two exemplar LTCs: diabetes and coronary heart disease (CHD).

Methods

Qualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper.

Results

Barriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management.

Conclusion

Depression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.     

AGRICOH: a consortium of agricultural cohorts

AGRICOH is a recently formed consortium of agricultural cohort studies involving 22 cohorts from nine countries in five continents: South Africa (1), Canada (3), Costa Rica (2), USA (6), Republic of Korea (1), New Zealand (2), Denmark (1), France (3) and Norway (3). The aim of AGRICOH, initiated by the US National Cancer Institute (NCI) and coordinated by the International Agency for Research on Cancer (IARC), is to promote and sustain collaboration and pooling of data to investigate the association between a wide range of agricultural exposures and a wide range of health outcomes, with a particular focus on associations that cannot easily be addressed in individual studies because of rare exposures (e.g., use of infrequently applied chemicals) or relatively rare outcomes (e.g., certain types of cancer, neurologic and auto-immune diseases). To facilitate future projects the need for data harmonization of selected variables is required and is underway. Altogether, AGRICOH provides excellent opportunities for studying cancer, respiratory, neurologic, and auto-immune diseases as well as reproductive and allergic disorders, injuries and overall mortality in association with a wide array of exposures, prominent among these the application of pesticides.     

Antibacterial peptides derived from caprine whey proteins, by digestion with human gastrointestinal juice

Peptides in caprine whey were identified after in vitro digestion with human gastrointestinal enzymes in order to determine their antibacterial effect. The digestion was performed in two continuing steps using human gastric juice (pH 2·5) and human duodenal juice (pH 8) at 37°C. After digestion the hydrolysate was fractionated and 106 peptides were identified. From these results, twenty-two peptides, located in the protein molecules, were synthesised and antibacterial activity examined. Strong activity of the hydrolysates was detected against Escherichia coli K12, Bacillus cereus RT INF01 and Listeria monocytogenes, less activity against Staphylococcus aureus ATCC 25?923 and no effect on Lactobacillus rhamnosus GG. The pure peptides showed less antibacterial effect than the hydrolysates. When comparing the peptide sequences from human gastrointestinal enzymes with previously identified peptides from non-human enzymes, only two peptides, β-lactoglobulin f(92-100) and β-casein f(191-205) matched. No peptides corresponded to the antibacterial caprine lactoferricin f(14-42) or lactoferrampin C f(268-284). Human gastrointestinal enzymes seem to be more complex and have different cleavage points in their protein chains compared with purified non-human enzymes. Multiple sequence alignment of nineteen peptides showed proline-rich sequences, neighbouring leucines, resulting in a consensus sequence LTPVPELK. In such a way proline and leucine may restrict further proteolytic processing. The present study showed that human gastrointestinal enzymes generated different peptides from caprine whey compared with non-human enzymes and a stronger antibacterial effect of the hydrolysates than the pure peptides was shown. Antimicrobial activity against pathogens but not against probiotics indicate a possible host-protective activity of whey.     

Small proportions: what to report for confidence intervals?

The original article to which this Erratum refers was published in Pharmacoepidemiology and Drug Safety 2005; 14: 239–247.     

The genetics of congenital aniridia—a guide for the ophthalmologist

Congenital aniridia is a rare panocular disease caused by fundamental disturbances in the development of the eye, characterized primarily by hypoplasia of the iris and macula. Severe secondary complications such as keratopathy, cataract, and glaucoma are common and often lead to considerable visual impairment or blindness. Many complications in aniridia patients are difficult to treat and present a challenge for the ophthalmologist. Increasingly, associated nonocular features of the disease are also being recognized. Over the past decades, major steps have been made in the understanding of the genetic basis of aniridia. Moreover, recent studies have prepared the ground for future treatment options based on specific mutations. Therefore, specific knowledge about genetics in aniridia has become more important than ever. We provide an overview of the field of aniridia genetics and its clinical implications.     

Periodontal ligament anesthesia — A clinical evaluation

Abstract Periodontal ligament (PDL) injection was used either as an alternative or as a supplement to conventional anesthesia techniques (CA) in connection with endodontic treatment of 339 teeth. Adequate analgesia was obtained more frequently with CA than with PDL. However, total lack of effect was registered only in a few cases for both techniques. PDL was found to be of particular value in the mandibular posterior segments where conventional techniques most frequently failed.     

Laryngeal zoster with multiple cranial nerve palsies

A young immunocompetent patient is presented with a very rare presentation of a common viral illness: herpes zoster of the left hemilarynx with sensorial and motoric neuropathy of three ipsilateral lower cranial nerves: IX, X and XI. The mucosal lesions were discovered during upper gastrointestinal endoscopy. PCR of erosional exsudate confirmed the clinical diagnosis. Antiviral therapy and corticosteroids possibly contributed to the prosperous evolution with complete healing.     

Pediatric heart support with a newly developed catheter based pulsatile 12F rotary blood pump: an animal study

Background: To evaluate mechanical and hematological compatibility of a pediatric, temporary left heart support system in a lamb model as a less traumatic alternative to the widely used ECMO. Methods: A small, pulsatile rotary blood pump (target flow 0.5 l/m at 80 mmHg pressure head at 120 pulses per min) was inserted in six lambs (15.1 ± 1 kg) via a left thoracotomy, through a purse string in the arcus aortae. With fluoroscopy the tip (=inflow) of the catheter was positioned in the outflow tract of the left ventricle. The outflow part was positioned immediately above the aortic valve. Animals were extubated at the end of the procedure. Mechanical and hematological parameters were followed for 14 days. Results: Five animals survived a 2-week follow-up. One animal died because of empyema on day 6. Flow maintained stable (0.8 ± 0.2 l/m) in all animals during the evaluation period. Free hemoglobin as a parameter of hemolysis and hematocrit remained also stable. Necropsy revealed minimal fibrous reaction on one aortic valve leaflet in one animal and small hematoma formation in three. All animals showed mild signs of endothelial damage on the aortic arch at the level of the motor housing. One animal showed signs of old kidney infarction suggesting possible embolization during placement. Conclusion: This newly developed, catheter based, pediatric heart support system generates a stable flow for 14 days without compromising hematological stability and with acceptable tissue damage due to positioning of the catheter.