Phenomenology: A Method for the Interpretation of Patient-Reported Outcomes

Patient-reported outcome measures (PROMs) play a central role in clinical research and patient care resulting in a plethora of standardized PROMs to measure a range of constructs, including disease symptoms, health-related quality of life, and health status (Meadows/Reaney) used in a range of settings, including the nursing environment. However, the use of PROMs in drug development and their use in healthcare evaluation do not easily marry together. In drug development, standardization of measurement is key to the interpretation of the formation at a population level with minimal biases. However, in health care, the individual patient perspective, priority, and needs should be taken into account whereas, in the clinical encounter, one has to also deal with what is particular and unique. The purpose of this paper is to describe the characteristics of the phenomenological method as a means within a mixed-method framework, to supplement participants' patient-reported outcome numeric scores with a more in-depth commentary on the essence of the lived health experiences.

A patient-centred conceptual model of nocturnal scratch and its impact in atopic dermatitis: A mixed-methods study supporting the development of novel digital measurements

Background

Emerging digital measures and clinical outcome assessments (COAs) leveraging digital health technologies (DHTs) could address the need for objective, quantitative measures of symptoms of atopic dermatitis (AD), such as nocturnal scratching. Development of such measures needs to be supported by evidence reflecting meaningfulness to patients.

Objectives

To assess nocturnal scratching as a concept of interest associated with meaningful aspects of health of patients with AD (adults and children); and to explore patient-centred considerations for novel COAs measuring nocturnal scratch using DHTs.

Methods

Phase 1 evaluated disease impacts on everyday life and the lived experience with nocturnal scratching through qualitative interviews of AD patients and caregivers. Phase 2 deployed a quantitative survey to a sample of AD patients as well as caregivers.

Results

Four cohorts with various AD severity levels participated in Phase 1: (1) adults with AD (n = 15), (2) their caregivers/spouses/partners (n = 6), (3) children with AD (n = 14), and (4) their adult caregivers (n = 14). Findings were used to develop a conceptual model for nocturnal scratching as a potential concept of interest. The Phase 2 survey was completed by 1349 of 27640 invited adults with AD and caregivers of children with AD. The most burdensome aspects of AD reported were itchy skin and scratching. Overall, ∼65% of participants reported nocturnal scratching ≥1 day/week, resulting in ∼1-1.4 h of sleep lost per night. In all, 85%-91% of respondents considered it at least somewhat valuable that a treatment reduces night-time scratching. About 50% reported willingness to use technology to this end and ∼25% were unsure.

Conclusion

Our results represented by the conceptual model confirm that nocturnal scratch is a concept of interest related to meaningful aspects of health for patients with AD and therefore is worth being captured as a distinct outcome for clinical and research purposes. DHTs are suitable tools presenting an important measurement opportunity to assess and evaluate occurrence, frequency, and other parameters of nocturnal scratching as a disease biomarker or COA of treatment efficacy.

Diabetes and Covid-19: Diabetes research funding and support during the pandemic

AIMS

Between late 2020 and early 2022, EURADIA undertook a survey of organisations and individuals supporting or working in the field of diabetes research with the aim of understanding better the impact of the Covid-19 pandemic on funding for diabetes research in Europe.

METHODS

Information was collected via online survey augmented in some cases by face-to-face interviews.

RESULTS

Findings were mixed but the majority of those responding suggested a moderate impact of the pandemic on diabetes research activity. Many respondents reported a reduction in funding during the pandemic and many of those involved in clinical research experienced a reduction in research clinicians' availability for diabetes research as they were redeployed to Covid-19 patient care. It was frequently reported that the impact might not be fully appreciated until several years after the end of the pandemic.

CONCLUSIONS

This preliminary survey suggests there may be a significant impact of the pandemic on all aspects of diabetes research and that a more detailed follow-up on the impact of the pandemic on funding of diabetes research should be carried out in the future.

Patient-reported Outcome Measures - A Call for More Narrative Evidence

This article puts forward the need to reconsider the current underlying quantitative approach underpinning the application of patient reported outcomes, to a mixed methods approach through the tandem use of patients’ narrative that enables informants in addition to their scores to express the reality of the ways in which their lives are physically and mentally impacted by their health status.

Developing preference-based measures for diabetes: DHP-3D and DHP-5D

AIMS

The aim of this study was to develop two diabetes-specific preference-based measures [the Diabetes Health Profile-3 Dimension (DHP-3D) and the Diabetes Health Profile-5 Dimension (DHP-5D)] for use in the calculation of Quality Adjusted Life Years, a key outcome in economic evaluation. These measures were based on the non-preference-based instrument the Diabetes Health Profile.

METHODS

For DHP-3D, psychometric and Rasch analyses were used to develop a health state classification system based on the Diabetes Health Profile-18 (DHP-18). The DHP-5D added two dimensions to the DHP-3D to extend the range of impacts measured. Each classification system was valued by 150 general public respondents in the United Kingdom using Time Trade Off (TTO). Multivariate regression was used to estimate utility value sets. The matched dimensions across each measure were compared using z-score tests.

RESULTS

The DHP-3D included three dimensions defined as mood, eating and social limitations, and the DHP-5D added dimensions defined as hypoglycaemic attacks and vitality. For both, the random effects generalized least squares regression model produced consistent value sets, with the DHP-3D and DHP-5D ranging from 0.983 (best state) to 0.717 (worst state), and 0.979 to 0.618 respectively. The addition of the two extra dimensions leads to significant differences for the more severe levels of each matched dimension.

CONCLUSIONS

We have developed two diabetes-specific preference-based measures that, subject to psychometric assessment, can be used to provide condition-specific utility values to complement generic utilities from more widely validated measures such as the EuroQol-5 Dimension.

Developing a questionnaire to determine the impact of self-management in diabetes: giving people with diabetes a voice

Background

The prevalence of diabetes mellitus (DM) is increasing dramatically, placing considerable financial burden on the healthcare budget of each country. Patient self-management is crucial for the control of blood glucose, which largely determines the chances of developing diabetes-related complications. Self-management interventions vary widely, and a method is required for assessing the impact of self-management. This paper describes the development of a questionnaire intended for use to measure the impact of self-management in diabetes.

Methods

An iterative development process was undertaken to identify the attributes of self-management using 5 steps. First, a literature review was undertaken to identify and understand themes relating to self-management of DM to inform a topic guide. Second, the topic guide was further refined following consultation with a Patient and Public Involvement group. Third, the topic guide was used to inform semi-structured interviews with patients with Type 1 DM (T1DM) and Type 2 DM (T2DM) to identify how self-management of DM affects individuals. Fourth, the research team considered potential attributes alongside health attributes from an existing measure (Diabetes Health Profile, DHP) to produce an instrument reflecting both health and self-management outcomes simultaneously. Finally, a draft instrument was tested in a focus group to determine the wording and acceptability.

Results

Semi-structured interviews were carried out with 32 patients with T1DM and T2DM. Eight potential attributes were identified: fear/worry/anxiety, guilt, stress, stigma, hassle, control, freedom, and feeling supported. Four of these self-management attributes were selected with four health attributes (mood, worry about hypos (hypoglycaemic episodes), vitality and social limitations) to produce the Health and Self-Management in Diabetes (HASMID^v1) questionnaire.

Conclusions

HASMID^v1 is a short questionnaire that contains eight items each with four response levels to measure the impact of self-management in diabetes for both T1DM and T2DM. The measure was developed using a mixed-methods approach that involved semi-structured interviews with people with diabetes. The measure has high face validity. Ongoing research is being undertaken to assess the validity of this questionnaire for measuring the impact of self-management interventions in economic evaluation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-017-0719-4) contains supplementary material, which is available to authorized users.

Treatment of facial erythema in patients with rosacea with topical brimonidine tartrate: correlation of patient satisfaction with standard clinical endpoints of improvement of facial erythema

BACKGROUND

Once-daily brimonidine tartrate (BT) 0.5% gel was shown to provide significantly greater efficacy vs. vehicle for the treatment of facial erythema in patients with rosacea.

OBJECTIVES

To demonstrate that patient satisfaction with overall appearance is correlated with reduction in facial erythema, as measured by clinician and patient assessments.

METHODS

Data from two identical phase III, multicentre, randomized, controlled trials of moderate facial erythema of rosacea (study A: n = 260; study B: n = 293) with topical BT 0.5% compared to vehicle gel once-daily for 4 weeks were analysed. Correlations of Patient's Assessment of Appearance (PAA) with Clinician's Erythema Assessment (CEA) and Patient's Self-Assessment (PSA) of erythema were evaluated by calculation of gamma statistics.

RESULTS

PAA correlated with CEA post-application on Days 1, 15 and 29 for the intent-to-treat population and provided a median gamma value of 0.57 (min = 0.28, max = 0.61). PAA and PSA was also highly correlated post-application on Days 1, 15 and 29; with a median gamma value of 0.87 (min = 0.66, max = 0.89). Subjects who achieved a clinically meaningful improvement in both CEA and PSA scales were more likely to report satisfaction with the overall appearance of their skin (P < 0.001).

CONCLUSIONS

Both one- and two-grade improvements in facial erythema assessed by subjects (PSA) and clinicians (CEA) correlate well with PAA, a patient-centered representation of meaningful change.

The construct validity and responsiveness of the EQ-5D, SF-6D and Diabetes Health Profile-18 in type 2 diabetes

BACKGROUND

Interest in the measurement of health related quality of life and psychosocial functioning from the patient's perspective in diabetes mellitus has grown in recent years. The aim of this study is to investigate the psychometric performance of and agreement between the generic EQ-5D and SF-6D and diabetes specific DHP-18 in Type 2 diabetes. This will support the future use of the measures by providing further evidence regarding their psychometric properties and the conceptual overlap between the instruments. The results will inform whether the measures can be used with confidence alongside each other to provide a more holistic profile of people with Type 2 diabetes.

METHODS

A large longitudinal dataset (n = 1,184) of people with Type 2 diabetes was used for the analysis. Convergent validity was tested by examining correlations between the measures. Known group validity was tested across a range of clinical and diabetes severity indicators using ANOVA and effect size statistics. Agreement was examined using Bland-Altman plots. Responsiveness was tested by examining floor and ceiling effects and standardised response means.

RESULTS

Correlations between the measures indicates that there is overlap in the constructs assessed (with correlations between 0.1 and 0.7 reported), but there is some level of divergence between the generic and condition specific instruments. Known group validity was generally good but was not consistent across all indicators included (with effect sizes from 0 to 0.74 reported). The EQ-5D and SF-6D displayed a high level of agreement, but there was some disagreement between the generic measures and the DHP-18 dimensions across the severity range. Responsiveness was higher in those who self-reported change in health (SRMs between 0.06 and 0.25).

CONCLUSIONS

The psychometric assessment of the relationship between the EQ-5D, SF-6D and DHP-18 shows that all have a level of validity for use in Type 2 diabetes. This suggests that the measures can be used alongside each other to provide a more holistic assessment of with the quality of life impacts of Type 2 diabetes.

Once-daily topical brimonidine tartrate gel 0·5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies

BACKGROUND

Erythema of rosacea is thought to result from abnormal cutaneous vasomotor activity. Brimonidine tartrate (BT) is a highly selective α(2) -adrenergic receptor agonist with vasoconstrictive activity.

OBJECTIVE

To determine the optimal concentration and dose regimen of topical BT gel for the treatment of erythema of rosacea and to evaluate its efficacy and safety.

METHODS

In study A, 122 subjects were randomized to receive a single application of BT 0·07%, 0·18%, 0·5% or vehicle. In study B (4-week treatment and 4-week follow-up), 269 subjects were randomized to receive BT 0·5% once daily, BT 0·18% once daily, vehicle once daily, BT 0·18% twice daily or vehicle twice daily. Evaluations included Clinician's Erythema Assessment (CEA), Patient's Self-Assessment (PSA), Chroma Meter measurements and adverse events.

RESULTS

In study A, a single application of topical BT gel reduced facial erythema in a dose-dependent fashion. A significant difference between BT 0·5% and vehicle in Chroma Meter redness value was observed from 30min to 12h after application. In study B, BT 0·5% once daily had a statistically superior success profile (defined as a two-grade improvement on both CEA and PSA over 12h) compared with vehicle once daily on days 1, 15 and 29 (all P<0·001). No tachyphylaxis, rebound of erythema or aggravation of other disease signs (telangiectasia, inflammatory lesions) was observed. All regimens were safe and well tolerated with similarly low incidence of adverse events.

CONCLUSIONS

Once-daily BT gel 0·5% is well tolerated and provides significantly greater efficacy than vehicle gel for the treatment of moderate to severe erythema of rosacea.

Factors associated with psychological and behavioral functioning in people with type 2 diabetes living in France

BACKGROUND

To identify demographic and clinical factors associated with psychological and behavioral functioning (PBF) in people with type 2 diabetes living in France.

METHODS

In March 2002, approximately 10,000 adults, who had been reimbursed for at least one hypoglycemic treatment or insulin dose during the last quarter of 2001, received a questionnaire about their health status and PBF (3,646 responders). For this analysis, the 3,090 persons with type 2 diabetes, aged 18-85 years old were selected.PBF was measured with the adapted version of the Diabetes Health Profile for people with type 2 diabetes. This permitted the calculation of three functional scores - psychological distress (PD), barriers to activity (BA), and disinhibited eating (DE) - from 0 (worst) to 100 (best).

RESULTS

Major negative associations were observed with PBF for microvascular complications (a difference of 6.7 in the BA score between persons with and without microvascular complications) and severe hypoglycemia (difference of 7.9 in the BA score), insulin treatment (-8.5 & -9.5 in the PD & BA scores respectively, as compared to treatment with oral hypoglycemic agents), non-adherence to treatment (-12.3 in the DE score for persons forgetting their weekly treatment), increasing weight (-8.5 & -9.7 in the PD & DE scores respectively, as compared to stable weight), at least one psychiatrist visit in 2001 (-8.9 in the DE score), and universal medical insurance coverage (-7.9 in the PD score) (due to low income).

CONCLUSION

Prevention and management of microvascular complications or adherence to treatment (modifiable factors) could be essential to preserving or improving PBF among people with type 2 diabetes. A specific approach to type 2 diabetes management may be required in groups with a low socioeconomic profile (particularly people with universal medical insurance coverage), or other non modifiable factors.

Development and validation of the insulin treatment satisfaction questionnaire

BACKGROUND

Treatment of diabetes mellitus (DM) is complex, requiring multifaceted lifestyle change or regulation and, for many, self-regulation of insulin levels in the blood. Historically, daily insulin treatment has been viewed as burdensome to patients, prompting newer formulations and improved delivery methods.

OBJECTIVE

This multicenter, clinical study was designed to develop a conceptually sound, clinically meaningful, and psychometrically valid measure of insulin treatment satisfaction, applicable to a wide range of insulin therapies.

METHODS

A 3-phase iterative process was employed to develop and validate the Insulin Treatment Satisfaction Questionnaire (ITSQ): (1) conceptual development of items, (2) preliminary validation among patients with DM, and (3) confirmatory validation among patients with DM.

RESULTS

The ITSQ was validated with 170 patients in phase 2 and 402 patients in phase 3. Confirmatory factor analysis produced a 5-factor, 22-item instrument assessing regimen inconvenience, lifestyle flexibility, glycemic control, hypoglycemic control, and satisfaction with the insulin delivery device. Results for reliability and construct validity of the final version were consistent in both samples of patients treated with insulin, with different data collection methods. Internal consistency (using Cronbach alpha coefficient) of the subscales ranged from 0.79 to 0.91. Test-retest reliability (using Spearman rank correlation coefficients) ranged from 0.63 to 0.94. ITSQ scores showed moderate to high correlation with related measures of treatment burden. The ITSQ differentiated among insulin delivery methods, glycosylated hemoglobin values, the number of times the patient required assistance administering insulin, and insulin adherence.

CONCLUSION

In our study samples, the ITSQ appeared to be conceptually and psychometrically sound and applicable to a wide range of insulin therapies.

Number of non-diabetic drugs: a simple comorbidity indicator for diabetes?

INTRODUCTION

The number of non-diabetic drugs, taken by a patient with diabetes at any one point in time, has been validated in previous studies as a comorbidity indicator.

AIM

The aim of the paper is to examine the relationship between this comorbidity indicator and health status in people with Type 2 diabetes.

METHOD

The analysis presented is from a prospective cohort study of people with Type 2 diabetes before and after commencing insulin therapy, with simultaneous collection of health status, clinical and other comparative data.

RESULTS

Of the 48 people for whom both health status and drug data were available, 26 (54%) were taking at least one non-diabetic drug and 16 (33%) were taking 3 or more non-diabetic drugs, at the baseline assessment. There were no significant relationships between the number of non-diabetic drugs taken, and age, duration of diabetes or baseline HbA1c measurements. However, there were statistically significant relationships between the number of non-diabetic drugs and health status, in terms of depression and physical function.

CONCLUSION

Drug data are routinely recorded in primary care and therefore the number of non-diabetic drugs is a potentially widely available indicator. This indicator could be a useful, simple addition to datasets that not only proxies comorbidity but also relates to patients' physical function and depression status.

Perceptions of good medical practice in the NHS: a survey of senior health professionals

OBJECTIVES

To categorize senior health professionals' experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staff have of good medical practice, and to describe how problems of poor medical practice are currently managed.

DESIGN

A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures.

SETTING

A range of NHS settings in the UK: hospital trusts, health authorities/boards, local medical committees, community health councils.

SUBJECTS

Senior health professionals involved in the management of medical professional performance.

MAIN MEASURES

Perceptions of what constitutes good medical practice.

RESULTS

Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors.

CONCLUSIONS

Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice.

The effectiveness of the use of patient-based measures of health in routine practice in improving the process and outcomes of patient care: a literature review

Despite a number of potential benefits to both the clinician and the patient, patient-based measures of health have not been routinely or systematically used within routine practice by clinicians in the care of individual patients. There are a number of practical, methodological and attitudinal barriers which have so far limited the use of patient-based measures of health within routine practice. The extent to which these barriers are overcome is likely to influence the effectiveness of such instruments in improving the process and outcomes of patient care. This study reviewed the evidence for the effectiveness of this intervention and identified some of the factors that may influence its effectiveness. Thirteen relevant studies were located using search strategies on three computerized databases for 1987-97. The study found that clinicians see information from patient-based measures of health as valuable in the overall assessment of the patient and that its feedback to clinicians increases the detection of psychological and, to a lesser extent, functional problems. However, there was little evidence to suggest their use substantially changed patient management or improved patient outcomes. Our findings suggest that the ways in which patient based measures of health are implemented in routine practice may have an impact on their effectiveness. It is recommended that implementation strategies that are guided by theories of individual and organizational change might allow the barriers to using patient-based measures of health in routine practice to be identified and overcome more effectively.

NHS attitudes to good medical practice

Perceptions of good medical practice among senior NHS staff were collected through a survey. There are differences between the perceived seriousness of poor communication skills and poor technical skills.

Microencapsulated octreotide pamoate in advanced gastrointestinal and pancreatic cancer: a phase I study

Fourteen patients suffering from advanced colorectal (n = 7), pancreatic (n = 4) or gastric (n = 3) carcinomas received treatment with microencapsulated octreotide pamoate 90 mg i.m. every 4 weeks (n = 4), 160 mg i.m. every 4 weeks (n = 4) or 160 mg i.m. every 2 weeks (n = 6). Two patients had stable disease, one for 4 and one for 6 months. Plasma insulin-like growth factor (IGF)-I decreased by 49-53%, IGF-II by 27-37% and total IGF-binding protein (IGFBP)-3 by 16-19%, whereas IGFBP-1 increased by 35-55%. Insulin and C-peptide levels decreased by 29-38% and 41-46% respectively. A non-significant decrease in urinary GH secretion and an increase in the ratio of fragmented to intact IGFBP-3 as well as IGFBP-3 protease activity was seen. The increase in IGFBP-3 fragmentation correlated negatively with alterations in IGF-I and IGF-II (P < 0.05). We conclude that microencapsulated octreotide administered in doses up to 160 mg every 2 weeks is well tolerated and has pronounced effects on several components of the IGF system in plasma. In addition, changes in IGFBP-3 protease activity because of cancer may contribute to alterations in IGF-I and -II, indicating the importance of measuring this parameter in addition to IGFs and IGFBPs when evaluating alterations in IGF-I.

The effects of recombinant human IGF-I administration on concentrations of acid labile subunit, IGF binding protein-3, IGF-I, IGF-II and proteolysis of IGF binding protein-3 in adolescents with insulin-dependent diabetes mellitus

The long term therapeutic potential of recombinant human (rh) IGF-I administration in insulin-dependent diabetes mellitus (IDDM) may be determined by changes in the IGF binding proteins (IGFBPs) and thus the bioavailability of IGF-I. We have therefore studied the effects of a single subcutaneous dose of rhIGF-I (40 micrograms/kg at 1800 h), when compared with an untreated control night, in 17 subjects with IDDM, on serum concentrations of IGF-I, IGF-II, IGFBP-3, acid labile subunit (ALS), and IGFBP-3 proteolysis. Mean (+/- S.E.M.) IGF-I levels increased from 242 +/- 30 ng/ml to 399 +/- 26 ng/ml (P = 0.01) after rhIGF-I whereas IGF-II levels declined from 600 +/- 45 ng/ml to 533 +/- 30 ng/ml. There was a small overnight reduction in baseline ALS levels from 48 +/- 2.8 to 44.5 +/- 3.2 micrograms/ml (P = 0.04) after rhIGF-I administration. An early fall in IGFBP-3 concentrations on the control night was not seen after rhIGF-I and overall mean levels were increased (5.2 +/- 0.2 micrograms/ml vs 4.9 +/- 0.2 micrograms/ml, P = 0.04, on the control night). On the baseline night, IGFBP-3 levels correlated with the sum of IGF-I and IGF-II (r = 0.73, P = 0.02) and with levels of the ALS (r = 0.7, P = 0.002). However after rhIGF-I, the sum of IGF-I and IGF-II no longer correlated with IGFBP-3, whereas the relationship with ALS was maintained. Immunoblot studies in six subjects indicated that 60%-70% of the IGFBP-3 was detected as a low molecular weight fragment at 1900 h on both study nights, but the amount of fragment declined to approximately 50% at 0100 h and 45% at 0700 h. In conclusion, despite a slight but significant fall in ALS, IGFBP-3 levels rise after rhIGF-I administration in IDDM. This cannot be explained by alterations in IGFBP-3 proteolysis, and may relate to the relative stability of ALS/IGFBP-3 when complexed principally with IGF-I rather than IGF-II.

Recurrence of primary spontaneous pneumothorax

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common clinical problem and its incidence is thought to be increasing. The risk of recurrence is high and various studies quote rates of 20-60%. Factors which may or may not predispose to recurrence have not yet been established.

METHODS

In a study period of four years 291 cases with a diagnosis of pneumothorax were reviewed; 153 patients with PSP were included in the study. Their risk of recurrence was analysed with particular reference to the following variables: age, sex, height and body mass index (BMI) of the patient, the initial size of pneumothorax, the smoking status of the patient, and the primary form of treatment employed. Univariate analysis was carried out by chi 2 testing and multivariate analysis was calculated by a logistic regression model.

RESULTS

A retrospective study of 275 episodes of PSP in 153 patients over a four year period confirmed a high incidence of recurrence (54.2%). PSP was twice as common in men as in women, though women were significantly more likely to develop a recurrence (chi 2 = 7.58, df = 1, p < 0.01). Male height was the second most important factor, and smoking cessation the only other variable which significantly influenced the risk of recurrence.

CONCLUSIONS

Analysis of several potential risk factors revealed that recurrence was not related to the BMI of the patient, the initial treatment of the pneumothorax, nor to its size. Recurrence was more common in taller men and in women. Smoking cessation appeared to reduce the risk of recurrence. These findings are discussed in the context of the possible aetiology of spontaneous pneumothorax, recurrences, and the management thereof.

A new self-completion outcome measure for diabetes: is it responsive to change?

Self-completion instruments assessing subjective health are increasingly being used to measure patient outcome. However, there is very little evidence as yet of existing instruments' responsiveness to change. This paper describes a study to evaluate the responsiveness to change of a self-completion instrument for the measurement of clinical outcome in patients with diabetes. A prospective follow-up study of 48 patients with non-insulin-dependent diabetes commencing insulin therapy was carried out, with assessments at baseline (i.e. pre-intervention), 6 weeks and 3 months post-intervention. The outcome measures used were the changes in scores on the self-completion instrument for symptom level, physical function, energy, depression, psychological distress and barriers to activity, HbA1c, non-fasting serum cholesterol and the body mass index (BMI). There were significant improvements in HbA1c and non-fasting serum cholesterol and worsening of the BMI, as expected. The self-completion instrument detected significant improvements in patient-reported symptoms within 6 weeks of the intervention (p < 0.01) and in energy levels (p < 0.05). There is evidence from this study of the self-completion instrument's ability to respond to change and it has potential for use in evaluative studies.

The relevance of chondroitin and keratan sulphate markers in normal and arthritic synovial fluid

This study investigated the synovial fluid concentrations of glycosaminoglycan (GAG), keratan sulphate (KS) epitope 5D4 and chondroitin sulphate (CS) sulphation patterns in healthy volunteers and patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Synovial fluids were collected from knee joints of healthy volunteers (n = 24), and patients with OA (n = 28) and RA (n = 29). Concentrations of GAG and the keratan sulphate epitope 5D4 were measured in 15 of the healthy volunteers, and all of the OA and RA synovial fluids. Total GAG was measured using a dye-binding method and 5D4 by an ELISA. The unsaturated CS disaccharides delta C4 and delta C6 were measured by capillary electrophoresis in all synovial fluids. The concentrations of GAG, 5D4 and delta C6 in the normal synovial fluid were higher but that of delta C4 lower than those of the disease groups. The delta C6:delta C4 ratios correlated with age (r = -0.437, P < 0.001) and the mean value was lower in females than males (2.92 compared with 5.22, P < 0.001). After allowing for age and sex, the delta C6:delta C4 ratio in the control group was significantly elevated (P < 0.001) compared to both OA and RA. The ratio was also related to proteoglycan markers (r = 0.383 for 5D4 and r = 0.357 for GAG). The finding that 5D4 and delta C6:delta C4 ratios are higher in synovial fluid from healthy volunteers compared to OA and RA suggests that they may be markers of the susceptibility of articular cartilage to early damage in arthritis.

Effects of friendship and gender on peer group entry

Effects of hosts' conflicting motives (to win a game vs. to be a good friend) on peer group entry processes and outcomes were examined. Subjects were 68 triads (35 female) of 10-12-year-old predominantly White children. Two host friends played a game for a large prize that was forfeited for a smaller prize if the guest (a friend or nonfriend of both hosts) was included. Hosts admitted guest friends more often than nonfriends (44% vs. 26%), suggesting that friendship norms prescribe self-sacrifice. Hosts behaved similarly with guest friends and nonfriends, but guest friends were more active than nonfriends, reflecting freedom derived from friendship security. Female hosts admitted guests more often than male hosts (51% vs. 21%), consistent with communal and agentic gender role prescriptions for girls and boys, respectively. Results suggest that hosts' friendship obligations and psychological orientation affect their response to a newcomer in a group entry situation.

The validity and reliability of the Diabetes Health Profile (DHP) in NIDDM patients referred for insulin therapy

Recently, a new diabetes-specific questionnaire, the Diabetes Health Profile (DHP), has been developed to identify psychosocial dysfunctioning of insulin-requiring (NIDDM) and insulin-dependent diabetes mellitus (IDDM) patients. The DHP comprises three dimensions: psychological distress (PSY: 14 items), barriers to activity (BAR: 12 items) and disinhibited eating (EAT: five items). This study investigates the psychometric properties of the DHP in Dutch non-insulin-dependent diabetes mellitus (NIDDM) patients referred for insulin therapy. In addition, the relationship between patient characteristics and the DHP outcome was examined. The factor structure found was similar but not identical to former studies, but construct validity was supported by high correlations of our factor structure and the original factor outcome and Cronbach's alpha. The three factors explained 32% of the variance, supporting earlier findings. It was shown that Cronbach's alpha was satisfactory (0.72, 0.72 and 0.79). Convergent validity showed strong and significant correlations between the PSY/BAR dimensions and predicted corresponding scales of the RAND-36. However, the PSY/BAR dimensions also showed, although less strong, significant correlations with the non-corresponding RAND-36 scales. The EAT dimension showed only correlations with two of the RAND-36 dimensions, thus measuring a different trait. Regression analysis showed that older patients had less problems with items of the EAT dimension and that no difference was found between men and women, supporting earlier findings. The hyperglycaemic complaint "fatigue' gave a significantly lower score (more problems) on the PSY and BAR dimensions. Younger age, the presence of hypertension and retinopathy resulted in a significantly lower score on the EAT dimension. DHP outcome was not significantly influenced by duration of diabetes, HbA1c (indicator of glycemic control), serum total cholesterol, body mass index, chronic diabetes complications and co-morbidity. Overall, the psychometric properties were good considering the small and diverse sample, suggesting that the DHP is promising for use in NIDDM patients, although more study is necessary in a larger sample.

The Diabetes Health Profile (DHP): a new instrument for assessing the psychosocial profile of insulin requiring patients--development and psychometric evaluation

The aim of the studies was to evaluate the psychometric properties and construct validity of the Diabetes Health Profile (DHP-1). Content for the DHP-1 was derived following in-depth interviews with 25 insulin dependent and insulin requiring patients, a review of the literature and discussions with health care professionals. Initial analysis of the factor structure of the DHP-1 was carried out on the responses of 239 insulin dependent and insulin requiring patients, with a mean age of 40.85 years (SD = 13.0), resulting in a 43 item three factor solution. The 43 item version of the DHP-1 was completed by 2,239 insulin dependent/requiring patients (mean age = 39.8, SD = 10) years. Fifty-one per cent were men. A forced three factor Principal Factoring Analysis with varimax rotation was carried out. Eleven items were excluded with item factor cross loadings > 0.30 or item factor loadings < 0.30. PAF analysis of the 32 items resulted in a three factor solution accounting for 33% of the total explained variance. The three factors were interpreted as Psychological Distress, Barriers to Activity and Disinhibited Eating. Factor congruence between subsamples were: Psychological distress (0.93), Barriers to Activity (0.93) and Disinhibited Eating (0.99). Coefficients of congruence between men and women were 0.94, 0.92 and 0.99 for Psychological Distress, Barriers to Activity and Disinhibited Eating respectively. Internal consistency of the three factors (Cronbach's alpha) were: Psychological Distress (0.86), Barriers to Activity (0.82), and Disinhibited Eating (0.77). Construct-convergent validity was investigated on a sample of 233 insulin dependent and insulin requiring patients (mean age = 51.46 years). Psychological Distress and Barriers to Activity subscales correlated with the Hospital Depression and Anxiety Scale = 0.50 to 0.62, p < 0.01) and subscales of the SF-36 (range: r = -0.17 to -0.62, p < 0.01). These findings lend support to the construct validity and reliability of the DHP-1 and that it is suitable for further development.

Intra-articular hyaluronic acid in osteoarthritis of the knee: an investigation into mechanisms of action

The objective of this study was to investigate mechanisms of action of intra-articular hyaluronic acid in osteoarthritis (OA) of the knee. Twelve patients with bilateral knee OA and synovial effusions entered a randomized, single-blind, blind observer study. Hyaluronic acid ("Hyalgan", Fidia SpA, Italy) or placebo were given by intra-articular injection weekly for 5 weeks. Assessments included clinical indices and imaging (magnetic resonance imaging (MRI) and 99m Tc bone scanning) before and after the course of injections. In addition, synovial fluid keratan sulfate (KS), chondroitin sulfate (CS) and C-propeptide of type II collagen (CPII) were measured. MRI and 99m Tc scanning showed no change in either treated or placebo knees over the 6-week study period. A fall in KS levels occurred in treated knees compared with placebo (Wilcoxon paired test, P = 0.1), although this did not reach significance perhaps due to small sample numbers). Ten out of 12 treated knees showed a fall in KS, compared with four out of 12 placebo knees. CS and CPII levels did not change significantly. Intra-articular injection of hyaluronic acid did not result in any improvement in the clinical indices compared to the placebo. In conclusion, assessment of cartilage markers may be of value when studying novel therapies in OA. MRI appearances remain remarkably stable over a 6-week period.

Public awareness of the symptoms of diabetes mellitus

A cross-sectional survey by standard questionnaire was conducted to determine the public's knowledge (n = 480) of diabetes and diabetes symptoms. Four hundred and sixty-two (96%) subjects had heard of diabetes, 350 (73%) could give a rudimentary definition of diabetes, but 231 (48%) were unable to name any symptom and only 20 (4%) knew of thirst and polyuria in combination. The public's knowledge of diabetes symptoms is poor. This may possibly contribute to delayed presentation of Type 2 diabetes.

A successful pregnancy outcome in transfusion dependent thalassaemia major

A case of a successful pregnancy outcome in a patient with transfusion dependent beta thalassaemia major is presented. This is the first case reported from Australia, the only other in the literature being from the United Kingdom (1).