Problems of video-based pain detection in patients with dementia: a road map to an interdisciplinary solution
Given the unreliable self-report in patients with dementia, pain assessment should also rely on the observation of pain behaviors, such as facial expressions. Ideal observers should be well trained and should observe the patient continuously in order to pick up any pain-indicative behavior; which are requisitions beyond realistic possibilities of pain care. Therefore, the need for video-based pain detection systems has been repeatedly voiced. Such systems would allow for constant monitoring of pain behaviors and thereby allow for a timely adjustment of pain management in these fragile patients, who are often undertreated for pain.
In this road map paper we describe an interdisciplinary approach to develop such a video-based pain detection system. The development starts with the selection of appropriate video material of people in pain as well as the development of technical methods to capture their faces. Furthermore, single facial motions are automatically extracted according to an international coding system. Computer algorithms are trained to detect the combination and timing of those motions, which are pain-indicative.
We hope to encourage colleagues to join forces and to inform end-users about an imminent solution of a pressing pain-care problem. For the near future, implementation of such systems can be foreseen to monitor immobile patients in intensive and postoperative care situations.
Relationship of 5-HTTLPR Polymorphism with Various Factors of Pain Processing: Subjective Experience, Motor Responsiveness and Catastrophizing
Anna J. Karmann
- Although serotonin is known to play an important role in pain processing, the relationship between the polymorphism in 5-HTTLPR and pain processing is not well understood. To examine the relationship more comprehensively, various factors of pain processing having putative associations with 5-HT functioning were studied, namely the subjective pain experience (pain threshold, rating of experimental pain), catastrophizing about pain (Pain Catastrophizing Scale = PCS) and motor responsiveness (facial expression of pain). In 60 female and 67 male participants, heat pain stimuli were applied by a contact thermode to assess pain thresholds, supra-threshold ratings and a composite score of pain-relevant facial responses. Participants also completed the PCS and were grouped based on their 5-HTTLPR genotype (bi-allelic evaluation) into a group with s-allele carriers (ss, sl) and a second group without (ll). S-allele carriers proved to have lower pain thresholds and higher PCS scores. These two positive findings were unrelated to each other. No other difference between genotype groups became significant. In all analyses, “age” and “gender” were controlled for. In s-allele carriers the subjective pain experience and the tendency to catastrophize about pain was enhanced, suggesting that the s-allele might be a risk factor for the development and maintenance of pain. This risk factor seems to act via two independent routes, namely via the sensory processes of subjective pain experiences and via the booster effects of pain catastrophizing.
Regulation During Cooperative and Collaborative Learning: A Theory-Based Review of Terms and Concepts
- This article reviews the terms and concepts that have been used for describing regulation of learning during cooperative and collaborative learning and suggests differentiating them on the basis of which parts of a regulatory feedback loop model are being shared. During cooperative and collaborative learning, not only self-regulation but also the regulation of the group process is important. This regulation might occur on both an individual level and a social level. Several modes of regulation have been identified, but the terms used for them vary tremendously—including social regulation, socially shared regulation, coregulation, and other-regulation. This article seeks to clarify the diverse terminology. To this end, we use a theoretical framework based on Winne and Hadwin's (1998) model of self-regulated learning to analyze how the different terms are used in the literature. We make and exemplify suggestions for a consistent usage of terms.
Comparison of the efficacy of a diabetes education programme for type 1 diabetes (PRIMAS) in a randomised controlled trial setting and the effectiveness in a routine care setting: Results of a comparative effectiveness study.
- Background: The effectiveness of an intervention in clinical practice is often reduced compared to the efficacy demonstrated in a randomised controlled trial (RCT). In this comparative effectiveness study, the RCT-proven efficacy of a diabetes education programme for type 1 diabetic patients (PRIMAS) was compared to the effectiveness observed in an implementation trial (IT) under routine care conditions.
Methods: 75 patients with type 1 diabetes received PRIMAS through an RCT, whereas 179 patients were observed in an implementation trial. Baseline characteristics and treatment outcomes at the 6-month follow-up (improvement of HbA1c, hypoglycaemia problems, and diabetes-related distress) were compared.
Results: At baseline, the type 1 diabetic patients in the RCT had a significant longer diabetes duration (18.7±12.3 vs. 13.8±12.7 yrs., p = .005), lower self-efficacy scores (21.9±4.7 vs. 23.7±6.1, p = .02) and a greater number of diabetes complications (0.8±1.3 vs. 0.4±0.9, p = .02). After 6 months, PRIMAS achieved comparable effects under RCT and implementation trial conditions, as demonstrated by improvement in HbA1c (-0.36%±1.1 vs. -0.37±1.2; Δ -0.01, 95% CI -0.33 to 0.31) and hypoglycaemia unawareness (-0.5±1.4 vs. -0.3±1.4; Δ 0.18, 95% CI -0.21 to 0.57). The likelihood of clinical improvement did not depend on the trial setting (RCT vs. IT: OR 1.18, 95% CI 0.60 to 2.33). The participants with worse glycaemic control (OR 1.40, 95% CI 1.02 to 1.92), hypoglycaemia problems (OR 2.13, 95% CI 1.53 to 2.97) or elevated diabetes distress (OR 1.40, 95% CI 1.03 to 1.89) had a better chance of clinical improvement.
Conclusions: The effectiveness of PRIMAS under routine care conditions was comparable to the efficacy demonstrated in the RCT. Clinical improvement was independent of the setting in which PRIMAS was evaluated. The PRIMAS education programme for type 1 diabetes can be delivered under conditions of routine care without a loss of effectiveness, compared to its original evaluation in an RCT.
How does Sexual Orientation Affect Perceptions of Single People?
- Past research has found that single people are perceived more negatively than coupled people. However, in past research, the target’s sexual orientation was not explicitly mentioned. The current experiment manipulated the sexual orientation of targets and also measured the sexual orientation of participants to test whether the relatively negative perceptions of single people are held about people and believed by people regardless of their sexual orientation. Three hundred ninety heterosexual and 226 gay and lesbian participants from Israel and the United States read descriptions of target people. Targets were described as heterosexual, gay, or lesbian; single or in a long-term relationship; and men or women. Although single people were consistently perceived more negatively than coupled people, F(1, 600) = 130.78, p < .001, η2 = .18, participants perceived the differences between coupled and single targets as being largest when they rated targets of the same sexual orientation as themselves, F(1, 600) = 10.38, p =.001, η2 = 0.02. Furthermore, regardless of their own sexual orientation, participants who expressed a stronger desire for a long-term romantic relationship held more negative views of single people compared to coupled people, r = .10, p < .01.
ELUSIVE MIGRATION SYSTEMS. LESSONS FROM EUROPE’S NEW MIGRATORY MAP
- Europe is facing a new era of migration. During the last decades, the European migration system underwent several shifts due to different reasons. A basic observation is that general changes, on the political map for example, do not necessarily have the same consequences in European regions, even in seemingly similar contexts. The major changes started in 1990 accelerated with the enlargement of the European Union in 2004 and found its continuation by crisis-driven migration from south European countries into Western European labour markets after 2008. All of these "migration waves" have been topped by a massive inflow of refugees in 2015 creating new migratory map of Europe.
Thus, important stages of contemporary and present European migration history are interpreted as indicators for a surplus in diversity, flexibility and spontaneity and will serve for formulating the hypothesis of Elusive Migration Systems as an analytical framework and a kind of hypothesis to study new features of migrants’ trajectories, which became more and more variable.. Being grounded may be the wish of the majority of Europeans and, in effect, the global population, but being on the move, voluntarily or forced, is reality for a certain number of migrants inside and heading towards Europe.
Treatment of subclinical depression with a CBT program (DIAMOS): Results of a prospective randomized, controlled study
- Depression without meeting the criteria of a major depression. However,
elevated depressive symptoms are associated with a reduced quality of
life, lower self-care activities, and a higher mortality. To target this large
group of people, a diabetes-specific treatment program (DIAMOS) was
developed and evaluated in a randomized controlled trial with a 12-month
DIAMOS is a group program based on cognitive-behavioral-therapy
(CBT). It consists of 5 group sessions which lasts for 90 minutes each. 214
inpatients with subclinical depression were randomized either to DIAMOS
or to a control group receiving diabetes education. Depression, diabetesrelated
distress, and quality of life were assessed via questionnaires (CES-D,
PAID, WHO-5 respectively). HbA1c was analyzed in a central laboratory.
181 patients (age: 45±14 yrs.; 57% female; 63% Type 1 DM; diabetes
duration 15±11 yrs.; 95% with insulin; 51% with late complications; HbA1c
8.8±1.7%; CES-D 23.3±8.1; PAID 39.5±18.4; WHO-5 8.9±4.5) were available
at the 12-month follow-up (drop-out rate: 15%). Compared to the control
group, patients treated with DIAMOS showed a significantly greater reduction of depressive symptoms (- 7.4 ± 11.4 vs. - 2.7 ± 11.7; p < .01), and
diabetes-related distress (- 13.0 ± 18.9 vs. - 4.2 ± 16.9; p < .01), as well as a
significantly greater improvement of quality of life (+ 4.5 ± 6.1 vs. + 2.5 ± 6.3;
p = .03). HbA1c improvement was comparable in both groups.
The results demonstrate that DIAMOS is an effective tool for the
treatment of subclinical depression in people with diabetes. In addition,
DIAMOS positively affects diabetes-related distress and quality of life.
Interestingly, the reduction of depressive symptoms and distress was not
associated with an improvement of glycemic control. DIAMOS proofs to be
an innovative tool for routine care to improve the situation of people with
diabetes and subclinical depression.
The effect of a diabetes-specific cognitive behavioural treatment programme (DIAMOS) for people with diabetes and subthreshold depression
- Background and aims: Subthreshold depression is one of the most frequent
mental comorbidities in people with diabetes and is associated with a poorer
long-term prognosis. Since specific intervention concepts are missing a new
self-management oriented group programme (DIAMOS) was developed for
this patient group and evaluated in a randomised trial.
Materials and methods: The active control group (CG) received diabetes education.
DIAMOS consisted of cognitive behavioural interventions aiming at
the reduction of diabetes distress. Patients completed several questionnaires
at baseline and follow-up: The Center of Epidemiological Studies-Depression
Scale (CES-D), the Patient Health Questionnaire (PHQ 9), the Problem Areas
in Diabetes Questionnaire (PAID) and the Diabetes Distress Scale (DDS).
Primary outcome was the reduction of depressive symptoms. Secondary outcomes
were diabetes distress, well-being, self-care behaviour, diabetes acceptance,
diabetes treatment satisfaction, HbA1c and inflammatory markers. 214
participants were randomised.
Results: Baseline characteristics (age 43.3 ±13.3 yrs., female gender 56.5%,
diabetes duration 14.2 ±10.5 yrs., type 2 diabetes 34.1%, BMI 28.7 ±71 kg/m²)
were comparable between both interventions groups except BMI and diabetes
type. At 12-month follow-up there was a significant greater reduction
of the CESD- and PHQ 9-scores in DIAMOS compared to the CG (Δ -3.7,
95%-CI 0.57 to 6.85 p=.021 respectively Δ -1.49, 95%-CI 0.08 to 2.90; p=.039
). The risk of incident major depression was reduced (OR 0.63, 95%-CI 0.42
to 0.96, p=.028) Also PAID-scores (Δ -8.3 95%-CI 3.33 to 12.72, p=.001) and
DDS-scores (Δ -0.22 95%-CI 0.02 to 0.42, p=.042) were significantly reduced.
C-reactive protein was significantly more lowered (Δ -0.25 95%-CI 0.02 to
0.48 p=.035). No effect of the intervention was observed in other inflammatory
markers (IL1RA, IL6 and adiponectin).
Conclusion: DIAMOS is more effective in lowering depressive symptoms
and diabetes related distress in diabetic patients with subthreshold depression.
DIAMOS also has a preventive effect regarding the incidence of major
The Diabetes Self-Management Questionnaire (DSMQ) can detect inadequate self-care behaviour and help identify patients at risk of a negative diabetes prognosis
- Background and aims: Existing psychometric instruments to assess diabetes
self-management often reveal weak or inconsistent associations with ‚hard
data‘ such as medical outcomes and HbA1c. To fill this gap, the Diabetes SelfManagement
Questionnaire (DSMQ) was developed, focussing on self-care
activities which directly impact medical diabetes outcomes. This study evaluates
the questionnaire’s practical utility in detecting high-risk patients at a
tertiary diabetes centre.
Materials and methods: 226 people with diabetes (age 43 ± 15 y.; 55% female;
BMI 29 ± 7; 70% type 1 diabetes; illness duration 15 ± 10 y.; 92% treated
with insulin; HbA1c 8.9 ± 1.6%) were assessed with the DSMQ and further
questionnaires regarding diabetes acceptance (AADQ), coping with illness
(FQCI), treatment satisfaction (DTSQ), diabetes distress (PAID), and depressive
symptoms (CES-D); additional data (demographic variables, self-monitoring
of blood glucose, HbA1c, and long-term complications) were gained
from electronic patient records. People were then categorized by a median
split of the DSMQ total score into groups performing ‘adequate’ (n = 107)
versus ‘inadequate’ diabetes self-care (n = 119); the groups were compared
regarding relevant outcomes using multivariate ANOVA (subsequently presented
data are M ± SD, F statistic, and effect size Cohen’s d).
Results: After adjusting for sex, age, BMI, diabetes type, diabetes duration,
and type of treatment, people performing ‘inadequate self-care’ compared to
those with ‘adequate self-care’ showed stronger diabetes non-acceptance (31
± 8 vs. 22 ± 6, F = 90.5, d = 1.24), less active coping with diabetes (2.7 ± 0.9
vs. 3.4 ± 0.8, F = 18.1, d = 0.82), lower diabetes treatment satisfaction (20 ± 7
vs. 24 ± 6, F = 21.3, d = 0.60), higher diabetes distress (43 ± 21 vs. 33 ± 19, F
= 17.0, d = 0.85), and more depressive symptoms (24 ± 11 vs. 20 ± 11, F = 4.8,
d = 0.36). Moreover, they performed fewer blood glucose self-tests (3.3 ± 3.5
vs. 5.6 ± 2.4 times per day, F = 24.7, d = 0.74), consulted their diabetologist
less often (1.9 ± 1.8 vs. 2.6 ± 2.3 times per half-year, F = 6.6, d = 0.34), had a
higher HbA1c value (9.5 ± 1.5 vs. 8.2 ± 1.4%, F = 34.6, d = 0.87), and showed
a higher prevalence of retinopathy (28% vs. 14%, F = 6.0, d = 0.35).
Conclusion: The DSMQ yields excellent distinction between people with
diabetes performing adequate versus insufficient diabetes self-care, thus enabling
detection of people at high risk of a negative diabetes prognosis. The
16-item questionnaire is an efficient tool which may be used for screening
and diagnostic purposes or clinical diabetes research.
A new assessment tool to measure the ability of Bolus Calculation and Carbohydrate Estimation (SMART) in people with diabetes performing an intensive insulin therapy
- Background and aims: Intensive insulin therapy relies on correct prandial
insulin dose adaptation dependent from current glucose level, amount of
planned carbohydrate intake and the consideration of other situational factors
like physical activity or circadian fluctuation of insulin sensitivity. People
with diabetes and intensive insulin therapy should be able to estimate carbohydrates
and calculate insulin bolus correctly, while regarding the factors
mentioned above. An assessment tool for the measurement of the ability of
carbohydrate estimation and bolus calculation is missing. The objective of
this study was the development and psychometric evaluation of an assessment
tool for carbohydrate estimation and bolus calculation (“aSsessMent of
the Ability of Bolus Calculation and CaRbohydrate esTimation” SMART). Of
special interest were the associations of both abilities with glycaemic control.
Materials and methods: The SMART consisted of one scale for the assessment
of bolus calculation (BOLUS) with 10 items and a scale for carbohydrate
estimation (CARB) with 12 items. People with type 1 or type 2 diabetes
on an intensive insulin regimen were invited to participate. HbA1c and stored
data of blood glucose meters were used to determine glycaemic control.
Results: 411 patients participated (age 42.9 ±15.7, 58% female, HbA1c 8.6
±1.8%, 28% with CSII-treatment) and approx. 56,000 blood glucose meter
readings could be obtained. The reliability of both scales was sufficient (Cron-bachs alpha for BOLUS r= 0.78 and the CARB r = 0.67). Better bolus calculation
was associated with a higher level of education (r = 0.24, p<.05), lower
HbA1c (r = -0.27, p<.05), lower mean blood glucose (r = -0.29, p<.05), and
a lower standard deviation of blood glucose values (r = -0.43, p<.05). Better
carbohydrate estimation was associated with a lower body mass index (r =
-0.2, p<.05), lower mean blood glucose (r = -0.3, p<.05), a lower frequency of
hyperglycaemia (r = -0.27, p<.05), and a higher frequency of euglycaemia (r
= 0.26, p<.05). Patients with an insulin pump were better on both scales than
patients with multiple daily insulin injections (BOLUS: 7.2 ± 2.4 vs. 6.4 ± 2.7,
p<.01; CARB: 7.8 ± 2.1 vs. 7.1 ± 2.6, p<.01). Patients with previous diabetes
education performed significantly better on both scales (BOLUS: 6.8 ± 2.5 vs.
5.7 ± 2.8, p<.01; CARB: 7.4 ± 2.4 vs. 6.5 ± 2.6, p<.01).
Conclusion: SMART provides a reliable and valid assessment of the ability to
estimate the correct amount of carbohydrates and to calculate the appropriate
prandial insulin dose. SMART is also sensitive to depict effects of diabetes
education and of CSII treatment in comparison to multiple daily insulin
injections. In summary SMART can assist the identification of people with
diabetes on an intensive insulin regimen, who are in need for improvements
in carbohydrate estimation and/or calculation of prandial insulin dose