Holistic psychosocial determinants of adherence to medication in people with type 2 diabetes.

BACKGROUND: The aim of this study was to determine whether adherent and non-adherent patients with type 2 diabetes can be differentiated according to psychosocial characteristics. METHODS: A total of 1214 patients were included in the analysis. Data were derived from a cross-sectional observational study of adults with diabetes of the Access Santé (Access Health) panel of Kantar Health France. Patients completed a questionnaire on adherence to medication, psychological determinants (trust in physicians, constancy of habits, patience, temporal horizon, health locus of control, obedience, psychological reactivity, prevention vs promotion, optimism vs pessimism) and social deprivation. RESULTS: Of these 1214 subjects, 46.2% were considered strictly adherent to antidiabetic medication, as reflected by negative answers to all six questions suggesting a non-adherent behaviours, whereas 48.9% provided 1-2 positive answers and 4.9% provided 3-6 positive answers, and were considered non-adherent. In addition to the effect of younger age (P=0.03), multivariate logistic regression analysis demonstrated the following psychosocial determinants of non-adherence: chance locus of control (P=0.02); lack of trust in physicians (P=0.010); and pessimism (P=0.021). Multiple factor analysis identified adherence and social deprivation as dimensions separating three distinct patient populations: (i) non-adherent; (ii) adherent and socially deprived; and (iii) adherent and non-socially deprived. It also revealed that patience, obedience, cautious behaviour, optimism, trust in physicians and constancy of habits were associated with adherence. CONCLUSION: Of the multiple determinants of adherence, trust in physicians and constancy of habits represent modifiable factors, and constitute targets to prevent non-adherence because they can be reinforced through patient education and improved physician - patient relationship. Also, psychosocial determinants of adherence differ widely between socially deprived and non-deprived patients.

A case of stunning of lung and bone metastases of papillary thyroid cancer after a therapeutic dose (3.7 GBq) of 131I and review of the literature: implications for sequential treatments.

Thyroid stunning is usually defined as the inhibition or suppression of iodide trapping by remnant thyroid tissue or by functioning metastases following a diagnostic dose of 131I. The risk of stunning increases progressively with larger doses. Because the threshold above which this effect occurs in thyroid remnants seems to be between 37 MBq and 111 MBq of 131I, therapeutic 131I doses of 3.7 GBq may cause stunning. We describe stunning of papillary thyroid cancer lung and bone metastases after a therapeutic dose of 131I (3.7 GBq). A T1 bone metastasis and bilateral lung metastases were diagnosed by post-therapeutic dose whole-body scan. Nuclear MRI detected another lesion at T4, whose 131I fixation was not obvious. An additional 0.7 GBq were given after recombinant TSH, 37 days after the therapeutic dose; 24 h later, uptake by the lung and T1 metastases had disappeared, but trapping was again seen 6 months later on the post-therapeutic scan. This re-appearance is evidence in favour of the transitory and reversible character of stunning, and confirms its correspondence to the decreased ability of viable thyroid cells to trap iodine and not to their destruction. A better understanding of stunning would make it possible, in the event of rapidly progressing disease and in conjunction with recombinant thyroid stimulating hormone (TSH), to give several therapeutic doses of 131I in close succession without each dose hampering the effectiveness of the subsequent one.

[Value of scintigraphy using meta-iodo-benzyl-guanidine (MIBG) in the investigation of cardiac autonomic neuropathy in diabetic patients. Comparison with Ewing tests]. / Apport de la scintigraphie à la méta-iodo-benzyl-guanidine (MIBG) dans l'exploration de la neuropathie végétative cardiaque du diabétique. Comparaison avec les tests d'ewing.

UNLABELLED: Cardiac autonomic neuropathy is a frequent complication of diabetes leading to resting tachycardia, postural hypotension, painless myocardial ischaemia, rhythm disturbances and sudden cardiac death. The aim of the study was to evaluate in a diabetic population the sensitivity of two exploration modes of autonomic neuropathy in diabetics: the Ewing tests which are, at present time, the reference method and the (123-I) meta-iodo-benzyl-guanidine (MIBG) single photon emission computed tomography (SPECT) which evaluates the cardiac sympathetic innervation. PATIENTS AND METHODS: 9 male insulin-dependent diabetes mellitus patients were studied. Mean age was 40.7 +/- 15 years and diabetes duration was 10.8 +/- 6 years. None had hypertension or macroangiography as demonstrated by patient's history, clinical examination, rest and exercise electrocardiography and ambulatory blood pressure monitoring. The complications observed were background retinopathy in 2 patients, incipient nephropathy in 3 and a peripheral neuropathy in 1 patient. Ewing tests, i.e. Valsalva maneuver, beat to beat heart rate variation during deep breathing and standing, blood pressure response to standing and to sustained handgrip, were performed. The results were considered as pathologic when the score was over 2. After injection of 10 mCi (123-I) MIBG, planar images were realized at times 1, 2 and 4 hours and SPECT images after 2 hours. The heart/mediastinum uptake ratio was calculated. RESULTS: We noted abnormalities of planar images in 3 patients, SPECT images in 1, and both in 1 patient. None was positive for Ewing tests. CONCLUSION: Although MIBG SPECT will explore only the sympathetic innervation, these preliminary findings suggest that this technique could be more sensitive for the evaluation of cardiac autonomic neuropathy. Nevertheless cost and lack of disponibility of this technique should limit its use.

[Diabetes and travel]. / Diabète et voyages.

With the continuing expansion in international air travel, increasing numbers of diabetic patients consult physicians for advice before going abroad. Careful planning is required taking into account climatic and medical conditions at the destination. Diabetic travelers should pack an appropriate treatment kit and contract special insurance coverage for medical evacuation. Precautions are necessary to limit the effects of motion sickness and time differences on diabetes control and especially the risk of hypoglycemia. Special attention is needed to avoid digestive problems and prevent foot injuries which can lead to serious complications in diabetic patients. Diabetic patients cannot forget their health problem during vacation and must be especially cautious when traveling. However with proper training, the risks of foreign travel can be reduced to acceptable levels.