Evaluation of universal, indicated, and combined cognitive-behavioral approaches to the prevention of depression among adolescents

A cluster, stratified randomized design was used to evaluate the impact of universal, indicated, and combined universal plus indicated cognitive-behavioral approaches to the prevention of depression among 13- to 15-year-olds initially reporting elevated symptoms of depression. None of the intervention approaches differed significantly from a no-intervention condition or from each other on changes in depressive symptoms, anxiety, externalizing problems, coping skills, and social adjustment. All high-symptom students, irrespective of condition, showed a significant decline in depressive symptoms and improvement in emotional well-being over time although they still demonstrated elevated levels of psychopathology compared with the general population of peers at 12-month follow-up. There were also no significant intervention effects for the universal intervention in comparison with no intervention for the total sample of students in those conditions.

An audit of structured diabetes care in a rural general practice

Objective: To assess the impact of structured diabetes care in a rural general practice. Design and setting: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor's usual practice. Participants: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003. Main outcome measures: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1(c]) concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk. Results: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, -2.6 cm; blood pressure [systolic, -3 mmHg; diastolic -7 mmHg]; and serum lipid levels [total cholesterol, -0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, -0.4 mmol/L; triglycerides, -0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, -2.2%; proportion with foot lesions, -14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with ideal blood pressure (systolic,

Ocular and systemic markers for vascular function in those at risk of type 2 diabetes mellitus and cardiovascular disease

The devastating impact of Type 2 Diabetes Mellitus (T2DM) -related morbidity and mortality on global healthcare is escalating with higher prevalences of obesity, poor diet, and sedentary lifestyles. Therefore, the clinical need for early diagnosis and prevention in groups of high-risk individuals is necessary. The purpose of this thesis was to investigate the use of surrogate markers, namely retinal vascular function, to determine future vascular endothelial dysfunction, atherosclerosis, large vessel disease and cardiovascular risk in certain groups. This namely covered normoglycaemic and normotensive South Asians (SAs), those with Impaired-Glucose Tolerance (IGT) and individuals with a familial history (FH) of T2DM. Additionally the effect of overweight and obesity was studied. The techniques and modified protocols adopted for this thesis involved the investigation of endothelial function by means of vascular reactivity at the ocular and systemic level. Furthermore, the relationships between retinal and systemic function with circulating markers for endothelial cell function and cardiovascular risk markers were explored. The principal studies and findings of the research were: Vascular Function in Normoglycaemic Individuals with and without a FH of T2DM WE FH individuals exhibited higher levels of total cholesterol levels that correlated well with the retinal arterial dilation amplitude to flicker light stimulus. However this did not extend to noticeable differences in markers for endothelial cell damage and impaired retinal and systemic function. Vascular Function in Normoglycaemic South-Asians vs. White-Europeans without a FH and Vascular Disturbances Compared to healthy WEs (normo -glycaemic and -tensive), SA participants exhibited levels of dyslipidaemia and a state of oxidative stress that extended to impaired vascular function as detected by reduced brachial artery flow-mediated dilation, slower retinal arterial vessel dilation reaction times (Appendix 3) and steeper constriction profiles. Furthermore, gender sub-group analysis presented in a sub-chapter shows that SA males demonstrated 24-hour systemic blood pressure (BP) and heart rate variability (HRV) abnormalities and heightened cardiovascular disease (CVD) risk. Vascular Function in Individuals Newly Diagnosed with IGT as compared to Normoglycaemic Healthy Controls Newly-diagnosed WE and SA IGT patients showed a greater risk for CVD and T2DM progression by means of 24-hour BP abnormalities, dyslipidaemia, increased carotid artery intimal-media thickness (c-IMT), Framingham scores and cholesterol ratios. Additionally, pre-clinical markers for oxidative stress and endothelial dysfunction, as evident by significantly lower levels of plasma glutathione and increased levels of von-Willebrand factor in IGT individuals, extended to impaired vascular systemic and retinal function compared to normal controls. This originally shows retinal, systemic and biochemical disturbances in newly-diagnosed IGT not previously reported before. Vascular Function in Normal, Overweight and Obese Individuals of SA and WE Ethnicity In addition to the intended study chapters, the thesis also investigated the influence of obesity and overweight on vascular function. Most importantly, it was found for the first time that compared to lean individuals it was overweight and not obese individuals that exhibited signs of vascular systemic and ocular dysfunction that was evident alongside markers of atherosclerosis, CVD risk and endothelial damage.

Effect of dapagliflozin in patients with type 2 diabetes who have inadequate glycaemic control with metformin:a randomised, double-blind, placebo-controlled trial

Correction of hyperglycaemia and prevention of glucotoxicity are important objectives in the management of type 2 diabetes. Dapagliflozin, a selective sodium-glucose cotransporter-2 inhibitor, reduces renal glucose reabsorption in an insulin-independent manner. We assessed the efficacy and safety of dapagliflozin in patients who have inadequate glycaemic control with metformin.

Proliferative diabetic retinopathy (R3) referrals from the digital diabetic retinopathy screening program:urgency of appointment in the hospital eye service achieved and needed?

DESIGN. Retrospective analysis PURPOSE. To assess the clinical characteristics and outcomes of patients identified with proliferative diabetic retinopathy (PDR) referred from the screening program to the hospital eye services (HES) METHODS. a retrospective analysis of urgently referred PDR cases to Birmingham Heartlands HES from august 2008 until July 2010 RESULTS. 130 urgent diabetic retinopathy referrals were made and reviewed. 103 (68% male, 80% type 2 diabetes) were referred for PDR with a mean age of 59 years, mean diabetes duration of 17.8years. 69% were on insulin treatment at the time of the screening, with mean HbA1c of 10.4% (range-5.7 to 16.5%). 65% of the patients were offered appointments at HES within two weeks after referral from the screening. 50.5% of the patients were seen in the HES within 2 weeks, 22 and 16 % were seen 2-4 and 4-8 weeks after referral respectively. 6 patients never attended ophthalmology examination during the two years of review. Of all the attendees, 56% were booked for pan retinal photocoagulation (PRP) & 9(9.3%) for macular laser respectively on their 1st HES visit. 75% of the patients were newly diagnosed PDR and 26 had previous PRP laser but lost to follow up. 63 patients ( 66%) received either PRP or macular laser treatment (85.7% of which is PRP). 63% of the PRP treatment was performed within a month of first HES attendance. Retinopathy grading discrepancy between the screening program and HES was noted in 20% (21 patients). CONCLUSIONS. This data suggests that the digital screening programme is appropriately identifying high risk patients with PDR with timely PRP laser treatment in the majority of patients but raises concern over patients lost to follow up (hence failsafe tracking of appointment attendance), and review of grading discrepancies between the ophthalmology and screening service.

Interpreting adverse signals in diabetes drug development programs

Detection and interpretation of adverse signals during preclinical and clinical stages of drug development inform the benefit-risk assessment that determines suitability for use in real-world situations. This review considers some recent signals associated with diabetes therapies, illustrating the difficulties in ascribing causality and evaluating absolute risk, predictability, prevention, and containment. Individual clinical trials are necessarily restricted for patient selection, number, and duration; they can introduce allocation and ascertainment bias and they often rely on biomarkers to estimate long-term clinical outcomes. In diabetes, the risk perspective is inevitably confounded by emergent comorbid conditions and potential interactions that limit therapeutic choice, hence the need for new therapies and better use of existing therapies to address the consequences of protracted glucotoxicity. However, for some therapies, the adverse effects may take several years to emerge, and it is evident that faint initial signals under trial conditions cannot be expected to foretell all eventualities. Thus, as information and experience accumulate with time, it should be accepted that benefit-risk deliberations will be refined, and adjustments to prescribing indications may become appropriate. © 2013 by the American Diabetes Association.

Partnering with governments and other institutions:driving change in diabetes care

The human and material cost of type 2 diabetes is a cause of increasing concern for health professionals, representative organisations and governments worldwide. The scale of morbidity and mortality has led the United Nations to issue a resolution on diabetes, calling for national policies for prevention, treatment and care. There is clearly an urgent need for a concerted response from all interested parties at the community, national and international level to work towards the goals of the resolution and create effective, sustainable treatment models, care systems and prevention strategies. Action requires both a 'bottom-up' approach of public awareness campaigns and pressure from healthcare professionals, coupled with a 'top-down' drive for change, via partnerships with governments, third sector (non-governmental) organisations and other institutions. In this review, we examine how existing collaborative initiatives serve as examples for those seeking to implement change in health policy and practice in the quest to alleviate the health and economic burden of diabetes. Efforts are underway to provide continuous and comprehensive care models for those who already have type 2 diabetes; in some cases, national plans extend to prevention strategies in attempts to improve overall public health. In the spirit of partnership, collaborations with governments that incorporate sustainability, long-term goals and a holistic approach continue to be a driving force for change. It is now critical to maintain this momentum and use the growing body of compelling evidence to educate, inform and deliver a long-term, lasting impact on patient and public health worldwide. © 2007 The Authors.

Lack of effect of aspirin in primary CV prevention in type 2 diabetic patients with nephropathy:results from 8 years follow-up of NID-2 study

The risk-to-benefit ratio for the use of low dose of aspirin in primary cardiovascular (CV) prevention in patients with diabetes mellitus remains to be clarified. We assessed the effect of aspirin on risk of CV events in type 2 diabetic patients with nephropathy, in order to verify the usefulness of Guidelines in clinical practice. We carried out a prospective multicentric study in 564 patients with type 2 diabetic nephropathy free of CV disease attending outpatient diabetes clinics. A total of 242 patients received antiplatelet treatment with aspirin 100 mg/day (group A), and 322 were not treated with antiplatelet drugs (group B). Primary end point was the occurrence of total major adverse cardio-vascular events (MACE). Secondary end points were the relative occurrence of fatal MACE. The average follow-up was 8 years. Total MACE occurred in 49 patients from group A and in 52 patients from group B. Fatal MACE occurred in 22 patients from group A and in 20 from group B; nonfatal MACE occurred in 27 patients from group A and in 32 patients from group B. Kaplan-Meier analysis did not show a statistically significant difference of cumulative MACE between the two groups. A not statistically significant difference in the incidence of both fatal (p = 0.225) and nonfatal CV events (p = 0.573) between the two groups was observed. These results were confirmed after adjustment for confounders (HR for MACE 1.11, 95 % CI 0.91-1.35). These findings suggest that low dose of aspirin is ineffective in primary prevention for patients with nephropathy. © 2014 Springer-Verlag Italia.

Paradoxical decrease in HDL-cholesterol and apolipoprotein A1 with simvastatin and atorvastatin in a patient with type 2 diabetes

Statins are agents widely used to lower LDL-cholesterol (LDL-C) in primary and secondary prevention of coronary heart disease. The five statins available in the UK (simvastatin, pravastatin, fluvastatin, atorvastatin and rosuvastatin) differ in many of their pharmacologic properties. In addition to lowering LDL-C, statins also increase HDL-cholesterol (HDL-C) moderately. There have been rare reports of significant HDL-C decreases in patients commenced on fibrates and when thiazolidinediones are added to fibrates. This is known as a 'paradoxical HDL-C decrease' as both groups of agents usually increase HDL-C. This phenomenon has never been clearly documented following statin therapy. We now describe a patient with type 2 diabetes who showed this paradoxical fall in HDL-C (baseline HDL-C: 1.8 mmol/L; on simvastatin 40 mg HDL-C 0.6 mmol/L; on atorvastatin 20 mg HDL-C 0.9 mmol/L) with a similar decrease in apolipoprotein A1. No similar decrease was observed with pravastatin and rosuvastatin therapy. This phenomenon appeared to be associated with statin treatment and not a statin/fibrate combination. Our patient clearly demonstrated a paradoxical HDL-C fall with simvastatin and atorvastatin, but not pravastatin or rosuvastatin. Simvastatin and atorvastatin share many pharmacokinetic properties such as lipophilicity while pravastatin and rosuvastatin are relatively hydrophilic and are not metabolized by cytochrome P450 3A4. However, these characteristics do not explain the dramatic reductions in HDL-C observed.

Making Life Choices Program: A psychoeducational intervention for promoting critical cognitive and affective competencies in adolescents at-risk for problem behaviors

The long term goal of the work described is to contribute to the emerging literature of prevention science in general, and to school-based psychoeducational interventions in particular. The psychoeducational intervention reported in this study used a main effects prevention intervention model. The current study focused on promoting optimal cognitive and affective functioning. The goal of this intervention was to increase potential protective factors such as critical cognitive and communicative competencies (e.g., critical problem solving and decision making) and affective competencies (e.g., personal control and responsibility) in middle adolescents who have been identified by the school system as being at-risk for problem behaviors. The current psychoeducational intervention draws on an ongoing program of theory and research (Berman, Berman, Cass Lorente, Ferrer Wreder, Arrufat, & Kurtines 1996; Ferrer Wreder, 1996; Kurtines, Berman, Ittel, & Williamson, 1995) and extends it to include Freire's (1970) concept of transformative pedagogy in developing school-based psychoeducational programs that target troubled adolescents. The results of the quantitative and qualitative analyses indicated trends that were generally encouraging with respect to the effects of the intervention on increasing critical cognitive and affective competencies. ^

Factors influencing the implementation of substance use prevention programs in elementary schools

Prevention scientists have called for more research on the factors affecting the implementation of substance use prevention programs. Given the lack of literature in this area, coupled with evidence that children as early as elementary school engage in substance use, the purpose of this study was to identify the factors that influence the implementation of substance use prevention programs in elementary schools. This study involved a mixed methods approach comprised of a survey and in-person interviews. Sixty-five guidance counselors and teachers completed the survey, and 9 guidance counselors who completed the survey were interviewed individually. Correlation analyses and hierarchical multiple regression were conducted. Quantitative findings revealed ease of implementation most frequently influenced program implementation, followed by beliefs about the program's effectiveness. Qualitative findings showed curriculum modification as an important theme, as well as difficulty of program implementation. The in-person interviews also shed light on three interrelated themes influencing program implementation – The Wheel, time, and scheduling. Results indicate the majority of program providers modified the curriculum in some way. Implications for research, policy, and practice are discussed, and areas for future research are suggested.^

Quality of life and application of the transtheoretical model to diabetes self -management behaviors in older adults with type 2 diabetes

One in five adults 65 years and older has diabetes. Coping with diabetes is a lifelong task, and much of the responsibility for managing the disease falls upon the individual. Reports of non-adherence to recommended treatments are high. Understanding the additive impact of diabetes on quality of life issues is important. The purpose of this study was to investigate the quality of life and diabetes self-management behaviors in ethnically diverse older adults with type 2 diabetes. The SF-12v2 was used to measure physical and mental health quality of life. Scores were compared to general, age sub-groups, and diabetes-specific norms. The Transtheoretical Model (TTM) was applied to assess perceived versus actual behavior for three diabetes self-management tasks: dietary management, medication management, and blood glucose self-monitoring. Dietary intake and hemoglobin A1c values were measured as outcome variables. Utilizing a cross-sectional research design, participants were recruited from Elderly Nutrition Program congregate meal sites (n = 148, mean age 75). ^ Results showed that mean scores of the SF-12v2 were significantly lower in the study sample than the general norms for physical health (p < .001), mental health (p < .01), age sub-group norms (p < .05), and diabetes-specific norms for physical health (p < .001). A multiple regression analysis found that adherence to an exercise plan was significantly associated with better physical health (p < .001). Transtheoretical Model multiple regression analyses explained 68% of the variance for % Kcal from fat, 41% for fiber, 70% for % Kcal from carbohydrate, and 7% for hemoglobin A 1c values. Significant associations were found between TTM stage of change and dietary fiber intake (p < .01). Other significant associations related to diet included gender (p < .01), ethnicity (p < .05), employment (p < .05), type of insurance (p < .05), adherence to an exercise plan (p < .05), number of doctor visits/year ( p < .01), and physical health (p < .05). Significant associations were found between hemoglobin A1c values and age ( p < .05), being non-Hispanic Black (p < .01), income (p < .01), and eye problems (p < .05). ^ The study highlights the importance of the beneficial effects of exercise on quality of life issues. Furthermore, application of the Transtheoretical Model in conjunction with an assessment of dietary intake may be valuable in helping individuals make lifestyle changes. ^

Obesity, cardiovascular disease risk factors and weight loss in a population of adult Mexican Americans

The study of obesity has evolved into one of the most important public health issues in the United States (U.S.), particularly in Hispanic populations. Mexican Americans, the largest Hispanic ethnic subgroup in the U.S., have been significantly impacted by obesity and related cardiovascular diseases. Mexican Americans living in the Lower Rio Grande Valley (the Valley) in the Texas-Mexico border are one of the most disadvantaged and hard-to-reach minority groups. Demographic factors, socioeconomic status, acculturation, and physical activity behavior have been found to be important predictors of health, although research findings are mixed when establishing predictors of obesity in this population. Furthermore, while obesity has long been linked to cardiovascular disease (CVD) risk factors such as hypertension, type 2 diabetes, and dyslipidemia; information on the relationships between obesity and these CVD risk factors have been mostly from non-minority population groups. Overall, research has been mixed in establishing the association between obesity and related CVD risk factors in this population calling attention to the need for further research. Nevertheless, identifying predictors of success for weight loss in this population will be important if health disparities are to be addressed. The overall objective of the findings presented in this dissertation was to attain a more informed profile of obesity and CVD risk factors in this population. In particular, we examined predictors of obesity, measures of obesity and association with cardiovascular disease risk factors in a sample of 975 Mexican Americans participating in a health promotion program in the Valley region. Findings suggest acculturation factors to be one of the most important predictors of obesity in this population. Results also point to the need of identifying other possible risk factors for predicting CVD risk. Finally, initial body mass index is an important predictor of weight loss in this population group. Thus, indicating that this population is not only amenable to change, but that improvements in weight loss are feasible. This finding strengthens the relevance of prevention programs such as Beyond Sabor for Mexican populations at risk, in particular, food bank recipients.