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Self-Monitoring of Blood Glucose in Type 1 Diabetes Patients with Insufficient Metabolic Control: Focused Self-Monitoring of Blood Glucose Intervention Can Lower Glycated Hemoglobin A1C.
No full textOBJECTIVE: Little attention has been given and few studies have been published focusing on how to optimize self-monitoring of blood glucose (SMBG) use to monitor daily therapy for persons with type 1 diabetes mellitus. This study was designed to evaluate the effect on glycated hemoglobin (A1C) of a structured intervention focused on SMBG in type 1 diabetes patients with insufficient metabolic control (A1C >/= 8%) using a randomized clinical trial design. METHOD: One hundred fifty-nine outpatients with type 1 diabetes on multiple injection therapy with insulin and A1C >/=8% were recruited and randomized to one group receiving a focused, structured 9-month SMBG intervention (n = 59) and another group receiving regular care based on guidelines (n = 64). RESULTS: Glycated hemoglobin values (mean % +/- standard deviation) at study start was similar: 8.65 +/- 0.10 in the intervention group and 8.61 +/- 0.09 in the control group. The two groups were comparable (age, gender, body mass index, complication rate, and treatment modality) at study start and had mean diabetes duration and SMBG experience of 19 and 20 years, respectively. At study end, there was decrease in A1C in the intervention group (p < .05), and the A1C was 0.6% lower compared with the control group (p < .05). No increase in the number of minor or major hypoglycemia episodes was observed in the intervention group during the study period. CONCLUSIONS: A simple, structured, focused SMBG intervention improved metabolic control in patients with longstanding diabetes type 1 and A1C >/= 8%. The intervention was based on general recommendations, realistic in format, and can be applied in a regular outpatient setting
SUPPORT Tools for Evidence-informed policymaking in health 6: Using research evidence to address how an option will be implemented.
No full textABSTRACT : This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.After a policy decision has been made, the next key challenge is transforming this stated policy position into practical actions. What strategies, for instance, are available to facilitate effective implementation, and what is known about the effectiveness of such strategies? We suggest five questions that can be considered by policymakers when implementing a health policy or programme. These are: 1. What are the potential barriers to the successful implementation of a new policy? 2. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes among healthcare recipients and citizens? 3. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary behavioural changes in healthcare professionals? 4. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary organisational changes? 5. What strategies should be considered in planning the implementation of a new policy in order to facilitate the necessary systems changes
Using a structured treatment, Friends for life, in Norwegian outpatient clinics. Results from a pilot study
No full textCBT treatment programmes for children and adolescents with anxiety disorders are promising as indicated by efficacy research. Replicating this research in ordinary clinical care is crucial in order to establish the validity of these results and disseminate empirically based treatments to practitioners. This paper presents the first experiences of using a structured programme, the Friends for Life manual, in ordinary clinical care in Norway targeting anxiety problems in children aged between 7 and 12 years. The effects of the treatment are presented as multiple single-case studies. Clinical meaningful change is considered from two perspectives; diagnostic change and changes in self-report measures. At a statistical significance level the treatment effect can be characterized as modest. Independent of the symptom reduction, the children, families and therapist are in the main satisfied with the structured approach indicating the acceptability of the programme
Bruk av informasjon fra kunnskapsoppsummeringer til å identifisere forskningsbehov
No full textNORSK: En systematisk kunnskapsoppsummering har til hensikt å vurdere og oppsummere all tilgjengelig forskningsbasert kunnskap om et tema eller spesifikt spørsmål. Kunnskapssenteret produserer slike oppsummeringer som del av metodevurderinger (HTA), og som enklere oppsummeringer av effekt av tiltak i helsetjenesten. En systematisk kunnskapsoppsummering skal gi et helhetlig bilde av kunnskapsstatus og kan bidra til ny kunnskap, men oppsummeringer kan også peke på kunnskapshull og vise vei for videre forskning. I denne rapporten oppsummerer vi forskningsbehov som er identifisert i forbindelse med oppsummeringene Kunnskapssenteret gjorde i 2008. Det er viktig å påpeke at disse temaene på ingen måte representerer alle forskningsbehov innen medisin og helsefag i Norge. Forskningsbehovene som vi viser til er fremkommet på basis av de spørsmål som vi har besvart i kunnskapsoppsummeringer, og med de metodene vi benytter
Effekten av psykoterapi for mennesker med depressive lidelser
No full textNORSK: Denne rapporten ble bestilt av Helsedirektoratet i oktober 2008. Kunnskapssenteret ble bedt om å framskaffe et kunnskapsgrunnlag som kunne hjelpe til å belyse effekten av psykoterapi på depresjonssymptomer og andre uttykk for nedsatt livskvalitet, for eksempel lav sosial funksjonsevne og trivsel.\ud
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Vi stilte ett hovedspørsmål: Hva er effekten av psykoterapi på depresjonssymptomer og andre uttykk for nedsatt livskvalitet for voksne mennesker med depressive lidelser?\ud
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Vi søkte systematisk etter litteratur i internasjonale forskningsdatabaser, og valgte ut systematiske oversikter og randomiserte kontrollerte studier (randomized controlled trials, RCT) som oppfylte våre predefinerte inklusjonskriterier. Vi vurderte deretter studienes metodiske kvalitet. I tråd med oppdraget la vi vekt på oversiktsartikler, samt data fra studier hvor psykodynamisk psykoterapi ble vurdert. Til slutt sammenstilte og oppsummerte vi resultatene.\ud
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Vi inkluderte ni artikler: Seks systematiske oppsummeringer og tre RCTer. De aller fleste av disse hadde høy metodekvalitet, men kunnskapsgrunnlaget var svært heterogent. Hovedkonklusjonen er at pasientene opplever bedring etter behandling i forhold til før behandling, uavhengig av hvilken behandling de mottar. Bedringen vedvarer over tid. Resultatene fra studiene antyder videre at psykoterapi fører til signifikant større bedring i depresjonssymptomer sammenlignet med standard legebehandling (for eksempel veiledning), men ser ikke ut til å være mer effektiv enn antidepressive medikamenter. Det ser ikke ut til å være markante forskjeller i effekt mellom ulike former for psykoterapi. Resultatene tyder på at det er få forskjeller i effekt mellom psykodynamisk terapi og andre former for psykoterapi.\ud
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Vi fant vitenskapelig dokumentasjon for at psykoterapi synes å redusere symptomer på depresjon for voksne med depressive lidelser. Denne kunnskapsoppsummeringen er en summarisk gjennomgang av nye systematiske oversikter og RCTer og de inkluderte studiene var svært heterogene. På tvers av artiklene var det derfor vanskelig å finne et empirisk grunnlag for solide konklusjoner på problemstillingenENGLISH: 1-page key messages\ud
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In October 2008, the Norwegian Directorate of Health commissioned the Norwegian Knowledge Centre for the Health Services (NOKC) to complete a review about the effects of psychotherapy for adults with depression. The review would help answer the question of how adults with depression should be best managed. We addressed one main question: What are the effects of psychotherapy on depression symptomatology and quality of life indicators for adults with depression?\ud
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We searched systematically for relevant literature in international scientific databases. We evaluated newly published systematic reviews and randomized controlled trials (RCTs) for inclusion using a pre-designed inclusion form. We then appraised the methodological quality of the included studies with appropriate check lists, and summarised the results in tables and text. In accordance with the commissioner's requests, we gave emphasis to findings from the systematic reviews and results related to psychodynamic psychotherapy.\ud
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We included and summarised results from a total of nine studies; six systematic reviews and three RCTs. The great majority of the studies were of high methodological quality. Study results show that patients significantly improved post-treatment. Findings suggest that psychotherapy is effective in reducing patients' depression symptomatology compared to treatment as usual. Improvements in depression symtomatology and social functioning appear to be modest, improvements are similar to those observed for psychopharmacological treatments, and no psychotherapy technique appears to be superior. Psychodynamic psychotherapy does not seem to cause greater improvements in depression symptomatology compared to other types of psychotherapy. \ud
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Based on the best available evidence, it appears that psychotherapy improves depression symptomatology in adults with depressive illnesses. However, the literature search was restricted and the evidence base for the current review was heterogeneous, thus the results must be viewed as tentative
Forskning på verdiarbeid i helsetjenesten – litteratursøk
No full textDette prosjektet ble gjort på oppdrag fra Diakonhjemmet sykehus. Mandatet for prosjektet var å identifisere litteratur som handlet om forskning på verdiarbeid i helsetjenesten publisert f.o.m. 1994.\ud
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Vi gjorde et systematisk litteratursøk for å identifisere oversikter og primærstudier som besvarte spørsmål knyttet til fire verdiområder: organisatoriske verdier, ledelsesverdier, profesjonsverdier og individuelle verdier. Verdiarbeid i organisasjoner utenfor helsetjenesten ble også inkludert. Det var ingen eksklusjonskriterier knyttet til studiedesign eller språk.\ud
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Vi søkte i følgende databaser: Ovid MEDLINE, Ovid EMBASE, Ovid British Nursing Index, ISI Web Of Science (Social Science Citation Index, Science Citation Index, Arts and Humanities Citation Index), SveMed, Cochrane Library of Systematic Reviews, Cochrane Method Studies, DARE, HTA, Sociological Abstracts, Emerald Management Journals og Google Scholar.\ud
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Søket resulterte i 5161 unike referanser som ble gjennomgått på sammedragsnivå. 256 publikasjoner ble vurdert som relevante i henhold til oppdraget.\ud
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Publikasjonene ble kategorisert i henhold til de fire verdiområdene:\ud
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organisatoriske verdier: 104 publikasjoner\ud
ledelsesverdier: 40 publikasjoner\ud
profesjonsverdier: 79 publikasjoner\ud
individuelle verdier: 33 publikasjoner\ud
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De fire verdiområdene som ble brukt til å sortere referansene gikk tematisk over i hverandre, men kan danne utgangspunkt for å få oversikt over et komplekst tema
Jevnlig testing av alle diabetespasienter for mikroalbuminuri
No full textNORSK: Nasjonalt kunnskapssenter for helsetjenesten ble etter forespørsel fra allmennlege Kjell Maartmann-Moe bedt om å vurdere effekten av å teste diabetespasienter for mikroalbuminuri (tilstand med vedvarende små, men høyere enn normale mengder proteiner i urinen). På bakgrunn av dette gikk vi høsten 2008 gjennom et utvalg nyere diabetesretningslinjer, inkludert utkast til norske nasjonale retningslinjer publisert våren 2009 og engelske retningslinjer fra NICE (National Institute for Health and Clinical Excellence) publisert i 2008. Vi fant at det gjennomgående anbefales at alle pasienter med diabetes følges opp med jevnlig måling av blodtrykk og testing for mikroalbuminuri.\ud
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Vi utførte deretter et innledende søk etter relevante systematiske oversikter om effekt av slik testing med hensyn til utfall som dødelighet, sykelighet, bivirkninger og kostnader. Vi fant ingen systematiske oversikter som oppsummerte oppfølging av diabetespasienter med testing for mikroalbuminuri sammenliknet med tilsvarende oppfølging uten en slik testing. Vi fant imidlertid en HTA-rapport fra 2005 som viste at pasienter med mikroalbuminuri hadde økt dødelighet og sykelighet sammenliknet med pasienter med normalt albuminnivå i urinen. Denne rapporten konkluderte med at det ikke foreligger tilstrekkelig kunnskapsgrunnlag for å kunne si at testing av alle diabetespasienter har en positiv helseeffekt. Derimot fant vi flere systematiske oversikter som oppsummerte diagnostisk nøyaktighet for påvisning av mikroalbuminuri og/eller albuminuri. Men disse oversiktene gir ikke noe sikre svar på spørsmål knyttet til effekt av testing.\ud
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Når det gjelder kostnader, fant vi ingen analyser som bygger på sikker informasjon om dødelighet og sykelighet.\ud
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Vi konkluderer derfor med at anbefalingen om jevnlig testing for mikroalbuminuri er basert på konsensus som tar utgangspunkt i en antatt positiv effekt. Vi finner det lite sannsynlig at det per i dag foreligger nye primærstudier som endrer konklusjonen og valgte derfor å ikke gjennomføre en full kunnskapsoppsummering. Vi understreker at mangel på kunnskapsgrunnlag av høy kvalitet for en effekt av testing i seg selv ikke gir grunnlag for å si at det er galt å anbefale testing. Dette notatet gir en kort sammenfatning av problemstillingen og bakgrunn for konklusjonen
Disruption of Vps4 and JNK function in Drosophila causes tumour growth.
No full textSeveral regulators of endocytic trafficking have recently been identified as tumour suppressors in Drosophila. These include components of the endosomal sorting complex required for transport (ESCRT) machinery. Disruption of subunits of ESCRT-I and -II leads to cell-autonomous endosomal accumulation of ubiquitinated receptors, loss of apicobasal polarity and epithelial integrity, and increased cell death. Here we report that disruption of the ATPase dVps4, the most downstream component of the ESCRT machinery, causes the same array of cellular phenotypes. We find that loss of epithelial integrity and increased apoptosis, but not loss of cell polarity, require the activation of JNK signalling. Abrogation of JNK signalling prevents apoptosis in dVps4 deficient cells. Indeed double deficiency in dVps4 and JNK signalling leads to the formation of neoplastic tumours. We conclude that dvps4 is a tumour suppressor in Drosophila and that JNK is central to the cell-autonomous phenotypes of ESCRT-deficient cells
Misoprostol ved igangsetting av fødsel
No full text1-PAGE KEY MESSAGES ***\ud
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BACKGROUND\ud
Approximately 55 000 children are born in Norway each year. It is sometimes necessary to induce labour artificially. With respect to induction with drugs, misoprostol and dinoprostone are used irrespective of whether the cervix is mature or not, while oxytocin only is used when the cervix is mature. The Norwegian Board of Health Supervision asked The Norwegian Knowledge Centre for the health Services to systematically review the efficacy and safety of misoprostol for induction of labour.\ud
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METHOD\ud
This report is an overview of systematic reviews. We performed systematic searches in Cochrane Library, CRD and Ovid Medline and Embase. All included publications were evaluated for quality. In addition, we evaluated the quality of the evidence and the strength of recommendations for selected outcomes.\ud
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We also performed an evaluation of legal aspects regarding the use of misoprostol for induction of labour.\ud
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RESULTS\ud
Five systematic reviews met our inclusion criteria. In the systematic reviews misoprostol was given vaginally, orally, sublingually or buccally. Misoprostol was used in different dosages and dosage intervals from study to study.\ud
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Our main findings were that vaginal and oral misoprostol was at least as effective as dinoprostone in inducing labour within 24 hours. However, it may have increased frequency of adverse events such as uterine hyperstimulation both without and with changes in fetal heart rate.\ud
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CONCLUSION\ud
It may appear that safety is more sensitive to the dose of misoprostol than efficacy. For sublingual and buccal administration of misoprostol the amount of data were limited and we were not able to conclude on efficacy and safety
Memantine in patients with Parkinson's disease dementia or dementia with Lewy bodies: a double-blind, placebo-controlled, multicentre trial.
No full textBACKGROUND: Dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) are common forms of dementia that substantially affect quality of life. Currently, the only treatment licensed for PDD is rivastigmine, and there are no licensed treatments for DLB. We aimed to test the safety and efficacy of the N-methyl D-aspartate (NMDA) receptor antagonist memantine in patients with PDD or DLB. METHODS: We did a parallel-group, 24-week, randomised controlled study of memantine (20 mg per day) versus placebo at four psychiatric and neurological outpatient clinics in Norway, Sweden, and the UK during 2005-08. Patients were included if they fulfilled the UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria for Parkinson's disease (PD) and developed dementia according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM IV) criteria at least 1 year after the onset of motor symptoms (PDD) or met the revised consensus operationalised criteria for DLB. Patients were assigned to a computer-generated randomisation list. All physicians who had contact with patients were masked to treatment allocation. The primary outcome measure was clinical global impression of change (CGIC), which ranged from 1 to 7 points, and a low score means a better outcome. Analysis was by intention to treat based on the last observation carried forward. This trial is registered, number ISRCTN89624516. FINDINGS: 72 patients with PDD or DLB were randomly assigned and started treatment: 34 with memantine and 38 with placebo. 56 (78%) completed the study. All withdrawals were owing to adverse events, but the proportion of withdrawals was similar in both groups. At week 24 the patients in the memantine group had better CGIC scores than those taking placebo (mean difference 0.7, 95% CI 0.04-1.39; p=0.03). With the exception of improved speed on attentional tasks in the memantine group (a quick test of cognition [AQT] form: difference 12.4, 95% CI 6.0-30.9; p=0.004), there were no significant differences between the groups in secondary outcome measures. INTERPRETATION: Patients with DLB or PDD might benefit from treatment with memantine, which was well tolerated. Large-scale studies are now required to confirm our preliminary findings. FUNDING: The Western Norway Regional Health Authority; H Lundbeck A/S