Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

Disabled Children Negotiating School Life: Agency, Difference and Teaching Practice

This paper explores the school experiences of seven 11–14 year old disabled children, and focuses on their agency as they negotiated a complex, changing, and often challenging social world at school where “difference” was experienced in negative ways. The paper draws on ethnographic data from a wider three-year study that explores the influence of school experiences on both disabled and non-disabled children’s identity as they make the transition from primary to secondary school in regular New Zealand schools (although the focus of the present paper is only on the experiences of disabled children). The wider study considers how Maori (indigenous people of Aotearoa/New Zealand) and Pakeha (New Zealanders of NZ European descent) disabled children and their non- disabled matched peers (matched for age, gender and classroom) understand their personal identity, and how factors relating to transition (from primary to secondary school); culture; impairment (in the case of disabled children); social relationships; and school experience impact on children’s identities. Data on Maori children’s school experiences is currently being collected, and is not yet available for inclusion in this paper. On the basis of our observations in schools we will illustrate how disabled children felt and were made to feel different through an array of structural barriers such as separate provision for disabled students, and peer and teacher attitudes to diversity. However, we agree with Davis, Watson, Shakespeare and Corker’s (2003) interpretation that disabled children’s rights and participation at school are also under attack from a “deeper cultural division” (p. 205) in schools based on discourses of difference and normality. While disabled students in our study were trying to actively construct and shape their social and educational worlds, our data also show that teachers and peers have the capacity to either support or supplant these attempts to be part of the group of “all children”. We suggest that finding solutions that support disabled children’s full inclusion and participation at school requires a multi-faceted and systemic approach focused on a pedagogy for diverse learners, and on a consistent and explicitly inclusive policy framework centred on children’s rights.

Association of retinal arteriolar dilatation with lower verbal memory::The Edinburgh Type 2 Diabetes Study

Abstract


AIMS/HYPOTHESIS:

Retinal vascular calibre changes may reflect early subclinical microvascular disease in diabetes. Because of the considerable homology between retinal and cerebral microcirculation, we examined whether retinal vascular calibre, as a proxy of cerebral microvascular disease, was associated with cognitive function in older people with type 2 diabetes.

METHODS:

A cross-sectional analysis of 954 people aged 60-75 years with type 2 diabetes from the population-based Edinburgh Type 2 Diabetes Study was performed. Participants underwent standard seven-field binocular digital retinal photography and a battery of seven cognitive function tests. The Mill Hill Vocabulary Scale was used to estimate pre-morbid cognitive ability. Retinal vascular calibre was measured from an image field with the optic disc in the centre using a validated computer-based program.

RESULTS:

After age and sex adjustment, larger retinal arteriolar and venular calibres were significantly associated with lower scores for the Wechsler Logical Memory test, with standardised regression coefficients -0.119 and -0.084, respectively (p?<?0.01), but not with other cognitive tests. There was a significant interaction between sex and retinal vascular calibre for logical memory. In male participants, the association of increased retinal arteriolar calibre with logical memory persisted (p?<?0.05) when further adjusted for vocabulary, venular calibre, depression, cardiovascular risk factors and macrovascular disease. In female participants, this association was weaker and not significant.

CONCLUSIONS/INTERPRETATION:

Retinal arteriolar dilatation was associated with poorer memory, independent of estimated prior cognitive ability in older men with type 2 diabetes. The sex interaction with stronger findings in men requires confirmation. Nevertheless, these data suggest that impaired cerebral arteriolar autoregulation in smooth muscle cells, leading to arteriolar dilatation, may be a possible pathogenic mechanism in verbal declarative memory decrements in people with diabetes.

Long-term renal outcomes of patients with type 1 diabetes mellitus and microalbuminuria:an analysis of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications cohort

Microalbuminuria is a common diagnosis in the clinical care of patients with type 1 diabetes mellitus. Long-term outcomes after the development of microalbuminuria are variable.

Effect of intensive glycemic control on levels of markers of inflammation in type 1 diabetes mellitus in the diabetes control and complications trial

Type 1 diabetes mellitus is associated with an increased risk of cardiovascular disease (CVD) that is not fully explained by conventional risk factors. The Diabetes Control and Complications Trial (DCCT) showed that intensive diabetes therapy reduced levels of LDL cholesterol and triglycerides but increased the risk of major weight gain, which might adversely affect CVD risk. The present study examined the effect of intensive therapy on levels of several markers of inflammation that have been linked to risk of CVD.

Combinations of Prompt and Target Response Modalities and Their Impact on Emergent Relations and Teaching Efficiency.

In the present study, native Spanish speakers were taught a small English vocabulary (Spanish-to-English intraverbals). Four different training conditions were created by combining textual and echoic prompts with written and vocal target responses. The efficiency of each training condition was examined by analysing emergent relations (i.e., tacts) and the total number of sessions required to reach mastery under each training condition. All combinations of prompt-response modalities generated increases in correct responding on tests for emergent relations but when target responses were written, mastery criterion was reached faster. Results are discussed in terms of efficiency for emergent relations and recommendations for future directions are provided.

Data on carotid intima-media thickness and lipoprotein subclasses in type 1 diabetes from the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC)

Type 1 diabetes (T1DM) is associated with increased risk of macrovascular complications. We examined longitudinal associations of serum conventional lipids and nuclear magnetic resonance (NMR)-determined lipoprotein subclasses with carotid intima-media thickness (IMT) in adults with T1DM (n=455) enrolled in the Diabetes Control and Complications Trial (DCCT). Data on serum lipids and lipoproteins were collected at DCCT baseline (1983-89) and were correlated with common and internal carotid IMT determined by ultrasonography during the observational follow-up of the DCCT, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, at EDIC 'Year 1' (199-1996) and EDIC 'Year 6' (1998-2000). This article contains data on the associations of DCCT baseline lipoprotein profiles (NMR-based VLDL & chylomicrons, IDL/LDL and HDL subclasses and 'conventional' total, LDL-, HDL-, non-HDL-cholesterol and triglycerides) with carotid IMT at EDIC Years 1 and 6, stratified by gender. The data are supplemental to our original research article describing detailed associations of DCCT baseline lipids and lipoprotein profiles with EDIC Year 12 carotid IMT (Basu et al. in press) [1].

An after-school literacy program : investigating the experiences of students with literacy difficulties, their volunteer tutors, and the tutors' transition into the teaching profession

This research responds to a pervasive call for our educational institutions to provide students with literacy skills, and teachers with the instructional supports necessary to facilitate this skill acquisition. Questions were posed to gain information concerning the efficacy ofteaching literacy strategies to students with learning difficulties, the impact of this training on their volunteer tutors, and the influence of this experience on these tutors' ensuing instructional practice as teacher candidates in a preservice education program. Study #1 compared a nontreatment group of students with literacy difficulties who participated in the program and found that program participants were superior at reading letter patterns and at comprehending the elements of story grammar. Concurrently, the second study explored the experiences of 19 volunteer tutors and uncovered that they acquired instructional skills as they established a knowledge base in teaching reading and writing, and they affirmed personal goals to become future teachers. Study #3 tracked 6 volunteer tutors into their pre-service year and identified their constructions, and beliefs about literacy instruction. These teacher candidates discussed how they had intended to teach reading and writing strategies based on their position that effective teaching ofthese skills in the primary grades is integral to academic success. The teacher candidates emphasized the need to build rapport with students, and the need to exercise flexibility in lesson plan delivery while including activities to meet emotional and developmental requirements of students. The teacher candidates entered their pre-service education with an initial cognition set based on the limited teaching context of tutoring. This foundational ii perception represented their prior knowledge of literacy instruction, a perception that appeared untenable once they were immersed in a regular instructional setting. This disparity provoked some of the teacher candidates to denounce their teacher mentors for not consistently employing literacy strategies and individualized instruction. This critical perspective could have been a demonstration of cognitive dissonance. In the end, when the teacher candidates began to look toward the future and how they would manage the demands of an inclusive classroom, they recognized the differences in the contexts. With an appreciation for the need for balance between prior and present knowledge, the teacher candidates remained committed to implementing their tutoring strategies in future teaching positions. This document highlights the need for teacher candidates with instructional experience prior to teacher education, to engage in cognitive negotiations to assimilate newly acquired pedagogies into existing pedagogies.

A Study of role conflict, role ambiguity, locus of control, job satisfaction and participation in decision making among front-line vocational service workers for mentally retarded adults

This study was an investigation of individual and organizational factors, as perceived by front-line vocational service workers from Adult Rehabilitation Centres (ARC Industries) for mentally retarded adults. The specific variables which were measured included role conflict/role ambiguity (role factors), internal/external locus of control (individual differences), job satisfaction with work and supervision (job attitudes) and participation in deci~ion making (organizational factor). The exploration of these constructs was conducted by means of self-report questionnaires which were completed by sixty-nine out of a total of ninety front-line employees. The surveys were distributed in booklet form to nine distinct rehabilitation facilities from St. Catharines, West Lincoln, Greater Niagara, Port Colborne, WeIland, Fort Erie, Hamilton, Guelph and Brantford. The survey data was evaluated by the statisti.cal Package for the Social Sciences (SPSS) which used the Pearson Product Moment Correlation procedure and a compar~son of means test. A comparison of correlation coefficients test was also conducted. This statistical procedure was calculated mathematically. The results obtained from the statistical evaluation confirmed the prediction that self-reported measures of participation in decision making and satisfaction (work and supervision) would be negatively correlated with role conflict and role ambiguity. As well, the speculation that perceived satisfaction (work and supervision) would be positively correlated with participation in decision making was empirically supported. Internal and external locus of control did not contribute to a significant difference in r~sponses to role perceptions (conflict and ambiguity) , satisfaction (work and supervision) or the correlational relationship between participation in decision making and satisfaction (work and supervision). Overall, the findings from this study substantiated the importance of examining employee perceptions in the workplace and the interrelationships among individual and organizational variables. This research was considered a contribution to the general area of occupational stress and to the study of individuals in work organizations.

Sentence combining and thinking : a study of adult ESL learners

Thesis (M.Ed.)--Brock University, 2003.

The association of faculty's teaching philosophy and teaching behaviour, and critical thinking and self- direction in learning

The intent in this study was to investigate in what ways teachers· beliefs about education and teaching are expressed in the specific teaching behaviours they employ, and whether teaching behaviours, as perceived by their students, are correlated with students· critical thinking and self-directed learning. To this end the relationships studied were: among faCUlty members· philosophy of teaching, locus of control orientation, psychological type, and observed teaching behaviour; and among students· psychological type, perceptions of teaching behaviour, self-directed learning readiness, and critical thinking. The overall purpose of the study was to investigate whether the implicit goals of higher education, critical thinking and self-direction, were actually accounted for in the university classroom. The research was set within the context of path-goal theory, adapted from the leadership literature. Within this framework, Mezirow·s work on transformative learning, including the influences of Habermas· writings, was integrated to develop a theoretical perspective upon which to base the research methodology. Both qualitative and quantitative methodologies were incorporated. Four faCUlty and a total of 142 students participated in the study. Philosophy of teaching was described through faCUlty interviews and completion of a repertory grid. Faculty completed a descriptive locus of control scale, and a psychological type test. Observations of their teaching behaviour were conducted. Students completed a Teaching Behaviour Assessment Scale, the Self-Directed Learning Readiness Scale, a psychological type test, and the Watson-Glaser Critical Thinking Appraisal. A small sample of students were interviewed. Follow-up discussions with faculty were used to validate the interview, observation, teaching behaviour, and repertory grid data. Results indicated that some discrepancies existed between faculty's espoused philosophy of teaching and their observed teaching behaviour. Instructors' teaching behaviour, however, was a function of their personal theory of practice. Relationships were found between perceived teaching behaviour and students· self-directed learning and critical thinking, but these varied across situations, as would be predicted from path-goal theory. Psychological type of students and instructor also accounted for some of the variability in the relationships studied. Student psychological type could be shown as a partial predictor of self-directed learning readiness. The results were discussed in terms of theory development and implications for further research and practice.

A case study investigation of the learning needs of the Niagara grape and wine community

The Niagara Grape and Wine Community (NGWC) is an industry that has undergone rapid change and expansion as a result of changes in governmental regulations and consumer preferences. As a result of these changes, the demands of the wine industry workforce have changed to reflect the need to implement new strategies and practices to remain viable and competitive. The influx of people into the community with little or no prior practical experience in grape growing (viticulture) or winemaking (oenology) has created a need for additional training and learning opportunities to meet workforce needs. This case study investigated the learning needs of the members of this community and how these needs are currently being met. The barriers to, and the opportunities for, members acquiring new knowledge and developing skills were also explored. Participants were those involved in all levels of the industry and sectors (viticulture, processing, and retail), and their views on needs and suggestions for programs of study were collected. Through cross analyses of sectors, areas of common and unique interest were identified as well as formats for delivery. A common fundamental component was identified by all sectors - any program must have a significant applied component or demonstration of proficiency and should utilize members as peer instructors, mentors, and collaborators to generate a larger shared collective of knowledge. Through the review of learning organizations, learning communities, communities of practices, and learning networks, the principles for the development of a Grape and Wine Learning Network to meet the learning needs of the NGWC outside of formal institutional or academic programs were developed. The roles and actions of members to make such a network successful are suggested.

Teaching persons with intellectual disabilities and limited receptive and expressive communication how to recognize and assert their human rights

Persons with intellectual disabilities (ID) are far more likely to be abused than the general population, but there is little research on teaching people with ID about their rights. The goal of this study was to teach four participants with ID and limited communication abilities about their human rights by training them on specific rights topics. The training program included icebreaker activities, instruction on rights concepts, watching and answering questions about videotaped scenarios of rights restrictions, watching and answering questions about role pl ay scenarios of rights restrictions, and responding to brief, low risk in situ rights restrictions imposed by the researchers. Participant performance did not improve significantly or consistently from baseline to training on the questions asked about the videotaped or the role play scenarios, but two of three participants demonstrated defmite improvements in responding to in situ rights restrictions.

The value of using short-format podcasts to enhance learning and teaching

This paper presents the findings of a podcasting trial held in 2007-2008 within the Faculty of Economics and Business at the University of Sydney, Australia. The trial investigates the value of using short-format podcasts to support assessment for postgraduate and undergraduate students. A multi-method approach is taken in investigating perceptions of the benefits of podcasting, incorporating surveys, focus groups and interviews. The results show that a majority of students believe they gained learning benefits from the podcasts and appreciated the flexibility of the medium to support their learning, and the lecturers felt the innovation helped diversify their pedagogical approach and support a diverse student population. Three primary conclusions are presented: (1) most students reject the mobile potential of podcasting in favour of their traditional study space at home; (2) what students and lecturers value about this podcasting design overlap; (3) the assessment-focussed, short-format podcast design may be considered a successful podcasting model. The paper finishes by identifying areas for future research on the effective use of podcasting in learning and teaching.

An effective course of study for teaching hearing-impaired children TTY/TDD skills

This paper includes a course of study for teaching hearing impaired children about the use of TTY/TDD.