Insulin therapy in people with type 2 diabetes:opportunities and challenges?

Given the continued interest in defining the optimal management of individuals with type 2 diabetes, the Editor of Diabetes Care convened a working party of diabetes specialists to examine this topic in the context of insulin therapy. This was prompted by recent new evidence on the use of insulin in such people. The group was aware of evidence that the benefits of insulin therapy are still usually offered late, and thus the aim of the discussion was how to define the optimal timing and basis for decisions regarding insulin and to apply these concepts in practice. It was noted that recent evidence had built upon that of the previous decades, together confirming the benefits and safety of insulin therapy, albeit with concerns about the potential for hypoglycemia and gain in body weight. Insulin offers a unique ability to control hyperglycemia, being used from the time of diagnosis in some circumstances, when metabolic control is disturbed by medical illness, procedures, or therapy, as well as in the longer term in ambulatory care. For those previously starting insulin, various other forms of therapy can be added later, which offer complementary effects appropriate to individual needs. Here we review current evidence and circumstances in which insulin can be used, consider individualized choices of alternatives and combination regimens, and offer some guidance on personalized targets and tactics for glycemic control in type 2 diabetes. © 2014 by the American Diabetes Association.

Medicines optimisation for young people with juvenile arthritis and other long-term conditions:system-level barriers to engagement

To explore the views of pharmacy and rheumatology stakeholders about system-related barriers to medicines optimisation activities with young people with long-term conditions. A three-phase consensus-building study comprising (1) focus groups with community and hospital pharmacists; (2) semi-structured telephone interviews with lay and professional adolescent rheumatology stakeholders and pharmacy policymakers, and (3) multidisciplinary discussion groups with community and hospital pharmacists and rheumatology staff. Qualitative verbatim transcripts from phases 1 and 2 were subjected to framework analysis. Themes from phase 1 underpinned a briefing for phase 2 interviewees. Themes from phases 1 and 2 generated elements of good pharmacy practice and current/future pharmacy roles for ranking in phase 3. Results from phase 3 prioritisation and ranking exercises were captured on self-completion data collection forms, entered into an Excel spreadsheet and subjected to descriptive statistical analysis. Institutional ethical approval was given by Aston University Health and Life Sciences Research Ethics Committee. Four focus groups were conducted with 18 pharmacists across England, Scotland and Wales (7 hospital, 10 community and 1 community/public health). Fifteen stakeholders took part in telephone interviews (3 pharmacist commissioners; 2 pharmacist policymakers; 2 pharmacy staff members (1 community and 1 hospital); 4 rheumatologists; 1 specialist nurse, and 3 lay juvenile arthritis advocates). Twenty-five participants took part in three discussion groups in adolescent rheumatology centres across England and Scotland (9 community pharmacists; 4 hospital pharmacists; 6 rheumatologists; 5 specialist nurses, and 1 physiotherapist). In all phases of the study, system-level issues were acknowledged as barriers to more engagement with young people and families. Community pharmacists in the focus groups reported that opportunities for engaging with young people were low if parents collected prescriptions alone, which was agreed by other stakeholders. Moreover, institutional/company prescription collection policies – an activity largely disallowed for a young person under 16 without an accompanying parent - were identified by hospital and community pharmacists as barriers to open discussion and engagement. Few community pharmacists reported using Medicines Use Review (England/Wales) or Chronic Medication Service (Scotland) as a medicines optimisation activity with young people; many were unsure about consent procedures. Despite these limitations, rheumatology stakeholders ranked highly the potential of pharmacists empowering young people with general health care skills, such as repeat prescription ordering. The pharmacy profession lacks vision for its role in the care of young people with long-term conditions. Pharmacists and rheumatology stakeholders identified system-level barriers to more engagement with young people who take medicines regularly. We acknowledge that the modest number of participants may have had a specific interest and thus bias for the topic, but this underscores their frank admission of the challenges. Professional guidance and policy, practice frameworks and institutional/company policies must promote flexibility for pharmacy staff to recognise and empower young people who are able to give consent and take responsibility for medicines activities. This will increase mutual confidence and trust, and foster pharmacy’s role in teaching general health care skills. In this way, pharmacists will be able to build long-term relationships with young people and families.

Uncertainty propagation in the model web:a case study with e-Habitat

eHabitat is a Web Processing Service (WPS) designed to compute the likelihood of finding ecosystems with equal properties. Inputs to the WPS, typically thematic geospatial "layers", can be discovered using standardised catalogues, and the outputs tailored to specific end user needs. Because these layers can range from geophysical data captured through remote sensing to socio-economical indicators, eHabitat is exposed to a broad range of different types and levels of uncertainties. Potentially chained to other services to perform ecological forecasting, for example, eHabitat would be an additional component further propagating uncertainties from a potentially long chain of model services. This integration of complex resources increases the challenges in dealing with uncertainty. For such a system, as envisaged by initiatives such as the "Model Web" from the Group on Earth Observations, to be used for policy or decision making, users must be provided with information on the quality of the outputs since all system components will be subject to uncertainty. UncertWeb will create the Uncertainty-Enabled Model Web by promoting interoperability between data and models with quantified uncertainty, building on existing open, international standards. It is the objective of this paper to illustrate a few key ideas behind UncertWeb using eHabitat to discuss the main types of uncertainties the WPS has to deal with and to present the benefits of the use of the UncertWeb framework.

Examining factors associated with excess mortality in older people (age ≥ 70 years) with diabetes - a 10-year cohort study of older people with and without diabetes

Aims: To compare all-cause mortality in older people with or without diabetes and consider the associated risk of comorbidity and polypharmacy. Methods: A 10-year cohort study using data from the Health Innovation Network database (2003-2013) comparing mortality in people aged ≥ 70 years with diabetes (DM cohort) (n = 35 717) and without diabetes (No DM cohort) (n = 307 918). Results: The mean age of the DM cohort was 78.1 ± 5.8 years vs. 79.0 ± 6.3 years in the No DM cohort. Mean diabetes duration was 8.2 ± 8.1 years, and 30% had diabetes for > 10 years. The DM cohort had a greater comorbidity load and people in this cohort were prescribed more therapies than the No DM cohort. The 5- and 10-year survival rates were lower in the DM cohort at 64% and 39%, respectively, compared with 72% and 50% in the No DM cohort. The excess mortality in the DM cohort was greatest in those aged <75 years with longer duration diabetes, the relative hazard for mortality was higher in females. Although comorbidity and polypharmacy were associated with increased mortality risk in the DM cohort, this risk was lower compared with the No DM cohort. The hazard ratios (95% confidence interval) for comorbidities > 4 and medicines ≥ 7 were 1.29 (1.19 to 1.41) and 1.34 (1.25 to 1.43) in the DM cohort and 1.63 (1.57 to 1.70) and 1.48 (1.40 to 1.56) in the No DM cohort, respectively. Conclusions: There is significant excess mortality in older people with diabetes, which is unexplained by comorbidity or polypharmacy. This excess is greatest in the younger old with longer disease duration, suggesting that it may be related to the effect of diabetes exposure.

Hogyan bonthatók le a látható és láthatatlan falak? – Kooperatív kutatás a megváltozott munkaképességűek foglalkoztatásával kapcsolatos mentális gátak lebontásáról (How to break down the visible and unvisible walls? – A cooperative research about the breaking down of mental barriers of the employment of disabled people)

A szerzők tanulmányukban egy kooperatív kutatási projekt eredményeit mutatják be, melyet emberierőforrás- menedzsment szakos master hallgatókkal folytattak megváltozott munkaképességűek foglalkoztatásával kapcsolatban. Magyarországon rendkívül magas a munkanélküliség a fogyatékkal élők körében, és a szerzők úgy vélik, hogy a HR-szakértőknek kulcsfontosságú szerepük van abban, hogy a foglalkoztatási korlátokat fenntartják-e, vagy változtatnak a jelenlegi helyzeten. A kritikai emberierőforrás-fejlesztés és a kritikai pedagógia hagyományait követve kutatásuk kettős célt tűzött ki. Céljuk volt egyrészt a jövő HRszakembereinek megváltozott munkaképességűek foglalkoztatásával kapcsolatos mentális mintázatainak, attitűdjeinek és hiedelmeinek feltárása, amelyek az elnyomás, diszkrimináció vagy kizsákmányolás gyökerei lehetnek. Másrészt pedig a kooperatív kutatás alkalmazásával a hallgatók emancipációját szándékoztak előmozdítani, továbbá az üzleti felsőoktatást uraló pozitivista filozófiát és értékrendszert kívánták kihívás elé állítani, s ily módon segíteni egy kritikusabb világnézet kibontakozását. ________ In this paper we present the results of a cooperative inquiry research project undertaken with Master students specialized in Human Resource Management on the employment of disabled people. Unemployment among people with disabilities is very high in Hungary and HR professionals have a key role in maintaining or reducing employment barriers and modifying the present situation. Following the tradition of critical Human Resource Development and critical pedagogy, the aim of the research project was twofold. First, we aimed to reveal the mental patterns, attitudes and beliefs of future HR professionals to the employment of people with disabilities, which might become roots causes of domination, discrimination or exploitation. Secondly, through applying cooperative inquiry, researchers aimed to emancipate students and challenge the positivist philosophy and value system which usually dominate business education and thereby engender a more critical worldview.

What individuals with rheumatic diseases know about the Americans with Disabilities Act: A survey

Individuals with rheumatic diseases often have disabilities which limit one or more major life activity. Common disabilities among individuals with rheumatic illnesses such as chronic pain, hand deformities, and fatigue may be hidden. With a hidden disability, an individual may be unaware that he or she could qualify as disabled under the Americans with Disabilities Act (ADA). The ADA provides for reasonable accommodation for qualified individuals with disability related limitations. Accommodations under the ADA are designed to remove barriers preventing full participation in society, including employment, for individuals with disability related limitations.^ The primary objective of this study was to determine the knowledge level of individuals with rheumatic conditions about the Americans with Disabilities Act (ADA). One hundred and seven individuals with various rheumatic illnesses participated in this survey. The forty question survey included questions about type of rheumatic condition, employment, pain level, and knowledge of the ADA. Results of this study show that individuals with rheumatic conditions are more familiar with general information about the ADA and less familiar with specific information. The longer an individual has been diagnosed with a rheumatic condition the more he or she knows about the ADA. Common sources of information about the ADA are media and networking with others, rather than health care professionals. The recommendation for occupational therapists is to include education about the ADA as an integral component of treatment for all individuals with rheumatic conditions. ^

A qualitative study of the impact of an educational intervention on older parents of adults with disabilities engaged in the phenomenon of future-care planning

This phenomenological study describes the impact of an educational intervention on the day-to-day experiences of older parent caregivers of adults with developmental disabilities who were engaged in the process of future-care planning. Qualitative strategies of individual and focus group interviewing were used with a purposive sample of older caregivers. Participants were members of an existing parent support group. Twenty-three caregivers representing 18 families were queried before and after the education program. The disabilities represented were mental retardation, cerebral palsy and autism. Parents whose children live at or away from home were included. The intervention was conducted on five Saturdays over a two month period; the duration of the study was five months. Findings used typical words of the respondents from their individual and focus group interviews to describe feelings, attitudes and experiences in making future-care plans. Data from verbatim transcriptions and researcher's field notes were coded, analyzed, sorted into themes, and subjected to interpretive analysis. Respondents showed a positive change in attitudes and actions after participating in the education program, regardless of their initial stage in care planning. Fears were replaced by hope and determination; hesitation and ineptitude by feelings of competence and confidence; and procrastination and delay by purposeful actions. Other key findings: use of a planning document greatly aided caregivers; barriers to planning were often intrinsic and amenable to education; residential plans were the most difficult aspect of planning; listening to the experiences of other parent caregivers was helpful; and making burial plans for their offspring was one aspect of planning parents wished to do themselves. ^

Teacher efficacy of special education teachers of English language learners with disabilities

This research examined the perceived teacher efficacy of special education teachers of English Language Learners (ELLs) with educational disabilities by surveying 202 elementary special education teachers using the EXCEL Teacher Inventory. EXCEL consists of 20 teacher efficacy items, three open-ended questions, and participant demographic items. ^ Overall participant teacher efficacy scores were high. Of the variables assessed, a statistically significant difference in perceived efficacy was found with self-reported proficiency in the language of the target students. No statistically significant differences in teacher efficacy scores were found for (a) levels of teacher preparation; (b) number of years of teaching experience; or (c) socioeconomic status of the students. A multiple regression analysis indicated that, of the variables listed above, proficiency in the language of the target students accounted for significant variance in predicting the level of teachers' perceived efficacy. ^ Responses to the open-ended questions about what was most helpful when working with ELLs with disabilities yielded two major themes: organizational issues and teacher issues. Participants wrote numerous comments about the value of support from educational professionals and parents. Many participants recommended individuals in preservice programs take ESOL content specific courses. ^ The results demonstrate the positive correlation between proficiency in the language of the target students and teacher efficacy. This suggests that teachers of ELLs with disabilities have proficiency in the ELLs' native language (or have support from others who are language proficient) that allows them to distinguish between language difference and language disability and provide instruction in the native language when needed. Further, results from open-ended questions suggest that special education teacher preparation programs should include courses related specifically to strategies for teaching ELLs with disabilities, not just ELLs. ^

Class placement and academic and behavioral variables as predictors of graduation for students with disabilities

Dropout rates impacting students with high-incidence disabilities in American schools remain staggering (Bost, 2006; Hehir, 2005). Of this group, students with Emotional Behavioral Disorders (EBD) are at greatest risk. Despite the mandated national propagation of inclusion, students with EBD remain the least included and the least successful when included (Bost). Accordingly, this study investigated the potential significance of inclusive settings and other school-related variables within the context of promoting the graduation potential of students with Specific Learning Disabilities (SLD) or EBD. This mixed-methods study investigated specified school-related variables as likely dropout predictors, as well as the existence of first-order interactions among some of the variables. In addition, it portrayed the perspectives of students with SLD or EBD on the school-related variables that promote graduation. Accordingly, the sample was limited to students with SLD or EBD who had graduated or were close to graduation. For the quantitative component the numerical data were analyzed using linear and logistic regressions. For the qualitative component guided student interviews were conducted. Both strands were subsequently analyzed using Ridenour and Newman’s (2008) model where the quantitative hypotheses are tested and are later built-upon by the related qualitative meta-themes. Results indicated that a successful academic history, or obtaining passing grades was the only significant predictor of graduation potential when statistically controlling all the other variables. While at a marginal significance, results also yielded that students with SLD or EBD in inclusive settings experienced better academic results and behavioral outcomes than those in self-contained settings. Specifically, students with SLD or EBD in inclusive settings were found to be more likely to obtain passing grades and less likely to be suspended from school. Generally, the meta-themes yielded during the student interviews corroborated these findings as well as provided extensive insights on how students with disabilities view school within the context of promoting graduation. Based on the results yielded, provided the necessary academic accommodations and adaptations are in place, along with an effective behavioral program, inclusive settings can be utilized as drop-out prevention tools in special education.

An analysis of Haitian parents' perceptions of their children with disabilities

Parental involvement is an integral part of the educational system in the U.S. Yet, parents from non-mainstream racial/ethnic backgrounds have not fully grasped the nature of parental involvement expectations in the educational process and how these expectations may impact student achievement. The purpose of this study was to identify Haitian parents’ perceptions of their children with disabilities and the education these children were receiving. Several authors have conducted studies on parents of children with disabilities to better gain an understanding of the level of their involvement with their children’s education, their perceptions of the children, and their views on the school system (Harry, 1992a, 1992b). In this study, Haitian parents of children with disabilities were interviewed using an interview protocol. Through these interviews, this study explored 10 Haitian parents’ perceptions of their child with a disability, the education the child was receiving, their interaction with the school system, and how the disability had affected their relationship with their child and their involvement with the school. Findings of the present study revealed that these Haitian parents seldom disagreed with school personnel and did not seem to fully grasp the different methods available to address their concerns as parents of children with disabilities nor the role they were expected to play in the process. The majority did not have basic literacy skills in Creole or English. The parents in this study were overwhelmed by school written communication. Additionally, this study discovered that parents’ perceptions were guided by two core concepts: coping mechanisms and locus of control. Parents with an internal locus of control, who tended to be more educated, focused inward to find solutions to problems encountered. Those with an external locus of control relied on outside influences to resolve their problems. Parental involvement was strongly influenced by their values, beliefs, customs, and conceptual knowledge about disability; all closely aligned with culture and acculturation. Overall, these parents’ perceptions greatly influenced their thoughts and behaviors when they realized that their children with disabilities might fall short of their immigrant dreams of success they held for these children.

The effects of self-monitoring on homework completion and accuracy rates of students with disabilities in an inclusive general education classroom

This study investigated the effects of self-monitoring on the homework completion and accuracy rates of four, fourth-grade students with disabilities in an inclusive general education classroom. A multiple baseline across subjects design was utilized to examine four dependent variables: completion of spelling homework, accuracy of spelling homework, completion of math homework, accuracy of math homework. Data were collected and analyzed during baseline, three phases of intervention, and maintenance. ^ Throughout baseline and all phases, participants followed typical classroom procedures, brought their homework to school each day and gave it to the general education teacher. During Phase I of the intervention, participants self-monitored with a daily sheet at home and on the computer at school in the morning using KidTools (Fitzgerald & Koury, 2003); a student friendly, self-monitoring program. They also participated in brief daily conferences to review their self-monitoring sheets with the investigator, their special education teacher. Phase II followed the same steps except conferencing was reduced to two days a week, which were randomly selected by the researcher and Phase III conferencing was one random day a week. Maintenance data were taken over a two-to-three week period subsequent to the end of the intervention. ^ Results of this study demonstrated self-monitoring substantially improved spelling and math homework completion and accuracy rates of students with disabilities in an inclusive, general education classroom. On average, completion and accuracy rates were highest over baseline in Phase III. Self-monitoring led to higher percentages of completion and accuracy during each phase of the intervention compared to baseline, group percentages also rose slightly during maintenance. Therefore, results suggest self-monitoring leads to short-term maintenance in spelling and math homework completion and accuracy. ^ This study adds to the existing literature by investigating the effects of self-monitoring of homework for students with disabilities included in general education classrooms. Future research should consider selecting participants with other demographic characteristics, using peers for conferencing instead of the teacher, and the use of self-monitoring with other academic subjects (e.g., science, history). Additionally, future research could investigate the effects of each of the two self-monitoring components used alone, with or without the conferencing.^

Evaluating the Effectiveness of a Public School Prekindergarten Program for Children with Disabilities

A stratified sample of teachers was surveyed to determine their opinion about a Pre-k Program for Children with Disabilities. The results revealed that the teachers were satisfied with their students' progress, the support received from their administrators and district, and their ability to implement the curriculum to meet students' needs.

Universal Design for Learning and Differentiated Instruction: Resolving Competing Mandates of the Individuals with Disabilities Education Act and No Child Left Behind

Recent federal mandates require accountability for providing students with disabilities access to the general education curriculum. In this paper, the authors recommend that principles of Universal Design for Learning and Differentiated Instruction can help school personnel tailor their teaching to meet the various strengths and needs of individual students.

A Study of Teacher Efficacy of Special Education Teachers of English Language Learners with Disabilities

This research examined the perceived teacher efficacy of special education teachers of English Language Learners with disabilities. The results demonstrate the positive correlation between proficiency in the language of the target students and teacher efficacy. An analysis of responses yielded two major themes, organizational and teacher issues, affecting teacher performance.