ObjectiveTo determine the effectiveness of a web-based self-management programme for people with type 2 diabetes in improving glycaemic control and reducing diabetes-related distress.Methods and designIndividually randomised two-arm controlled trial.Setting21 general practices in England.ParticipantsAdults aged 18 or over with a diagnosis of type 2 diabetes registered with participating general practices.Intervention and comparatorUsual care plus either Healthy Living for People with Diabetes (HeLP-Diabetes), an interactive, theoretically informed, web-based self-management programme or a simple, text-based website containing basic information only.Outcomes and data collectionJoint primary outcomes were glycated haemoglobin (HbA1c) and diabetes-related distress, measured by the Problem Areas in Diabetes (PAID) scale, collected at 3 and 12 months after randomisation, with 12 months the primary outcome point. Research nurses, blind to allocation collected clinical data; participants completed self-report questionnaires online.AnalysisThe analysis compared groups as randomised (intention to treat) using a linear mixed effects model, adjusted for baseline data with multiple imputation of missing values.ResultsOf the 374 participants randomised between September 2013 and December 2014, 185 were allocated to the intervention and 189 to the control. Final (12 month) follow-up data for HbA1c were available for 318 (85%) and for PAID 337 (90%) of participants. Of these, 291 (78%) and 321 (86%) responses were recorded within the predefined window of 10–14 months. Participants in the intervention group had lower HbA1c than those in the control (mean difference −0.24%; 95% CI −0.44 to −0.049; p=0.014). There was no significant overall difference between groups in the mean PAID score (p=0.21), but prespecified subgroup analysis of participants who had been more recently diagnosed with diabetes showed a beneficial impact of the intervention in this group (p = 0.004). There were no reported harms.ConclusionsAccess to HeLP-Diabetes improved glycaemic control over 12 months.Trial registration numberISRCTN02123133.

A 17 year old girl with active Crohn's colitis developed idiopathic thrombocytopenic purpura that was managed with intravenous immune globulins and cyclosporin A. The possible association between Crohn's disease and immune thrombocytopenia is explored. (Postgrad Med J 2000;76:299-300) Keywords: Crohn's disease; colitis; thrombocytopenia Various autoimmune diseases have been associated with inflammatory bowel disease, with the majority of reports describing clustering of autoimmune haemolytic anaemia 1 with ulcerative colitis. An unusual case of Crohn's colitis with the subsequent development of idiopathic thrombocytopenic purpura (ITP) is described. Case reportA 17 year old girl with a history of Crohn's pancolitis without ileal involvement since age 8, was relatively well until the age of 16, when she had several hospitalisations for exacerbations of her Crohn's disease. This necessitated a medical regimen of prednisone (30 mg/day), azathioprine (100 mg/day), metronidazole, and mesalamine but the symptoms of colitis persisted.Apart from an anaemia of chronic disease (packed cell volume 0.247), her blood counts were normal until May 1996 when her platelet count was 3 × 10 9 /l, haemoglobin 85 g/l, packed cell volume 0.258, and leucocyte count 9.2 × 10 9 /l. She was also experiencing epistaxis and bloody diarrhoea. She had no history of recent viral infections, immunisations, recent blood transfusions, or use of recreational drugs. Physical examination revealed only mild cushingoid facies and there was no hepatosplenomegaly. Erythrocyte sedimentation rate was 60 mm/hour. Antinuclear antibodies, anti-HIV, Coombs' tests, platelet associated IgG, white cell diVerential, partial thromboplastin time, and prothrombin time were unremarkable. A peripheral blood smear showed marked thrombocytopenia with occasional giant platelets and no evidence of microangiopathic haemolytic anaemia. A bone marrow biopsy specimen revealed normocellularity with megakaryocytic hyperplasia compatible with peripheral platelet destruction.The patient's medications were discontinued and she was managed initially with methylprednisone (2 mg/kg/day) and platelet transfusions but without eVect. She was then treated with intravenous gammaglobulin (1 g/kg/day) which raised her platelet count to 45 × 10 9 /l and maintained on cyclosporin A (5 mg/kg/day) and prednisone (60 mg/day) as an outpatient. Her platelet counts remained between 400 and 680 × 10 9 /l. A colonoscopy, one month after discharge, revealed no active Crohn's disease. However, two months later, the return of active colitis prompted the addition of mesalamine to her regimen. One month later, she developed an inflammatory colonic mass necessitating left hemicolectomy. Histology of the mass was consistent with severely active Crohn's colitis. She remained asymptomatic, with normal platelet counts and did not require immunosuppressive medication. DiscussionThere are multiple case reports in the literature describing the association of inflammatory bowel disease with extraintest...

BackgroundExisting initiatives to support patient self-management of heart disease do not appear to be reaching patients most in need. Providing self-management programs over the Internet (web-based interventions) might help reduce health disparities by reaching a greater number of patients. However, it is unclear whether they can achieve this goal and whether their effectiveness might be limited by the digital divide.ObjectiveTo explore the effectiveness of a web-based intervention in decreasing inequalities in access to self-management support in patients with coronary heart disease (CHD).MethodsQuantitative and qualitative methods were used to explore use made of a web-based intervention over a period of 9 months. Patients with CHD, with or without home Internet access or previous experience using the Internet, were recruited from primary care centers in diverse socioeconomic and ethnic areas of North London, UK. Patients without home Internet were supported in using the intervention at public Internet services.ResultsOnly 10.6% of eligible patients chose to participate (N=168). Participants were predominantly Caucasian well-educated men, with greater proportions of male and younger CHD patients among participants than were registered at participating primary care practices. Most had been diagnosed with CHD a number of years prior to the study. Relatively few had been newly diagnosed or had experienced a cardiac event in the previous 5 years. Most had home Internet access and prior experience using the Internet. A greater use of the intervention was observed in older participants (for each 5-year age increase, OR 1.25 for no, low or high intervention use, 95% CI, 1.06-1.47) and in those that had home Internet access and prior Internet experience (OR 3.74, 95% CI, 1.52-9.22). Less use was observed in participants that had not recently experienced a cardiac event or diagnosis (≥ 5 years since cardiac event or diagnosis; OR 0.69, 95% CI, 0.50-0.95). Gender and level of education were not statistically related to level of use of the intervention. Data suggest that a recent cardiac event or diagnosis increased the need for information and advice in participants. However, participants that had been diagnosed several years ago showed little need for information and support. The inconvenience of public Internet access was a barrier for participants without home Internet access. The use of the intervention by participants with little or no Internet experience was limited by a lack of confidence with computers and discomfort with asking for assistance. It was also influenced by the level of participant need for information and by their perception of the intervention.ConclusionsThe availability of a web-based intervention, with support for use at home or through public Internet services, did not result in a large number or all types of patients with CHD using the intervention for self-management support. The effectiveness of web-based interventions for patients with chronic diseases remains a significant challenge.

Objectives: To determine whether a computerised decision support system for initiation and control of oral anticoagulant treatment improves quality of anticoagulant control achieved by trainee doctors. Design: Randomised controlled trial. Setting: District general hospital in North London. Subjects: 148 inpatients requiring start of warfarin treatment. Interventions: Management by trainee doctors (to achieve therapeutic range of international normalised ratio of 2 to 3) with indirect assistance from computerised decision support system (intervention group) or without such assistance (control group). Main outcome measures: Median time to therapeutic range, stable dose, and first pseudoevent (excessive international normalised ratio after therapeutic range has been reached) and person time spent in the therapeutic range. Results: 72 patients were randomised to the intervention group and 76 to control group. Median time to reach international normalised ratio of >2 was not significantly different in the two groups (3 days). Median time to achieve a stable dose was significantly lower in intervention group than in controls (7 days v 9 days, P = 0.01) without excessive overtreatment or undertreatment with anticoagulant. Patients in intervention group spent greater proportion of time in therapeutic range, both as inpatients (59% v 52%) and outpatients (64% v 51%). Conclusion:The computerised decision support system was safe and effective and improved the quality of initiation and control of warfarin treatment by trainee doctors.

Case reportDirect current cardioversion is reported as being a safe procedure during pregnancy 1,2 . However, the importance of carrying out fetal monitoring with an obstetrician at hand is illustrated by a woman treated in the third trimester of pregnancy, where direct current cardioversion resulted in an emergency caesarean section.A 24 year old woman attended the casualty department complaining of palpitations and heavy central chest pain that had begun 1 hour earlier. She was 28 weeks pregnant.At nine months of age she had received a Mustard operation for transposition of the great arteries (after intra-atrial repair, systemic venous blood is routed to the left ventricle and pulmonary artery. Pulmonary venous blood reaches the systemic circulation via the right ventricle). During childhood she had recurrent episodes of supraventricular tachycardia, which had responded to carotid sinus massage. A pacemaker was inserted at 13 years of age to treat nocturnal bradycardia. At 22 years of age, she delivered her first child spontaneously at term without complications.There had been no problems previously during her current pregnancy. A fetal cardiac ultrasound scan at 25 weeks of gestation was normal. She was not taking any medication.On examination she was centrally cyanosed. Her pulse rate was 200 beats per minute and her blood pressure was 100/50 mmHg. Her heart sounds were normal and she had no signs of cardiac failure. A 12-lead electrocardiogram confirmed a supraventricular tachycardia, with lateral ST depression and T wave inversion. A cardiogram showed a fetal heart rate of 160 beats per minute, with no abnormal features.Carotid sinus massage and the Valsalva manoeuvre failed to terminate the tachycardia. She was treated with intravenous adenosine 3, 6 and 12 mg. With a dose of 12 mg adenosine, she converted to sinus rhythm and the blood pressure remained at 100/50 mmHg. Within minutes, the supraventricular tachycardia returned and she was treated with verapamil 5 mg intravenously. Again, sinus rhythm was restored. The fetal heart rate was monitored throughout. The woman was admitted to the ward for observation.Two hours later, the supraventricular tachycardia recurred, the heart rate being 185 beats per minute. Adenosine and verapamil failed to terminate the tachycardia. Her blood pressure was 110/60 mmHg. The woman was turned to the left lateral position to maximise her venous return. She was treated with 240 mg sotalol and a loading dose of 500 Ag of digoxin orally in an attempt to control the ventricular rate. Thirty minutes later, she developed increasing chest pain. Her blood pressure decreased to 60/40 mmHg, with a persisting heart rate of 200 beats per minute. She was transferred urgently to the operating theatre for direct current cardioversion under general anaesthesia.The fetal heart rate was monitored constantly. A synchronised shock of 50 J was delivered and the maternal heart rhythm was converted immediately to sinus rhythm, at a rate of 90 beats per minute. Her blood pressure increased to 110...