Physical symptom complaints, cognitive emotion regulation strategies, self-compassion and diabetes distress among adults with Type 2 diabetes.

AIMS: Diabetes-related distress is common among adults with Type 2 diabetes and is consistently associated with poorer self-management and treatment outcomes. However, little is known about the psychological factors that may contribute to or protect against diabetes distress. This study examined illness burden, and positive and negative ways of thinking and relating to oneself in times of stress, as independent correlates of diabetes distress, cross sectionally and longitudinally. METHOD: A total of 120 adults treated for Type 2 diabetes reported their physical symptom complaints, cognitive emotion regulation, self-compassion and diabetes distress at baseline; 110 completed a 3-month follow-up assessment of diabetes distress. Pearson correlations and multivariable linear regression tested baseline and longitudinal relationships. RESULTS: Baseline diabetes distress was associated with greater use of negative cognitive emotion regulation strategies (r = 0.43, P < 0.01), greater tendency towards self-criticism, self-judgement and over-identification (r = 0.37, P < 0.01), and greater physical symptom burden (r = 0.50, P < 0.01). Baseline physical symptoms and negative cognitive emotion regulation were independently associated with baseline diabetes distress. Baseline physical symptoms and negative aspects of self-compassion significantly predicted diabetes distress over 3 months. Positive aspects of cognitive emotion regulation and self-compassion were not independently associated with diabetes distress cross sectionally or longitudinally. CONCLUSION: Greater symptom burden along with the use of negative cognitive emotion regulation and negative aspects of self-compassion were independently associated with diabetes distress. If these relations are explained by causal influence, these modifiable factors could be fruitful targets for intervention research.

Diabetes technology: improving care, improving patient-reported outcomes and preventing complications in young people with Type 1 diabetes.

With the evolution of diabetes technology, those living with Type 1 diabetes are given a wider arsenal of tools with which to achieve glycaemic control and improve patient-reported outcomes. Furthermore, the use of these technologies may help reduce the risk of acute complications, such as severe hypoglycaemia and diabetic ketoacidosis, as well as long-term macro- and microvascular complications. In addition, diabetes technology can have a beneficial impact on psychosocial health by reducing the burden of diabetes. Unfortunately, diabetes goals are often unmet and people with Type 1 diabetes too frequently experience acute and long-term complications of this condition, in addition to often having less than ideal psychosocial outcomes. Increasing realization of the importance of patient-reported outcomes is leading to diabetes care delivery becoming more patient-centred. Diabetes technology in the form of medical devices, digital health and big data analytics have the potential to improve clinical care and psychosocial support, resulting in lower rates of acute and chronic complications, decreased burden of diabetes care, and improved quality of life.

Adapting and validating a measure of diabetes-specific self-compassion.

AIMS: Self-compassion (SC), or treating oneself with kindness when dealing with personal challenges, has not been rigorously examined in people with T1D. SC has been shown to buffer against negative emotions and to be linked to improved health outcomes, but diabetes-specific SC has not been studied. This study aimed to adapt the Self-Compassion Scale and validate it for a diabetes-specific population. METHODS: We developed and validated a diabetes-specific version of the Self-Compassion Scale (Neff, 2003) in a sample of adults with T1D (N=542; 65% female; 97% non-Hispanic White; M age 41, SD=15.7; M A1c=7.3, SD=1; 72% insulin pump users; 50% continuous glucose monitoring [CGM] users). Confirmatory factor analyses (CFA), and reliability and construct validity analyses were conducted. Validity measures included diabetes distress, diabetes empowerment, diabetes numeracy, and A1c. RESULTS: A two-factor bi-factor structure showed best fit, providing support for use of the adapted scale (SCS-D) as a unitary construct. The 19-item unidimensional SCS-D demonstrated excellent internal consistency (ɑ=0.94; range of item-total correlations: 0.52-0.71) and construct validity. As hypothesized, higher SCS-D was associated with less distress, greater empowerment, and lower A1c, and was not associated with numeracy. CONCLUSIONS: The SCS-D is a reliable and valid measure of diabetes-specific self-compassion in adults with T1D.

Diabetes distress from the patient's perspective: Qualitative themes and treatment regimen differences among adults with type 2 diabetes.

AIMS: To explore diabetes distress in a sample of adults with type 2 diabetes, treated and not treated with insulin. METHODS: Six focus groups were conducted with 32 adults with type 2 diabetes, divided by treatment regimen (insulin-treated N=15; 67% female; 60% black; 46% Hispanic; M age 54; M HbA1c 73mmol/mol (8.8%); non-insulin-treated N=17; 53% female; 65% black; 13% Hispanic; M age 58; M HbA1c 55mmol/mol (7.2%)). A coding team transcribed and analyzed interviews to describe themes. Themes were then compared between groups and with existing diabetes distress measures. RESULTS: Participants in both groups described a range of sources of diabetes distress, including lack of support/understanding from others, difficulties communicating with providers, and distress from the burden of lifestyle changes. Insulin-treated participants described significant emotional distress related to the burden of their insulin regimen. They were more likely to report physical burden related to diabetes; to describe feeling depressed as a result of diabetes; and to express distress related to challenges with glycemic control. Non-insulin-treated participants were more likely to discuss the burden of comorbid medical illnesses. CONCLUSIONS: Our data generate hypotheses for further study into the emotional burdens of diabetes for insulin-treated adults with type 2 diabetes and are in line with quantitative research documenting increased diabetes-related distress among insulin-treated individuals. Data describe needs, currently unmet by most models of care, for comprehensive assessment and tailored management of diabetes-related distress.

Successful self-management among non-insulin-treated adults with Type 2 diabetes: a self-regulation perspective.

AIMS: To clarify the role of self-monitoring of blood glucose (SMBG) in the self-management of Type 2 diabetes from the patient's perspective, using in-depth interviews with non-insulin-treated adults to investigate how they learned to manage their diabetes effectively and whether SMBG played a significant role in this process. METHODS: Individual interviews were conducted with 14 non-insulin-treated adults with Type 2 diabetes who had significantly improved their glycaemic control [64% women; 50% black; 21% Hispanic; mean age 60 years; mean HbA(1c) concentration 43 mmol/mol (6.1%)]. Interviews were transcribed and analysed by a coding team, applying the concept of illness coherence from the Common Sense Model of Self-Regulation. RESULTS: The majority of participants relied on SMBG to evaluate their self-management efforts. Key themes included: adopting an experimental approach; experiencing 'a-ha' moments; provider-assisted problem-solving; using SMBG and other feedback to evaluate when their efforts were working; and normalizing diabetes-specific behaviour changes as being healthy for everyone. CONCLUSIONS: Our qualitative data are consistent with the argument that SMBG, if implemented appropriately with enough education and provider access, can be a powerful tool for non-insulin-treated adults with Type 2 diabetes to monitor their self-management. Establishing sufficient conditions for illness coherence to develop while individuals are learning to use SMBG could increase their sense of personal control in managing a complex and demanding illness.

Extraocular muscle metastasis 16 years following primary prostate carcinoma.

An 83-year-old man with a history of localized prostate carcinoma treated 16 years prior with transurethral partial prostatectomy and radioactive seed implants presented with a 2-month history of right globe proptosis. Computed tomography demonstrated a right medial rectus mass. Serum prostate specific antigen (PSA) level was normal. Tumor biopsy revealed poorly differentiated carcinoma with diffuse staining of tumor cells with PSA and prostatic acid phosphatase. This case demonstrates that prostate carcinoma may metastasize to an extraocular muscle many years after treatment of the primary tumor and may not be accompanied by elevated serum PSA. Immunohistochemical stains are helpful in establishing the diagnosis.

Management and prognosis of Merkel cell carcinoma of the eyelid.

OBJECTIVE: To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS: Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES: Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS: Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS: Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

Excision of multiple eyelid apocrine hidrocystomas via an en-bloc lower eyelid blepharoplasty incision.

A 39-year-old man presented with upper and lower eyelid apocrine hidrocystomas that had recurred after each of three prior attempts at excision. These multiple, cystic tumors were adherent to the epidermis, thus precluding complete dissection and excision of each individual lesion. We report a surgical technique using a lower eyelid blepharoplasty incision to remove the confluent tumors of the lower eyelids en-bloc. We paid careful attention to both removing the lesions without rupturing the cysts and to achieving adequate depth of excision. Histology revealed features typical of apocrine hidrocystomas. The patient has remained free of recurrence three years since the en-bloc excision of the lesions.

Aesthetic oculoplastic surgery.

Important concepts and advances continue to evolve in the field of aesthetic oculoplastic surgery. A keen interest in aesthetics exists, both on the part of the youth-oriented, aging baby-boomer population and on the part of many physicians and surgeons in a variety of different specialities. This review article highlights recent, important developments regarding cosmetic Botox injections for lines of facial expression, laser facial-resurfacing techniques, endoscopic and updated browlift techniques, lower-lid blepharoplasty with suborbicularis oculi fat lift, and subcutaneous Gore-Tex implants for treatment of deep facial rhytids. Because of the space limitations of this review, it is not possible to include a thorough step-by-step description of all surgical techniques. Rather, important concepts, references, and updates are emphasized. The information presented should be of interest to readers of varying levels of expertise.

Solitary fibrous tumor of the lacrimal gland fossa.

BACKGROUND: Solitary fibrous tumors are rare spindle cell neoplasms that most commonly arise in the pleura. Recently, solitary fibrous tumors of the orbital soft tissues have been described. The authors report the first case of solitary fibrous tumor arising in the lacrimal gland fossa and discuss features that may distinguish solitary fibrous tumor from other lacrimal fossa lesions. METHODS: A left lacrimal gland fossa tumor was excised via lateral orbitotomy from a 76-year-old man and analyzed by light microscopy. Immunohistochemical studies were performed using antibodies to CD34, vimentin, epithelial membrane antigen, cytokeratins AE1-3 and Cam5.2, S-100 protein, and actin. RESULTS: The histopathologic features of the tumor were typical of solitary fibrous tumor. A well-circumscribed, variably cellular proliferation of bland spindle cells displayed both "patternless" and storiform growth patterns. Immunohistochemical studies showed that the tumor cells expressed vimentin and CD34 but did not express epithelial membrane antigen, cytokeratins, S-100 protein, or actin. The patient is free of tumor recurrence after 1 year of follow-up. CONCLUSION: The authors report the first case of solitary fibrous tumor arising in the lacrimal gland fossa. The clinical presentation of this tumor was similar to that of pleomorphic adenoma (benign mixed tumor) of the lacrimal gland; fortunately, the treatment for both of these lacrimal gland fossa neoplasms is en bloc excision. The histopathologic appearance of solitary fibrous tumor is varied, and immunohistochemical analysis may help in distinguishing solitary fibrous tumor from other lacrimal fossa lesions. Careful follow-up of patients with solitary fibrous tumor is important because recurrence may present years after excision of the primary tumor.

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.

Merkel cell carcinoma of the eyelid and periocular tissues.

Five patients had eyelid and periocular Merkel cell carcinoma. The tumor was located on the left lower eyelid in two patients, the left upper eyelid in one patient, the right upper eyelid in one patient, and was metastatic to the right outer canthus in one patient. The mean duration of symptoms was approximately four months. The diagnosis of Merkel cell carcinoma was not suspected clinically in any of the four primary eyelid cases, but was only established on histopathologic examination of biopsy specimens. Light microscopy disclosed carcinoma with small primitive cells in all five tumor biopsy specimens. Immunohistochemical studies showed neuron-specific enolase and keratin and transmission electron microscopy demonstrated neurosecretory granules typical for Merkel cell carcinoma. All five patients in this study were treated with wide surgical excision of the eyelid tumors with intraoperative frozen-section monitoring of the margins of resection. The left lower eyelid Merkel cell carcinoma spread to the preauricular lymph node in one patient. This patient subsequently died of metastatic Merkel cell carcinoma. One patient with metastatic right outer canthus Merkel cell carcinoma received radiotherapy (6,550 cGy). Eyelid Merkel cell carcinoma has the potential for recurrence and metastatic spread. We recommend lifetime follow-up for patients treated for eyelid Merkel cell carcinoma.

A prospective study of angiographic cystoid macular edema one year after Nd: YAG posterior capsulotomy.

We prospectively studied 120 eyes with intact opacified posterior capsules in 120 consecutive patients to determine the incidence of new late-onset angiographic cystoid macular edema (CME) after neodynium: yttrium aluminum garnet (Nd:YAG) laser posterior capsulotomy. Fifty-seven of 120 patients (48%) had both precapsulotomy and one-year post-capsulotomy angiograms done. Of these 57 patients, three eyes had angiographic CME before capsulotomy and two of these three cases had persistent CME one year after capsulotomy. In the other 54 patients, three new late-onset cases occurred (5.6%). Because the incidence of postcapsulotomy new CME was low, the statistical significance of possible risk factors, such as rupture of the anterior hyaloid face or pseudophakic status cannot be determined. However, aphakic patients with vitreous prolapse after capsulotomy tended to have a higher incidence to CME than pseudophakic patients. We recommend fluorescein angiography to identify occult CME in cases of unexplained visual-acuity decrease after capsulotomy.

Laser ablation of blepharopigmentation.

This article discusses laser ablation of blepharopigmentation in four stages: first, experimentally, where pigment vaporization is readily achieved with the argon blue-green laser; second, in the rabbit animal model, where eyelid blepharopigmentation markings are ablated with the laser; third, in human subjects, where the argon blue-green laser is effective in the ablation of implanted eyelid pigment; and fourth, in a case report, where, in a patient with improper pigment placement in the eyelid, the laser is used to safely and effectively ablate the undesired pigment markings. This article describes in detail the new technique of laser ablation of blepharopigmentation. Potential complications associated with the technique are discussed.

Calcified cytoid bodies in acquired immunodeficiency syndrome.

The postmortem histopathologic findings of eyes from two patients with acquired immunodeficiency syndrome (AIDS) are presented. Both patients had succumbed to multiple opportunistic infections. All of the eyes demonstrated calcified cotton-wool patches of the retina. To date, there have been no prior descriptions of calcification of cotton-wool spots (CWS). The pathophysiologic mechanisms unique to AIDS that allow some of these CWSs to calcify have yet to be determined.