To summarize and critically appraise evidence regarding the effectiveness of educational and/or behavioural interventions in reducing fear of hypoglycaemia among adults with type 1 diabetes.

Aims: To examine in adults with type 1 diabetes (a) the effect of initiation of real-time continuous glucose monitoring (RT-CGM) on glycaemic and patient-reported outcomes (PROs), and (b) factors related to clinically relevant improvements and sustained device use. Methods: 60 persons initiating RT-CGM completed questionnaires at device start and six months later. Demographics and clinical characteristics including (dis)continuation up until July 31st 2018 were obtained from medical records. Results: After six months, 54 adults were still using RT-CGM. Short-term discontinuation (10%) was mainly related to end of pregnancy (wish). Longer-term discontinuation in those with an initial non-pregnancy indication was related to changes in the medical condition and behavioural/psychological reasons. After six months, HbA(1c), diabetes-specific worries and self-efficacy improved (range d = vertical bar 0.4 vertical bar-vertical bar 0.8 vertical bar), while hypoglycaemia rate or awareness and more general distress did not change. More suboptimal scores at baseline were related to meaningful improvements in HbA(1c) (>= 10 mmol/mol; 0.9%) and PROs (>= 0.5 SD). Changes in glycaemic variables and PROs were not related. Conclusions: People with more suboptimal HbA(1c) and PRO values appear to benefit most from RT-CGM. Given the lack of association between improvements in medical outcomes and PROs, both should be included in evaluations of RT-CGM therapy on an individual level. (C) 2019 Elsevier B.V. All rights reserved.

To investigate qualitatively how residents cope with clinical uncertainty while caring for their complex geriatric patients. Residents experience clinical uncertainty and judge it positive as well as negative. Despite the impact on their feelings, behavior and well-being, they do not discuss it with others. Clinical uncertainty is an inherent part of caring for complex geriatric patients and influences the well-being of residents, but training in tolerance of clinical uncertainty is lacking. With the growing complexity in health care, clinical uncertainty increases, even more so in geriatrics. Intolerance of clinical uncertainty can result in stress, burnout and additional costs. This makes tolerance of clinical uncertainty a highly relevant skill to learn. This study investigated how residents cope with clinical uncertainty and explored options to improve their tolerance of it. We interviewed nine residents from the geriatric department of a university medical center and analyzed the interviews conform template analysis using the ‘integrative model of uncertainty tolerance’. All residents experienced clinical uncertainty regularly and emphasized it was a relevant topic. Residents described clinical uncertainty as both negative and positive, explaining it was difficult to deal with and could lead to stress, but it also kept them focused, challenged them and stimulated learning. While most of the reported topics fitted in the theoretical model, the model did not reflect the dynamics of clinical uncertainty and lacked its consequences outside the workplace. Residents mainly responded to clinical uncertainty by asking supervisors and peers to double-check their decisions concerning a patient. Residents indicated that they barely discussed their own emotions, cognitions or learning processes with peers or their supervisors. They would welcome the incorporation of clinical uncertainty as standard theme in patient supervision and educational meetings. Clinical uncertainty is not a problem of an insecure, failing resident, but an inherent part of caring for complex geriatric patients. Residents deserve to be trained in tolerance of clinical uncertainty to improve their well-being and care for geriatric patients.

Background: Fatigue is frequently reported by patients with type 1 diabetes mellitus. A recent study showed that 40 % of patients experienced severe fatigue that lasted for more than six months and was accompanied by substantial impairments in daily functioning. Currently, there is no effective treatment available for chronic fatigue in patients with type 1 diabetes. Cognitive behaviour therapy aimed at cognitions and behaviours that perpetuate fatigue is effective in reducing fatigue in other chronic diseases. Recent research showed that these cognitions and behaviours are also potential determinants of fatigue in type 1 diabetes. We designed Dia-Fit, a web-based cognitive behaviour therapy for severe and chronic fatigue in patients with type 1 diabetes. This patient-tailored intervention is aimed at reducing fatigue by changing cognitions and behaviours assumed to maintain fatigue. The efficacy of Dia-Fit will be investigated in this study. Methods/design: A randomised controlled trial will be conducted in 120 patients with type 1 diabetes who are chronically and severely fatigued. Patients will be randomised to a treatment or waiting list group. The treatment group will receive Dia-Fit, a blended care therapy consisting of up to eight internet modules and face-to-face sessions with a therapist during a five-month period. The treatment will be tailored to the fatigue-maintaining cognitions and behaviours that are relevant for the patient and are determined at baseline. The waiting list group will receive Dia-Fit after a waiting period of five months. The primary outcome measure is fatigue severity. Secondary outcome measures are functional impairment and glucose control determined by haemoglobin A1c and blood glucose variability. Discussion: To our knowledge, this is the first study investigating the efficacy of a cognitive behavioural intervention for chronic fatigue in patients with type 1 diabetes. Trial registration: Dutch trial register NTR4312 (10 December 2013).

Purpose: Automated bolus calculation may benefit patients with poorly 'controlled type 1 diabetes who are relatively new to continuous subcutaneous insulin infusion (CSII). This study investigated the effect of automated bolus calculation on glucose variability, glucose control, and diabetes-related quality of life in patients with reasonably well-controlled type 1 diabetes, accustomed to treatment with CSII for several years. Methods: This open-label, single-center study included 32 patients (mean age, 45.9 [15.1] years; 34% male; disease duration, 27.3 [12.9] years; glycosylated hemoglobin [HbA(1c)] level, 64.6 [12.5] mmol/mol [8.1% (1.1%)]; CSII treatment, 9.0 [7.8] years) who were randomly assigned to receive 4 months' treatment with a bolus calculator (n = 14) or continuation of standard care without a bolus calculator (n = 18). All participants received dietary counseling on carbohydrate counting. Primary outcome was glucose variability, as assessed by the SD of 7-point glucose profiles. Secondary outcomes included HbA(1c), rate of (severe) hypoglycemia, and diabetes-related quality of life. Findings: After 4 months of follow-up, glucose variability had improved in the bolus calculator group compared with the control group (change, -0.8 [0.9] vs 0.1 [0.9] mmol/L; P = 0.030). Mean glucose levels did not change in either group (0.4 [1.1] vs 0.3 [0.9] mmol/L; P = 0.95). There were also no differences in change in hypoglycemia rate (-0.6 [1.6] vs -0.4 [1.6] event per patient per week; P = 0.67), HbA(1c) value (-0.5 [6.6] vs -4.9 [10.6] mmol/mol; P = 0.21), or diabetes-related quality of life between the bolus calculator group and the control group. (C) 2018 The Authors. Published by Elsevier HS Journals, Inc.

Background Fatigue is frequently reported by patients with type 1 diabetes mellitus. A recent study showed that 40 % of patients experienced severe fatigue that lasted for more than six months and was accompanied by substantial impairments in daily functioning. Currently, there is no effective treatment available for chronic fatigue in patients with type 1 diabetes. Cognitive behaviour therapy aimed at cognitions and behaviours that perpetuate fatigue is effective in reducing fatigue in other chronic diseases. Recent research showed that these cognitions and behaviours are also potential determinants of fatigue in type 1 diabetes. We designed Dia-Fit, a web-based cognitive behaviour therapy for severe and chronic fatigue in patients with type 1 diabetes. This patient-tailored intervention is aimed at reducing fatigue by changing cognitions and behaviours assumed to maintain fatigue. The efficacy of Dia-Fit will be investigated in this study. Methods/design A randomised controlled trial will be conducted in 120 patients with type 1 diabetes who are chronically and severely fatigued. Patients will be randomised to a treatment or waiting list group. The treatment group will receive Dia-Fit, a blended care therapy consisting of up to eight internet modules and face-to-face sessions with a therapist during a five-month period. The treatment will be tailored to the fatigue-maintaining cognitions and behaviours that are relevant for the patient and are determined at baseline. The waiting list group will receive Dia-Fit after a waiting period of five months. The primary outcome measure is fatigue severity. Secondary outcome measures are functional impairment and glucose control determined by haemoglobin A 1c and blood glucose variability. Discussion To our knowledge, this is the first study investigating the efficacy of a cognitive behavioural intervention for chronic fatigue in patients with type 1 diabetes. Trial registration Dutch trial register NTR4312 (10 December 2013).

Title Chronic fatigue in type 1 diabetes: highly prevalent but not explained by hyperglycaemia or glucose variability. Objective: Fatigue is a classical symptom of hyperglycemia, but the relationship between chronic fatigue and diabetes has not been systematically studied. We investigated prevalence, impact and potential determinants of chronic fatigue in patients with type 1 Diabetes Mellitus (DM1). Research Design and Methods: Out of 324 random selected DM1 outpatients, 214 participated in this cross-sectional observational study. Participants were compared with age-and sex-matched population based controls. Chronic fatigue, functional impairments, current health status, comorbidity, diabetes-related factors and fatigue-related cognitions and behaviors were assessed with questionnaires, HbA 1c values and comorbidity with medical records. Sixty-six patients underwent continuous glucose monitoring combined with an electronic fatigue diary for five days. Acute fatigue and four glucose parameters were determined; mean, variability and relative time spent in hypo-and hyperglycemia.

OBJECTIVE Fatigue is a classical symptom of hyperglycemia, but the relationship between chronic fatigue and diabetes has not been systematically studied. We investigated prevalence, impact, and potential determinants of chronic fatigue in patients with type 1 diabetes mellitus (T1DM). RESEARCH DESIGN AND METHODS Out of 324 randomly selected T1DM outpatients, 214 participated in this cross-sectional observational study. Participants were compared with age- and sex-matched population-based controls. Chronic fatigue, functional impairments, current health status, comorbidity, diabetes-related factors, and fatigue-related cognitions and behaviors were assessed with questionnaires, and HbA1c values and comorbidity were assessed with medical records. Sixty-six patients underwent continuous glucose monitoring combined with an electronic fatigue diary for 5 days. Acute fatigue and four glucose parameters were determined: mean, variability, and relative time spent in hypoglycemia and hyperglycemia. RESULTS T1DM patients were significantly more often chronically fatigued (40%; 95% CI 34–47%) compared with matched controls (7%; 95% CI 3–10%; P < 0.001). Chronically fatigued patients had significantly more functional impairments. Fatigue was the most troublesome symptom. Age, depression, pain, sleeping problems, low self-efficacy concerning fatigue, and physical inactivity were significantly associated with chronic fatigue. Chronically fatigued patients spent slightly less time in hypoglycemia (proportion 0.07 ± 0.06 vs. 0.12 ± 0.10; P = 0.025). Glucose parameters were not related to acute fatigue. CONCLUSIONS Chronic fatigue is highly prevalent and clinically relevant in T1DM. Its significant relationship with cognitive behavioral variables and weak association with blood glucose levels suggests that behavioral interventions could be helpful in managing chronic fatigue in T1DM.

Background Home parenteral nutrition (HPN) is a life-saving therapy for patients with diseases that preclude adequate oral or enteral food intake. HPN has a large impact on daily life. Many patients suffer from fatigue and depression, and they experience limits in social activities. This all contributes to a lower quality of life.Purpose Fatigue is the most frequently mentioned problem in Dutch HPN patients. Therefore, we studied the prevalence, course and predictors of fatigue in these patients.Methods Patients completed questionnaires at baseline and follow-up (12 months later). Measurements included fatigue, depression, functional impairment, social support, self-efficacy, coping, anxiety and acceptance. Laboratory measures, including total bilirubin, creatinine, albumin and haemoglobin levels, were obtained from the medical records. Descriptive statistics, correlations and linear regression analysis were performed.Results The response rate was 71% (n = 75). Sixty-five per cent of the patients were severely fatigued (n = 49). Eighty-nine per cent experienced persistent fatigue. Baseline fatigue predicted 57% of the variance of fatigue at follow-up, and avoidance was responsible for 3% of the variance. No significant correlations between fatigue and laboratory measures were found. A cross-sectional analysis showed that 46% of the variance of fatigue was explained by functional impairment, self-efficacy and depression.Conclusion Severe fatigue is a persistent problem for HPN patients. Baseline fatigue was the strongest predictor of fatigue at follow-up. Functional impairment, self-efficacy and depression are strongly related to fatigue. Early recognition and treatment of fatigue are important.

In chronic fatigue syndrome (CFS), facilitating, initiating, and perpetuating factors are distinguished. Although somatic factors might have initiated symptoms in CFS, they do not explain the persistence of fatigue. Cognitive behavior therapy (CBT) for CFS focuses on factors that perpetuate and prolong symptoms. Recently it has been shown that, based on their level of activity, two groups of patients can be distinguished. For so-called “relatively active” CFS patients, the main perpetuating factors are nonaccepting and demanding cognitions leading to bursts of activity. For so-called “passive” CFS patients, their fear that activity might worsen their symptoms (which results in an avoidance of activity) is the most important perpetuating factor. These differences in perpetuating factors result in separate treatment manuals for relatively active and for passive CFS patients. Before describing the treatment manuals, we outline basic assumptions, considerations before starting CBT for CFS, and ways to determine the activity pattern.

Huibers MJH, Beurskens AJHM, Van Schayck CP, Bazelmans E, Metsemakers JFM, Knottnerus JA, Bleijenberg G. Effectiviteit van cognitieve gedragstherapie door huisartsen bij onverklaarde vermoeidheid onder werknemers: een gerandomiseerd vergelijkend onderzoek. Huisarts Wet 2005;48(6):267-72.

Several randomized controlled trials have indicated that cognitive behaviour therapy is an effective treatment for chronic fatigue syndrome. In 1 of these studies 13 therapists applied cognitive behaviour therapy for chronic fatigue syndrome in 83 chronic fatigue syndrome patients. In the present study therapists' adherence and perceptions of the manual are studied. Following completion of the study the therapists were asked to complete a questionnaire. Audiotaped sessions were conducted to verify the therapists' adherence. Analyses of the audiotapes showed that in 87% of the sessions this appeared to be the case. The questionnaire revealed that the therapists found it more difficult to treat patients with chronic fatigue syndrome than to treat patients with psychological or other physical problems. Treatment aspects posing the most problems were integrating individual problems into the standardized treatment, dealing with the patients' lack of confidence in the treatment and handling insufficient motivation.

Although cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) is effective in several RCTs, little is known about predictors of treatment outcome. With the data of our RCT, where CBT for CFS was significantly more effective in improving fatigue severity and functional impairment than guided support groups and natural course, the predictive value of activity pattern, disability claims and psychiatric comorbidity was tested for outcome of CBT. Patients with a passive activity pattern and patients who were engaged in a legal procedure concerning financial benefits had a worse outcome. Psychiatric comorbidity was not a predictor. For patients with a passive activity pattern, another type of CBT has to be offered. CBT should not be offered to patients during their engagement in legal procedures of disability claims.

Onlangs is het protocol ‘cognitieve-gedragstherapie bij het chronisch vermoeidheidssyndroom’ (cvs) verschenen. Met een eerdere versie van dit protocol is door dertien psychotherapeuten ervaring opgedaan in het kader van wetenschappelijk onderzoek. Deze psychotherapeuten behandelden met dit protocol 82 patiënten met cvs. Uit de resultaten van dit onderzoek is gebleken dat de behandeling effectief is. Daarom is het belangrijk ook zicht te krijgen op de mogelijkheden de uitvoering van de behandeling over te dragen aan perifere behandelaars. De psychotherapeuten in dit onderzoek waren uitgebreid getraind en gesuperviseerd. Maar hebben zij ook gedaan wat zij verondersteld werden te doen? En wat vonden zij van de uitvoerbaarheid van deze protocollaire vorm van cognitieve-gedragstherapie voor cvs? Om hier antwoord op te krijgen, is aan het eind van eerdergenoemd onderzoek aan de dertien psychotherapeuten die de behandelingen uitvoerden, een vragenlijst voorgelegd. Door analyse van audio-opnamen van de sessies is nagegaan in hoeverre de therapeuten de verschillende aspecten van de behandeling ook volgens protocol hebben uitgevoerd. In 89 procent van de sessies bleek dat in voldoende mate te zijn gebeurd. Uit de vragenlijst bleek dat de psychotherapeuten vonden dat cvs-patiënten moeilijker te behandelen zijn dan patiënten met psychische klachten en patiënten met andere lichamelijke klachten. Het moeilijkste vond men het integreren van individuele problemen in de behandeling, het gebrek aan vertrouwen in de behandeling van de patiënt en het omgaan met onvoldoende motivatie. Met name voor deze aspecten lijkt, naast het ter beschikking stellen van het protocol, extra training noodzakelijk. Het protocol zal zo geschreven moeten zijn dat de therapeut het protocol kan individualiseren en handreikingen krijgt met betrekking tot het motiveren van de patiënten.