[Show abstract][Hide abstract] ABSTRACT: Objective:
To test the effects of implementing computer-assisted Monitoring of Individual Needs in Diabetes (MIND) in routine diabetes care on psychological status and glycemic control, identify predictors of poor psychological outcomes, and evaluate care providers' experiences.
Research design and methods:
The MIND procedure was implemented as part of the annual review in diabetes clinics across eight countries in a prospective observational study with a 1-year follow-up. MIND encompasses well-being (World Health Organization Five Well-Being Index [WHO-5]), diabetes-related distress (Problem Areas in Diabetes [PAID]), a Life Event Inventory, and the patient's agenda for their consultation. Medical data and agreed case-management actions were retrieved from the charts.
Of the total 1,567 patients, 891 patients (57%) were monitored at a 1-year follow-up. Twenty-eight percent of the patients screened positive for depression and/or diabetes distress at baseline and considered cases, 17% of whom were receiving psychological care. Cases were significantly more often female and had type 2 diabetes and worse glycemic control compared with noncases. Clinically relevant improvements in WHO-5 and PAID were observed over time in cases, irrespective of referral (effects sizes 0.59 and 0.48, respectively; P < 0.0001). Glycemic control did not change. Female sex, life events, and concomitant chronic diseases were predictors of poor psychological outcomes. MIND was well received by patients and staff.
MIND appears suitable for screening and discussion of emotional distress as part of the annual review. Broader dissemination in diabetes care is recommendable, but sustainability will depend on reimbursement and availability of support services.
Diabetes care 07/2012; 35(11):2128-32. DOI:10.2337/dc11-1326 · 8.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thyroglobulin is an excellent biological marker of persistent or recurrent thyroid cancer during long-term follow-up. Most studies investigated its diagnostic value but not its prognostic value over time. We aim to study the prognostic value of thyroglobulin levels early after total thyroidectomy, before iodine ablation.
The study was based on the Rabin Medical Center registry of patients with non-medullary thyroid carcinoma. Data were collected on the clinical, laboratory, and outcome characteristics of 420 consecutive patients followed at our institution for whom early post-operative pre-ablation thyroglobulin values (baseline thyroglobulin) were available.
Patients were classified into 4 groups by baseline thyroglobulin level: 0-2, 2-10, 10-100, and >100 ng/ml. Higher levels were associated with a shift toward male gender (p=0.01), larger tumor size (p=0.02), and a more extensive disease (p<0.0001). They were also related to disease persistence and evidence of disease at last follow-up (p<0.0001). The 10 ng/ml cut-off level identified patients with persistent disease with a sensitivity and specificity of 73%, positive predictive value of 43%, and negative predictive value of 89%. On multivariate analysis, the following variables were predictive of persistent disease: baseline thyroglobulin level, male gender, lymph-node involvement, distant metastases, higher tumor invasiveness, and larger tumor size. However, the predictive power of baseline thyroglobulin level was relatively weak (odds ratio 1.002, 95% confidence interval 1.00-1.04).
In patients with well-differentiated thyroid cancer, a post-thyroidectomy thyroglobulin level <10 ng/ml is associated with a low probability of having persistent disease and can be used combined with other disease characteristics for decisions regarding treatment and follow-up.
[Show abstract][Hide abstract] ABSTRACT: To test the feasibility and impact of implementing the computer-assisted Monitoring of Individual Needs in Diabetes (MIND) procedure, which is aimed at improving recognition and management of the psychological needs of diabetic patients in routine care.
The MIND study was implemented in diabetes clinics across eight countries as part of the annual review. The computerized assessment covered emotional well-being (World Health Organization 5 Well-Being Index), diabetes-related distress (Problem Areas in Diabetes), life events, and the patient's agenda. Medical data were retrieved from the charts, and agreed-upon actions were recorded.
Of 1,567 patients monitored using the MIND, 24.9% had either likely depression or high diabetes-related distress; 5.4% had both. Over 80% of these patients were newly identified cases, and 41% of patients with depression were referred to a mental health professional.
Monitoring of well-being and diabetes-related distress as part of routine diabetes care is feasible and helps to identify and discuss unmet psychosocial needs.
Diabetes care 02/2011; 34(3):601-3. DOI:10.2337/dc10-1552 · 8.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Papillary thyroid cancer (PTC) commonly affects women of child-bearing age. During normal pregnancy, several factors may have a stimulatory effect on normal and nodular thyroid growth. The aim of the study was to determine whether pregnancy in thyroid-cancer survivors poses a risk of progression or recurrence of the disease.
The files of 63 consecutive women who were followed at the Endocrine Institute for PTC in 1992-2009 and had given birth at least once after receiving treatment were reviewed for clinical, biochemical, and imaging data. Thyroglobulin levels and neck ultrasound findings were compared before and after pregnancy. Demographic and disease-related characteristics and levels of thyroid-stimulating hormone (TSH) during pregnancy were correlated with disease persistence before conception and disease progression during pregnancy using Pearson's analysis.
Mean time to the first delivery after completion of thyroid-cancer treatment was 5.08 ± 4.39 years; mean duration of follow up after the first delivery was 4.84 ± 3.80 years. Twenty-three women had more than one pregnancy, for a total of 90 births. Six women had evidence of thyroid cancer progression during the first pregnancy; one of them also showed disease progression during a second pregnancy. Another two patients had evidence of disease progression only during their second pregnancy. Mean TSH level during pregnancy was 2.65 ± 4.14 mIU/L. There was no correlation of disease progression during pregnancy with pathological staging, interval from diagnosis to pregnancy, TSH level during pregnancy, or thyroglobulin level before conception. There was a positive correlation of cancer progression with persistence of thyroid cancer before pregnancy and before total I-131 dose was administered.
Pregnancy does not cause thyroid cancer recurrence in PTC survivors who have no structural or biochemical evidence of disease persistence at the time of conception. However, in the presence of such evidence, disease progression may occur during pregnancy, yet not necessarily as a consequence of pregnancy. The finding that a nonsuppressed TSH level during pregnancy does not stimulate disease progression suggests that it may be an acceptable therapeutic goal in this setting.
Thyroid: official journal of the American Thyroid Association 10/2010; 20(10):1179-85. DOI:10.1089/thy.2010.0081 · 4.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Familial nonmedullary thyroid cancer (FNMTC) is a disease defined by clustering of thyroid cancers of follicular cell origin, and it is estimated to account for 5% of all thyroid cancers. Several studies found FNMTC to be more aggressive than sporadic disease, whereas others found them to have a similar course and outcome. The purpose of this study was to determine whether FNMTC is more aggressive than sporadic thyroid cancer.
A retrospective controlled study of FNMTC versus sporadic nonmedullary thyroid cancers was conducted using a registry of patients with thyroid cancer. Data on disease severity at presentation, treatment modalities, and outcome were collected.
Sixty-seven patients with FNMTC and 375 controls with sporadic disease were included. Follow-up period was 8.6 ± 10 years for patients with FNMTC and 8.4 ± 9.1 years for sporadic cases. Patients with FNMTC had comparable disease severity at diagnosis as sporadic patients, underwent similar surgical and radioiodine treatments, and had similar long-term disease-free survival. Long-term outcome in families with three or more affected relatives was similar to families with only two affected relatives.
Our results suggest that FNMTC is not more aggressive than sporadic thyroid cancer within our studied population. After a similar therapeutic strategy, FNMTC and sporadic cases had comparable prognosis, including in families with three or more affected members.
Thyroid: official journal of the American Thyroid Association 10/2010; 21(1):43-8. DOI:10.1089/thy.2009.0406 · 4.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with differentiated thyroid cancer (DTC) usually have a good prognosis but may experience a decline in quality of life (QOL). The way patients perceive their illness may have a major impact on their QOL. Our hypothesis was that patients with DTC frequently perceive their illness as much more severe than its objective clinical characteristics indicate. The aim of the study was to investigate how patients with DTC perceive their illness and to correlate these findings to various demographic parameters as well as objective indices of disease severity.
The self-administered Illness Perception Questionnaire-Revised (IPQ-R) was completed by consecutive patients with DTC during routine follow-up at the endocrine clinic. The questionnaire consists of three parts that measure different aspects of illness perception. The patients' medical records were reviewed for data on demographic parameters (sex, age) and indices of disease severity (duration of DTC, disease stage at diagnosis, number of operations, number of radioactive iodine treatments, and evidence of disease persistence/recurrence). The patients were also asked for additional data on family status, level of education, and employment status. Pearson and Spearman correlations and analysis of variance were used for statistical analysis.
The study group included 110 patients (91 women) of mean age 53.5 years. Level of education was the only demographic factor found to affect the patients' perception of their illness. There was no correlation of patient illness perception and cancer stage. Among the disease-severity parameters, time since last treatment, evidence of disease persistence, and number of iodine treatments were significantly associated with a negative disease perception. Number of iodine treatments was the most broadly affecting factor. There was a high correlation of scores among the various illness perception subscales.
Patients with DTC perceive their illness on a subjective, emotional basis unrelated to its actual severity. To improve patients' illness representations and, consequently, their QOL, a trained psychologist should be included in the multidisciplinary team that manages patients with DTC. Attention should be particularly directed to less-educated patients and patients who require repeated iodine treatments.
Thyroid: official journal of the American Thyroid Association 06/2009; 19(5):459-65. DOI:10.1089/thy.2008.0360 · 4.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The rapid increase in the incidence of well-differentiated thyroid cancer in recent years is the result of smaller thyroid tumors (1 cm or less) being diagnosed more frequently. Few studies are available regarding the appropriate approach to this previously known postmortem incidental finding, and their results remain controversial.
In 2005, our center started a registry of all patients with nonmedullary thyroid carcinoma who were followed at our institute. In the present study, data on the background, clinical, and outcome characteristics were collected from the registry for 225 patients with microscopic disease and 543 patients with macroscopic disease.
Patients with microscopic disease were slightly older (51 vs. 47.5 years, p = 0.003), had a higher female to male ratio (189:37 vs. 419:123; p = 0.06), and were affected more by papillary carcinoma (98.2% vs. 85.5%; p < 0.001). Multifocal disease was documented in 50.2% of the patients with microscopic disease and 46.8% of the patients with macroscopic disease (NS), and bilateral disease, in 42.6% and 36.8%, respectively (NS). Corresponding rates for the two groups for other tumor-related factors were as follows: lymph node involvement at initial treatment, 25.7% and 30% (NS); distant metastases, 2.4% and 5.1% (p = 0.16); persistent/recurrent disease, 11% and 32% (p < 0.001); and new distant metastases, 2.65% and 6.5% (p = 0.07). At a median follow-up of 5 years, 96% of the microscopic carcinoma group were disease free compared to 77% of the macroscopic group (p < 0.001).
The differences between patients with microscopic and macroscopic well-differentiated thyroid carcinoma may not justify a different therapeutic approach.
Thyroid: official journal of the American Thyroid Association 04/2009; 19(5):487-94. DOI:10.1089/thy.2008.0228 · 4.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The distribution of HLA class II alleles and genotypes in Israelis of different ethnic origin with adult-onset type 1 diabetes (T1D) was examined. The results were compared with published findings in healthy Israelis and childhood-onset T1D Israelis. An additional comparison was made between subgroups of patients with rapidly and slowly progressive adult-onset T1D (LADA). A DNA-based low-resolution analysis was performed for DRB1* and DQB1* alleles and a high-resolution analysis for DRB1*04 and DQB1*1 alleles. In all, 87% of the study group was positive for DRB1*03 or DRB1*04 compared with 36% of the healthy controls. The main alleles accounting for susceptibility to T1D were DRB1*0402, found in 77.9% of carriers of DRB1*04 and DQB1*0302, found in 74.6% of carriers of DQB1*03. The DQB1*0602 was not detected in any patient. The distribution was similar to that reported in Israeli children with T1D and significantly different from healthy Israelis. There was no significant difference in the distribution of HLA class II alleles between patients with rapidly progressive T1D or LADA. It may be concluded that the different ages of onset of T1D and its different forms of development in Israeli patients are apparently not caused by a different prevalence of HLA class II alleles.
Human Immunology 08/2007; 68(7):616-22. DOI:10.1016/j.humimm.2007.03.016 · 2.14 Impact Factor