Parental home-based pulse oximetry monitoring for adults with intellectual disabilities at risk of serious respiratory problems including COVID-19: a brief report

BACKGROUND

People with intellectual disabilities (ID) are at high risk of developing respiratory health issues. The COVID-19 pandemic has compounded this, with serious consequences, and for some, death. Despite home-based oxygen saturation monitoring being recommended for people with ID, there is a stark lack of evidence in the literature on its feasibility.

METHOD

We conducted 3-day baseline home-based oxygen saturation monitoring, using pulse oximeters, with eight parents of nine adults with ID in Scotland. Two eligible parents also completed a further 2 weeks of monitoring, and returned an evaluation questionnaire on its feasibility.

RESULTS

Baseline mean readings for eight adults with ID were within the normal range (%Sp0₂  ≥ 95), and for another one 94%. Fluctuations over the 3-day assessment period were experienced by six of these individuals. However, these variations were within limits which are not dangerous (lowest reading 92%), implying that parental home-based pulse oximetry monitoring is likely to be safe for adults with ID. The two parents who completed the evaluation found home-based pulse oximetry monitoring to be easy/very easy to do, and effective/very effective.

CONCLUSIONS

This is the first research study, albeit with a very small sample, to report on the potential feasibility of parental home-based pulse oximetry monitoring for adults with ID. Home-based pulse oximetry monitoring appears to be safe in adults with ID at risk of developing serious respiratory problems, and not difficult for their parents to do. There is an urgent need to replicate this work, using a larger sample, to promote home-based respiratory health monitoring more widely for people with ID.

Characterizing and predicting the relationship between translaminar fracture toughness and pull-out length distributions under distinct temperatures

The translaminar fracture toughness reflects the damage tolerance of a fibre-reinforced composite under longitudinal tension, which often governs the final failure of structures. One of the main energy-dissipation mechanisms that contributes to the translaminar toughness of composites is the fibre pull-out process. The present study aims to quantify and model the statistical distribution of fibre pull-out lengths formed on the translaminar fracture surface of composites, for the first time in the literature; this is done under different temperatures, so that the relationship between pull-out length distributions, micromechanical properties and the translaminar fracture toughness can be established. The fracture surfaces of cross-ply compact tension specimens tested under three different temperatures have been scanned through X-ray computed tomography to quantify the extent of fibre pull-out on the fracture surfaces; the distribution of pull-out lengths showed alarger average and larger variability with an increase in temperature, which also lead to an increase in translaminar fracture toughness. A similar trend has been captured by the proposed analytical model, which predicts the pull-out length distribution based on the analysis of quasi-fractal idealizations of the fracture surface, yielding an overall accuracy of more than 85%. This article is part of the theme issue 'Ageing and durability of composite materials'.

Prevalence of factors associated with edentulousness (no natural teeth) in adults with intellectual disabilities

BACKGROUND

Poor oral health is largely preventable. Prevention includes toothbrushing and regular dental checks. Oral health has important consequences for general nutrition, chewing, communication, wider systemic disease, self-confidence and participation in society. This study investigated the prevalence of edentulousness (no natural teeth) in adults with intellectual disabilities (IDs) compared with the general population and associated factors.

METHODS

An adult cohort with IDs residing in Greater Glasgow and Clyde, Scotland, underwent detailed health assessments between 2002 and 2004. Between 2004 and 2006, a subsample had an oral check. Data on edentulousness in the cohort were compared with adult participants from Greater Glasgow and Clyde in the 2008 Scottish Health Survey. Within the IDs cohort, binary logistic regression analyses investigated potential relationships between edentulousness and demographic and clinical factors.

RESULTS

Five hundred sixty adults with IDs were examined [53.2% (298) male, mean age = 46.3 years, range 18-81 years] and compared with 2547 general population: edentulousness was 9% vs. 1% aged 25-34 years; 22% vs. 2% aged 35-44 years; 39% vs. 7% aged 45-54 years; 41% vs. 18% aged 55-64 years; and 76% vs. 34% aged 65-74 years. In both groups, edentulousness increased with age. After stratification for age, rates of edentulousness were consistently higher in the ID cohort. Odds ratios within age strata were not homogenous (Mantel-Haenszel test, P < 0.0001). Edentulousness was more likely in those with more severe IDs (adjusted odds ratio (AOR) = 2.36; 95% confidence interval (CI) [1.23 to 4.51]); those taking antipsychotics (AOR = 2.09; 95% CI [1.25 to 3.51]) and those living in the most deprived neighbourhoods (AOR = 2.69; 95% CI [1.11 to 6.50]). There was insufficient evidence for associations with sex, type of accommodation/support, antiepileptics, problem behaviours or autism.

CONCLUSIONS

Adults with IDs have a high prevalence of edentulousness and need supported daily oral care to reduce the need for extractions. Despite previous reports on poor oral care and the move towards person-centred care, carers and care-giving organisations need greater support to implement daily oral care. Prescribers need awareness of the potentially contributory role of antipsychotics, which may relate to xerostomia.

Lycra splinting garments for adults with intellectual disabilities who fall due to gait or balance issues: a feasibility study

BACKGROUND

Adults with intellectual disabilities (IDs) experience high rates of falls and have high rates of gait or balance issues which contribute to falls. Lycra splinting garments (LSGs) have potential to improve gait or balance, but they have never before been tested with adults with IDs who fall due to gait or balance issues. The aim of this study was to test in adults with IDs, the feasibility of using LSGs to improve movement and function and reduce falls, whilst also exploring usability and likely compliance.

METHOD

A convenience sample of nine adults with IDs wore tailored LSGs over a 6-week assessment period. Laboratory-based foot clearance, balance, and gait measures were collected pre- and post-LSG-wear. Falls charts and questionnaires on usability and likely compliance were also completed.

RESULTS

Seven participants experienced a reduction in falls during their six weeks of LSG wear; most notably in the group of five participants who wore lycra splinting socks, compared with only two in the group of four who wore lycra splinting shorts or leggings only.

CONCLUSION

Lycra splinting socks are likely to bring about positive outcomes for adults with IDs who fall due to gait/balance issues on an individual case by case basis over time, but further research is required to test this hypothesis under randomised controlled trial conditions. Potential benefits of more intrusive LSGs are outweighed by reported problems with usability and compliance.

Dominant and sensitive control of oxidative flux by the ATP-ADP carrier in human skeletal muscle mitochondria: Effect of lysine acetylation

The adenine nucleotide translocase (ANT) of the mitochondrial inner membrane exchanges ADP for ATP. Mitochondria were isolated from human vastus lateralis muscle (n = 9). Carboxyatractyloside titration of O₂ consumption rate (J_o) at clamped [ADP] of 21 μM gave ANT abundance of 0.97 ± 0.14 nmol ANT/mg and a flux control coefficient of 82% ± 6%. Flux control fell to 1% ± 1% at saturating (2 mM) [ADP]. The KmADP for J_o was 32.4 ± 1.8 μM. In terms of the free (-3) ADP anion this KmADP was 12.0 ± 0.7 μM. A novel luciferase-based assay for ATP production gave KmADP of 13.1 ± 1.9 μM in the absence of ATP competition. The free anion KmADP in this case was 2.0 ± 0.3 μM. Targeted proteomic analyses showed significant acetylation of ANT Lysine23 and that ANT1 was the most abundant isoform. Acetylation of Lysine23 correlated positively with KmADP, r = 0.74, P = 0.022. The findings underscore the central role played by ANT in the control of oxidative phosphorylation, particularly at the energy phosphate levels associated with low ATP demand. As predicted by molecular dynamic modeling, ANT Lysine23 acetylation decreased the apparent affinity of ADP for ANT binding.

Characterization of Immune System Cell Subsets in Fixed Tissues from Alpine Chamois (Rupicapra rupicapra)

Immune system cell subsets in lymph nodes and spleen from alpine chamois (Rupicapra rupicapra subspecies rupicapra) living in the Italian Alps were characterized immunohistochemically. Seven primary antibodies (against human CD3, CD79αcy, CD68, or ovine CD4, CD8, CD21 and γδ T-cell receptor [TCR] epitopes) were tested on tissues fixed either in formalin or in zinc salts (ZS) and cross-reactivity with chamois immune cell epitopes was shown. ZS fixation allowed wider identification of immune cells, without the need for antigen retrieval. CD4(+) and CD21(+) cells were labelled only in ZS-fixed tissues. Reagents specific for human CD3, CD79 and CD68 antigens successfully detected chamois immune cells, both in ZS-fixed and formalin-fixed tissues. The reactivity and distribution of immune cells in lymph nodes and spleen were similar to those described in other domestic and wild ruminants. Results from this study may allow future investigation of the immune response and pathogenesis of diseases in the chamois.

The provision of aids and adaptations, risk assessments, and incident reporting and recording procedures in relation to injury prevention for adults with intellectual disabilities: cohort study

BACKGROUND

Adults with intellectual disabilities (IDs) experience a higher incidence of injury, compared with the general population. The aim of this study was to investigate the provision of aids and adaptations, residential service providers' individual risk assessments and training in these, and injury incident recording and reporting procedures, in relation to injury prevention.

METHOD

Interviews were conducted with a community-based cohort of adults with IDs (n = 511) who live in Greater Glasgow, Scotland, UK and their key carer (n = 446). They were asked about their aids and adaptations at home, and paid carers (n = 228) were asked about individual risk assessments, their training, and incident recording and reporting procedures.

RESULTS

Four hundred and twelve (80.6%) of the adults with IDs had at least one aid or adaptation at home to help prevent injury. However, a proportion who might benefit, were not in receipt of them, and surprisingly few had temperature controlled hot water or a bath thermometer in place to help prevent burns/scalds, or kitchen safety equipment to prevent burns/scalds from electric kettles or irons. Fifty-four (23.7%) of the paid carers were not aware of the adult they supported having had any risk assessments, and only 142 (57.9%) had received any training on risk assessments. Considerable variation in incident recording and reporting procedures was evident.

CONCLUSION

More work is needed to better understand, and more fully incorporate, best practice injury prevention measures into routine support planning for adults with IDs within a positive risk-taking and risk reduction framework.

Pathogenesis of scrapie in ARQ/ARQ sheep after subcutaneous infection: effect of lymphadenectomy and immune cell subset changes in relation to prion protein accumulation

It is well established that the infectious agent of scrapie can replicate in the lymphoreticular system (LRS). However, the effects of removal of LRS target tissues on the pathogenesis of the infection and the accumulation of disease-associated prion protein (PrP(d)) in LRS tissues on specific immune cell subsets are poorly understood aspects. To address these questions 16 ARQ/ARQ sheep were subcutaneously inoculated in the drainage area of the prefemoral lymph node with brain homogenate derived from Suffolk sheep naturally infected with scrapie. Fourteen sheep were then subjected to either early (14-17 days post-inoculation [dpi]) or late (175-201 dpi) lymphadenectomy and culled at preclinical or clinical stages of infection. Neither late nor even early lymphadenectomy prevented infection or had any effect on the accumulation of PrP(d) in the LRS or CNS suggesting a rapid organic dissemination of the infectious agent after inoculation. Lymph nodes from eight scrapie inoculated sheep selected on the basis of the amount of PrP(d) in their LRS tissues (negative, low or high) were examined for six different immune cell markers. The PrP(d) negative lymph nodes from two sheep with no evidence of scrapie infection showed lower numbers of cluster of determination (CD) 21 positive cells than PrP(d) positive nodes, irrespective of their location (hind leg or head). However, quantitative differences in the expression of this marker were not detected when comparing lymph nodes with low and high levels of PrP(d) accumulation, suggesting that proliferation of CD21 positive cells is related to scrapie infection, but not directly linked to the magnitude of PrP(d) accumulation. An additional observation of the study was that sheep that were methionin-threonine at codon 112 of the prion protein gene showed lower attack rates than methionine homozygotes (67% and 100%, respectively) and also generally lower levels of PrP(d) accumulation in the LRS and brain and increased survival times, suggesting an influence of such polymorphism in the susceptibility to scrapie.

Evaluation of a new rapid anti-HbF FITC assay, Trillium QuikQuant, for detection and quantitation of foetomaternal haemorrhage

INTRODUCTION

This study evaluated a new product for flow cytometric foetomaternal haemorrhage (FMH) quantitation, Trillium QuikQuant anti-HbF FITC kit (Trillium Diagnostics, USA), in comparison with the Millipore anti-HbF FITC method.

METHODS

Blood from 67 antenatal or postpartum RhD-negative women together with 108 samples spiked with 0.2%, 0.4%, 0.6%, 2%, 4%, 5%, 6%, 8% and 10% of foetal red cells were analysed by both methods.

RESULTS

Results for both methods were linear to 10% foetal red cells. Analysis using the Wilcoxon test found that there was no difference between the paired results of Trillium QuikQuant and the expected values of the spiked samples (P = 0.48). In contrast, Millipore anti-HbF FITC gave statistically higher results compared with both the expected values and Trillium QuikQuant anti-HbF FITC (P = 0.0003 and P < 0.0001, respectively). The Bland-Altman plot for Trillium QuikQuant showed a mean difference of only 0.06% below the expected values, whilst Millipore was 0.13% above. The analysis time with Trillium QuikQuant was approximately 40 min, requiring significantly less hands-on time than the Millipore method that required an additional four wash steps.

CONCLUSION

Trillium QuikQuant is a new precise, accurate and rapid flow cytometric kit method for the quantitation of FMH in both the antenatal and postpartum period.

Global IRS-1 phosphorylation analysis in insulin resistance

AIMS/HYPOTHESIS

IRS-1 serine phosphorylation is often elevated in insulin resistance models, but confirmation in vivo in humans is lacking. We therefore analysed IRS-1 phosphorylation in human muscle in vivo.

METHODS

We used HPLC-electrospray ionisation (ESI)-MS/MS to quantify IRS-1 phosphorylation basally and after insulin infusion in vastus lateralis muscle from lean healthy, obese non-diabetic and type 2 diabetic volunteers.

RESULTS

Basal Ser323 phosphorylation was increased in type 2 diabetic patients (2.1 ± 0.43, p ≤ 0.05, fold change vs lean controls). Thr495 phosphorylation was decreased in type 2 diabetic patients (p ≤ 0.05). Insulin increased IRS-1 phosphorylation at Ser527 (1.4 ± 0.17, p ≤ 0.01, fold change, 60 min after insulin infusion vs basal) and Ser531 (1.3 ± 0.16, p ≤ 0.01, fold change, 60 min after insulin infusion vs basal) in the lean controls and suppressed phosphorylation at Ser348 (0.56 ± 0.11, p ≤ 0.01, fold change, 240 min after insulin infusion vs basal), Thr446 (0.64 ± 0.16, p ≤ 0.05, fold change, 60 min after insulin infusion vs basal), Ser1100 (0.77 ± 0.22, p ≤ 0.05, fold change, 240 min after insulin infusion vs basal) and Ser1142 (1.3 ± 0.2, p ≤ 0.05, fold change, 60 min after insulin infusion vs basal).

CONCLUSIONS/INTERPRETATION

We conclude that, unlike some aspects of insulin signalling, the ability of insulin to increase or suppress certain IRS-1 phosphorylation sites is intact in insulin resistance. However, some IRS-1 phosphorylation sites do not respond to insulin, whereas other Ser/Thr phosphorylation sites are either increased or decreased in insulin resistance.

Immunophenotype of cells within cervine rectoanal mucosa-associated lymphoid tissue and mesenteric lymph nodes

Rectoanal mucosa-associated lymphoid tissue (RAMALT) is a part of the lymphoid system that can be sampled easily in live animals, especially ruminants. RAMALT biopsy is useful for the diagnosis of transmissible spongiform encephalopathies, including scrapie in sheep and goats and chronic wasting disease (CWD) in cervids. Diagnosis is reliant on detection of abnormal prion protein (PrP(d)), which is associated with lymphoid follicles. For enzyme linked immunosorbent assays (ELISAs) detecting PrP(d) it is necessary to ensure that lymphoid follicles are present in biopsy samples to avoid false-negative results. Monoclonal antibodies known to recognize specific immune cell subsets present in lymphoid tissues of sheep were tested for cross-reactivity with cervine RAMALT and mesenteric lymph nodes (MLNs) preserved in zinc salts fixative. The distribution of cells expressing CD3, CD4, CD79, CD21 and class II molecules of the major histocompatibility complex was determined in these tissues. Cells of each immunophenotype had similar distributions in RAMALT and MLNs and these distributions were similar to those reported previously for sheep and cattle. The identification and validation of cervine lymphoid follicle cell markers (CD79 and CD21) may allow reduction in false-negative results during diagnosis of CWD by ELISA.

Increased abundance of the adaptor protein containing pleckstrin homology domain, phosphotyrosine binding domain and leucine zipper motif (APPL1) in patients with obesity and type 2 diabetes: evidence for altered adiponectin signalling

AIMS/HYPOTHESIS

The adiponectin signalling pathway is largely unknown, but recently the adaptor protein containing pleckstrin homology domain, phosphotyrosine binding domain and leucine zipper motif (APPL1), has been shown to interact directly with adiponectin receptor (ADIPOR)1. APPL1 is present in C2C12 myoblasts and mouse skeletal muscle, but its presence in human skeletal muscle has not been investigated.

METHODS

Samples from type 2 diabetic, and lean and non-diabetic obese participants were analysed by: immunoprecipitation and western blot; HPLC-electrospray ionisation (ESI)-mass spectrometry (MS) analysis; peak area analysis by MS; HPLC-ESI-MS/MS/MS analysis; and RT-PCR analysis of APPL1 mRNA.

RESULTS

Immunoprecipitation and western blot indicated a band specific to APPL1. Tryptic digestion and HPLC-ESI-MS analysis of whole-muscle homogenate APPL1 unambiguously identified APPL1 with 56% sequence coverage. Peak area analysis by MS validated western blot results, showing APPL1 levels to be significantly increased in type 2 diabetic and obese as compared with lean participants. Targeted phosphopeptide analysis by HPLC-ESI-MS/MS/MS showed that APPL1 was phosphorylated specifically on Ser(401). APPL1 mRNA expression was significantly increased in obese and type 2 diabetic participants as compared with lean participants. After bariatric surgery in morbidly obese participants with subsequent weight loss, skeletal muscle APPL1 abundance was significantly reduced (p < 0.05) in association with an increase in plasma adiponectin (p < 0.01), increased levels of ADIPOR1 (p < 0.05) and increased muscle AMP-activated protein kinase (AMPK) phosphorylation (p < 0.05).

CONCLUSIONS/INTERPRETATION

APPL1 abundance is significantly higher in type 2 diabetic muscle; APPL1 is phosphorylated in vivo on Ser(401). Improvements in hyperglycaemia and hypoadiponectinaemia following weight loss are associated with reduced skeletal muscle APPL1, and increased plasma adiponectin levels and muscle AMPK phosphorylation.

Prevalence of Pasteurella multocida and other respiratory pathogens in the nasal tract of Scottish calves

The prevalence of Pasteurella multocida, a cause of bovine respiratory disease, was studied in a random sample of beef suckler and dairy farms throughout Scotland, by means of a cross-sectional survey. A total of 637 calves from 68 farms from six geographical regions of Scotland were sampled between February and June 2008. Deep nasal swabs were taken, and samples that were culture-positive for P multocida were confirmed by PCR. Prevalence of P multocida was 17 per cent (105 of 616 calves); 47 per cent of farms had at least one positive animal. A higher prevalence was detected in dairy calves than beef calves (P=0.04). It was found that P multocida was associated with Mycoplasma-like organisms (P=0.06) and bovine parainfluenza type 3 virus (BPI-3) (P=0.04), detected by culture and quantitative PCR of nasal swabs, respectively. Detection of P multocida was not associated with bovine respiratory syncytial virus (BRSV), bovine herpesvirus type 1 (BoHV-1) or bovine viral diarrhoea virus (BVDV). Mycoplasma-like organisms, BPI-3, BRSV, BoHV-1 and BVDV were detected in 58, 17, four, 0 and eight calves, on 25, five, two, 0 and five of the 68 farms, respectively.

Injuries, falls and accidents among adults with intellectual disabilities. Prospective cohort study

BACKGROUND

Injuries are among the leading causes of death and disability in the world and a major public health concern. Falls are a common cause. Young persons with intellectual disabilities (ID) have a higher rate and different pattern of injuries than the general population, but little is known regarding adults.

METHODS

The aim of this study was to determine the incidence and types of injuries experienced by a community-based cohort of adults with ID (n = 511) in a 12-month period. Face-to-face interviews were conducted with participants 2 years after they had first been recruited into a longitudinal study.

RESULTS

Incidence of at least one injury in a 12-month period was 20.5% (105), of which 12.1% (62) was because of falls. Incident injury was predicted by having epilepsy and not having autism. Incident fall injury was predicted by urinary incontinence, while Down syndrome reduced risk.

CONCLUSIONS

Adults with ID do experience a higher rate of injuries and falls when compared with the general population. The results of this study highlight this, and hence the need to work towards the development of interventions for injury and falls prevention in this population.

Profitability of grazing crop stubbles may be overestimated by using the metabolisable energy intake from the stubble

Grazing crop stubbles affects soil structure, groundcover, and the productivity of subsequent crops, but the cost of this practice is highly variable and not easily compared against the value of feed provided to livestock. To compare with and without grazing stubbles in terms of whole-farm profit and water-use efficiency we created a mixed enterprise farm model using the Agricultural Production Systems Simulator and GRAZPLAN biophysical simulation submodels, and the Model of Integrated Dryland Agricultural System linear programming model. We hypothesised that grazing crop stubbles would increase farm profit by an amount equivalent to the value of the metabolisable energy (ME) consumed by sheep when they grazed the crop stubbles. Representative mixed farms where sheep were or were not allowed to graze crop stubbles were compared for two locations in the wheatbelt of Western Australia (Cunderdin and Geraldton) at two stocking rates. Across locations and stocking rates, the estimated value of the ME intake from crop stubbles was 2.2 times the increase in farm gross margin when stubble grazing was allowed. Contributing to this difference was that stubble grazing provided a less flexible feed source than supplementary feeding and in the absence of adjustments in stocking rates sheep tended to utilise more of the annual and permanent pastures when stubble grazing was not permitted. Therefore, the value of grazing crop stubbles to the profitability of the farm enterprise was overestimated by the ME value of the intake. Owing to reduced consumption of supplementary feed by livestock, whole-farm water-use efficiency of protein production was increased by 15% when grazing of crop stubbles was permitted. This simulation study shows that the value of grazing crop stubbles cannot be predicted well using energy intake from stubble grazing or reduced supplementary feeding costs.

Characterization and time course of pulmonary lesions in calves after intratracheal infection with Pasteurella multocida A:3

Pasteurella multocida A:3 is a common cause of suppurative bronchopneumonia in calves and results in significant production losses and mortality. Here we describe the lesions in three calves at each of four time points (1 day and 4, 7 and 10 days) after experimental intratracheal infection with approximately 1x10(9) colony-forming units of P. multocida A:3 Moredun Research Institute (MRI isolate 671/90). Equivalent age- and time-matched sham-dosed negative control animals were also studied. Infected calves developed significantly elevated mean rectal temperatures (P<0.001) and respiratory rates (P<0.001) compared with negative control animals. Extensive consolidation of multiple lung lobes was present on each of the day/s post-infection (dpi). Histologically, large numbers of alveoli contained either or both polymorphonuclear neutrophils (PMNs) and oedema fluid (1 dpi). At 4 dpi a severe fibrinosuppurative bronchopneumonia had developed. At this time, PMNs and macrophages formed focal lesions containing central necrotic and mineralized debris, while the interlobular septa were severely distended by oedema. Early abscess formation was present in the lung parenchyma at 7 dpi and many of the interlobular septa were thrombosed. At 10 dpi abscesses within the lung parenchyma were mature and comprised of central necrosis with surrounding layers of PMN, macrophages and fibrous tissue. This study describes, for the first time, the commencement, nature and progression of lesions in bovine pneumonic pasteurellosis caused by P. multocida A:3 and provides the foundations for further investigation of the pathogenesis of this disease in cattle.

Cost estimation of a health-check intervention for adults with intellectual disabilities in the UK

BACKGROUND

High rates of health needs among adults with intellectual disabilities flag the need for information about the economic consequences of strategies to identify and address unmet needs. Health-check interventions are one such strategy, and have been demonstrated to effect health gains over the following 12-month period. However, little is known about their effects on service use and costs, and hence how affordable such interventions are.

METHODS

We examined service use patterns and costs over a 12-month period for 50 adult participants with intellectual disabilities who received a health-check intervention and 50 individually matched control participants who received standard care only.

RESULTS

The health-check intervention was cheap, and it did not have associated higher costs in terms of service usage. Indeed, mean cost of care for the adults who received standard care only was greater than for the adults who received the health-check intervention. The higher costs were due to differences in unpaid carer support costs.

CONCLUSION

This is the first study to report the associated service use, and costs of a health-check intervention to improve the health of adults with intellectual disabilities and reduce health inequalities. Results suggest this intervention is cheap and affordable compared with standard care, supporting clinical outcome evidence for its introduction into health care policy and implementation. However, further research is needed to confirm this finding with a larger sample.

Adults with intellectual disabilities: prevalence, incidence and remission of self-injurious behaviour, and related factors

BACKGROUND

Self-injurious behaviour (SIB) is a serious condition, with implications for the person, their family and financial costs to the state providing care. The previously reported prevalence of SIB has ranged from 1.7% to 41%, or 1.7%-23.7% in community studies. There has been little study of remission rate, and incidence has not previously been reported. SIB has been reported to be individually associated with lower ability, autism and communication impairments, but given the inter-relationships between these three factors, it is not known whether they are independently associated with SIB. This study investigates the point prevalence, incidence and remission rates of SIB among the adult population with intellectual disabilities (ID), and explores which factors are independently associated with SIB.

METHOD

A prospective cohort study design was used in a general community setting. The participants were all adults (16 years and over) with ID in a defined geographical area. Individual assessments were conducted with all participants.

RESULTS

The point prevalence of SIB (as defined by DC-LD) was 4.9%, the two-year incidence was 0.6%, and two-year remission rate was 38.2%. Independently related to SIB were: lower ability level, not living with a family carer, having attention deficit hyperactivity disorder, visual impairment, and not having Down syndrome. Other factors, including communication impairment, autism, and level of deprivation of the area resided within, were not related.

CONCLUSIONS

SIB is not as enduring and persistent as previously thought; a significant proportion gains remission in this time period. This should provide hope for families, paid carers and professionals, and reduce therapeutic nihilism. Our study is a first tentative step towards identifying risk-markers for SIB, and developing aetiological hypotheses for subsequent testing. The extent to which SIB may be a relapsing-remitting (episodic) condition requires further investigation, so does further hypothesis-based investigation of factors that might be predictive of incidence of, and remission from, SIB.

Adults with intellectual disabilities: prevalence, incidence and remission of aggressive behaviour and related factors

INTRODUCTION

Aggressive behaviours can be disabling for adults with intellectual disabilities (ID), with negative consequences for the adult, their family and paid carers. It is surprising how little research has been conducted into the epidemiology of these needs, given the impact they can have. This study investigates point prevalence, 2-year incidence and 2-year remission rates for aggressive behaviour (physically aggressive, destructive and verbally aggressive), and it investigates which factors are independently associated with aggressive behaviour.

METHODS

All adults with ID - within a geographically defined area of Scotland, UK - were recruited to a longitudinal cohort. At baseline, assessments were undertaken of demography, lifestyle, supports, development, problem behaviours, disabilities and physical and mental health. These were repeated for a 2-year period.

RESULTS

At baseline, the participation rate was 1023 (65.5%). After 2 years, the cohort retention was 651 adults. The point prevalence of Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) aggressive behaviour was 9.8% (95% confidence interval = 8.0-11.8%), 2-year incidence was 1.8%, and 2-year remission rate from all types of aggressive behaviour meeting DC-LD criteria was 27.7%. The factors independently associated with aggressive behaviours were lower ability, female gender, not living with a family carer, not having Down syndrome, having attention-deficit hyperactivity disorder and having urinary incontinence. Incidence of aggressive behaviour meeting DC-LD criteria in adult life is similar to that for each of psychotic, anxiety and organic disorders.

CONCLUSIONS

Aggressive behaviour is common among adults with ID, but contrary to previous suggestions, more than a quarter remit within the short to medium term. This is important knowledge for professionals as well as the person and her/his family and paid carers. There is much yet to learn about the mechanisms underpinning aetiology and maintenance of aggressive behaviour in this population, and exploratory epidemiological investigations such as this have a role to play in progressing research towards further hypothesis testing and trials to influence clinical practice, service development and policy.

Occurrence and cellular localization of PrPd in kidneys of scrapie-affected sheep in the absence of inflammation

Following a preliminary description of disease-associated prion protein (PrPd) deposition in the kidneys of scrapie-affected sheep, detailed studies have been undertaken in order to evaluate the factors that could account for such PrPd accumulation and to determine the precise location of PrPd in the renal papillae. Immunohistochemical (IHC) examinations for PrPd were conducted in kidneys collected at post-mortem from 30 naturally and 37 experimentally infected sheep. In addition, PrPd detection by western blot analysis (WB) and ultrastructural examination was carried out in a selection of kidneys. PrPd-specific, multifocal IHC labelling with antibody R145 was achieved in the kidneys of 44% and 51% of the naturally and experimentally infected sheep, respectively. The specificity of these results was confirmed by further IHC and WB using several PrP antibodies raised to different amino acid sequences, and by examination of control tissues. PrPd was shown to accumulate in the interstitium of the renal papillae, in association with the cell membrane and lysosomes of fibroblast-like cells, or extracellularly, in close contact with collagen and basal membranes. These deposits were unrelated to inflammatory changes in the kidney as shown by routine histology and by IHC for different immune cell markers. PrPd accumulated in the kidney of sheep that showed widespread PrPd deposition in the lymphoreticular system and had long incubation periods; these findings argue for a haematogenous origin of renal PrPd, although the precise site and mechanism-glomerular filtration and reabsorption at Henle's loop, or extravasation from vasa recta capillaries, or both-by which PrPd leaves the blood to accumulate in the interstitium of renal papillae remain to be determined. Either of these pathogenetic mechanisms could lead to environmental contamination via urine.

The prevalence and incidence of mental ill-health in adults with Down syndrome

BACKGROUND

While there is considerable literature on adults with Down syndrome who have dementia, there is little published on the epidemiology of other types of mental ill-health in this population.

METHOD

Longitudinal cohort study of adults with Down syndrome who received detailed psychiatric assessment (n = 186 at the first time point; n = 134 at the second time point, 2 years later).

RESULTS

The prevalence of Down syndrome for the 16 years and over population was 5.9 per 10 000 general population. Point prevalence of mental ill-health of any type, excluding specific phobias, was 23.7% by clinical, 19.9% by Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities/Mental Retardation (DC-LD), 11.3% by ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research (DCR-ICD-10) and 10.8% by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Revised (DSM-IV-TR) criteria. Two-year incidence of mental ill-health of any type was 14.9% by clinical and DC-LD, 9.0% by DCR-ICD-10 and 3.7% by DSM-IV-TR criteria. The highest incidence was for depressive episode (5.2%) and dementia/delirium (5.2%). Compared with persons with intellectual disabilities (ID) of all causes, the standardized rate for prevalence of mental ill-health was 0.6 (0.4-0.8), or 0.4 (0.3-0.6) if organic disorders are excluded, and the standardized incidence ratio for mental ill-health was 0.9 (0.6-1.4), or 0.7 (0.4-1.2) if organic disorders are excluded. Urinary incontinence was independently associated with mental ill-health, whereas other personal factors, lifestyle and supports, and other types of health needs and disabilities were not.

CONCLUSIONS

Mental ill-health is less prevalent in adults with Down syndrome than for other adults with ID. The pattern of associated factors differs from that is found for other adults with ID, with few associations found. This suggests that the protection against mental ill-health is biologically determined in this population, or that there are other factors protective for mental ill-health yet to be identified for the population with Down syndrome.

Immunological differences between susceptible and resistant sheep during the preclinical phase of scrapie infection

In order to investigate the relationship between the immune response to scrapie infection and genetic susceptibility to the disease in sheep, immune cell subsets and prion protein (PrP) expression were determined in susceptible and resistant Suffolk sheep in the preclinical phase of infection. At 6 months of age, 12 ARQ/ARQ (susceptible) and nine ARR/ARR (resistant) scrapie-free Suffolk lambs were challenged subcutaneously with scrapie inoculum. Prefemoral lymphadenectomies were carried out at 14 and 180 days post-inoculation (p.i.) and serial bleeds were collected at monthly intervals for up to 1 year p.i. An indirect double-labelling procedure was carried out on peripheral blood mononuclear cells (PBMCs) and lymph node cell preparations and analysed using flow cytometry. Prior to scrapie challenge, significantly more PrP+cells were detected in PBMCs from the susceptible sheep. Furthermore, following challenge, significantly more CD8+andγΔ+T cells were detected in the PBMCs of the resistant sheep. However, at both 14 and 180 days p.i, CD21+cell expression was significantly higher in the lymph node preparations of the susceptible sheep. In contrast, more CD4+cells were detected in the lymph nodes of the resistant sheep at both time points. It was concluded that significant differences in immune cell subsets and PrP expression occur between ARQ/ARQ and ARR/ARR Suffolk sheep in the preclinical phase of infection.

Improving the health of people with intellectual disabilities: outcomes of a health screening programme after 1 year

BACKGROUND

People with intellectual disabilities (IDs) have a higher level of health needs, a higher level of which is unmet, compared with the general population. Health screening can detect unmet health needs, but it is unknown whether it effects beneficial health outcomes in the longer term. People with IDs are reliant on health management by proxy and there are many potential access barriers that may prevent health needs identified at screening from subsequently being met. This study aims to determine whether health gains can be detected 1 year after a health screening programme specific to the needs of adults with IDs.

METHODS

A total of 50 participants offered the health screen intervention were individually matched for gender, age and level of IDs with 50 control participants who received standard treatment only. Outcome measures after 1 year were semi-structured review of medical case notes, and semi-structured assessment with the people with IDs and their carer.

RESULTS

During the 1-year period, the incidence of health need detection was more than twice as great for intervention, compared with control participants (mean number of new needs was 4.80 compared with 2.26; P < 0.001), and the level of met new health needs was greater (mean of 3.56 compared with 2.26; P = 0.001). The level of met health promotion needs was also greater (P < 0.001), and more health monitoring needs were met for intervention compared with control participants (P = 0.039).

CONCLUSIONS

This is the first study to demonstrate sustained benefits in health outcomes from a clinical intervention for adults with IDs compared with standard treatment alone. Its routine implementation is feasible, and would reduce health inequalities.

The outcomes of an intervention study to reduce the barriers experienced by people with intellectual disabilities accessing primary health care services

BACKGROUND

People with intellectual disabilities (IDs) experience significant health inequalities compared with the general population. The barriers people with IDs experience in accessing services contribute to these health inequalities. Professionals' significant unmet training needs are an important barrier to people with IDs accessing appropriate services to meet their health needs.

METHOD

A three group, pre- and post-intervention design was used to test the hypothesis that a training intervention for primary health care professionals would increase the knowledge and self-efficacy of participants. The intervention had two components - a written training pack and a 3-hour face-to-face training event. One group received the training pack and attended the training event, a second group received the training pack only, and a third group did not participate in the training intervention. Research measures were taken prior to the intervention and 3 months after the intervention. Statistical comparisons were made between the three groups.

RESULTS

The participants in the training intervention reported that it had a positive impact upon their knowledge, skills and clinical practice. As a result of the intervention, 35 (81.4%) respondents agreed that they were more able to meet the needs of their clients with IDs, and 33 (66.6%) reported that they had made changes to their clinical practice. The research demonstrated that the intervention produced a statistically significant increase in the knowledge of participants (F = 5.6, P = 0.005), compared with the group that did not participate in the intervention. The self-efficacy of the participants that received both components of the intervention was significantly greater than the group that did not participate in the training (t = 2.079, P = 0.04). Participation in the two components of the training intervention was associated with significantly greater change in knowledge and self-efficacy than those receiving the training pack alone.

CONCLUSION

This intervention was effective in addressing the measured training needs of primary health care professionals. Future research should directly evaluate the positive benefits of interventions on the lives of people with IDs.

Enhancing primary health care services for adults with intellectual disabilities

BACKGROUND

Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID.

METHODS

All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed.

RESULTS

Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n=179) of participants reported having infrequent contact, 25% (n=50) reported a growing workload with people with ID. Only 8% (n=16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training.

CONCLUSIONS

Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.

Effects on coagulation of intravenous crystalloid or colloid in patients undergoing peripheral vascular surgery

BACKGROUND

This study investigated whether haemodilution-enhanced coagulation can be demonstrated under regional anaesthesia, whether this occurs before surgery, and whether the fluid used influences the effect.

METHODS

Patients were randomly allocated to receive either crystalloid or colloid intravenous fluid. An epidural was administered. Samples of venous blood were taken before fluid administration, after completion of the epidural and initial fluid load, during surgery before heparin, and after 24 h. Thrombelastograph analysis was performed, and full blood count, international normalised ratio, activated partial thromboplastin time, D-dimers and thrombin-antithrombin complex were measured.

RESULTS

In the crystalloid group, enhanced coagulation compared with baseline was demonstrated after initial fluid load (mean (SD) r-time 10.1 (4.9) min; P < 0.033; k-time 3.5 (1.7) min; P < 0.01; alpha-angle 54.9 (13.9) degrees; P < 0.01) and before heparin administration (r-time 8.8 (3.9) min; P < 0.01; alpha-angle 54.9 (12.6) degrees; P < 0.02). There was no enhancement of coagulation in the colloid group. There were no changes from baseline after 24 h.

CONCLUSIONS

This study confirms that the enhanced perioperative coagulation mechanism is related to dilution, rather than surgery, and is triggered by rapid crystalloid haemodilution. Consideration should be given to the use of colloid rather than crystalloid solutions for rapid fluid loading in vasculopathic patients undergoing surgery.

Increased apoptosis of bone marrow cells and preserved proliferative capacity of selected progenitors predict for clinical response to anti-inflammatory therapy in myelodysplastic syndromes

To determine the relation of apoptosis and clonal proliferation in the bone marrow (BM) to the effectiveness of a therapeutic protocol described to downmodulate monokine activity in patients with myelodysplastic syndromes (MDS). Prior to protocol therapy, BM stroma was cultivated and selected CD34(+) cells were studied in stroma and cytokine-dependent clonogenic assays. The TUNEL assay was used to establish the degree of apoptosis occurring in the marrow and CD34(+) population. The effectiveness of oral ciproloxacin 500 mg b. i.d., pentoxifylline 800 mg t.i.d., and dexamathasone 4 mg t.i.d. (CPD) antiinflammatory therapy was correlated with the intensity of cell apoptosis and proliferation of BM progenitor cells. Seventeen patients were studied. Twelve patients (10 transfusion dependent) received therapy for a median of 99 days (range 49-284). Toxicity caused four patients to discontinue the drug combination. Six patients fulfilled response criteria. Four patients became transfusion independent, and 50% reduction in the need for blood transfusions was noted in one patient. Blood parameters of one untransfused patient increased by >30%. Blood count remained unsupported in three patients, even at a median of 12 months after trial discontinuation. Apoptosis of marrow cells and selected CD34(+) progenitors was detected in a median of 49.5% (range 3. 6%-90%) and 10.6% (range 3.6%-100%; p < 0.01), respectively. In patients who responded to therapy, the median apoptosis rate in the bone marrow population was 71%, in contrast to the nonresponder's rate of 13% (p = 0.002). Overall clonogenic growth of selected precursors corresponded significantly with response to CPD protocol (p = 0.004). In some patients with MDS, ineffective hematopoiesis is related to high apoptotic index despite proliferation of the CD34(+) precursors. These patients seem to benefit from CPD cytokine modulatory therapeutic strategy.